A new endoscopic technique for the resection of flat polypoid lesions

Correct marking of the stricture margins so that the stent can be appropriately positioned is mandatory. Current techniques used to identify the stricture margins include the placement of external radiopaque markers and noting the distances from the mouth on the endoscope to be correlated with the stent pusher tube.1°- 12 However, these techniques are prone to movement artifact. Rotation of the patient during two-dimensional fluoroscopy without the option of a rotating head displaces the plane of the skin markers in relation to the tumor. Miscalculations using the endoscopic markers that are then transcribed to the pusher tube are frequent. Pulsion force may stretch the tissues involved to a small extent as well. In addition to the standard methods, we have found the adjunctive use of intramucosal injection of contrast to be of benefit. The enhanced accuracy is important with expandable stents, which are more easily displaced because of the uneven expansion process and associated shortening of the stent during expansion. This method is easy, safe, and reliable, and may obviate the need for the less reliable external markers. REFERENCES 1. Loizou LA, Grigg D, Atkinson M, et al. A prospective comparison of laser therapy and intubation in endoscopic palliation for malignant dysphagia. Gastroenterology 1991;100:1303-10. 2. Fugger R, Niederle B, Jantsche H, Schiessel R, Schulz F. Endoscopic tube implantation for the palliation of malignant esophageal stenosis. Endoscopy 1990;22:101-4.

A new endoscopic technique for the resection of flat polypoid lesions Dalton M. Chaves, Paulo Sakai, Marcelo Mester, Sergio R. Spinosa, Tashiro Tomishige, Shinishi Ishioka,

MD MD MD MD MD MD

The development of fiberoptic endoscopy was a major advance for the diagnosis and treatment of elevated mucosal gastrointestinal lesions. Whereas moderatesized polyps are easily resectable, flat or slightly Received October 6, 1993. Accepted November 18, 1993. From the Gastrointestinal Endoscopy Unit, Hospital das Clinicas da FMUSP, University of sao Paulo Medical School, sao Paulo, Brazil. Reprint requests: Paulo Sakai, MD, Rua Jofio Juliao #331,01323020, sao Paulo, SP, Brazil. 0016-5107/94/4002-0224$3.00 + 0 GASTROINTESTINAL ENDOSCOPY Copyright © 1994 by the American Society of Gastrointestinal Endoscopy

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3. Gasparri G, Casalegno PA, Camandona M, et al. Endoscopic insertion of 248 prostheses in inoperable carcinoma of the esophagus and cardia: short-term and long-term results. Gastrointest Endosc 1987;33:354-6. 4. Tytgat GNJ, Huibregtse K, Bartelsman JFWM, den Hartog Jager FCA. Endoscopic palliative therapy of gastrointestinal and biliary tumours with prosthesis. Clin Gastroenterol 1986; 15:249-71. 5. Song HY, Choi KC, Cho BH, Ahn DS, Kim KS. Esophagogastric neoplasms: palliation with a modified Gianturco stent. Radiology 1991;180:349-354. 6. Neuhaus H, Hoffmann W, Dittler HJ, Niedermeyer HP, Classen M. Implantation of self-expanding esophageal metal stents for palliation of malignant dysphagia. Endoscopy 1992;24:40510. 7. Bethge N, Knyrim K, Wagner HJ, Starck E, Pausch J, Kleist DV. Self-expanding metal stents for palliation of malignant esophageal obstruction: a pilot study of eight patients. Endoscopy 1992;24:411-5. 8. Kozarek RA, Ball T J. Metallic self-expanding stent application in the upper gastrointestinal tract: caveats and concerns. Gastrointest Endosc 1992;38:1-6. 9. Schaer J, Katon RM, Ivancev K, Uchida B, Rosch J, Binmoeller KF. Treatment of malignant esophageal obstruction with silicone-coated metallic self-expanding stents. Gastrointest Endosc 1992;38:7 -11. 10. Tytgat GNJ. Benign and malignant tumors of the esophagus. In: Sivak MV Jr, ed. Gastroenterologic endoscopy. Philadelphia: WB Saunders, 1987:373-400. 11. Therapeutic upper endoscopy. In: Cotton PB, Williams CB, eds. Practical gastrointestinal endoscopy. Oxford: Blackwell Scientific Publications, 1990:56-84. 12. Fleischer D. Treatment of esophageal and other GI cancers. In: Waye J, Geenen J, Fleischer D, Venu RP, eds. Techniques in therapeutic endoscopy. Philadelphia: WB Saunders, 1987:3.13.25.

elevated mucosal lesions are essentially difficult to manage with conventional polypectomy snare devices. Currently, lift-and-cut and strip-biopsy techniques are the methods of choice for the latter types, but experience with these cumbersome procedures is limited'! Herein, we present a new and simpler technique for the resection of flat or slightly elevated mucosal lesions, which is based on Stiegmann's original esophageal varix band-ligation procedure. 2 PATIENTS AND METHODS

Eight patients (5 men and 3 women) were treated from January to November of 1992. Ages ranged from 35 to 65 years (mean, 50 years). A total of 8 lesions were endoscopically removed: 3 gastric adenomas, 2 gastric carcinoids (previously diagnosed through endoscopic biopsy), 1 gastric angiodysplasia with a prior history of bleeding, and 2 submucosal esophageal tumors (no previous biopsy). All lesions were smaller than 1 em in diameter. Basically, the technique transforms a fiat or slightly elevated lesion into an elevated lesion amenable to conventional snare polypectomy. The lesion is first aspirated, and then an elastic ligation is applied as described by Stiegmann for esophageal varices; this creates a pedunculated lesion. GASTROINTESTINAL ENDOSCOPY

Figure 1. Resection of a polypoid lesion following rubber band ligation. A, Small sessile lesion. B, Ligation at the base of the lesion. C, Polypectomy snare in use. D, Rubber band remaining at the base of the resected lesion.

hemostatic ally resected above the elasFinally, the lesion is hemostatically tic ligation with a conventional polypectomy snare (Fig. 1). A video-endoscope and the Stiegmann-Goff endoscopic ligator kit (Bard Interventional Products, Tewksbury, Mass.) are used during the procedure. 2 RESULTS

All lesions were easily and safely resected. No hemorrhage, perforations, or any other complications occurred. The polypectomy procedure produced ulcers of only a few millimeters, and the elastic ligation allowed excellent hemostasis. Pathologic examination confirmed the diagnoses of all previous gastric biopsies and yielded the diagnoses of leiomyoma and granular cell tumor in the esophageal lesions (Table 1). The margins of all resected specimens were safe and included the adjacent submucosa. The flat gastric adenomas proved to be totally benign, and the gastric carcinoid lesions did not present any recurrence during 1 year of follow-up. DISCUSSION

The relative incidence of gastric polyps in a large autopsy series is relatively low, ranging from 0.4 % to VOLUME 40, NO.2, PART 1, 1994

Table 1. Histopathologic diagnoses of resected lesions (aspiration-ligation endoscopic technique) Histopathology Gastric lesions Gastric adenoma Gastric carcinoid Gastric angiodysplasia Esophageal submucosal lesions Leiomyoma Granular cell tumor Total

N

(%) (%)

3 2 1

37.5 25.0 12.5

1 1 8

12.5 12.5 100.0

0.7 %.3,4 0.7% .3,4 Sessile lesions comprise 22 % of all polypoid lesions, lesions,55 and only a few of them are amenable to resection via standard snare polypectomy. For flat or slightly elevated lesions, lift-and-cut and strip-biopsy techniques developed in Japan are currently the methods of choice. 1 The lift-and-cut procedure involves use of a two-channeled therapeutic endoscope, or the simultaneous use of two endoscopes (one to pull and elevate the lesion, and the second to resect the lesion with a snare). The strip-biopsy procedure requires 225

submucosal injection of saline; a standard snare can then be used on the newly protruded mucosal lesion. Both methods are cumbersome and may cause significant ulcerations that are much larger than the originallesion. Our method is simpler and produces a much smaller mucosal wound that allows effective hemostasis. Use of our method is limited to lesions of up to 1 cm in diameter, but larger lesions may also be treated if a bigger cylinder is used for the elastic ligation at the tip of the endoscope. The simplicity and safety of this method may make it suitable for the endoscopic resection of early gastric and esophageal cancers provided that cylinders of adequate size are available. Inoue et al. 6 utilized a similar methQd to resect dysplastic esophageal lesions as well as early gastric cancer. However, elastic ligation at the base was not

performed. The procedure presented herein eliminates the need for submucosal infiltration with saline and permits resection of flat or slightly elevated mucosallesions with safety.

REFERENCES 1. Tada M, Shimada M, Yanai H, et al. A new technique of gastric biopsy. Stomach Intestine 1984;17:1107-16. 2. Stiegmann GV, Cambre T, Sun JH. A new endoscopic elastic band ligating device. Gastrointest Endosc 1986;32:230-3. 3. Stewart MJ. Observations on the relation of malignant disease to benign tumors of the intestinal tract. BMJ 1929;2:567-9. 4. Lawrence JC. Gastrointestinal polyps: statistical study of malignancy incidence. Am J Surg 1936;31:499-505. 5. ReMine SG, Hughes RW, Weiland LH. Endoscopic gastric polypectomies. Mayo Clin Proc 1981;56:371-5. 6. Inoue H, Takeshita K, Hori H, et al. Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach and colon mucosal lesions. Gastrointest Endosc 1993;39:58-61.

Endosonography of stenotic esophageal carcinomas: preliminary experience with an ultra-thin, balloon-fitted ultrasound probe in four patients Paul Fockens, MD Hendrik M. van Dullemen, MD Guido N.J. Tytgat MD, PhD

Endosonography (ES) is a generally accepted technique for the pre-operative staging of malignant tumors in the upper or lower gastrointestinal tract. One of the main indications for ES is the pre-operative staging of esophageal carcinoma, where T (depth of tumor invasion) and N (regional lymph node metastasis) stage are vital for determining prognosis. 1, 2 In series that have been published, an accuracy of 85 % for T stage and approximately 80 % for N stage have been reached. 3-7 A major limiting factor for the use of ES is the fact that a considerable number of esophageal lesions cannot be traversed with standard echo-endoscopes (Olympus GF-UM3 or GF-UM20, Olympus America Inc., Lake Success, N.Y.). Percentages of esophageal strictures not permitting passage range from 12 % to 62 %, with an average of about 30 %.8 In these patients, the pre-operative staging for T stage, N

Received November 3, 1993. Accepted November 13, 1993. From the Department of Gastroenterology, Academic Medical Center, Amsterdam, the Netherlands. Reprint requests: Paul Fockens, MD, Department of Gastroenterology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. 0016-5107/94/4002-0226$3.00 + 0 GASTROINTESTINAL ENDOSCOPY Copyright 1994 by the American Society of Gastrointestinal Endoscopy

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Figure 1. Ultra-thin radial scanning probe with 2.4 mm outer diameter (top) and 3.2 mm sheath fitted with balloon at the tip (bottom).

stage, and for the detection of distant malignant lymph nodes near the celiac axis (M stage) is incomplete. Dilation of such obstructing tumors up to 45F to permit instrument passage has been done, but perforations were not uncommon and occurred in 25 % of patients in the only prospective study on this subject. 9 Therefore, we strongly oppose performing dilation solely for the purpose of a full ES staging. 10 A better solution would be the manufacture of instruments with a smaller outer diameter. Experience with a blind ultrasound probe that was advanced through a stenosis over a guide wire has been published,11 and mini-probes were constructed and even commercially marketed in Europe. 12 Here we report our experience with one of those ultra-thin probes (2.4 mm). This probe can be fitted in an outer sheath that carries a balloon at the tip to achieve better acoustic coupling between probe and esophageal wall. GASTROINTESTINAL ENDOSCOPY