- Email: [email protected]
Endoscopic Nd:YAG laser therapy for gastric borderline lesions
0016-5107/84/3001-0077$02.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1984 by the American Society for Gastrointestinal Endoscopy
Endoscopic Nd:YAG laser therapy for gastric borderline lesions Osamu Kato, MD Kazuhiko Hattori, MD Takashi Suzuki, MD Kazuki Yoshio, MD Yoshiro Shimizu, MD Nagoya, Japan Endoscopic Nd:YAG laser treatment was used to eradicate 14 broad-based protruded borderline lesions of the stomach in which snare excision might be difficult and hazardous. Multiple pulse irradiations of Nd:YAG laser with a power of 40 to 50 W ablated all the lesions. During and after laser treatments, no complications were recognized. The laser-induced ulcers healed within 4 to 7 weeks after the last procedure, and the biopsy material taken from the sites of the scars showed regenerative epithelium without evidence of atypical cells. These encouraging results suggest that endoscopic laser treatment is the method of choice for therapy of the gastric borderline lesions where snare excision is not feasible.
With development of a special quartz fiberoptic transmission system, application of laser energy through a flexible fiberendoscope can be made. 1 Endoscopic laser therapy was first reported for cases with active gastrointestinal bleeding. 2,3 Recently, laser endoscopy has been used to destroy mucosal tumors of the gastrointestinal tract. 4 The purpose of this article is to document our experience and to emphasize the efficacy and safety of endoscopic Nd-YAG laser treatment for ablation of the broad-based protruded borderline lesion of the stomach.
The quartz fiber with a polyethylene sheath was guided through the biopsy channel of a prototype panendoscope, Olympus model GIF-XQ.5 This instrument has a filtering lens at the eyepiece to prevent damage to the operator's eye from the laser beam. Multiple I-sec pulse irradiations of Nd:YAG laser (Medilas YAG) with a power of 40 to 50 W at the tip of the quartz fiber were utilized. The tip was positioned at about I-em distance from the lesion. Overinsufflation of the stomach was prevented by attaching a gastric tube to the shaft of the endoscope (Fig. 1).
MATERIALS AND METHODS
During the period from January to December 1982, endoscopic Nd:YAG laser treatment was utilized to eradicate 14 borderline lesions of the stomach in 11 patients. To establish an accurate histological diagnosis of these lesions, endoscopic biopsies were repeated at least twice before applying laser treatment. The biopsies always showed borderline atypical cells. All the lesions were broad-based protruded ones in which snare excision was not feasible. From the Department of Internal Medicine, Fujita Gakuen University, School of Medicine, The Second Hospital, Nagoya, Japan. Reprint requests: Osamu Kato, MD, Department of Internal Medicine, Fujita Gakuen University, School of Medicine, The Second Hospital, 3-6-10 Otobashi, Nakagawa-ku, Nagoya 454, Japan. VOLUME 30, NO.2, 1984
Figure 1. A laser probe is passed through the biopsy channel of the endoscope (GIF-XQ). A tube to deflate the stomach is attached to the instrument by tape.
77
The location of the 14 borderline lesions in 11 patients was as follows: 8 were located in the antrum, 5 in the distal body, and the remainder in the mid body (Table 1). The longest diameter measured on the upper gastrointestinal x-ray films ranged from 13 to 65 mm except for three lesions in which x-ray films were unsatisfactory in estimating size (Table 1). While the three small lesions were completely ablated by the first endoscopic laser treatment (Figs. 2 and 3), the other lesions required repetitive laser treatments to achieve complete ablation (Figs. 4 and 5). The posterior lesions were rather difficult to aim at, and more frequent laser applications were necessary than for lesions at the other sites. After laser treatment, sucralfate (4.0 g daily) for the laser-induced ulcers was administered perorally. The ulcers were healed within 4 to 7 weeks after the last laser endoscopy. The biopsy specimens taken from the site of the scars showed regenerative epithelium without atypical cells. During and after endoscopic laser treatment, no complications were encountered except for mild bleeding and occasional mild epigastric burning pain.
Figure 2. Endoscopic view of a borderline lesion in the mid body prior to laser treatment.
DISCUSSION
The gastric borderline lesion has been interpreted as a precancerous lesion, although there may be a focal Table 1. Laser treatment in borderline lesions. Patient Age 74 2
3
53
4
47
5
43
6
50
7
63
8
78
66
74
9
87
10
64
11
52
Location Antrum, anterior wall Antrum, greater curvature Lower body, posterior wall Lower body, posterior wall Antrum, anterior wall Antrum, lesser curvature Antrum, greater curvature Lower body, anterior wall Antrum, greater curvature Lower body, posterior wall Antrum, lesser curvature Lower body, anterior wall Antrum, posterior wall Mid body, posterior wall
Size (mm)
No. of applications (40-50 W, 1 sec)
35 x 30
128
65
x 60
868
15
X
10
43
27 x 15
156
25 x 18
91
25 x 11
73
27 x 20
100
31 x 21
90
Figure 3. Endoscopic view of the lesion 3 weeks after laser treatment. A healing stage laser-induced ulcer is seen.
30 35 x 30
87
50 19 26 x 11
181
13 x 7
39
Figure 4. Endoscopic view of a borderline lesion in the antrum prior to laser treatment.
carcinoma in the lesion.6-8 Since these lesions are usually broad based, snare excision may be difficult and hazardous. Surgical resection of this type oflesion has been advocated by many authors,8 and in Japan GASTROINTESTINAL ENDOSCOPY
power output. 4 We ablated 14 gastric borderline lesions with the endoscopic Nd:YAG laser without complication. We therefore conclude that endoscopic laser treatment is the most suitable method for ablation of the broad-based protruded borderline lesion of the stomach. Because laser ablation precludes a total biopsy, long-term follow-up study is required.
REFERENCES
Figure 5. Endoscopic view of the lesion 3 weeks after laser treatment. A laser-induced ulcer with residual borderline lesion is seen.
gastrectomy has been recommended for the borderline lesion larger than 2.0 cm in diameter. Frequent endoscopic follow-up study with biopsy has been advised for borderline lesions smaller than 1.9 cm in diameter. 7 Rosch and Fruhmorgen9 have reported the efficacy of endoscopic argon laser application to the gastric borderline lesion and protruded early gastric carcinoma. Dixon et al. 10 also treated both gastric and rectal polyps by endoscopic argon laser photocoagulation. However, there is a trend in many countries toward using Nd:YAG laser because of its greater
VOLUME 30, NO. 2, 1984
1. Nath G, Gorisch W, Kiefhaber P. First laser endoscopy via a fiberoptic transmission system. Endoscopy 1973;5:208-13. 2. Fruhmorgen P, Bodem F, Reidenbach HD, Kaduk B, Bembling L. Endoscopic laser coagulation of bleeding gastrointestinal lesions with report of the first therapeutic application in man. Gastrointest Endosc 1976;23:73-5. 3. Kiefhaber P, Nath G, Moritz K. Endoscopic control of massive gastrointestnal hemorrhage by irradiation with a high power neodymium-VAG laser. Prog Surg 1977;15:140-5. 4. Fleischer D. The current status of gastrointestinal laser activity in the United States. Gastrointest Endosc 1982;28:157-61. 5. Kato 0, Hattori K, Suzuki T, et al. Clinical experience with a prototyped panendoscope GIF-XQ. Gastroenterol Endosc 1982;24:1605-9. 6. Nagayo T. Histological diagnosis of biopsied gastric mucosa with special reference to that of borderline lesions. 1972;2:24558. 7. Nakamura K, Takagi K. Some considerations on lesion of atypical epithelium of the stomach. Stomach Intestine 1975;10:1455-63. 8. ROsch W. Endoscopic therapy of precancerosis. In: Herfarth CH, Schlag P, eds. Gastric cancer. Berlin: Springer-Verlag, 1979:108. 9. ROsch W, Fruhmorgen P. Endoscopic treatment of precancerosis and early gastric carcinoma. Endoscopy 1980;12:109-13. 10. Dixon JA, Burt RW, Rotering RH, McCloskey DW. Endoscopic argon laser photocoagulation of sessile colonic polyps. Gastrointest Endosc 1981;27:133.
79
Endoscopic Nd:YAG laser therapy for gastric borderline lesions Osamu Kato, MD Kazuhiko Hattori, MD Takashi Suzuki, MD Kazuki Yoshio, MD Yoshiro Shimizu, MD Nagoya, Japan Endoscopic Nd:YAG laser treatment was used to eradicate 14 broad-based protruded borderline lesions of the stomach in which snare excision might be difficult and hazardous. Multiple pulse irradiations of Nd:YAG laser with a power of 40 to 50 W ablated all the lesions. During and after laser treatments, no complications were recognized. The laser-induced ulcers healed within 4 to 7 weeks after the last procedure, and the biopsy material taken from the sites of the scars showed regenerative epithelium without evidence of atypical cells. These encouraging results suggest that endoscopic laser treatment is the method of choice for therapy of the gastric borderline lesions where snare excision is not feasible.
With development of a special quartz fiberoptic transmission system, application of laser energy through a flexible fiberendoscope can be made. 1 Endoscopic laser therapy was first reported for cases with active gastrointestinal bleeding. 2,3 Recently, laser endoscopy has been used to destroy mucosal tumors of the gastrointestinal tract. 4 The purpose of this article is to document our experience and to emphasize the efficacy and safety of endoscopic Nd-YAG laser treatment for ablation of the broad-based protruded borderline lesion of the stomach.
The quartz fiber with a polyethylene sheath was guided through the biopsy channel of a prototype panendoscope, Olympus model GIF-XQ.5 This instrument has a filtering lens at the eyepiece to prevent damage to the operator's eye from the laser beam. Multiple I-sec pulse irradiations of Nd:YAG laser (Medilas YAG) with a power of 40 to 50 W at the tip of the quartz fiber were utilized. The tip was positioned at about I-em distance from the lesion. Overinsufflation of the stomach was prevented by attaching a gastric tube to the shaft of the endoscope (Fig. 1).
MATERIALS AND METHODS
During the period from January to December 1982, endoscopic Nd:YAG laser treatment was utilized to eradicate 14 borderline lesions of the stomach in 11 patients. To establish an accurate histological diagnosis of these lesions, endoscopic biopsies were repeated at least twice before applying laser treatment. The biopsies always showed borderline atypical cells. All the lesions were broad-based protruded ones in which snare excision was not feasible. From the Department of Internal Medicine, Fujita Gakuen University, School of Medicine, The Second Hospital, Nagoya, Japan. Reprint requests: Osamu Kato, MD, Department of Internal Medicine, Fujita Gakuen University, School of Medicine, The Second Hospital, 3-6-10 Otobashi, Nakagawa-ku, Nagoya 454, Japan. VOLUME 30, NO.2, 1984
Figure 1. A laser probe is passed through the biopsy channel of the endoscope (GIF-XQ). A tube to deflate the stomach is attached to the instrument by tape.
77
The location of the 14 borderline lesions in 11 patients was as follows: 8 were located in the antrum, 5 in the distal body, and the remainder in the mid body (Table 1). The longest diameter measured on the upper gastrointestinal x-ray films ranged from 13 to 65 mm except for three lesions in which x-ray films were unsatisfactory in estimating size (Table 1). While the three small lesions were completely ablated by the first endoscopic laser treatment (Figs. 2 and 3), the other lesions required repetitive laser treatments to achieve complete ablation (Figs. 4 and 5). The posterior lesions were rather difficult to aim at, and more frequent laser applications were necessary than for lesions at the other sites. After laser treatment, sucralfate (4.0 g daily) for the laser-induced ulcers was administered perorally. The ulcers were healed within 4 to 7 weeks after the last laser endoscopy. The biopsy specimens taken from the site of the scars showed regenerative epithelium without atypical cells. During and after endoscopic laser treatment, no complications were encountered except for mild bleeding and occasional mild epigastric burning pain.
Figure 2. Endoscopic view of a borderline lesion in the mid body prior to laser treatment.
DISCUSSION
The gastric borderline lesion has been interpreted as a precancerous lesion, although there may be a focal Table 1. Laser treatment in borderline lesions. Patient Age 74 2
3
53
4
47
5
43
6
50
7
63
8
78
66
74
9
87
10
64
11
52
Location Antrum, anterior wall Antrum, greater curvature Lower body, posterior wall Lower body, posterior wall Antrum, anterior wall Antrum, lesser curvature Antrum, greater curvature Lower body, anterior wall Antrum, greater curvature Lower body, posterior wall Antrum, lesser curvature Lower body, anterior wall Antrum, posterior wall Mid body, posterior wall
Size (mm)
No. of applications (40-50 W, 1 sec)
35 x 30
128
65
x 60
868
15
X
10
43
27 x 15
156
25 x 18
91
25 x 11
73
27 x 20
100
31 x 21
90
Figure 3. Endoscopic view of the lesion 3 weeks after laser treatment. A healing stage laser-induced ulcer is seen.
30 35 x 30
87
50 19 26 x 11
181
13 x 7
39
Figure 4. Endoscopic view of a borderline lesion in the antrum prior to laser treatment.
carcinoma in the lesion.6-8 Since these lesions are usually broad based, snare excision may be difficult and hazardous. Surgical resection of this type oflesion has been advocated by many authors,8 and in Japan GASTROINTESTINAL ENDOSCOPY
power output. 4 We ablated 14 gastric borderline lesions with the endoscopic Nd:YAG laser without complication. We therefore conclude that endoscopic laser treatment is the most suitable method for ablation of the broad-based protruded borderline lesion of the stomach. Because laser ablation precludes a total biopsy, long-term follow-up study is required.
REFERENCES
Figure 5. Endoscopic view of the lesion 3 weeks after laser treatment. A laser-induced ulcer with residual borderline lesion is seen.
gastrectomy has been recommended for the borderline lesion larger than 2.0 cm in diameter. Frequent endoscopic follow-up study with biopsy has been advised for borderline lesions smaller than 1.9 cm in diameter. 7 Rosch and Fruhmorgen9 have reported the efficacy of endoscopic argon laser application to the gastric borderline lesion and protruded early gastric carcinoma. Dixon et al. 10 also treated both gastric and rectal polyps by endoscopic argon laser photocoagulation. However, there is a trend in many countries toward using Nd:YAG laser because of its greater
VOLUME 30, NO. 2, 1984
1. Nath G, Gorisch W, Kiefhaber P. First laser endoscopy via a fiberoptic transmission system. Endoscopy 1973;5:208-13. 2. Fruhmorgen P, Bodem F, Reidenbach HD, Kaduk B, Bembling L. Endoscopic laser coagulation of bleeding gastrointestinal lesions with report of the first therapeutic application in man. Gastrointest Endosc 1976;23:73-5. 3. Kiefhaber P, Nath G, Moritz K. Endoscopic control of massive gastrointestnal hemorrhage by irradiation with a high power neodymium-VAG laser. Prog Surg 1977;15:140-5. 4. Fleischer D. The current status of gastrointestinal laser activity in the United States. Gastrointest Endosc 1982;28:157-61. 5. Kato 0, Hattori K, Suzuki T, et al. Clinical experience with a prototyped panendoscope GIF-XQ. Gastroenterol Endosc 1982;24:1605-9. 6. Nagayo T. Histological diagnosis of biopsied gastric mucosa with special reference to that of borderline lesions. 1972;2:24558. 7. Nakamura K, Takagi K. Some considerations on lesion of atypical epithelium of the stomach. Stomach Intestine 1975;10:1455-63. 8. ROsch W. Endoscopic therapy of precancerosis. In: Herfarth CH, Schlag P, eds. Gastric cancer. Berlin: Springer-Verlag, 1979:108. 9. ROsch W, Fruhmorgen P. Endoscopic treatment of precancerosis and early gastric carcinoma. Endoscopy 1980;12:109-13. 10. Dixon JA, Burt RW, Rotering RH, McCloskey DW. Endoscopic argon laser photocoagulation of sessile colonic polyps. Gastrointest Endosc 1981;27:133.
79