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Endoscopic resection of submucosal tumors of gatrointestinal tract
S T O M A C H AND D U O D E N U M *289
291
A PROSPECTIVE OUTCOME STUDY OF PATIENTS WITH CLOTS IN AN ULCER AND THE EFFECT OF IRRIGATION. L Laine, C. Stein. V. Sharma. USC School of Medicine. L.A., CA. Prevalence and rebleeding rates reported for ulcers with clots vary widely. Differing degrees of vigor used to clear the clot may influence these rates since removal of the clot may reveal other stigmata. We prospectively assessed the natural history of patients with clots after vigorous irrigation. METHODS: Patients with upper GI bleeding found to have a clot in an ulcer had irrigation via 3.2mm bipolar probe for up to 5 rain. Stigmata after washing were recorded; endoscopic therapy was given for active bleeding which persisted ~ 5 min or non-bleeding visible vessels. Patients were observed in hospital for ~ 3 days. RESULTS: In a 2-yr period, 247 patients with bleeding ulcers had endoscopy and 46 with clots comprise this study. Mean age was 51 :L2 yrs; 40 had unstable vital signs or transfusion prior to endoscopy. After irrigation, the stigmata were Clean Flat Spot Adherent Clot Visible Vessel Oozin 9 Spurtinq 1 (2%) 5 (11%) 26 (58%) 7 (13%) 6 (13%) 1 (2%) Three (7%) patients rebled: 2/26 (8%) with adherent clots rebled (days 2, 3)--treetment with endoscopic therapy resulted in no further bleeding; 1/14 (7%) with visible vessel/active bleeding treated with hemostatic therapy tabled; repeat endoscopic therapy resulted in no further bleeding. No deaths occurred; units of blood after endoscopy were 1.0• All 3 patients with rebleeding had ulcers ~ 1.5 cm (vs. 12/43 (28%) without rebleeding; p = 0.03). CONCLUSION: An adherent clot remains in -60% of ulcers with clots which are irrigated and rebleeding is infrequent in these cases. Visible vessels or active bleeding are seen in over 25% of ulcers after clot irrigation. The endoscopic findings present after washing dictate the appropdate management at initial endoscopy: use of hemostatic therapy in patients with active bleeding or visible vessels and observation of patients with other stigmata (including clots resistant to washing) result in an excellent outcome. Therefore, irrigation should be performed for all ulcers with clots.
ESOPHAGEAL MANOMETRY FINDINGS OF THE GASTRIC MUCOSAL PROLAPSE (PROLAPSED GASTROPATHY SYNDROME) ~ DW Song, CW Park, MS Lee, SW Cho, CS Shim_ Division of Gastroentomlogy, Department of Internal Medicine, Soon Chun Hyang. University, Seoul, Korea ~ Gastric mucosal prolapse (GMP) is an uncomrc~n event during routine endoscopy. The clinical fea.t~-.e.s of GMP are persistent and recurrent retching, extraordinary senaltavity to gag and retch during endoscopy, demonstration of the prolapse of a tense inflamed or bleeding knuckle of gastric muoosa into the esophageal lumen during retching, usually no other abnormality at endoscopy, normal liver function test, and no history of alcohol abuse. The possible factv~ of GMP are 1~.laxation of the eso~agogastric opaning, excessive redundancy of the gastric muoosa, retrograde peristalsis of the stomach, and repeated reg~gitafion and excessive ~" violent vomiting, but there is no systematic study for the LES I~essure of GMP by esophageal manometry. Pumose: To investigate the roles of the abnormalities of LES and esophageal body as a factors of gastric mucosal prolapse. Metb0ds: The GMP group (n = 51) is selected by above findings of GMP during endoscopy, and control group (n = 40) by normal findings in endoscopy for general check-up. AJl of them had routine esophageal manometry (Andorfer ESM3 8R catheter, low compliance pneumohydraulic capillary infusion system; 0.5 ram/rain), and 14 patients of GMP group and 18 normal controls had dynamic study for rule out excessive sensitivity to routine endoscopic premedieation in GMP group (checking the LES & body peristalsis at 20 min after scopolamine butylbromide 1/2 ample & atropin 1/2 ample intramuscular injectioh after routine esophageal manometry). Results: The mean pressure of LES in GMP group was lower than control group (22.99 • 9.97 mmHg vs 25.46 i 7.92 mmHg), but statistically not significant. LES length of GMP group was shorter than control group (3.33 e 0.6 mm vs 3.88 t 0.78 ram, P < 0.05), but bias of measurement would he considered. Mean amplitude, duration and velocity of the peristaltic waves in upper, mid and distal esophageal body were no difference in two groups. Abnormal endoscopic and manometry findings of GMP were hiatal hernia (9/51), nut-cracker esophagus (2/51), hypertensive LES (1/51), NEMD (5/51; 2 retrograde contractions, 1 prolonged duration of contractions, 1 nontransmitted contractions, 1 low-amplitude of contractions), but control group showed only intermittent abnormal waves without mortor disorder. In dynamic study, mean basal pressures of LES were significantly decreased after premedication in both group (P < 0.05), and percentage of pressure reduction in GMP group was not different from that of control group (71.93 • 6.16 % vs 73.56 • 10.61%). Conolusion: The pathogenesis of the gastric mucosal prolapse should not he associated with decreased LES pressure except hiatal hernia, and not be associated with sensitivity for premedication. It may be associated with redundancy of gastric mucosa, and partially hintal hernia. For the relationship of the primary esophageal motility disorders such as nutcracker esophagus and NEMD with gastric mucosal prolapse, the more investigation is recomrnanded.
~90
292
STIGMATA OF RECEN'I' HEMORRHAGE IN PEPTIC ULCER BLEEDING: IS THERE INTER-OBSERVER AGREEMENT AMONG INTERNATIONAL EXPERTS? JYW Lau, JY Sung', JFT kau*,ACW Chan, EKW Ng, SCS Chung Departmentof Surgery, Departmentof Medicine"and the Center for Qinical Trials and EpidemiologicalResearch*,Princeof Wales Hospital,The Chinese Universityof Hon9 Kong.
ENDOSCOPIC RESECTION OF SUBMUCOSAL T U M O R S OF G A T R O I N T E S T I N A L T R A C T .
Obiective: to determine the inter-observer agreement among international expertson endoscopicsignsof hemorrhagein bleedingpepticulcers. Method: One hundred consecutivebleeding peptic ulcers were recordedby video-endoscopy.An editedvideo-tapewas sent to 11 internationalexpertson endoscopic treatment of bleeding peptic ulcers. They were invited to rate these ulcers exclusively into one of the six categories in the Forrest classification; [a (spurter), Ib (oozing), Ila (visible vessel), lib (adherentclot), IIc (flat pigmentedspot) and Ill (clean base). The inter-observeragreement among these experts was analyzed t/sing the kappa and weighted kappa statistics. Kappa estimates (k) were obtained in a pair-wise fashion between any two experts and an overall weighted k to signify the agreementin the entire group. Individualkappaestimatewas also computedfor each category of stigmata. Results: The weighted k for the entire group is 0.453_+0.006(K<0.4 = poor agreement, 0.40.75 = fair to good agreement, k>0.75 = excellent agreement).For eachcategoryof the Forrestclassification;the k is: k estimate la (spurter) 0.719 Ib (oozing) 0.425 Ila (visiblevessel) 0.337 I/b (adherentclot) 0.436 IIc (flat pigmentedspot) 0.412 Ill (cleanbase) 0.350 Conclusion: The inter-observeragreementamonginternationalexpertsis poor for visiblevesselsand clean base ulcers, fair for activeoozing, adherentdots and flat pigmentspots. Goodagreementis obtainedonly over activespurters.
368
GASTROINTESTINAL ENDOSCOPY
M S Lee, D W Song, C W Park, JS Lee, S W Cho, CS Shim. Dept. of Internal Medicine, S o o n C h u n H y a n g University, Seoul, Korea. W e p e r f o r m e d endoscopic resection of s u b m u c o s a l t u m o r s in 38 patients. T h e criteria for selection for endoscopic resection were; 1) the p a t i e n t s complained of g a s t r o i n t e s t i n a l s y m p t o m s w h i c h could be a t t r i b u t e d to the s u b m u c o s a l t u m o r s , or the lesions w e r e s u s p e c t e d to m a l i g n a n c y , or the lesions w e r e c h a n g e d in size or shape, a n d 2)the t u m o r s w e r e less t h a n 3 c m in diameter, a n d located s u b m u c o s a l o r p r o p e r m u s c l e l a y e r w i t h intraluminal or i n t r a m u r a l g r o w t h p a t t e r n s on the endoscopic u l t r a s o n o g r a p h y . Endoscopic m e t h o d s for resection of the t u m o r s w e r e u s e d convetional s n a r e p o l y p e c t o m y in 9 patients(24%) w i t h pedunculated tumors, a n d double channel p o l y p e c t o m y or incisional enucleation in remained 29 patients(76%) w i t h sessile or b r o a d b a s e d tumors. T h e t u m o r s w e r e 1 - 3 c m ( m e a n 1.4cm) in diameter. T h e locations of t u m o r s w e r e s u b m u c o s a l l a y e r in 23 (61%), proper m u s c l e in 15(39%), a n d their g r o w t h p a t t e r n s w e r e intraluminal in 30(79%), i n t r a m u r a l in 8 patients(21%). O f 38 patients, the t u m o r s w e r e s u c c e s s f u l l y a n d completely r e m o v e d in 30 (79%), partially r e m o v e d in 6(16%) patients. In r e m a i n e d 2 patients(5% ), resection of the t u m o r s w e r e failed a n d histological d i a g n o s i s of the t u m o r s could not be available. Histological d i a g n o s i s of the 36 resected t u m o r s w e r e e s o p h a g e a l l e i o m y o m a in 5, g a s t r i c l e i o m y o m a in 7, g a s t r i c i n f l a m m a t o r y fibroid polyp in 6, g a s t r i c ectopie p a n c r e a s in 4, g a s t r i c Iipoma in 1, duodenal B r u n n e r ' s a d e n o m a in 4, duodenal l e i o m y o m a in 2, colonic l y m p h a n g i o m a in 4, colonic lipoma in 2, colonic h e m a n g i o m a in 1 patient. T h e r e w e r e no serious complications a s s o c i a t e d with the procedures. F o l l o w - u p for 2 to 38 m o n t h s ( m e a n 13.2 m o n t h s ) in 26 p a t i e n t s w h o s e t u m o r s w e r e complefly r e s e c t e d did not reveal recurrence. T h e s e results indicated t h a t endoscopic resection is a safe a n d effective m e t h o d of conf'trmative diagnosis a n d t r e a t m e n t of s u b m u c o s a l t u m o r s w h i c h are less t h a n 3 c m in the longest d i a m e t e r a n d located in s u b m u c o s a l or p r o p e r muscle l a y e r with intraluminal or i n t r a m u r a l g r o w t h .
V O L U M E 41, NO. 4, 1995
291
A PROSPECTIVE OUTCOME STUDY OF PATIENTS WITH CLOTS IN AN ULCER AND THE EFFECT OF IRRIGATION. L Laine, C. Stein. V. Sharma. USC School of Medicine. L.A., CA. Prevalence and rebleeding rates reported for ulcers with clots vary widely. Differing degrees of vigor used to clear the clot may influence these rates since removal of the clot may reveal other stigmata. We prospectively assessed the natural history of patients with clots after vigorous irrigation. METHODS: Patients with upper GI bleeding found to have a clot in an ulcer had irrigation via 3.2mm bipolar probe for up to 5 rain. Stigmata after washing were recorded; endoscopic therapy was given for active bleeding which persisted ~ 5 min or non-bleeding visible vessels. Patients were observed in hospital for ~ 3 days. RESULTS: In a 2-yr period, 247 patients with bleeding ulcers had endoscopy and 46 with clots comprise this study. Mean age was 51 :L2 yrs; 40 had unstable vital signs or transfusion prior to endoscopy. After irrigation, the stigmata were Clean Flat Spot Adherent Clot Visible Vessel Oozin 9 Spurtinq 1 (2%) 5 (11%) 26 (58%) 7 (13%) 6 (13%) 1 (2%) Three (7%) patients rebled: 2/26 (8%) with adherent clots rebled (days 2, 3)--treetment with endoscopic therapy resulted in no further bleeding; 1/14 (7%) with visible vessel/active bleeding treated with hemostatic therapy tabled; repeat endoscopic therapy resulted in no further bleeding. No deaths occurred; units of blood after endoscopy were 1.0• All 3 patients with rebleeding had ulcers ~ 1.5 cm (vs. 12/43 (28%) without rebleeding; p = 0.03). CONCLUSION: An adherent clot remains in -60% of ulcers with clots which are irrigated and rebleeding is infrequent in these cases. Visible vessels or active bleeding are seen in over 25% of ulcers after clot irrigation. The endoscopic findings present after washing dictate the appropdate management at initial endoscopy: use of hemostatic therapy in patients with active bleeding or visible vessels and observation of patients with other stigmata (including clots resistant to washing) result in an excellent outcome. Therefore, irrigation should be performed for all ulcers with clots.
ESOPHAGEAL MANOMETRY FINDINGS OF THE GASTRIC MUCOSAL PROLAPSE (PROLAPSED GASTROPATHY SYNDROME) ~ DW Song, CW Park, MS Lee, SW Cho, CS Shim_ Division of Gastroentomlogy, Department of Internal Medicine, Soon Chun Hyang. University, Seoul, Korea ~ Gastric mucosal prolapse (GMP) is an uncomrc~n event during routine endoscopy. The clinical fea.t~-.e.s of GMP are persistent and recurrent retching, extraordinary senaltavity to gag and retch during endoscopy, demonstration of the prolapse of a tense inflamed or bleeding knuckle of gastric muoosa into the esophageal lumen during retching, usually no other abnormality at endoscopy, normal liver function test, and no history of alcohol abuse. The possible factv~ of GMP are 1~.laxation of the eso~agogastric opaning, excessive redundancy of the gastric muoosa, retrograde peristalsis of the stomach, and repeated reg~gitafion and excessive ~" violent vomiting, but there is no systematic study for the LES I~essure of GMP by esophageal manometry. Pumose: To investigate the roles of the abnormalities of LES and esophageal body as a factors of gastric mucosal prolapse. Metb0ds: The GMP group (n = 51) is selected by above findings of GMP during endoscopy, and control group (n = 40) by normal findings in endoscopy for general check-up. AJl of them had routine esophageal manometry (Andorfer ESM3 8R catheter, low compliance pneumohydraulic capillary infusion system; 0.5 ram/rain), and 14 patients of GMP group and 18 normal controls had dynamic study for rule out excessive sensitivity to routine endoscopic premedieation in GMP group (checking the LES & body peristalsis at 20 min after scopolamine butylbromide 1/2 ample & atropin 1/2 ample intramuscular injectioh after routine esophageal manometry). Results: The mean pressure of LES in GMP group was lower than control group (22.99 • 9.97 mmHg vs 25.46 i 7.92 mmHg), but statistically not significant. LES length of GMP group was shorter than control group (3.33 e 0.6 mm vs 3.88 t 0.78 ram, P < 0.05), but bias of measurement would he considered. Mean amplitude, duration and velocity of the peristaltic waves in upper, mid and distal esophageal body were no difference in two groups. Abnormal endoscopic and manometry findings of GMP were hiatal hernia (9/51), nut-cracker esophagus (2/51), hypertensive LES (1/51), NEMD (5/51; 2 retrograde contractions, 1 prolonged duration of contractions, 1 nontransmitted contractions, 1 low-amplitude of contractions), but control group showed only intermittent abnormal waves without mortor disorder. In dynamic study, mean basal pressures of LES were significantly decreased after premedication in both group (P < 0.05), and percentage of pressure reduction in GMP group was not different from that of control group (71.93 • 6.16 % vs 73.56 • 10.61%). Conolusion: The pathogenesis of the gastric mucosal prolapse should not he associated with decreased LES pressure except hiatal hernia, and not be associated with sensitivity for premedication. It may be associated with redundancy of gastric mucosa, and partially hintal hernia. For the relationship of the primary esophageal motility disorders such as nutcracker esophagus and NEMD with gastric mucosal prolapse, the more investigation is recomrnanded.
~90
292
STIGMATA OF RECEN'I' HEMORRHAGE IN PEPTIC ULCER BLEEDING: IS THERE INTER-OBSERVER AGREEMENT AMONG INTERNATIONAL EXPERTS? JYW Lau, JY Sung', JFT kau*,ACW Chan, EKW Ng, SCS Chung Departmentof Surgery, Departmentof Medicine"and the Center for Qinical Trials and EpidemiologicalResearch*,Princeof Wales Hospital,The Chinese Universityof Hon9 Kong.
ENDOSCOPIC RESECTION OF SUBMUCOSAL T U M O R S OF G A T R O I N T E S T I N A L T R A C T .
Obiective: to determine the inter-observer agreement among international expertson endoscopicsignsof hemorrhagein bleedingpepticulcers. Method: One hundred consecutivebleeding peptic ulcers were recordedby video-endoscopy.An editedvideo-tapewas sent to 11 internationalexpertson endoscopic treatment of bleeding peptic ulcers. They were invited to rate these ulcers exclusively into one of the six categories in the Forrest classification; [a (spurter), Ib (oozing), Ila (visible vessel), lib (adherentclot), IIc (flat pigmentedspot) and Ill (clean base). The inter-observeragreement among these experts was analyzed t/sing the kappa and weighted kappa statistics. Kappa estimates (k) were obtained in a pair-wise fashion between any two experts and an overall weighted k to signify the agreementin the entire group. Individualkappaestimatewas also computedfor each category of stigmata. Results: The weighted k for the entire group is 0.453_+0.006(K<0.4 = poor agreement, 0.4
368
GASTROINTESTINAL ENDOSCOPY
M S Lee, D W Song, C W Park, JS Lee, S W Cho, CS Shim. Dept. of Internal Medicine, S o o n C h u n H y a n g University, Seoul, Korea. W e p e r f o r m e d endoscopic resection of s u b m u c o s a l t u m o r s in 38 patients. T h e criteria for selection for endoscopic resection were; 1) the p a t i e n t s complained of g a s t r o i n t e s t i n a l s y m p t o m s w h i c h could be a t t r i b u t e d to the s u b m u c o s a l t u m o r s , or the lesions w e r e s u s p e c t e d to m a l i g n a n c y , or the lesions w e r e c h a n g e d in size or shape, a n d 2)the t u m o r s w e r e less t h a n 3 c m in diameter, a n d located s u b m u c o s a l o r p r o p e r m u s c l e l a y e r w i t h intraluminal or i n t r a m u r a l g r o w t h p a t t e r n s on the endoscopic u l t r a s o n o g r a p h y . Endoscopic m e t h o d s for resection of the t u m o r s w e r e u s e d convetional s n a r e p o l y p e c t o m y in 9 patients(24%) w i t h pedunculated tumors, a n d double channel p o l y p e c t o m y or incisional enucleation in remained 29 patients(76%) w i t h sessile or b r o a d b a s e d tumors. T h e t u m o r s w e r e 1 - 3 c m ( m e a n 1.4cm) in diameter. T h e locations of t u m o r s w e r e s u b m u c o s a l l a y e r in 23 (61%), proper m u s c l e in 15(39%), a n d their g r o w t h p a t t e r n s w e r e intraluminal in 30(79%), i n t r a m u r a l in 8 patients(21%). O f 38 patients, the t u m o r s w e r e s u c c e s s f u l l y a n d completely r e m o v e d in 30 (79%), partially r e m o v e d in 6(16%) patients. In r e m a i n e d 2 patients(5% ), resection of the t u m o r s w e r e failed a n d histological d i a g n o s i s of the t u m o r s could not be available. Histological d i a g n o s i s of the 36 resected t u m o r s w e r e e s o p h a g e a l l e i o m y o m a in 5, g a s t r i c l e i o m y o m a in 7, g a s t r i c i n f l a m m a t o r y fibroid polyp in 6, g a s t r i c ectopie p a n c r e a s in 4, g a s t r i c Iipoma in 1, duodenal B r u n n e r ' s a d e n o m a in 4, duodenal l e i o m y o m a in 2, colonic l y m p h a n g i o m a in 4, colonic lipoma in 2, colonic h e m a n g i o m a in 1 patient. T h e r e w e r e no serious complications a s s o c i a t e d with the procedures. F o l l o w - u p for 2 to 38 m o n t h s ( m e a n 13.2 m o n t h s ) in 26 p a t i e n t s w h o s e t u m o r s w e r e complefly r e s e c t e d did not reveal recurrence. T h e s e results indicated t h a t endoscopic resection is a safe a n d effective m e t h o d of conf'trmative diagnosis a n d t r e a t m e n t of s u b m u c o s a l t u m o r s w h i c h are less t h a n 3 c m in the longest d i a m e t e r a n d located in s u b m u c o s a l or p r o p e r muscle l a y e r with intraluminal or i n t r a m u r a l g r o w t h .
V O L U M E 41, NO. 4, 1995