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Endoscopic Submucosal Dissection for Lesions of the Esophago-Gastric Junction and Gastric Cardia
*M1799 The Effectiveness of Through-the-scope Self-Expandable Metal Stent in Palliation of Malignant Gastrointestinal Obstruction Jeong Seop Moon, Eun Soon Kim, You Sun Kim, Jung Whan Lee, Soo Hyung Ryu Background/Aims: Malnutrition and various symptoms due to malignant gastrointestinal obstruction impair quality of life. Self-expandable metal stents (SEMS) have been used in the palliation of malignant gastrointestinal obstruction. Insertion of SEMS in malignant stenosis after gastrectomy is particularly difficult because of the anatomical variation after surgery and severe angulation of the narrowed region. The purpose of this study was to evaluate the effectiveness, safety and outcome of SEMS using through-the-scope (TTS) in the patients with malignant gastrointestinal obstruction, including recurrent gastric cancer after gastrectomy. Methods: Twenty seven patients (31 cases of stent insertion) were palliatively treated by SEMS between October 2000 and July 2003; eighteen had inoperable malignant gastric outlet obstruction, eight had recurrent gastric cancer after gastrectomy, and one had metastatic duodenal cancer. We analyzed technical and clinical success, complication, and outcome. Results: A total technical success rate was 90.3% (28/31 cases); malignant gastric outlet obstruction was 94.7% (18/ 19), recurrent gastric cancer after gastrectomy was 81.8% (9/11), and metastatic duodenal cancer was 100% (1/1). A total clinical success rate was 92.6% (25/27 patients). Two with recurrent gastric cancer after gastrectomy were not improved in diet and symptoms after technical success. Complications occurred in 8 of 27 patients (29.6%) including stent migration (3 patients), aspiration pneumonia (1 patient), and recurrent obstruction (4 patients). Three of four patients with recurrent obstruction had successful further stenting. The mean survival period was 90.8 days (range 5-288 days) and mean patent period was 78.9 days (range 5288 days). Conclusions: SEMS using TTS is an effective, safe, and less invasive palliative treatment in malignant gastrointestinal obstruction, especially recurrent gastric cancer after surgery.
*M1801 Endoscopic Submucosal Dissection for Lesions of the EsophagoGastric Junction and Gastric Cardia Naohisa Yahagi, Mitsuhiro Fujishiro, Naomi Kakushima, Atsushi Imagawa, Katsuya Kobayashi, Takuhei Hashimoto, Masashi Oka, Masao Omata Background & Aim: The esophago-gastric junction (EGJ) and gastric cardia are considered to be difficult areas for endoscopic treatment, because of the drastic change of the width and angle of the digestive tract. In this location, laparotomy has been the standard treatment, even for tumors still in its early stage. However, by the emergence of endoscopic submucosal dissection (ESD), larger lesions and those of difficult areas including the EGJ have become possible candidates for endoscopic treatment. We evaluated the efficacy and safety of this new technique for the treatment of superficial tumors located in this difficult area. Method: From June 2002 to November 2003, 9 patients of superficial tumor located in the EGJ or gastric cardia including barrett’s cancer, were treated by ESD at the University of Tokyo Hospital. ESD using thin-type snare or flex-knifeÒ (Olympus, Tokyo, Japan) was performed as we have previously reported. A combination use of endoscope with water-jet system (Pentax, Japan) and a high frequency generator Erbotom ICC 200 (ERBE, Germany) was used. A solution of hyaluronate sodium and 20% dextrose with minimal indigocarmine dye and epinephrine was used for submucosal injection. Result: The average size of the lesions was 20.8 mm (7-40 mm); the average specimen size removed by ESD was 35.2 mm (19-60 mm). The overall rate of successful en-bloc resection rate was 100 % (9/9). Histopathologic evaluation confirmed complete resection in 100 % (9/9). In one patient, minute submucosal invasion was found (500lm in depth) with vessel involvement. This patient was followed without additional therapy, since the patient refused total gastrectomy. Neither blood transfusion nor surgical rescue were required for any patient. Postoperative stenosis occurred in 1 patient, which was successfully managed by several balloon dilatation. The mean period of follow up was 8 months (1-18 months), and no local and distant recurrence was observed among the patients. Conclusion: ESD is an less invasive, ultimate treatment in preserving gastric function. It is a safe and reliable treatment technique for superficial tumors of the EGJ and gastric cardia. It should be a useful treatment even for barrett’s esophagus, a disease of which incidence rate is rapidly increasing around the world.
*M1800 Fundamental Endoscopic Findings of Early Gastric Cancer: Importance of Recognition Tatsuo Hirano Purpose: Although gastric cancer is one of leading causes of death in many countries, endoscopic findings of early gastric cancer (EGC) is not still widely known. To contribute to a better understanding, typical cases of EGC are presented, and the points for early detection by endoscopy are stressed. Also several characteristic features of EGCs observed by magnifying endoscopy and endoscopic ultrasonography (EUS) are presented. Patients and Methods: Between September 2001 and September 2003, 46 new cases of EGC limited to the mucosa and/or submucosa were found by a single endoscopist (TH) in an outpatient clinic. Of these, 34 EGCs of 32 cases (including 2 cases of double EGCs) were evaluated by magnifying endoscope GIF-Q240Z (Olympus, Tokyo, Japan) and by endoscopic ultrasonography (Olympus). There were 17 males and 15 females with mean age 65.1 years (range: 41-81). Results: Elevated and superficially elevated types, superficially depressed types, and flat types were 13 lesions, 18 lesions, and 3 lesions, respectively. Of these, 27 lesions were differentiated adenocarcinoma and 7 lesions were undifferentiated adenocarcinoma including 4 lesions of signet-ring cell carcinoma. Twenty-six lesions were mucosal cancer and 8 lesions were submucosal cancer. In magnifying endoscopy, clear expansive growth margin in elevated types and scale-like margin in depressed type were characteristic. Patterns of cancer surface were irregular in all lesions. Non-structured surface pattern was observed in 16 of 18 depressed lesions and in 7 of 13 elevated lesions. Abnormalities of microvascular structure and/or density were seen in 29 of 34 lesions. Localized discoloration of the mucosal surface was the only important tool to find mucosal signet-ring cell carcinoma where cancer vascularity was low. EUS was performed for 31 of 34 lesions to ensure the depth of cancer invasion. Only one submucosal cancer of elevated type was misdiagnosed as mucosal cancer before EUS was done. All patients underwent curative treatments including endoscopic resection only for 17 lesions, endoscopic resection plus surgery for 3 lesions and surgery only for 14 lesions. All patients are alive and well. Conclusion: Endoscopic mucosal resection or less-invasive gastric resection can be performed for cure in selected cases of EGC. For a better prognosis and quality of life of patients, recognition of fundamental endoscopic findings of EGC is requisite.
VOLUME 59, NO. 5, 2004
*M1802 The Discordance Between Endoscopic Forceps Biopsy and Endoscopic Polypectomy Specimen of Gastric Polyps Dong Ho Lee, Na Young Kim, Jin Wook Kim, Jin Hyeok Hwang, Won Jae Yoon, Hyun Chae Jung, Yong Bum Yoon, In Sung Song Background: Gastric polyp is a descriptive term referring to mucosal prominence that protrudes beyond the flat lining of the stomach. Almost 90% of gastric polyps are hyperplastic polyps. Adenomatous polyps may contain focal carcinomatous changes or undergo carcinomatous changes. It is known that there is some degree of discordance between the results of endoscopic forceps biopsy and pathology of resected specimens. The aim of this study was to investigate the discordance between endoscopic forceps biopsy and endoscopic polypectomy specimen of gastric polyps and to review the pathology of polypectomy specimen. Methods: We reviewed endoscopic photographs, medical records, and pathology results of the patients who underwent endoscopic polypectomy from April of 1996 to February of 2003. Results: 86 patients and 101 cases of gastric polyps were reviewed. Male-to-female ratio was 1:1.9. Mean age was 58.6612.7 years. 87.2% of the patients had 1 polyp, 8.1% had 2, and 4.7% had 3. Gastric polyps occurred in the antrum most frequently (59.4%). Postpolypectomy pathology results were as follows: tubular adenoma 38.6%, hyperplastic polyp 27.7%, inflammatory polyp 9.9%, hamartoma 3%, fundic gland polyp 3%, tubulovillous adenoma 2%, adenocarcinoma 2%, dysplasia 1%, mucosal pseudolipomatosis 1%. Pathology was not checked in 6.9%; 4% did not undergo polypectomy. Concordance rate between endoscopic biopsy and pathology of resected specimens was 64.1%. There was no relationship between the size of the polyp and concordance rate. Conclusion: The concordance rate between endoscopic biopsy and pathology of resected specimens was 64.1%. There was no relationship between the size of the polyp and concordance rate. Therefore, additional approaches to review the histology of an entire polyp should be performed, especially when an adenoma is suspected.
GASTROINTESTINAL ENDOSCOPY
P171
*M1801 Endoscopic Submucosal Dissection for Lesions of the EsophagoGastric Junction and Gastric Cardia Naohisa Yahagi, Mitsuhiro Fujishiro, Naomi Kakushima, Atsushi Imagawa, Katsuya Kobayashi, Takuhei Hashimoto, Masashi Oka, Masao Omata Background & Aim: The esophago-gastric junction (EGJ) and gastric cardia are considered to be difficult areas for endoscopic treatment, because of the drastic change of the width and angle of the digestive tract. In this location, laparotomy has been the standard treatment, even for tumors still in its early stage. However, by the emergence of endoscopic submucosal dissection (ESD), larger lesions and those of difficult areas including the EGJ have become possible candidates for endoscopic treatment. We evaluated the efficacy and safety of this new technique for the treatment of superficial tumors located in this difficult area. Method: From June 2002 to November 2003, 9 patients of superficial tumor located in the EGJ or gastric cardia including barrett’s cancer, were treated by ESD at the University of Tokyo Hospital. ESD using thin-type snare or flex-knifeÒ (Olympus, Tokyo, Japan) was performed as we have previously reported. A combination use of endoscope with water-jet system (Pentax, Japan) and a high frequency generator Erbotom ICC 200 (ERBE, Germany) was used. A solution of hyaluronate sodium and 20% dextrose with minimal indigocarmine dye and epinephrine was used for submucosal injection. Result: The average size of the lesions was 20.8 mm (7-40 mm); the average specimen size removed by ESD was 35.2 mm (19-60 mm). The overall rate of successful en-bloc resection rate was 100 % (9/9). Histopathologic evaluation confirmed complete resection in 100 % (9/9). In one patient, minute submucosal invasion was found (500lm in depth) with vessel involvement. This patient was followed without additional therapy, since the patient refused total gastrectomy. Neither blood transfusion nor surgical rescue were required for any patient. Postoperative stenosis occurred in 1 patient, which was successfully managed by several balloon dilatation. The mean period of follow up was 8 months (1-18 months), and no local and distant recurrence was observed among the patients. Conclusion: ESD is an less invasive, ultimate treatment in preserving gastric function. It is a safe and reliable treatment technique for superficial tumors of the EGJ and gastric cardia. It should be a useful treatment even for barrett’s esophagus, a disease of which incidence rate is rapidly increasing around the world.
*M1800 Fundamental Endoscopic Findings of Early Gastric Cancer: Importance of Recognition Tatsuo Hirano Purpose: Although gastric cancer is one of leading causes of death in many countries, endoscopic findings of early gastric cancer (EGC) is not still widely known. To contribute to a better understanding, typical cases of EGC are presented, and the points for early detection by endoscopy are stressed. Also several characteristic features of EGCs observed by magnifying endoscopy and endoscopic ultrasonography (EUS) are presented. Patients and Methods: Between September 2001 and September 2003, 46 new cases of EGC limited to the mucosa and/or submucosa were found by a single endoscopist (TH) in an outpatient clinic. Of these, 34 EGCs of 32 cases (including 2 cases of double EGCs) were evaluated by magnifying endoscope GIF-Q240Z (Olympus, Tokyo, Japan) and by endoscopic ultrasonography (Olympus). There were 17 males and 15 females with mean age 65.1 years (range: 41-81). Results: Elevated and superficially elevated types, superficially depressed types, and flat types were 13 lesions, 18 lesions, and 3 lesions, respectively. Of these, 27 lesions were differentiated adenocarcinoma and 7 lesions were undifferentiated adenocarcinoma including 4 lesions of signet-ring cell carcinoma. Twenty-six lesions were mucosal cancer and 8 lesions were submucosal cancer. In magnifying endoscopy, clear expansive growth margin in elevated types and scale-like margin in depressed type were characteristic. Patterns of cancer surface were irregular in all lesions. Non-structured surface pattern was observed in 16 of 18 depressed lesions and in 7 of 13 elevated lesions. Abnormalities of microvascular structure and/or density were seen in 29 of 34 lesions. Localized discoloration of the mucosal surface was the only important tool to find mucosal signet-ring cell carcinoma where cancer vascularity was low. EUS was performed for 31 of 34 lesions to ensure the depth of cancer invasion. Only one submucosal cancer of elevated type was misdiagnosed as mucosal cancer before EUS was done. All patients underwent curative treatments including endoscopic resection only for 17 lesions, endoscopic resection plus surgery for 3 lesions and surgery only for 14 lesions. All patients are alive and well. Conclusion: Endoscopic mucosal resection or less-invasive gastric resection can be performed for cure in selected cases of EGC. For a better prognosis and quality of life of patients, recognition of fundamental endoscopic findings of EGC is requisite.
VOLUME 59, NO. 5, 2004
*M1802 The Discordance Between Endoscopic Forceps Biopsy and Endoscopic Polypectomy Specimen of Gastric Polyps Dong Ho Lee, Na Young Kim, Jin Wook Kim, Jin Hyeok Hwang, Won Jae Yoon, Hyun Chae Jung, Yong Bum Yoon, In Sung Song Background: Gastric polyp is a descriptive term referring to mucosal prominence that protrudes beyond the flat lining of the stomach. Almost 90% of gastric polyps are hyperplastic polyps. Adenomatous polyps may contain focal carcinomatous changes or undergo carcinomatous changes. It is known that there is some degree of discordance between the results of endoscopic forceps biopsy and pathology of resected specimens. The aim of this study was to investigate the discordance between endoscopic forceps biopsy and endoscopic polypectomy specimen of gastric polyps and to review the pathology of polypectomy specimen. Methods: We reviewed endoscopic photographs, medical records, and pathology results of the patients who underwent endoscopic polypectomy from April of 1996 to February of 2003. Results: 86 patients and 101 cases of gastric polyps were reviewed. Male-to-female ratio was 1:1.9. Mean age was 58.6612.7 years. 87.2% of the patients had 1 polyp, 8.1% had 2, and 4.7% had 3. Gastric polyps occurred in the antrum most frequently (59.4%). Postpolypectomy pathology results were as follows: tubular adenoma 38.6%, hyperplastic polyp 27.7%, inflammatory polyp 9.9%, hamartoma 3%, fundic gland polyp 3%, tubulovillous adenoma 2%, adenocarcinoma 2%, dysplasia 1%, mucosal pseudolipomatosis 1%. Pathology was not checked in 6.9%; 4% did not undergo polypectomy. Concordance rate between endoscopic biopsy and pathology of resected specimens was 64.1%. There was no relationship between the size of the polyp and concordance rate. Conclusion: The concordance rate between endoscopic biopsy and pathology of resected specimens was 64.1%. There was no relationship between the size of the polyp and concordance rate. Therefore, additional approaches to review the histology of an entire polyp should be performed, especially when an adenoma is suspected.
GASTROINTESTINAL ENDOSCOPY
P171