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Full Thickness Gastric Incision Closure in Healthy Versus Diseased Animals
Abstracts
T1519 Clinical Impact of ESD for Superficial Adenocarcinoma Located On SCJ Shigetaka Yoshinaga, Takuji Gotoda, Chika Kusano, Ichiro Oda Background & Aims: Surgery is the standard treatments for neoplasms located on squamous-columner junction (SCJ), and recently endoscopic mucosal resection (EMR) and/or photodynamic therapy (PDT) are also used for early stage neoplasms located on SCJ. Endoscopic submucosal dissection (ESD) is a newly developed technique in the field of endoscopic treatment for gastrointestinal neoplasms because of its high rate of en-bloc resection. We applied ESD for superficial neoplasm located on SCJ. Methods: Twenty-four lesions of superficial adenocarcinoma located on SCJ from 23 patients were treated with ESD between June 2001 and January 2006 at NCCH. Adenocarcinoma located on SCJ was defined as "junctional cancer (Type II)" according to Siewert’s classification. We diagnosed "curative resection" based on the histological assessment after performing ESD; the lateral and vertical margins were free, differentiated type and mucosal or submucosal (less than 500mm from the musclaris mucosa) invasion. After ESD, the patients revealed "curative resection" usually underwent upper gastrointestinal endoscopy annually. For the patients revealed "non-curative resection", surgical resection was carried out basically. If the patient with "non-curative resection" refused surgical resection, he was followed up by CT or endoscopic ultrasound (EUS) in addition to endoscopy every 6 months. In those patients, complications, en-bloc resection rate, curative resection rate, local recurrence rate, and distant metastases of cancer were evaluated. Results: The average of the maximum size of resected specimen was 39.0 mm, and the average of the size of lesions was 14.5 mm. En-bloc resection rate was 100%. No complication occurred. Twelve lesions (50%) were arising from Barrett’s esophagus pathologically. Nineteen lesions (79.2%) were judged as "curative resection" and showed no local and distant recurrence during 30 months median follow-up periods. Five lesions (five patients) invaded more than 500mm in the submucosal layer were diagnosed as "non-curative resection" and 2/5 underwent additional surgical resections. In the 1/2 surgical materials, however, we could not revealed a residual cancer. Out of 3 patients who refused additional surgical resection, lung metastases were found in 1 patient after 3 years from ESD. Conclusions: Although surgery for non-curative resection remains as standard treatment, ESD showed high-curative resection rate is useful for the treatment of junctional cancer.
T1521 The Use of 2TQ260M Endoscope with Bipolar Needle Knife (B-Knife) and Insulation-Tipped Knife (IT-Knife) Could Facilitate Endoscopic Submucosal Dissection (ESD) Procedure Akihiko Kurosawa, Yoshiaki Kawakubo, Akihito Nagahara, Hiroya Ueyama, Yuji Shimada, Kenshi Matumoto, Akira Konno, Tomoyoshi Shibuya, Naoto Sakamoto, Taro Osada, Akihiro Namihisa, Takashi Yoshizawa, Toshihumi Ookusa, Tatuo Ogihara, Sumio Watanabe Background and aims: We have demonstrated new and safe techniques to facilitate the procedures of endoscopic submucosal dissection (ESD) for early gastric cancer. The use of the bipolar-knife (B-knife, Xemex Co. Ltd.) and the insulation-tipped diathermic knife (IT-knife, Olympus Optical Co. Ltd.), the procedures of ESD have become easier and safer. In this study, we retrospectively analyzed whether the use of newly developed 2TQ260M endoscope (Olympus Optical Co. Ltd.), which has two channel forceps whole, multi bending function and water jet channel could facilitate the ESD procedure. Methods: Thirty three cases which underwent endoscopically resected gastric adenoma or carcinoma between November 2005 and October 2006 were retrospectively analyzed. ESD was performed using conventional endoscope ‘‘Q260’’ or newly developed ‘‘2TQ260M’’ (Olympus Optical Co. Ltd.) with B-knife and IT-knife. Size of the total resection area in specimen, size of the tumor in specimen, surgery time, one piece complete resection rate and complications were analyzed between Q260 and 2TQ260M groups. Results: Out of 33 cases by using both B-knife and IT-knife, 18 cases were used Q260 and 15 cases were used 2TQ260M scope. Average size of the total resection area was 1094/936.3 mm2, average size of the tumor was 274.1/144.3 mm2, surgery time was 1.59/1.42 hours and one piece complete resection rate was 83.3/ 93.3% in Q260 and 2TQ260M group, respectively. There was one case which could not undergo ESD because tumor was located in the difficult part in Q260 group. Regarding the complications, there was no perforation nor sever bleeding case in both group. Considerations: Using the newly developed 2TQ260M with B-knife and IT-knife for ESD made surgery time shorten and increased one piece complete resection rate, suggesting that this method could facilitate the ESD procedure.
T1520 Multicenter Study Using Air Filled Stomach Balloon As a Valid Option for Morbid Obesity Yogesh Shastri, Stephan Haass, Udo Martin, Ju ¨rgen Stein, Wolfgang Caspary, Nicolas Hoepffner Background: Morbid obesity is an evolving epidemic all over the World especially so in the affluent population. About 10% of the people in America have severe obesity i.e. BMI O40. Conventional treatment in the form of reduced caloric intake, increased physical activity and pharmacotherapy are not so effective in inducing sufficient weight loss, which is soon regained once the treatment is stopped. Given the comorbidities in these obese high risk patients, bariatric surgeons often advocate a less invasive first stage intervention. The endoscopic implantation of various water filled balloons in 80’s & 90’s could not come become popular because of discomfort and complications associated with it. Since 2004 a new pneumatic intra-gastric balloon has come into practice. Ours is the first multicenter study reporting the safety, effecticacy, and tolerance of this new technique. Patients and Methods: A pneumatic intra-gastric balloon system (heliosphereÒ bag, Helioscopie, France) was placed endoscopically 62 times in 59 patients in a multicenter study from Sept. 2004-Nov. 2006. They were followed up prospectively with clinical information about symptoms, complications, loss of weight, BMI, etc. till explantation of balloon. Results: There were 22 male and 37 females (age range 18-65, mean 45 yrs) with a BMI range of 30-63 (mean 38) and a body weight of 71-194 kg (mean 112 kg). In 2 female and 1 male patients the procedure was repeated twice (after 5, 10 and 11 months). There were no procedure related complications. 47 (76%) of patients had balloon induced immediate side effects as shown in Table. In two patients we had to perform premature extraction of the balloons after 5 and 14 days of implantation because of intolerance and severe bleeding (Dieulafoy’s ulcer) respectively. The remaining balloons were explanted 5-13 months (mean 7 months)) after implantation. Except for 10 patients all patients lost weight ranging from 1 to 29 kg (mean 7 kg). 2 of 10 gained weight (3 and 7 kg), remaining 8 had no change in weight. Conclusion: This novel endoscopic technique has shown promising results in bariatrics. It can be used as a minimally invasive first step treatment for those with moderate to severe obesity. Once these patients have achieved weight loss they can be subjected to further morbid bariatric procedures if deemed necessary. Side effects with gastric balloon Side effects Nil Mild nausea or vomiting (!3 days) Moderate nausea or vomiting (3-5 days) Severe nausea or vomiting (i.v. fluids, hospitalization) Premature extraction of the balloon
www.giejournal.org
No. of procedures (%) 13 23 22 4 2
(20%) (37%) (35%) (6%) (3%)
T1522 Full Thickness Gastric Incision Closure in Healthy Versus Diseased Animals Annette Fritscher-Ravens, Alexander C. Mosse, Micheal Boyd Introduction: Notes procedures require reliable closure of the gastric full thickness incision. Several techniques have been published and we have successfully used endoscopic T-anchors and locking in the healthy animal. None of the procedures have been performed in the ill and immuno-suppressed as such a pig model would be difficult. However, the results obtained in healthy animals may not be comparable to patients as diseases may compromise healing etc. We obtained data of animals with severe viral disease, unknown to the veterinarians and examiners at time of examination. Method: Four experimental studies for endoscopic closure of gastric full thickness incisions with T-anchors and locks were performed. In all procedures a 3 cm long full thickness needle-knife incision was made into the anterior gastric wall and subsequently closed with T-anchors after an endoscope had been pushed through the incision into the peritoneal cavity. During the 2 week survival the animals were closely watched. After one week the results of suturing were inspected endoscopically and with EUS for intraperitoneal abnormalities. An autopsy with histology was performed on day 14 after final endoscopic inspection of the result of gastric suturing. Results: All incisions were closed successfully without any complications, all pigs survived two weeks. Endoscopic inspection after one week revealed a fibrinous ulcer in the area of anchor-suturing in all pigs with most of the anchors still in place; same time EUS revealed massive mediastinal lymphadenopathy in 2/4 pigs but the area of and beyond the incision appeared to be clear. The animals were kept alive as no obvious change in behaviour or food intake was verified. After 2 weeks endoscopy revealed nearly completely healed incisions with some of the anchors in the middle of regular mucosa. There was no difference in healing or appearance of the scars of the diseased compared to the healthy animals. While the diseased pigs remained at 30 kg, the healthy thrived showing significant difference in weight. Autopsy revealed massive general lymphadenopathy, atrophic lungs with pleural adhesions in 2 animals due to viral disease. The inspection and later histology of the incision closure site of the stomach revealed some minor adhesisons in one animal of each group but no micro-or macro-abscesses or peritonitis. All of the incisions had completely healed. Conlusion: Gastric Incision closure with T-anchors was successful in all animals. No difference in healing was seen in the diseased compared to the healthy animals.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB281
T1519 Clinical Impact of ESD for Superficial Adenocarcinoma Located On SCJ Shigetaka Yoshinaga, Takuji Gotoda, Chika Kusano, Ichiro Oda Background & Aims: Surgery is the standard treatments for neoplasms located on squamous-columner junction (SCJ), and recently endoscopic mucosal resection (EMR) and/or photodynamic therapy (PDT) are also used for early stage neoplasms located on SCJ. Endoscopic submucosal dissection (ESD) is a newly developed technique in the field of endoscopic treatment for gastrointestinal neoplasms because of its high rate of en-bloc resection. We applied ESD for superficial neoplasm located on SCJ. Methods: Twenty-four lesions of superficial adenocarcinoma located on SCJ from 23 patients were treated with ESD between June 2001 and January 2006 at NCCH. Adenocarcinoma located on SCJ was defined as "junctional cancer (Type II)" according to Siewert’s classification. We diagnosed "curative resection" based on the histological assessment after performing ESD; the lateral and vertical margins were free, differentiated type and mucosal or submucosal (less than 500mm from the musclaris mucosa) invasion. After ESD, the patients revealed "curative resection" usually underwent upper gastrointestinal endoscopy annually. For the patients revealed "non-curative resection", surgical resection was carried out basically. If the patient with "non-curative resection" refused surgical resection, he was followed up by CT or endoscopic ultrasound (EUS) in addition to endoscopy every 6 months. In those patients, complications, en-bloc resection rate, curative resection rate, local recurrence rate, and distant metastases of cancer were evaluated. Results: The average of the maximum size of resected specimen was 39.0 mm, and the average of the size of lesions was 14.5 mm. En-bloc resection rate was 100%. No complication occurred. Twelve lesions (50%) were arising from Barrett’s esophagus pathologically. Nineteen lesions (79.2%) were judged as "curative resection" and showed no local and distant recurrence during 30 months median follow-up periods. Five lesions (five patients) invaded more than 500mm in the submucosal layer were diagnosed as "non-curative resection" and 2/5 underwent additional surgical resections. In the 1/2 surgical materials, however, we could not revealed a residual cancer. Out of 3 patients who refused additional surgical resection, lung metastases were found in 1 patient after 3 years from ESD. Conclusions: Although surgery for non-curative resection remains as standard treatment, ESD showed high-curative resection rate is useful for the treatment of junctional cancer.
T1521 The Use of 2TQ260M Endoscope with Bipolar Needle Knife (B-Knife) and Insulation-Tipped Knife (IT-Knife) Could Facilitate Endoscopic Submucosal Dissection (ESD) Procedure Akihiko Kurosawa, Yoshiaki Kawakubo, Akihito Nagahara, Hiroya Ueyama, Yuji Shimada, Kenshi Matumoto, Akira Konno, Tomoyoshi Shibuya, Naoto Sakamoto, Taro Osada, Akihiro Namihisa, Takashi Yoshizawa, Toshihumi Ookusa, Tatuo Ogihara, Sumio Watanabe Background and aims: We have demonstrated new and safe techniques to facilitate the procedures of endoscopic submucosal dissection (ESD) for early gastric cancer. The use of the bipolar-knife (B-knife, Xemex Co. Ltd.) and the insulation-tipped diathermic knife (IT-knife, Olympus Optical Co. Ltd.), the procedures of ESD have become easier and safer. In this study, we retrospectively analyzed whether the use of newly developed 2TQ260M endoscope (Olympus Optical Co. Ltd.), which has two channel forceps whole, multi bending function and water jet channel could facilitate the ESD procedure. Methods: Thirty three cases which underwent endoscopically resected gastric adenoma or carcinoma between November 2005 and October 2006 were retrospectively analyzed. ESD was performed using conventional endoscope ‘‘Q260’’ or newly developed ‘‘2TQ260M’’ (Olympus Optical Co. Ltd.) with B-knife and IT-knife. Size of the total resection area in specimen, size of the tumor in specimen, surgery time, one piece complete resection rate and complications were analyzed between Q260 and 2TQ260M groups. Results: Out of 33 cases by using both B-knife and IT-knife, 18 cases were used Q260 and 15 cases were used 2TQ260M scope. Average size of the total resection area was 1094/936.3 mm2, average size of the tumor was 274.1/144.3 mm2, surgery time was 1.59/1.42 hours and one piece complete resection rate was 83.3/ 93.3% in Q260 and 2TQ260M group, respectively. There was one case which could not undergo ESD because tumor was located in the difficult part in Q260 group. Regarding the complications, there was no perforation nor sever bleeding case in both group. Considerations: Using the newly developed 2TQ260M with B-knife and IT-knife for ESD made surgery time shorten and increased one piece complete resection rate, suggesting that this method could facilitate the ESD procedure.
T1520 Multicenter Study Using Air Filled Stomach Balloon As a Valid Option for Morbid Obesity Yogesh Shastri, Stephan Haass, Udo Martin, Ju ¨rgen Stein, Wolfgang Caspary, Nicolas Hoepffner Background: Morbid obesity is an evolving epidemic all over the World especially so in the affluent population. About 10% of the people in America have severe obesity i.e. BMI O40. Conventional treatment in the form of reduced caloric intake, increased physical activity and pharmacotherapy are not so effective in inducing sufficient weight loss, which is soon regained once the treatment is stopped. Given the comorbidities in these obese high risk patients, bariatric surgeons often advocate a less invasive first stage intervention. The endoscopic implantation of various water filled balloons in 80’s & 90’s could not come become popular because of discomfort and complications associated with it. Since 2004 a new pneumatic intra-gastric balloon has come into practice. Ours is the first multicenter study reporting the safety, effecticacy, and tolerance of this new technique. Patients and Methods: A pneumatic intra-gastric balloon system (heliosphereÒ bag, Helioscopie, France) was placed endoscopically 62 times in 59 patients in a multicenter study from Sept. 2004-Nov. 2006. They were followed up prospectively with clinical information about symptoms, complications, loss of weight, BMI, etc. till explantation of balloon. Results: There were 22 male and 37 females (age range 18-65, mean 45 yrs) with a BMI range of 30-63 (mean 38) and a body weight of 71-194 kg (mean 112 kg). In 2 female and 1 male patients the procedure was repeated twice (after 5, 10 and 11 months). There were no procedure related complications. 47 (76%) of patients had balloon induced immediate side effects as shown in Table. In two patients we had to perform premature extraction of the balloons after 5 and 14 days of implantation because of intolerance and severe bleeding (Dieulafoy’s ulcer) respectively. The remaining balloons were explanted 5-13 months (mean 7 months)) after implantation. Except for 10 patients all patients lost weight ranging from 1 to 29 kg (mean 7 kg). 2 of 10 gained weight (3 and 7 kg), remaining 8 had no change in weight. Conclusion: This novel endoscopic technique has shown promising results in bariatrics. It can be used as a minimally invasive first step treatment for those with moderate to severe obesity. Once these patients have achieved weight loss they can be subjected to further morbid bariatric procedures if deemed necessary. Side effects with gastric balloon Side effects Nil Mild nausea or vomiting (!3 days) Moderate nausea or vomiting (3-5 days) Severe nausea or vomiting (i.v. fluids, hospitalization) Premature extraction of the balloon
www.giejournal.org
No. of procedures (%) 13 23 22 4 2
(20%) (37%) (35%) (6%) (3%)
T1522 Full Thickness Gastric Incision Closure in Healthy Versus Diseased Animals Annette Fritscher-Ravens, Alexander C. Mosse, Micheal Boyd Introduction: Notes procedures require reliable closure of the gastric full thickness incision. Several techniques have been published and we have successfully used endoscopic T-anchors and locking in the healthy animal. None of the procedures have been performed in the ill and immuno-suppressed as such a pig model would be difficult. However, the results obtained in healthy animals may not be comparable to patients as diseases may compromise healing etc. We obtained data of animals with severe viral disease, unknown to the veterinarians and examiners at time of examination. Method: Four experimental studies for endoscopic closure of gastric full thickness incisions with T-anchors and locks were performed. In all procedures a 3 cm long full thickness needle-knife incision was made into the anterior gastric wall and subsequently closed with T-anchors after an endoscope had been pushed through the incision into the peritoneal cavity. During the 2 week survival the animals were closely watched. After one week the results of suturing were inspected endoscopically and with EUS for intraperitoneal abnormalities. An autopsy with histology was performed on day 14 after final endoscopic inspection of the result of gastric suturing. Results: All incisions were closed successfully without any complications, all pigs survived two weeks. Endoscopic inspection after one week revealed a fibrinous ulcer in the area of anchor-suturing in all pigs with most of the anchors still in place; same time EUS revealed massive mediastinal lymphadenopathy in 2/4 pigs but the area of and beyond the incision appeared to be clear. The animals were kept alive as no obvious change in behaviour or food intake was verified. After 2 weeks endoscopy revealed nearly completely healed incisions with some of the anchors in the middle of regular mucosa. There was no difference in healing or appearance of the scars of the diseased compared to the healthy animals. While the diseased pigs remained at 30 kg, the healthy thrived showing significant difference in weight. Autopsy revealed massive general lymphadenopathy, atrophic lungs with pleural adhesions in 2 animals due to viral disease. The inspection and later histology of the incision closure site of the stomach revealed some minor adhesisons in one animal of each group but no micro-or macro-abscesses or peritonitis. All of the incisions had completely healed. Conlusion: Gastric Incision closure with T-anchors was successful in all animals. No difference in healing was seen in the diseased compared to the healthy animals.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB281