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Improved Endoscopic Mucosal Resection (EMR) Using Endoscopic Submucosal Dissection (ESD) Method for Colorectal Laterally Spreading Tumors (LSTs)
Abstracts
T1349 Improved Endoscopic Mucosal Resection (EMR) Using Endoscopic Submucosal Dissection (ESD) Method for Colorectal Laterally Spreading Tumors (LSTs) Mario Jin, Michiro Otaka, Masaru Odashima, Koga Komatsu, Isao Wada, Youhei Horikawa, Tamotsu Matsuhashi, Reina Ohba, Jinko Oyake, Natsumi Hatakeyama, Sumio Watanabe Background: Endoscopic mucosal resection (EMR) is now widely accepted as one of the standard treatment for colonic laterally spreading tumors (LSTs). However, local recurrence is frequently seen after endoscopic piecemeal resection of LSTs. Also, en-block resection is superior to piecemeal resection in view of accurate histopathologic assessment of the resected speciemens. Therefore, en-block and complete resection is important to prevent recurrence after EMR for LSTs. Methods: In order to resect LSTs completely, we have been performing endoscopic submucosal dissection (ESD) using needle knife, insulation tipped diathermic knife (IT knife), and hook knife. Furthermore, we used sodium hyaluronate to inject into the submucosal layer for better elevation of lesions. This method utilizes longlasting mucosal protrusion for safety and ease of mucosal and submucosal incision. Results: Eleven LSTs were treated by ESD method between January 2002 and March 2004. Mean size of LST in diameter was 33 mm (range 22 to 50). The percentage of LSTs removed by en-block resection was 73% (8/11) and, by piecemeal resection, it was 18% (2/11). One could not be resected endoscopically and treated by surgery because of severe submucosal fibrosis. In piecemeal resection cases, additional argon plasma coagulation therapy was performed to prevent local recurrence. There were 2 cases of perforation but they were treated with endoscopic clipping and administration of antibiotics. Local recurrence is not found by follow up endoscopy. Conclusion: EMR treatment using ESD method is feasible and effective technique for colorectal LSTs.
T1351 Double Balloon Enteroscopy (DBE): New Information and Limitations Defined Bradford H. Jones, M.E. Harrison, David E. Fleischer, Nancy L. Maltby, Jonathan A. Leighton Purpose: DBE is a new enteroscope that has the capability to examine most, if not all of the small intestine to aid in the diagnosis and therapy of small intestinal disease. This enteroscope device, which includes an overtube and two balloons, is capable of advancing to the distal ileum by cycling the inflation and deflation of the two balloons with coordinated alternating pushing and retraction of the endoscope and the overtube. The aims of this study include (1) to determine at what point during the procedure it is reasonable to cease advancement of the enteroscope and begin withdrawal; (2) to assess the complications and adverse effects of DBE. Methods: 6 patients underwent DBE. Estimated distance advanced and time elapsed with each balloon cycle of the enteroscope were recorded. Each patient completed a symptom survey 7 days following the procedure. Procedural complications were also recorded. Results: The average distance advanced and time elapsed per balloon cycle are graphed below. The progression per cycle diminished after 12 cycles or approximately 50 minutes into the procedure. Five of 6 (83%) patients reported transient sore throat following DBE. Three of 6 (50%) patients reported abdominal discomfort. In all cases, these symptoms resolved within 72 hours. The only serious complication was a case of pulmonary aspiration. The patient experienced mild hypoxemia that quickly resolved, and she was discharged home after 48 hours of inpatient observation. Conclusions: Our data suggest that the rate of advancement of the DBE diminishes after approximately 12 cycles or 50 minutes, and thus this may be an appropriate time to initiate withdrawal of the scope. This conclusion will be tested as more data is collected regarding the distance advanced and time elapsed with each balloon cycle. The most commonly reported adverse effects of DBE include transient sore throat and abdominal discomfort.
T1350 The Optical Dilator: A Clear, Over-The-Scope Bougie with Sequential Dilating Segments Michael Jones, Jason Bratten, Stephen McClave Purpose: Dilation is often performed blindly and can lack precision. The ability to directly visualize and progressively dilate strictures may improve control and therefore outcomes. The Optical Dilator is a flexible, transparent bougie fitted over a standard endoscope. It has 3 dilating segments allowing sequential dilation under direct visualization (left fig). We report our experience with this device in treating peptic strictures (PS) and Schatzki’s rings (SR). Methods: Pts with SF dysphagia (DYS) and PS or SR at endoscopy were studied. Endoscopy was performed using 27 or 29Fr. endoscopes. Based on stricture appearance, 1 of 3 dilator sizes was chosen: OD14 (14-15-16 mm dilat. segments), OD16 (16-17-18 mm dilat. segments) or OD18 (18-19-20 mm dilat. segments). Prior to dilation, pts rated DYS on a 7-point scale (0 Z no DYS; 6 Z unable to handle secretions). Procedure tolerance was rated on a 5-point scale (0 Z no recollection; 4 Z worst experience of my life) immediately after the procedure and at 3 wk FU. DYS improvement was rated on a 5-point scale (0 Z no change; 4 Z complete relief) at 3 wk FU. Results: 26 pts were dilated (17 PS; 9 SR). Median preprocedure DYS score was 4 (‘‘difficulties with solids at every meal’’). Median improvement 3 wks after dilation was 3 (‘‘substantial relief ’’). Median dilation tolerance scores were 1 (‘‘not at all unpleasant’’) immediately after endoscopy and 0 (‘‘no recollection’’) at 3 wks. There were no complications. Endoscopists rated dilator use as typical of experience with other bougies and visualization was rated as high. An image of the dilator in use is shown in the right panel below. The stricture is effectively disrupted and the dilating segment clearly visible. Conclusion: The Optical Dilator maintains the value of tactile sensation and the convenience of 3 dilating sizes for each passage of the instrument with the added benefit of direct visualization. Supported by a grant from Ethicon Endo-Surgery
www.mosby.com/gie
Graph 1. Average distance advanced per enteroscope balloon cycle T1352 The Effect of Combination Therapy with Endoscopic Mucosal Resection and Argon Plasma Coagulation for Early Gastric Cancer and Gastric Adenoma Kim Jong Soo, Jeong Young Choi, Ki Myung Lee, Byung Moo Yoo, Kwang Jae Lee, Ki Baik Hahm, Jin Hong Kim, Sung Won Cho Background and Aims: Endoscopic mucosal resection (EMR) is an alternative surgery for the removal of superficial neoplastic lesions of the GI tract. The ‘en bloc’ resection method has a merit of being applied to the large lesion with a high complete resection rate, but the procedure takes a long time with a high complication rate. The ‘piecemeal’ resection method is a relatively easy procedure with only a short procedure time, but the recurrence rate is relatively high. Argon plasma coagulation (APC) seems to be a useful therapeutic tool for the ablation of remnant tumor tissues after piecemeal resection. The aim of this study was to evaluate the feasibility, safety and efficacy of APC for the prevention of recurrence when it was applied to the edge and base of the resection site after piecemeal resection. Methods: A total 59 patients were randomly sorted in to an EMR-APC group (33 patients treated with APC on the edge and base of the resection site) or a EMR group (26 patients treated with EMR only). The study group comprised of 37 patients with gastric adenoma and 22 patients with intramucosal carcinoma who were treated with endoscopic piecemeal snare resection. The procedures were performed by one expert endoscopist and all lesions believed to be completely excised. Follow-up endoscopy was performed 3 months after the procedure and multiple biopsy specimens were taken routinely from the resection site. Results: There were fewer recurrences in the EMR-APC group (1/33 EMR-APC group, 3/26 EMR group). But, there was no statistical significance (p Z 0.23). Bleeding occurred in 5 (15.2%) patients in the EMR-APC group and 3 (11.5%) patients in the EMR group, bleeding could be controlled with endoscopic treatment. Conclusions: In patients with apparent complete endoscopic snare resection of gastric mucosal lesions, post-EMR application of APC showed a tendency to reduce recurrence. But, there was no statistical significance. A large number of patients and long-term follow up studies are necessary to determine the effect of patients undergoing this treatment.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB229
T1349 Improved Endoscopic Mucosal Resection (EMR) Using Endoscopic Submucosal Dissection (ESD) Method for Colorectal Laterally Spreading Tumors (LSTs) Mario Jin, Michiro Otaka, Masaru Odashima, Koga Komatsu, Isao Wada, Youhei Horikawa, Tamotsu Matsuhashi, Reina Ohba, Jinko Oyake, Natsumi Hatakeyama, Sumio Watanabe Background: Endoscopic mucosal resection (EMR) is now widely accepted as one of the standard treatment for colonic laterally spreading tumors (LSTs). However, local recurrence is frequently seen after endoscopic piecemeal resection of LSTs. Also, en-block resection is superior to piecemeal resection in view of accurate histopathologic assessment of the resected speciemens. Therefore, en-block and complete resection is important to prevent recurrence after EMR for LSTs. Methods: In order to resect LSTs completely, we have been performing endoscopic submucosal dissection (ESD) using needle knife, insulation tipped diathermic knife (IT knife), and hook knife. Furthermore, we used sodium hyaluronate to inject into the submucosal layer for better elevation of lesions. This method utilizes longlasting mucosal protrusion for safety and ease of mucosal and submucosal incision. Results: Eleven LSTs were treated by ESD method between January 2002 and March 2004. Mean size of LST in diameter was 33 mm (range 22 to 50). The percentage of LSTs removed by en-block resection was 73% (8/11) and, by piecemeal resection, it was 18% (2/11). One could not be resected endoscopically and treated by surgery because of severe submucosal fibrosis. In piecemeal resection cases, additional argon plasma coagulation therapy was performed to prevent local recurrence. There were 2 cases of perforation but they were treated with endoscopic clipping and administration of antibiotics. Local recurrence is not found by follow up endoscopy. Conclusion: EMR treatment using ESD method is feasible and effective technique for colorectal LSTs.
T1351 Double Balloon Enteroscopy (DBE): New Information and Limitations Defined Bradford H. Jones, M.E. Harrison, David E. Fleischer, Nancy L. Maltby, Jonathan A. Leighton Purpose: DBE is a new enteroscope that has the capability to examine most, if not all of the small intestine to aid in the diagnosis and therapy of small intestinal disease. This enteroscope device, which includes an overtube and two balloons, is capable of advancing to the distal ileum by cycling the inflation and deflation of the two balloons with coordinated alternating pushing and retraction of the endoscope and the overtube. The aims of this study include (1) to determine at what point during the procedure it is reasonable to cease advancement of the enteroscope and begin withdrawal; (2) to assess the complications and adverse effects of DBE. Methods: 6 patients underwent DBE. Estimated distance advanced and time elapsed with each balloon cycle of the enteroscope were recorded. Each patient completed a symptom survey 7 days following the procedure. Procedural complications were also recorded. Results: The average distance advanced and time elapsed per balloon cycle are graphed below. The progression per cycle diminished after 12 cycles or approximately 50 minutes into the procedure. Five of 6 (83%) patients reported transient sore throat following DBE. Three of 6 (50%) patients reported abdominal discomfort. In all cases, these symptoms resolved within 72 hours. The only serious complication was a case of pulmonary aspiration. The patient experienced mild hypoxemia that quickly resolved, and she was discharged home after 48 hours of inpatient observation. Conclusions: Our data suggest that the rate of advancement of the DBE diminishes after approximately 12 cycles or 50 minutes, and thus this may be an appropriate time to initiate withdrawal of the scope. This conclusion will be tested as more data is collected regarding the distance advanced and time elapsed with each balloon cycle. The most commonly reported adverse effects of DBE include transient sore throat and abdominal discomfort.
T1350 The Optical Dilator: A Clear, Over-The-Scope Bougie with Sequential Dilating Segments Michael Jones, Jason Bratten, Stephen McClave Purpose: Dilation is often performed blindly and can lack precision. The ability to directly visualize and progressively dilate strictures may improve control and therefore outcomes. The Optical Dilator is a flexible, transparent bougie fitted over a standard endoscope. It has 3 dilating segments allowing sequential dilation under direct visualization (left fig). We report our experience with this device in treating peptic strictures (PS) and Schatzki’s rings (SR). Methods: Pts with SF dysphagia (DYS) and PS or SR at endoscopy were studied. Endoscopy was performed using 27 or 29Fr. endoscopes. Based on stricture appearance, 1 of 3 dilator sizes was chosen: OD14 (14-15-16 mm dilat. segments), OD16 (16-17-18 mm dilat. segments) or OD18 (18-19-20 mm dilat. segments). Prior to dilation, pts rated DYS on a 7-point scale (0 Z no DYS; 6 Z unable to handle secretions). Procedure tolerance was rated on a 5-point scale (0 Z no recollection; 4 Z worst experience of my life) immediately after the procedure and at 3 wk FU. DYS improvement was rated on a 5-point scale (0 Z no change; 4 Z complete relief) at 3 wk FU. Results: 26 pts were dilated (17 PS; 9 SR). Median preprocedure DYS score was 4 (‘‘difficulties with solids at every meal’’). Median improvement 3 wks after dilation was 3 (‘‘substantial relief ’’). Median dilation tolerance scores were 1 (‘‘not at all unpleasant’’) immediately after endoscopy and 0 (‘‘no recollection’’) at 3 wks. There were no complications. Endoscopists rated dilator use as typical of experience with other bougies and visualization was rated as high. An image of the dilator in use is shown in the right panel below. The stricture is effectively disrupted and the dilating segment clearly visible. Conclusion: The Optical Dilator maintains the value of tactile sensation and the convenience of 3 dilating sizes for each passage of the instrument with the added benefit of direct visualization. Supported by a grant from Ethicon Endo-Surgery
www.mosby.com/gie
Graph 1. Average distance advanced per enteroscope balloon cycle T1352 The Effect of Combination Therapy with Endoscopic Mucosal Resection and Argon Plasma Coagulation for Early Gastric Cancer and Gastric Adenoma Kim Jong Soo, Jeong Young Choi, Ki Myung Lee, Byung Moo Yoo, Kwang Jae Lee, Ki Baik Hahm, Jin Hong Kim, Sung Won Cho Background and Aims: Endoscopic mucosal resection (EMR) is an alternative surgery for the removal of superficial neoplastic lesions of the GI tract. The ‘en bloc’ resection method has a merit of being applied to the large lesion with a high complete resection rate, but the procedure takes a long time with a high complication rate. The ‘piecemeal’ resection method is a relatively easy procedure with only a short procedure time, but the recurrence rate is relatively high. Argon plasma coagulation (APC) seems to be a useful therapeutic tool for the ablation of remnant tumor tissues after piecemeal resection. The aim of this study was to evaluate the feasibility, safety and efficacy of APC for the prevention of recurrence when it was applied to the edge and base of the resection site after piecemeal resection. Methods: A total 59 patients were randomly sorted in to an EMR-APC group (33 patients treated with APC on the edge and base of the resection site) or a EMR group (26 patients treated with EMR only). The study group comprised of 37 patients with gastric adenoma and 22 patients with intramucosal carcinoma who were treated with endoscopic piecemeal snare resection. The procedures were performed by one expert endoscopist and all lesions believed to be completely excised. Follow-up endoscopy was performed 3 months after the procedure and multiple biopsy specimens were taken routinely from the resection site. Results: There were fewer recurrences in the EMR-APC group (1/33 EMR-APC group, 3/26 EMR group). But, there was no statistical significance (p Z 0.23). Bleeding occurred in 5 (15.2%) patients in the EMR-APC group and 3 (11.5%) patients in the EMR group, bleeding could be controlled with endoscopic treatment. Conclusions: In patients with apparent complete endoscopic snare resection of gastric mucosal lesions, post-EMR application of APC showed a tendency to reduce recurrence. But, there was no statistical significance. A large number of patients and long-term follow up studies are necessary to determine the effect of patients undergoing this treatment.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB229