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Incidence and Clinical Course of Submucosal Lesions of the Stomach
Abstracts
M1337 Novel Procedure of Endoscopic Submucosal Dissection Using Double Graspers for Early Stage Gastric Cancer Hiroyuki Imaeda, Yasushi Iwao, Haruhiko Ogata, Hitoshi Ichikawa, Hidekazu Suzuki, Nagamu Inoue, Mikiji Mori, Naoki Hosoe, Tatsuhiro Masaoka, Manabu Nakashita, Koichi Aiura, Hiroshi Nagata, Koichiro Kumai, Toshifumi Hibi Background and Aim: Endoscopic submucosal dissection (ESD) for early stage gastric cancer (EGC) has improved the success rate for en bloc resection. It has been also reported that several techniques of traction of lesions are useful for ESD; however, these are complicated and invasive. The aim of this study is to assess the usefulness of ESD using double graspers for EGC. Subjects and Methods: Subjects were 23 lesions of EGC, which were histopathologically differentiated adenocarcinomas within the mucosa and without ulcers. Mean size of the lesions was 16.3 mm, range from 10-35 mm. Sixteen of 23 lesions were at the gastric body, 5 at the antrum and 2 at the angulus. A short hood was attached to the distal tip of an endoscope. After marking around lesions, 10% glycerin with indigocarmine and epinephrine was injected into the submucosa. After circumferential cutting around the lesions using a needle knife at a Endo-Cut mode, the endoscope was pulled out once. Next, a grasper (inside grasper) inserted through an accessory channel of the endoscope grasped the tip of the other grasper (outside grasper), which was outside the endoscope. Both graspers and endoscope were inserted into the stomach, and the anal side of the lesions was grasped by the outside grasper controlled by the endoscope and the inside grasper. Thereafter, the inside grasper was released and pulled out. Finally, with traction of the lesions towards the oral side by the outside grasper, the submucosal layer of lesions was dissected using the needle knife at a forced coagulation mode. Hemostasis for bleeding was carried out using the needle knife at a spray coagulation mode or clips. Results: (1) All lesions were able to be grasped with the outside grasper. (2) Traction of the lesion towards the oral side by the outside grasper was able to make the submucosal layer wider and more visible. Therefore, dissection could be more easily carried out under direct vision, with both safety and certainty. (3) Both the endoscope and the outside grasper was able to be moved easily and independently. (4) All lesions were able to be resected en block. (5) No bleeding requiring blood transfusion or a perforation occurred. Conclusion: ESD using double graspers is very useful for easily dissecting EGC with safety and certainty not only at the body but also the angulus and the antrum.
M1338 Incidence and Clinical Course of Submucosal Lesions of the Stomach Hiroshi Imaoka, Akira Sawaki, Nobumasa Mizuno, Kuniyuki Takahashi, Tsuneya Nakamura, Masahiro Tajika, Hiroki Kawai, Toshihumi Isaka, Yasuyuki Okamoto, Hiroyuki Inoue, Masatoshi Aoki, Ahmed A. Salem, Kenji Yamao Background: The natural history of submucosal lesions (SMLs) of the stomach is still unknown. Most of them are mesenchymal tumors located in submucosa and muscular layer, and they are incidentally detected on barium meal study or endoscopy. The frequency of SMLs has been reported to be about 0.3%. But really are SMLs uncommon? Furthermore, no obvious treatment policy for SMLs had been established yet. Purpose: Clarify the frequency and the clinical course of SMLs. Material & Methods: We investigated 5307 medical records of upper gastrointestinal endoscopy (upper GI endoscopy) underwent in our hospital during 1998. 188 SMLs without ulceration were found: gender 81 men, 107 women; mean age 63.3 years, range 35-87 years; location 105 in body, 42 in antrum, 41 in fornix. Out of 188 SMLs, 132 have been followed up by upper GI endoscopy for 5 years. We evaluated the change of and configuration. Then we proposed our treatment strategy for SMLs. Results: Out of 5307 cases, 188 (3.5%) cases were detected in upper GI endoscopy cases in our hospital. 132 of 188 SMLs received regular follow-up for 5 years. 103 SMLs (78%) did not change in size and shape, 27 SMLs (20.5%) showed decrease in size or obscurity, 2 SMLs (1.5%) showed increase in size, but no change of shape. Surgical resection was performed for these 2 cases, and they were diagnosed as gastrointestinal stromal tumor (GIST) by immunohistochemical staining. One patient had liver metastasis after resection, the other patient was not free. Conclusions: The frequency of SMLs is 3.5% in our study and this is higher than the previous reports. Quite a few cases of SMLs were considered as candidate for resection by change of the endoscopic findings. Rapid growth of SML is supposed to be one of the remarkable signs that indicate malignant change. Our study suggests that most cases of SMLs are not candidate for radical resection, and only follow up is recommended.
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M1339 New Diagnostic and Therapeutic Strategy: Combination of Capsule Endoscopy (CE) and Double-Balloon Endoscopy (DBE) Michiko Iwamoto, HIronori Yamamoto, Hiroto Kita, Keijiro Sunada, Yoshikazu Hayashi, Hiroyuki Sato, Kentaro Sugano, Katuro Shirakawa, Tetuya Nakamura, Akira Terano Background: Capsule endoscopy (CE) and double-balloon endoscopy (DBE) both offer visualization of the entire small intestine (SI). CE is considered an effective diagnostic procedure, while DBE is potentially a therapeutic as well as a diagnostic technique but DBE requires both oral and anal approaches to view entire SI. Aim: To determine if the combination of CE and DBE is a useful as a diagnostic and therapeutic strategy for SI diseases. Methods: Thirteen patients with melena and anemia who had no specific findings by previous esophagogastroduodenoscopy (EGD) and colonoscopy were examined by both CE and DBE. CE was performed prior to DBE in order to both compare the findings of both tests, and to determine if CE data about the location of lesions CE was helpful in to the endoscopist performing DBE. Results: Visualization of the entire small bowel was adequate in all subjects. CE and DBE both identified the same source of bleeding in 9 of 13 (69%) subjects, 1 bleeding polyp, 2 arteriovenous malformations (AVM), 2 submucosal tumors (SMT), 1 bleeding small intestinal ulcer, 1 segmental edematous lesion, 1 gastric ulcer, 1 gastric antral vascular ectasia (GAVE); in one additional patient no lesions were seen by either exam. In 3 cases, SMT was suggested by CE but not found by DBE. Endoscopic treatment was performed in 6 patients (1 polypectomy, argon plasma coagulation in 3 patients, 2 for AVMs and 1 for GAVE, and clipping for 1 bleeding gastric ulcer.) Surgical resection was performed for 2 SMT. In 1 patient with bleeding small intestinal ulcer, capsule retention occurred near the ring like stricture DBE with Balloon dilatation of the stricture to 15 mm allowed the capsule to pass naturally within 2 days. DBE was helpful for this case. Conclusion: In this small series the combination of CE and DBE appeared to be complementary. The identification and localization of lesions by CE was useful to the endoscopist performing DBE and DBE with stricture dilatation allowed a retained capsule to pass.
M1340 Clinical Features of the Upper Gastrointestinal Bleeding After Acute Burn Injury Hyun Joo Jang, Guen Sook Kim, Chang Soo Eun, Sea Hyub Kae, Jin Lee Background/Aim: Upper gastrointestinal (UGI) bleeding is one of the most common and serious complications in major burns. However, the clinical features of UGI bleeding have hardly been studied and no report of UGI bleeding after burn injury presented in Korea. The aim of this study is to determine the clinical features of the UGI bleeding after acute burn injury. Methods: Among 2340 acute burn patients who have admitted from January 2000 to June 2004, 33 patients had UGI bleeding presenting hematemesis, melena, hematochezia, or blood drainage via nasogastric tube, and they undertook gastroscopy. We retrospectively reviewed the medical records of those 33 patients about their age, underlying diseases, burned body surface area, time post-burn UGI bleeding, causes of bleeding, treatments and outcomes. Results: Of the 33 patients comprised 24 (72.7%) males and 9 (27.3%) females, 10 (30.3%) patients died. Age ranged from 11 to 83 years (average 49.7) and mean burned body surface area was 30.3%. Five patients (15.2%) had diabetes mellitus, and four patients (12.1%) had history of peptic ulcer. All patients took NSAID for pain of burn. Post-burn bleeding occurred within 2 weeks in 13 patients (39%), and the rest 20 patients (61%) after 2 weeks. Causes of bleeding were gastric ulcer (45.5%), duodenal ulcer (36.4%), esophageal ulcer (6%), Mallory-Weiss tear (6%), hemorrhagic gastritis (3%), and gastric varix (3%). Endoscopic intervention and medical treatment were taken in 13 patients (39.4%), and 20 patients (60.6%) were managed with medical treatment only. Mortality rate of post-burn UGI bleeding patients recorded 30.3% of which 40% in direct relation to uncontrolled bleeding and 60% from systemic complications of burn such as sepsis. Conclusions: The most common cause of UGI bleeding in burn is peptic ulcer. Treatment of systemic complications of burn as well as UGI bleeding itself may be important in clinical course of UGI bleeding after burn. Large, randomized, and prospective studies for prevention of post-burn UGI bleeding with high mortality rate may be considered to be necessary.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB167
M1337 Novel Procedure of Endoscopic Submucosal Dissection Using Double Graspers for Early Stage Gastric Cancer Hiroyuki Imaeda, Yasushi Iwao, Haruhiko Ogata, Hitoshi Ichikawa, Hidekazu Suzuki, Nagamu Inoue, Mikiji Mori, Naoki Hosoe, Tatsuhiro Masaoka, Manabu Nakashita, Koichi Aiura, Hiroshi Nagata, Koichiro Kumai, Toshifumi Hibi Background and Aim: Endoscopic submucosal dissection (ESD) for early stage gastric cancer (EGC) has improved the success rate for en bloc resection. It has been also reported that several techniques of traction of lesions are useful for ESD; however, these are complicated and invasive. The aim of this study is to assess the usefulness of ESD using double graspers for EGC. Subjects and Methods: Subjects were 23 lesions of EGC, which were histopathologically differentiated adenocarcinomas within the mucosa and without ulcers. Mean size of the lesions was 16.3 mm, range from 10-35 mm. Sixteen of 23 lesions were at the gastric body, 5 at the antrum and 2 at the angulus. A short hood was attached to the distal tip of an endoscope. After marking around lesions, 10% glycerin with indigocarmine and epinephrine was injected into the submucosa. After circumferential cutting around the lesions using a needle knife at a Endo-Cut mode, the endoscope was pulled out once. Next, a grasper (inside grasper) inserted through an accessory channel of the endoscope grasped the tip of the other grasper (outside grasper), which was outside the endoscope. Both graspers and endoscope were inserted into the stomach, and the anal side of the lesions was grasped by the outside grasper controlled by the endoscope and the inside grasper. Thereafter, the inside grasper was released and pulled out. Finally, with traction of the lesions towards the oral side by the outside grasper, the submucosal layer of lesions was dissected using the needle knife at a forced coagulation mode. Hemostasis for bleeding was carried out using the needle knife at a spray coagulation mode or clips. Results: (1) All lesions were able to be grasped with the outside grasper. (2) Traction of the lesion towards the oral side by the outside grasper was able to make the submucosal layer wider and more visible. Therefore, dissection could be more easily carried out under direct vision, with both safety and certainty. (3) Both the endoscope and the outside grasper was able to be moved easily and independently. (4) All lesions were able to be resected en block. (5) No bleeding requiring blood transfusion or a perforation occurred. Conclusion: ESD using double graspers is very useful for easily dissecting EGC with safety and certainty not only at the body but also the angulus and the antrum.
M1338 Incidence and Clinical Course of Submucosal Lesions of the Stomach Hiroshi Imaoka, Akira Sawaki, Nobumasa Mizuno, Kuniyuki Takahashi, Tsuneya Nakamura, Masahiro Tajika, Hiroki Kawai, Toshihumi Isaka, Yasuyuki Okamoto, Hiroyuki Inoue, Masatoshi Aoki, Ahmed A. Salem, Kenji Yamao Background: The natural history of submucosal lesions (SMLs) of the stomach is still unknown. Most of them are mesenchymal tumors located in submucosa and muscular layer, and they are incidentally detected on barium meal study or endoscopy. The frequency of SMLs has been reported to be about 0.3%. But really are SMLs uncommon? Furthermore, no obvious treatment policy for SMLs had been established yet. Purpose: Clarify the frequency and the clinical course of SMLs. Material & Methods: We investigated 5307 medical records of upper gastrointestinal endoscopy (upper GI endoscopy) underwent in our hospital during 1998. 188 SMLs without ulceration were found: gender 81 men, 107 women; mean age 63.3 years, range 35-87 years; location 105 in body, 42 in antrum, 41 in fornix. Out of 188 SMLs, 132 have been followed up by upper GI endoscopy for 5 years. We evaluated the change of and configuration. Then we proposed our treatment strategy for SMLs. Results: Out of 5307 cases, 188 (3.5%) cases were detected in upper GI endoscopy cases in our hospital. 132 of 188 SMLs received regular follow-up for 5 years. 103 SMLs (78%) did not change in size and shape, 27 SMLs (20.5%) showed decrease in size or obscurity, 2 SMLs (1.5%) showed increase in size, but no change of shape. Surgical resection was performed for these 2 cases, and they were diagnosed as gastrointestinal stromal tumor (GIST) by immunohistochemical staining. One patient had liver metastasis after resection, the other patient was not free. Conclusions: The frequency of SMLs is 3.5% in our study and this is higher than the previous reports. Quite a few cases of SMLs were considered as candidate for resection by change of the endoscopic findings. Rapid growth of SML is supposed to be one of the remarkable signs that indicate malignant change. Our study suggests that most cases of SMLs are not candidate for radical resection, and only follow up is recommended.
www.mosby.com/gie
M1339 New Diagnostic and Therapeutic Strategy: Combination of Capsule Endoscopy (CE) and Double-Balloon Endoscopy (DBE) Michiko Iwamoto, HIronori Yamamoto, Hiroto Kita, Keijiro Sunada, Yoshikazu Hayashi, Hiroyuki Sato, Kentaro Sugano, Katuro Shirakawa, Tetuya Nakamura, Akira Terano Background: Capsule endoscopy (CE) and double-balloon endoscopy (DBE) both offer visualization of the entire small intestine (SI). CE is considered an effective diagnostic procedure, while DBE is potentially a therapeutic as well as a diagnostic technique but DBE requires both oral and anal approaches to view entire SI. Aim: To determine if the combination of CE and DBE is a useful as a diagnostic and therapeutic strategy for SI diseases. Methods: Thirteen patients with melena and anemia who had no specific findings by previous esophagogastroduodenoscopy (EGD) and colonoscopy were examined by both CE and DBE. CE was performed prior to DBE in order to both compare the findings of both tests, and to determine if CE data about the location of lesions CE was helpful in to the endoscopist performing DBE. Results: Visualization of the entire small bowel was adequate in all subjects. CE and DBE both identified the same source of bleeding in 9 of 13 (69%) subjects, 1 bleeding polyp, 2 arteriovenous malformations (AVM), 2 submucosal tumors (SMT), 1 bleeding small intestinal ulcer, 1 segmental edematous lesion, 1 gastric ulcer, 1 gastric antral vascular ectasia (GAVE); in one additional patient no lesions were seen by either exam. In 3 cases, SMT was suggested by CE but not found by DBE. Endoscopic treatment was performed in 6 patients (1 polypectomy, argon plasma coagulation in 3 patients, 2 for AVMs and 1 for GAVE, and clipping for 1 bleeding gastric ulcer.) Surgical resection was performed for 2 SMT. In 1 patient with bleeding small intestinal ulcer, capsule retention occurred near the ring like stricture DBE with Balloon dilatation of the stricture to 15 mm allowed the capsule to pass naturally within 2 days. DBE was helpful for this case. Conclusion: In this small series the combination of CE and DBE appeared to be complementary. The identification and localization of lesions by CE was useful to the endoscopist performing DBE and DBE with stricture dilatation allowed a retained capsule to pass.
M1340 Clinical Features of the Upper Gastrointestinal Bleeding After Acute Burn Injury Hyun Joo Jang, Guen Sook Kim, Chang Soo Eun, Sea Hyub Kae, Jin Lee Background/Aim: Upper gastrointestinal (UGI) bleeding is one of the most common and serious complications in major burns. However, the clinical features of UGI bleeding have hardly been studied and no report of UGI bleeding after burn injury presented in Korea. The aim of this study is to determine the clinical features of the UGI bleeding after acute burn injury. Methods: Among 2340 acute burn patients who have admitted from January 2000 to June 2004, 33 patients had UGI bleeding presenting hematemesis, melena, hematochezia, or blood drainage via nasogastric tube, and they undertook gastroscopy. We retrospectively reviewed the medical records of those 33 patients about their age, underlying diseases, burned body surface area, time post-burn UGI bleeding, causes of bleeding, treatments and outcomes. Results: Of the 33 patients comprised 24 (72.7%) males and 9 (27.3%) females, 10 (30.3%) patients died. Age ranged from 11 to 83 years (average 49.7) and mean burned body surface area was 30.3%. Five patients (15.2%) had diabetes mellitus, and four patients (12.1%) had history of peptic ulcer. All patients took NSAID for pain of burn. Post-burn bleeding occurred within 2 weeks in 13 patients (39%), and the rest 20 patients (61%) after 2 weeks. Causes of bleeding were gastric ulcer (45.5%), duodenal ulcer (36.4%), esophageal ulcer (6%), Mallory-Weiss tear (6%), hemorrhagic gastritis (3%), and gastric varix (3%). Endoscopic intervention and medical treatment were taken in 13 patients (39.4%), and 20 patients (60.6%) were managed with medical treatment only. Mortality rate of post-burn UGI bleeding patients recorded 30.3% of which 40% in direct relation to uncontrolled bleeding and 60% from systemic complications of burn such as sepsis. Conclusions: The most common cause of UGI bleeding in burn is peptic ulcer. Treatment of systemic complications of burn as well as UGI bleeding itself may be important in clinical course of UGI bleeding after burn. Large, randomized, and prospective studies for prevention of post-burn UGI bleeding with high mortality rate may be considered to be necessary.
Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB167