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M1518: Unique Observation Method Using Ultrathin Transnasal Endoscopy Is Feasible for Screening Major Papilla and Duodenal Diverticula
Abstracts magnification endoscopy plus narrow band imaging (NBIM) and chromoendoscopy (MCh). Among these subjects were analyzed 240 biopsies. METHODS: CE, NBIM and MCh with 3 % acetic acid and 0.6 % indigo carmine dye were performed in the gastric antrum. Biopsy specimens were obtained from regions containing a villous pattern sugestive of gastric intestinal metaplasia. RESULTS: 205 and 35 biopsy specimens were randomized and targeted, respectively. Targeted biopsies were detected by NBIM in 48.5 % (17/35) and MCh in 51.4 % (18/35). Intestinal metaplasia was evident in 25.7 % (9/35), 3 were complete and 6 incomplete. The sensitivity, specificity, positive and negative predictive values of randomized and targeted biopsies were 91 vs 74 %, 51 vs 95 %, 20 vs 84 % and 97 vs 91 %, respectively. The interobserver variability showed a k value of 0.86 (range 0.74-0.99). LIMITATION: Sample size and single center study. CONCLUSIONS: Targeted biopsies are better than randomized biopsies to detect intestinal metaplasia in the stomach. There is no difference between narrow band imaging and chromoendoscopy both with magnification. Sensitivity Sensitivity Sensitivity Specificity Specificity Specificity Methods Randomized biopsies Targeted biopsies
CE 80
NBIM 80
MCh 72
CE 72
NBIM 63
MCh 54
84
70
77
98
97
98
CE conventional endoscopy; NBIM magnification narrow band imaging; MCh magnification chromoendoscopy
M1518 Unique Observation Method Using Ultrathin Transnasal Endoscopy Is Feasible for Screening Major Papilla and Duodenal Diverticula Yusuke Hashimoto, Yuichi Takano, Ayumi Sakiyama, Hiroshi Takahashi (Introduction) Conventional EGD screening is not capable of indentifying major papilla because of its forward-looking endoscopy. Transnasal endoscopy is an ultrathin, light and flexible in angulation.(Aim) To investigate the feasibility of observation of major papilla and duodenal diverticula by unique observation method using ultrathin transnasal endoscopy(Method) From 2008 August to 2009 August, we randomly enrolled 294 patients (145 male and 149 female, mean age: 57.8 y.o.) for routine EGD screening and 230 patients (129 male and 101 female, mean age: 63.5 y.o.) for unique observation method using ultrathin endoscopy (Fujinon: EG-530N2). The unique observation method involves three steps. First, we insert transnasal endoscopy into the descending portion of duodenum, deflating the stomach. Second, we use the angulation 180° up, pushing it forward. Third, we adjust the camera direction.(Result) The group of conventional EGD screening showed 96/294(32%) major papilla observation and 3/294 duodenal diverticula (1%). The group of unique observation method showed 220/230(95%) major papilla observation, 43/230(18%) duodenal diverticula observation, major papilla adenoma 1/230 (0.4%) and mucus leakage from major papilla 1/230 (0.4%). Unique observation method using ultrathin transnasal endoscopy is significantly superior to conventional screening EGD in observation of major papilla (P⫽0.004) and duodenal diverticula (P⫽0.001)(Conclusion) Unique observation method using ultrathin transnasal endoscopy is feasible for screening major papilla and duodenal diverticula.
Ultrathin transnasal endosocpy is fully angulated 180° to observe major papilla and periampullar diverticula.
www.giejournal.org
M1519 A Novel Device, the Variable-Traction Spring, Is Easy and Safe to Use Patients Undergoing Endoscopic Submucosal Dissection for Gastric Tumors Nobuyuki Sakurazawa, Shunji Kato, Masao Miyashita, Itsuro Fujita, Yoshikazu Kanazawa, Hiroyuki Onodera, Tsutomu Nomura, Hiroshi Makino, Nobutoshi Hagiwara, Eiji Uchida Purpose: We perform endoscopic submucosal dissection (ESD) with a good field of view using the variable-traction spring to apply appropriate countertraction during submucosal dissection.Methods: One end of the stainless-steel spring (spring length, 20 mm; spring diameter, 1.67 mm; wire diameter, 0.09 mm) is fitted with a polyurethane loop and the other end with a clip. An additional loop is fitted in the middle of the spring. (1) Allowing a 5 mm margin around the mucosal lesion, the entire circumference is incised. (2) The spring is introduced into the stomach via the forceps channel. (3) The spring device, with one end fixed to the edge of the lesion and the other end fixed to the contra-lateral gastric wall, provides countertraction during the ESD. If the traction force is not appropriate, it can be manipulated by re-fixation using the additional loop. (4) The submucosal layer is dissected under good visualization. (5) The tumor and spring are retrieved after the clip fixed to the contra-lateral gastric wall is released. Patients: After obtaining the patients’ informed consent, ESD with the novel device was performed on 4 male patients and 1 female patient between September and November 2009. Case 1. 71-y M, Mid, Great, IIc, tub1, 20x14mm. Case 2. 69-y F, Low, Gre, SMT, lipoma, 25x14mm. Case 3. 76-y M, Upper, Less, IIa, tub1, 17x15mm. Case 4. 67-y M, Upper, Post, IIc, tub1, 20x15mm. Case 5. 72-y M, Low, Post, IIa, tub1, 30x17mm. Results: In all 5 cases, the variabletraction spring allowed sufficient countertraction and direct visualization of the cutting line, and en bloc resection was successfully accomplished without complications. The resection area sizes were 48x35, 25x14, 35x30, 40x35, 62x32mm, respectively. The circumferential mucosa cutting time was 27.6min (36,14,23,33,32) and the submucosal dissection time was 37.4min (36,32,27,46,46). The average hospital stay after the ESD was 7 days (7,8,7,6,7). Histopathological examination of the resected specimens revealed a submucous lipoma in Case 2, submucosal (200m) differentiated adenocarcinoma in Case 5 and differentiated mucosal adenocarcinoma in the remaining three cases. None of the patients showed evidence of blood or lymphatic vessel invasion. We concluded that the resection was curative in all the cases. Conclusion: The variable-traction spring provides sufficient countertraction for ESD. This novel device may be an easy-to-use and safe device for ESD.
M1520 Does FICE Improve Inter-Observer Agreement in Diagnosis of Erosive Esophagitis? Si Hyung Lee, Byung-Ik Jang, Tae Nyeun Kim, Seongwoo Jeon, Joong Goo Kwon, Eun Young Kim, Kyung Sik Park, Kwangbum Cho, Chang Keun Park, Hyun Soo Kim, Chang Heon Yang Introduction: The diagnosis of gastroesophageal reflux disease (GERD) by endoscopy was usually diagnosed by presence of esophagitis. Several systems for endoscopic diagnosis of GERD were developed, Los Angelesclassification was widely used so far. But, inter-observer and intra-observer variation was documented for esophagitis using Los Angeles classification. Fijinon Intelligent Color enhancement (FICE) system is a new dyeless imaging technique that enhances mucosal and vascular pattern. The aims of this study was to evaluate the inter-observer variation in the endoscopic scoring of esophagitis by using conventional endoscopy with and without FICE and to evaluate FICE could improve inter-observer agreement in diagnosis of erosive esophagitis. Materials and methods: Endoscopic images of 51 patients with GERD symptoms were obtained with conventional endoscopy and FICE system. Observers were divided into expert group (16 gastroenterologic specialist) and trainee group (fellowship, first year of specialty training in gastroenterology). GERD using Los Angeles classification was diagnosed with/without FICE. We calculated inter-observer k statistics to measure the consistency in interpretations. Results: Erosive esophagitis was diagnosed in 376(28.4%) by conventional endoscopy. The prevalence of grades A, B, C and D erosive esophagitis were 220 (16.6%), 102 (7.7%), 39 (2.9%) and 15 (1.1%), respectively. Erosive esophagitis using conventional endoscopy with FICE was increased from 376(28.4%) to 425 (32.1%). Grades A erosive esophagitis was increased from 220 (16.6%) to 291 (21.9%). Of them, 128 (43.9%) of images judged to show grades A esophagitis by using conventional endoscopy with FICE were diagnosed as normal by conventional endoscopy alone. The mean weighted paired k statistics for interobserver constancy in grading erosive esophagitis in expert group and trainee group by conventional endoscopy was 0.51 and 0.42, respectively. The mean weighted paired k statistics in expert group and trainee group by conventional endoscopy with FICE was 0.42 and 0.42, respectively. Conclusion: The diagnosis of erosive esophagitis was increased after FICE system used with conventional endoscopy. Inter-observer variation in expert group using conventional endoscopy was better than that in trainee group. Inter-observer variation in grading esophagitis could not be improved when FICE was applied with conventional endoscopy.
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB243
CE 80
NBIM 80
MCh 72
CE 72
NBIM 63
MCh 54
84
70
77
98
97
98
CE conventional endoscopy; NBIM magnification narrow band imaging; MCh magnification chromoendoscopy
M1518 Unique Observation Method Using Ultrathin Transnasal Endoscopy Is Feasible for Screening Major Papilla and Duodenal Diverticula Yusuke Hashimoto, Yuichi Takano, Ayumi Sakiyama, Hiroshi Takahashi (Introduction) Conventional EGD screening is not capable of indentifying major papilla because of its forward-looking endoscopy. Transnasal endoscopy is an ultrathin, light and flexible in angulation.(Aim) To investigate the feasibility of observation of major papilla and duodenal diverticula by unique observation method using ultrathin transnasal endoscopy(Method) From 2008 August to 2009 August, we randomly enrolled 294 patients (145 male and 149 female, mean age: 57.8 y.o.) for routine EGD screening and 230 patients (129 male and 101 female, mean age: 63.5 y.o.) for unique observation method using ultrathin endoscopy (Fujinon: EG-530N2). The unique observation method involves three steps. First, we insert transnasal endoscopy into the descending portion of duodenum, deflating the stomach. Second, we use the angulation 180° up, pushing it forward. Third, we adjust the camera direction.(Result) The group of conventional EGD screening showed 96/294(32%) major papilla observation and 3/294 duodenal diverticula (1%). The group of unique observation method showed 220/230(95%) major papilla observation, 43/230(18%) duodenal diverticula observation, major papilla adenoma 1/230 (0.4%) and mucus leakage from major papilla 1/230 (0.4%). Unique observation method using ultrathin transnasal endoscopy is significantly superior to conventional screening EGD in observation of major papilla (P⫽0.004) and duodenal diverticula (P⫽0.001)(Conclusion) Unique observation method using ultrathin transnasal endoscopy is feasible for screening major papilla and duodenal diverticula.
Ultrathin transnasal endosocpy is fully angulated 180° to observe major papilla and periampullar diverticula.
www.giejournal.org
M1519 A Novel Device, the Variable-Traction Spring, Is Easy and Safe to Use Patients Undergoing Endoscopic Submucosal Dissection for Gastric Tumors Nobuyuki Sakurazawa, Shunji Kato, Masao Miyashita, Itsuro Fujita, Yoshikazu Kanazawa, Hiroyuki Onodera, Tsutomu Nomura, Hiroshi Makino, Nobutoshi Hagiwara, Eiji Uchida Purpose: We perform endoscopic submucosal dissection (ESD) with a good field of view using the variable-traction spring to apply appropriate countertraction during submucosal dissection.Methods: One end of the stainless-steel spring (spring length, 20 mm; spring diameter, 1.67 mm; wire diameter, 0.09 mm) is fitted with a polyurethane loop and the other end with a clip. An additional loop is fitted in the middle of the spring. (1) Allowing a 5 mm margin around the mucosal lesion, the entire circumference is incised. (2) The spring is introduced into the stomach via the forceps channel. (3) The spring device, with one end fixed to the edge of the lesion and the other end fixed to the contra-lateral gastric wall, provides countertraction during the ESD. If the traction force is not appropriate, it can be manipulated by re-fixation using the additional loop. (4) The submucosal layer is dissected under good visualization. (5) The tumor and spring are retrieved after the clip fixed to the contra-lateral gastric wall is released. Patients: After obtaining the patients’ informed consent, ESD with the novel device was performed on 4 male patients and 1 female patient between September and November 2009. Case 1. 71-y M, Mid, Great, IIc, tub1, 20x14mm. Case 2. 69-y F, Low, Gre, SMT, lipoma, 25x14mm. Case 3. 76-y M, Upper, Less, IIa, tub1, 17x15mm. Case 4. 67-y M, Upper, Post, IIc, tub1, 20x15mm. Case 5. 72-y M, Low, Post, IIa, tub1, 30x17mm. Results: In all 5 cases, the variabletraction spring allowed sufficient countertraction and direct visualization of the cutting line, and en bloc resection was successfully accomplished without complications. The resection area sizes were 48x35, 25x14, 35x30, 40x35, 62x32mm, respectively. The circumferential mucosa cutting time was 27.6min (36,14,23,33,32) and the submucosal dissection time was 37.4min (36,32,27,46,46). The average hospital stay after the ESD was 7 days (7,8,7,6,7). Histopathological examination of the resected specimens revealed a submucous lipoma in Case 2, submucosal (200m) differentiated adenocarcinoma in Case 5 and differentiated mucosal adenocarcinoma in the remaining three cases. None of the patients showed evidence of blood or lymphatic vessel invasion. We concluded that the resection was curative in all the cases. Conclusion: The variable-traction spring provides sufficient countertraction for ESD. This novel device may be an easy-to-use and safe device for ESD.
M1520 Does FICE Improve Inter-Observer Agreement in Diagnosis of Erosive Esophagitis? Si Hyung Lee, Byung-Ik Jang, Tae Nyeun Kim, Seongwoo Jeon, Joong Goo Kwon, Eun Young Kim, Kyung Sik Park, Kwangbum Cho, Chang Keun Park, Hyun Soo Kim, Chang Heon Yang Introduction: The diagnosis of gastroesophageal reflux disease (GERD) by endoscopy was usually diagnosed by presence of esophagitis. Several systems for endoscopic diagnosis of GERD were developed, Los Angelesclassification was widely used so far. But, inter-observer and intra-observer variation was documented for esophagitis using Los Angeles classification. Fijinon Intelligent Color enhancement (FICE) system is a new dyeless imaging technique that enhances mucosal and vascular pattern. The aims of this study was to evaluate the inter-observer variation in the endoscopic scoring of esophagitis by using conventional endoscopy with and without FICE and to evaluate FICE could improve inter-observer agreement in diagnosis of erosive esophagitis. Materials and methods: Endoscopic images of 51 patients with GERD symptoms were obtained with conventional endoscopy and FICE system. Observers were divided into expert group (16 gastroenterologic specialist) and trainee group (fellowship, first year of specialty training in gastroenterology). GERD using Los Angeles classification was diagnosed with/without FICE. We calculated inter-observer k statistics to measure the consistency in interpretations. Results: Erosive esophagitis was diagnosed in 376(28.4%) by conventional endoscopy. The prevalence of grades A, B, C and D erosive esophagitis were 220 (16.6%), 102 (7.7%), 39 (2.9%) and 15 (1.1%), respectively. Erosive esophagitis using conventional endoscopy with FICE was increased from 376(28.4%) to 425 (32.1%). Grades A erosive esophagitis was increased from 220 (16.6%) to 291 (21.9%). Of them, 128 (43.9%) of images judged to show grades A esophagitis by using conventional endoscopy with FICE were diagnosed as normal by conventional endoscopy alone. The mean weighted paired k statistics for interobserver constancy in grading erosive esophagitis in expert group and trainee group by conventional endoscopy was 0.51 and 0.42, respectively. The mean weighted paired k statistics in expert group and trainee group by conventional endoscopy with FICE was 0.42 and 0.42, respectively. Conclusion: The diagnosis of erosive esophagitis was increased after FICE system used with conventional endoscopy. Inter-observer variation in expert group using conventional endoscopy was better than that in trainee group. Inter-observer variation in grading esophagitis could not be improved when FICE was applied with conventional endoscopy.
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB243