- Email: [email protected]
M1601: Change in Percutaneous Feeding Tube Stoma Length From Supine to Sitting Position and Correlation With BMI
Abstracts reviewed. They received conventional dose of oral PPIs once daily for 1 week (1-week group, n ⫽ 30), for 4 weeks (4-week group, n ⫽ 34) or for 8 weeks (8-week group, n ⫽ 128), respectively. All patients underwent a follow-up endoscopy to evaluate the healing rate at 8 weeks after ESD. The end point was complete healing or incomplete healing by the presence of ulcer. We analyzed the various clinical and endoscopic factor to deciding healing of ESD-induced ulcer, which include PPI treatment duration, characteristics of EGC (morphology, location, size, and differentiation etc), and characteristics of ESD procedure (time, presence of complication etc). Results: Healing rates at 8 weeks were significantly higher in the longer treatment group of PPIs than in the shorter treatment group (50% [1-week group] versus 80.5% [8-week group], P ⫽ 0.001; 61.8% [4-week group] versus 80.5% [8-week group], P ⬍ 0.05, respectively). Initial size of artificial ulcer, location of the lesion, the presence of perforation and treatment duration were significantly associated with healing rate (P ⬍ 0.05) in the univariate analysis. Multivariate analysis revealed that the initial size of the artificial ulcer (⬍ 40 mm in diameter) and treatment duration (8 weeks) were independent factors associated with complete healing of ESD-induced artificial ulcers (adjusted hazard ratio 0.288 [95% confidence interval 0.140-0.593], P ⬍ 0.001; adjusted hazard ratio 0.380 [95% confidence interval 0.185-0.780], P ⬍ 0.05, respectively). Conclusions: For ESD-induced artificial ulcers, the initial ulcer size and treatment duration of PPIs were associated with complete healing of artificial ulcers after ESD. Eight-week treatment of PPIs should be recommended for complete healing in large (ⱖ 40 mm in diameter) gastric ulcer after ESD.
M1598 PEG-Related Complications: Long-Term Results in 2052 Patients Thomas Kratt, Dietmar Stu¨ker, Andreas Kirschniak, Lena Minkley, Karl-Ernst Grund, Alfred Ko¨nigsrainer Background: Though many PEG studies are available, they show inconsistent results concerning early and late complications with a range of 3-70%. Methods: Single center study of 2052 patients with PEG placement in pull-throughtechnique between 1990 and 2005. No routinely given prophylactic antibiotics in all cases. Evaluation of early (up to 30 days after PEG) and late complications (more than 30 days after PEG). Mean follow-up 5 months (0.5 to 55 months). Results: 2038 adult patients (range 18 - 94 years. Indications: Malignant diseases: 56% (259 patients with prophylactic PEG placement and 882 PEG placements after radiochemotherapy), neurological diseases: 34%, other indications: 10.1%. Early complications in 14.8%: peristomal infection 11.6%, accidental puncture of nearby organs 0.15%, peritonitis 0.5%, abdominal wall abscess 0.1%, metachroneous bleedings 2.3%, PEG-related mortality 0.15% (3 cases). Late complications in 13.6%: peristomal infection 4.6%, abdominal wall abscess 0.05%, peristomal hypergranulations 1.7%, buried-bumper-syndrome 2.0%, tube occlusion/PEG damage 5.3%. Evaluation of all early and late PEG infections ¨ LLING classification): Grade I: 81.4% (local therapy sufficient), grade II: (KU 15.3% (local therapy and systemic antibiosis), grade III: 3.3% (surgical intervention necessary). Significant differences (p⬍0.05) regarding the risk of infections: 1. Local infection rate subject to the underlying disease (at risk: patient with malignancies) and 2. PEG placement in patients with malignancies before or after radiochemotherapy (at risk: patients with prophylactic PEG placement). No significant differences were found concerning patients with intensive care stay vs. regular in-patient stay, age and sex of patient, clinical experience of the endoscopist. Conclusion: Peristomal infections represent the main problem after PEG placement. Most of them were sufficiently treated by local therapy, only in few cases surgical intervention was necessary (3.3%). Surprisingly patients suffering from cancer with prophylactic PEG placement developed significantly more infectious complications than all other groups. Therefore we recommend a restricted indication of prophylactic PEG placement and a periinterventional antibiosis respectively.
treatment (PPI: Rabeprazole, 10 mg per day) was given for 2 months after ESD. Patients then received periodic endoscopic follow-up regardless of symptoms to detect metachronous lesions. Ulcer recurrence at the site of ESD was recorded and a biopsy was taken to determine if the ulcer was benign. Ulcer recurrence was defined as a new ulcer occurring at the site of ESD. Patient characteristics and histological data of lesions dissected by ESD were collected and factors related to ulcer recurrence were analyzed statistically.Results: Median observation period was 35 months (range 12 to 77 months). The median size of dissected specimen in diameter was 45.5mm (range 10-130mm). The rate of ulcer recurrence after ESD was 2.8% (11/395 Pt.). Univariate analysis showed that past history of peptic ulcer (yes vs. no, 6.7% vs. 2.4%; P⬍0.05) and presence of pathological ulcer scar within the lesion (yes vs. no, 7.6% vs. 1.0%; P⬍0.05) were significantly related to the risk of recurrence of an ulcer after ESD. Multivariate analysis revealed that presence of pathological ulcer scar within the lesion was significantly associated with ulcer recurrence after ESD. (P⬍0.05)Conclusion: Although the frequency is low, there is a possibility of recurrence of gastric artificial ulcers after ESD. Presence of pathological ulcer scar within the lesion and past history of peptic ulcer may cause a recurrence of an ulcer after ESD.
M1600 Predictors for the Therapeutic Outcome and Procedural Time of Endoscopic Submucosal Dissection for Gastric Epithelial Neoplasm Jong-Sun Rew, Seon-Young Park, Hae-Kyeng Jeong, Tae-Jin Seo, Kyoung-Won Yoon, Sung-Bum Cho, Wan-Sik Lee, Chang-Hwan Park, Young-Eun Joo, Hyun-Soo Kim, Sung Kyu Choi Background/Aims: The technique of endoscopic submucosal dissection (ESD) was introduced to be able to obtain en bloc specimens of gastric epithelial neoplasm. The drawback of ESD is its technical difficulty, which, consequently, is associated with a higher rate of complication and which requires advanced endoscopic techniques and a long procedure time. We investigated the influential factors on the en bloc resection and procedural time of ESD for gastric epithelial neoplasm. Method: From March 2008 to March 2009, 155 patients with gastric epithelial neoplasm (103 men, 52 women; mean age 61.1⫾10.9 years) were treated by using ESD. We used indigo carmine and epinephrine (1 ml of 0.1%) mixed normal saline (1:1000) and 0.14% sodium hyaluronate (SH) as a submucosal injection solution. We performed ESD procedures with typical sequences (marking, incision, and submucosal dissection). The rates of en bloc resection and complete resection, incidence of complication and procedural time were investigated. Results: The rates of en bloc resection and complete resection were 90.3% (140/155) and 94.8% (147/155), respectively. The rates of early bleeding, delayed bleeding and perforation were 1.3% (2/155), 0% and 0%, respectively. The median procedure time was 27 (3-265) minutes. Univariate analysis demonstrated that location, presence of ulcer scar and submucosal solution were considered influential factors of en bloc resection. Multivariate analysis demonstrated that location (upper 2/3, aOR 0.15, 95% CI 0.04-0.56), submucosal fibrosis (presence, aOR 0.10, 95% CI 0.03-0.37) and submucosal injection solution (0.14% SH, aOR 6.68, 95% CI 1.69-26.41) appeared to be independent influential factors of en bloc resection. Multiple linear regression analysis using procedural time as the dependent variable showed that tumor size (⫽0.927, p⬍0.001), submucosal fibrosis (presence, ⫽0.927, p⬍0.001), location (lower 1/3, ⫽-0.292, p⫽0.004), and submucosal injection solution (0.14% SH, ⫽-0.269, p⫽0.005) were significant independent factors. Conclusion: The possibility of en bloc resection can be predicted by location, presence of submucosal fibrosis and submucosal injection solution. The procedural time of ESD can be predicted by tumor size, location, presence of submucosal fibrosis and submucosal injection solution. Use of 0.14% sodium hyaluronate as a submucosal injection solution showed better en bloc resection rates and reduces the procedural time.
M1599 Long Term Outcome of Gastric Artificial Ulcers After Endoscopic Submucosal Dissection Yongze Huang, Naomi Kakushima, Hiroyuki Ono, Kohei Takizawa, Masaki Tanaka, Hisatomo Ikehara, Yuichiro Yamaguchi, Hiroyuki Matsubayashi
M1601 Change in Percutaneous Feeding Tube Stoma Length From Supine to Sitting Position and Correlation With BMI Matthew Steenblik, Kristen Hilden, John C. Fang
Background: Endoscopic submucosal dissection (ESD) has been widely performed as a treatment for gastric neoplasm. It has been previously reported that gastric artificial ulcers after ESD would heal within 2 months, irrespective of its size and location, if there were no submucosal fibrosis under the lesion before ESD. Since they are artificial ulcers, they are considered to have a good outcome with little risk of recurrence. However, there are almost no studies that have reported on the long-term outcome of these ulcers.Aim: To describe longterm outcomes of gastric ulcers after ESD.Method: This was a retrospective single center study involving 488 lesions in 395 patients (319 man, 76 women, mean age 69.1 years, range 37-91 years) treated by ESD from September 2002 to August 2008 and were followed for more than 12 months after gastric ESD. Patients who received additional treatment such as gastrectomy, argon plasma coagulation, and photodynamic therapy were excluded. As a rule, anti-ulcer
Background: Percutaneous endoscopic gastrostomy (PEG) is the most common method of long term enteral feeding. Accurate knowledge of stoma tract length is important to prevent gastric ulcer formation underneath the internal bolster, buried bumper syndrome and peristomal leakage/infection. Current guidelines suggest 0.5-1.0 cm of play between the skin and external bolster. Placement of percutaneous feeding tubes and setting of the external bolster occurs in the supine position. However, abdominal wall thickness and stoma tract length may change significantly from supine to sitting position. This change may be more pronounced in patients with higher body mass index (BMI). There are no data regarding changes in stoma tract length from supine to sitting position or change in this length in relation to BMI. Our aim was to determine if stoma tract length changes significantly from supine and sitting position and if this change is related to BMI.Methods: Consecutive patients undergoing percutaneous feeding
AB264 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
www.giejournal.org
Abstracts tube change from Nov 2006 - Sept 2009 were enrolled. We collected gender, sitting and supine position stoma length, body mass index (BMI), feeding tube type, and any complications. Stoma tract length was measured using a balloon stoma measuring device (AMT, Cleveland, OH). Correlations were made between BMI and stoma tract length in both sitting and supine positions with Spearman’s rank test.Results: 28 patients (24 PEG’s, 4 DPEJ’s) were included, 19 (68%) were female. The mean stoma length in the supine position was 3.6 ⫾ 0.9 cm. The mean stoma length in sitting position was 4.9 ⫾ 1.4 cm. The mean stoma length change from supine to sitting position was 1.53 ⫾ 0.9 cm. Mean BMI was 21.2 ⫾ 4.5 (range 14.9-33.8). Complications included leakage 2/28 (7%) and infection 2/28 (7%). Stoma length in supine position is strongly correlated to BMI r⫽0.65, p⫽0.0002. Stoma length in sitting position is also strongly correlated to BMI, r⫽0.6, p⫽0.0009. Change in stoma tract length is correlated with BMI, r⫽0.43, p⫽ 0.02Conclusions: Stoma tract length is strongly correlated to BMI in both sitting and supine position. PEG stoma tract length changes significantly from supine and sitting position. To prevent complications, most patients should have a longer distance set between internal and external bolsters than is recommended.
M1602 Reduced Risk of Peristomal Infection of Percutaneous Endoscopic Gastrostomy (PEG) by Using Modified Introducer Technique With Gastropexy (Direct Technique): Comparison With the Pull-Through Technique Yoshinobu Saito, Akira Takeda, Atsuo Inoue Background and aim: Peristomal infection is one of the most common complications of Percutaneous endoscopic gastrostomy (PEG). Oropharyngeal bacteria can be brought to the abdominal wall when we use a pull-through technique. A novel extracorporeal technique, modified introducer technique with gastropexy (direct technique), as the instrument doesn’t pass the oral cavity, is expected to reduce the risk of peristomal infection. Since June 2006, we have employed direct technique. Our aim was to assess the preventive effect on peristomal infection of direct technique.Patients and methods: In a single, highvolume center in Japan, data of 538 patients were collected retrospectively from January 1994 to May 2007 for PEG by using pull-through technique (Pull-PEG) and from June 2007 to October 2009 for PEG by using direct technique (DirectPEG). Pull-PEG was performed on 284 patients while Direct-PEG was performed on 254 patients.Results: The incidence of peristomal infection was lower in the Direct-PEG group (1.6%) than in the Pull-PEG Group (7.4%; p⬍0.05).Conclusion: This result suggests that Direct-PEG may be superior to Pull-PEG because of reduced risks of peristomal infection.
M1603 Symptomatic Management of Bowel Obstruction in Advanced Cancer Using Percutaneous Endoscopic Gastrostomy Akira Takeda, Yoshinobu Saito, Satoshi Tanaka, Atsuo Inoue BACKGROUND: Conservative treatment of inoperable bowel obstruction in advanced cancer patients has been known to be effective in controlling the distresses. A number of treatment options are now available for the patients. For intestinal decompression, percutaneous endoscopic gastrostomy (PEG) can be a potential method in place of nasogastric tubing. The aim of this retrospective study was to evaluate the safety of PEG placement in patients with inoperable bowel obstruction. METHODS: A retrospective chart review of all patients who underwent a successful PEG between January 1994 and October 2009 was done. Data included demographics, type of cancer, procedural complications, and survival period for patients. RESULTS: In a total of 538 cases, 40 cases underwent PEG for intestinal decompression. Twenty seven (68%) were men and 13 (32%) were women. The mean age was 68 years (range, 43-82). Underlying cancers included: colorectal (13), gastric cancer (10), pancreatic (7), other gastrointestinal (2) and others (8). Thirty cases (75%) were associated with a complication of ascites and cancerous peritonitis. The PEG procedure was as follows: 14 cases performed using a standard pull-through technique and 26 cases a modified introducer technique. There were 2 procedural complications, 1 major and 1 minor: a gastrostomy through liver (1), and submucoal hematoma (1). Conservative management could deal with these complications. Average survival period after PEG was 87 days (range, 6-392). Seven cases needed a combination therapy with octreotide. These cases were all with lower intestinal obstruction. CONCLUSIONS: These results suggest that PEG could be a substituting method for nasogastirc tubing for intestinal decompression and avoid the distressing symptoms caused by nasogastirc tubing, especially in cases with upper gastrointestinal obstruction.
www.giejournal.org
M1604 Risk Factors Related to Local Recurrence of Early Gastric Cancers After Endoscopic Resection, in Special Reference to Differences Between Early and Late Local Recurrence Keun Man Lee, Jie-Hyun Kim, Sung Ill Jang, Jung Hwan Yu, Jung Soo Park, Chaul Woung Huh, Yong Chan Lee, Hyun Chul Lim, Young Hoon Yoon, Hyojin Park, Sang in Lee Background/Aims: Endoscopic resection (ER) is widely accepted as the standard treatment for early gastric cancer (EGC). The risk of local recurrence after ER is important to validate the clinical outcomes after ER. Thus, we retrospectively analyzed the risk factors related to local recurrence of EGC after ER, in special reference to differences between early and late local recurrence. Methods: From January 2002 to December 2008, 355 lesions in 351 patients were treated by ER (22.8 % conventional EMR; 17.7 % EMR with precut; 59.5 % endoscopic submucosal dissection) in Severance & Gangnam Severance Hospital, Yonsei University College of medicine. ER was performed for EGC based on absolute and extended criteria by Gotada (Gastric cancer, 2000). The clinical and pathologic features of cases with local recurrence of EGC after ER were analyzed in 1-89 months follow-up period. Local recurrence within 1 year after ER was regarded as early local recurrence.Results: The histological complete resection rate was 77.7%. During the follow-up period, a local recurrence was found in 17 cases (1.1 %) with 50.0 % early local recurrence. Female, conventional EMR method, elevated gross type, upper 1/3 location, posterior wall site, signet ring pathology, and piecemeal resection were significantly associated with histological incomplete resection. However, there was no significant risk factor associated with local recurrence in both absolute and extended criteria. When compared between early and late local recurrence after ER, non-eradication rate of Helicobacter pylori was higher in early local recurrence (P⫽0.05). Conclusions: Local recurrence after ER may not be different between absolute and extended criteria for ER in EGC. The eradication of Helicobacter pylori can be helpful to prevent early local recurrence after ER.
M1605 Clinical Experience of Full-Thickness Resection (CLEAN-NET: Combination of Laparoscopic and Endoscopic Approaches to Neoplasia With Non-Exposure Technique) for Early Gastric Cancer With Severe Scar Hironari Shiwaku, Haruhiro Inoue, Hitomi Minami, Hitoshi Satodate, Shin-Ei Kudo INTRODUCTION: ESD (Endoscopic submucosal dissection) becomes widely accepted as a standard endoscopic procedure for early gastric cancer. Marked advancement of endoscopic skill with new devices allows us to perform ESD procedure much easier than before. But we still experience difficult cases due to severe scar of the lesion. For such difficult cases, we conduct laparoscopic local resection (full-thickness resection) assisted by endoscopy and call it ‘CLEANNET’. We introduce the summary and present result of this procedure. AIMS & METHODS: The indication of this procedure is ‘the intra-mucosal cancer within 30 mm in diameter with severe scar’. We experienced 16 cases. The technique of CLEAN-NET is followings. We observe the boundary of the lesion with magnifying Narrow Band Imaging (NBI) System and mark around 10mm outside the margin of the lesion. After sticking a needle knife into gastric wall from inside to confirm the resection range, circumferential incision is made as deep as the submucosal layer from outside laparoscopically (Fig.). Then, full-thickness resection is done by linear stapler. The mucosal layer we left becomes a ‘NET’ not to expose a cancer cell into abdominal cavity. The specimen packed into pouch is withdrawn from 12mm trocar. In the case which the lesion is on smaller or greater curvature, full-thickness resection with lymphedectomy is done en bloc. RESULTS: The mean operation time was 182.1min, and the estimated blood loss was 19.4ml. No case showed positive surgical margin and lymph node metastasis pathologically. There was one case which needed re-operation by laparoscopic surgery due to the deformity of stomach, but now there is no problem. In all cases including that case, there was no apparent problem of resumption after operation. CONCLUSION: CLEAN-NET is a new approach to the cases which ESD procedure is difficult due to severe scar. It enables en bloc and whole-layer excision of lesions, in appropriate operation time, with less bleeding, and with an adequate surgical margin, both vertically and laterally.
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB265
M1598 PEG-Related Complications: Long-Term Results in 2052 Patients Thomas Kratt, Dietmar Stu¨ker, Andreas Kirschniak, Lena Minkley, Karl-Ernst Grund, Alfred Ko¨nigsrainer Background: Though many PEG studies are available, they show inconsistent results concerning early and late complications with a range of 3-70%. Methods: Single center study of 2052 patients with PEG placement in pull-throughtechnique between 1990 and 2005. No routinely given prophylactic antibiotics in all cases. Evaluation of early (up to 30 days after PEG) and late complications (more than 30 days after PEG). Mean follow-up 5 months (0.5 to 55 months). Results: 2038 adult patients (range 18 - 94 years. Indications: Malignant diseases: 56% (259 patients with prophylactic PEG placement and 882 PEG placements after radiochemotherapy), neurological diseases: 34%, other indications: 10.1%. Early complications in 14.8%: peristomal infection 11.6%, accidental puncture of nearby organs 0.15%, peritonitis 0.5%, abdominal wall abscess 0.1%, metachroneous bleedings 2.3%, PEG-related mortality 0.15% (3 cases). Late complications in 13.6%: peristomal infection 4.6%, abdominal wall abscess 0.05%, peristomal hypergranulations 1.7%, buried-bumper-syndrome 2.0%, tube occlusion/PEG damage 5.3%. Evaluation of all early and late PEG infections ¨ LLING classification): Grade I: 81.4% (local therapy sufficient), grade II: (KU 15.3% (local therapy and systemic antibiosis), grade III: 3.3% (surgical intervention necessary). Significant differences (p⬍0.05) regarding the risk of infections: 1. Local infection rate subject to the underlying disease (at risk: patient with malignancies) and 2. PEG placement in patients with malignancies before or after radiochemotherapy (at risk: patients with prophylactic PEG placement). No significant differences were found concerning patients with intensive care stay vs. regular in-patient stay, age and sex of patient, clinical experience of the endoscopist. Conclusion: Peristomal infections represent the main problem after PEG placement. Most of them were sufficiently treated by local therapy, only in few cases surgical intervention was necessary (3.3%). Surprisingly patients suffering from cancer with prophylactic PEG placement developed significantly more infectious complications than all other groups. Therefore we recommend a restricted indication of prophylactic PEG placement and a periinterventional antibiosis respectively.
treatment (PPI: Rabeprazole, 10 mg per day) was given for 2 months after ESD. Patients then received periodic endoscopic follow-up regardless of symptoms to detect metachronous lesions. Ulcer recurrence at the site of ESD was recorded and a biopsy was taken to determine if the ulcer was benign. Ulcer recurrence was defined as a new ulcer occurring at the site of ESD. Patient characteristics and histological data of lesions dissected by ESD were collected and factors related to ulcer recurrence were analyzed statistically.Results: Median observation period was 35 months (range 12 to 77 months). The median size of dissected specimen in diameter was 45.5mm (range 10-130mm). The rate of ulcer recurrence after ESD was 2.8% (11/395 Pt.). Univariate analysis showed that past history of peptic ulcer (yes vs. no, 6.7% vs. 2.4%; P⬍0.05) and presence of pathological ulcer scar within the lesion (yes vs. no, 7.6% vs. 1.0%; P⬍0.05) were significantly related to the risk of recurrence of an ulcer after ESD. Multivariate analysis revealed that presence of pathological ulcer scar within the lesion was significantly associated with ulcer recurrence after ESD. (P⬍0.05)Conclusion: Although the frequency is low, there is a possibility of recurrence of gastric artificial ulcers after ESD. Presence of pathological ulcer scar within the lesion and past history of peptic ulcer may cause a recurrence of an ulcer after ESD.
M1600 Predictors for the Therapeutic Outcome and Procedural Time of Endoscopic Submucosal Dissection for Gastric Epithelial Neoplasm Jong-Sun Rew, Seon-Young Park, Hae-Kyeng Jeong, Tae-Jin Seo, Kyoung-Won Yoon, Sung-Bum Cho, Wan-Sik Lee, Chang-Hwan Park, Young-Eun Joo, Hyun-Soo Kim, Sung Kyu Choi Background/Aims: The technique of endoscopic submucosal dissection (ESD) was introduced to be able to obtain en bloc specimens of gastric epithelial neoplasm. The drawback of ESD is its technical difficulty, which, consequently, is associated with a higher rate of complication and which requires advanced endoscopic techniques and a long procedure time. We investigated the influential factors on the en bloc resection and procedural time of ESD for gastric epithelial neoplasm. Method: From March 2008 to March 2009, 155 patients with gastric epithelial neoplasm (103 men, 52 women; mean age 61.1⫾10.9 years) were treated by using ESD. We used indigo carmine and epinephrine (1 ml of 0.1%) mixed normal saline (1:1000) and 0.14% sodium hyaluronate (SH) as a submucosal injection solution. We performed ESD procedures with typical sequences (marking, incision, and submucosal dissection). The rates of en bloc resection and complete resection, incidence of complication and procedural time were investigated. Results: The rates of en bloc resection and complete resection were 90.3% (140/155) and 94.8% (147/155), respectively. The rates of early bleeding, delayed bleeding and perforation were 1.3% (2/155), 0% and 0%, respectively. The median procedure time was 27 (3-265) minutes. Univariate analysis demonstrated that location, presence of ulcer scar and submucosal solution were considered influential factors of en bloc resection. Multivariate analysis demonstrated that location (upper 2/3, aOR 0.15, 95% CI 0.04-0.56), submucosal fibrosis (presence, aOR 0.10, 95% CI 0.03-0.37) and submucosal injection solution (0.14% SH, aOR 6.68, 95% CI 1.69-26.41) appeared to be independent influential factors of en bloc resection. Multiple linear regression analysis using procedural time as the dependent variable showed that tumor size (⫽0.927, p⬍0.001), submucosal fibrosis (presence, ⫽0.927, p⬍0.001), location (lower 1/3, ⫽-0.292, p⫽0.004), and submucosal injection solution (0.14% SH, ⫽-0.269, p⫽0.005) were significant independent factors. Conclusion: The possibility of en bloc resection can be predicted by location, presence of submucosal fibrosis and submucosal injection solution. The procedural time of ESD can be predicted by tumor size, location, presence of submucosal fibrosis and submucosal injection solution. Use of 0.14% sodium hyaluronate as a submucosal injection solution showed better en bloc resection rates and reduces the procedural time.
M1599 Long Term Outcome of Gastric Artificial Ulcers After Endoscopic Submucosal Dissection Yongze Huang, Naomi Kakushima, Hiroyuki Ono, Kohei Takizawa, Masaki Tanaka, Hisatomo Ikehara, Yuichiro Yamaguchi, Hiroyuki Matsubayashi
M1601 Change in Percutaneous Feeding Tube Stoma Length From Supine to Sitting Position and Correlation With BMI Matthew Steenblik, Kristen Hilden, John C. Fang
Background: Endoscopic submucosal dissection (ESD) has been widely performed as a treatment for gastric neoplasm. It has been previously reported that gastric artificial ulcers after ESD would heal within 2 months, irrespective of its size and location, if there were no submucosal fibrosis under the lesion before ESD. Since they are artificial ulcers, they are considered to have a good outcome with little risk of recurrence. However, there are almost no studies that have reported on the long-term outcome of these ulcers.Aim: To describe longterm outcomes of gastric ulcers after ESD.Method: This was a retrospective single center study involving 488 lesions in 395 patients (319 man, 76 women, mean age 69.1 years, range 37-91 years) treated by ESD from September 2002 to August 2008 and were followed for more than 12 months after gastric ESD. Patients who received additional treatment such as gastrectomy, argon plasma coagulation, and photodynamic therapy were excluded. As a rule, anti-ulcer
Background: Percutaneous endoscopic gastrostomy (PEG) is the most common method of long term enteral feeding. Accurate knowledge of stoma tract length is important to prevent gastric ulcer formation underneath the internal bolster, buried bumper syndrome and peristomal leakage/infection. Current guidelines suggest 0.5-1.0 cm of play between the skin and external bolster. Placement of percutaneous feeding tubes and setting of the external bolster occurs in the supine position. However, abdominal wall thickness and stoma tract length may change significantly from supine to sitting position. This change may be more pronounced in patients with higher body mass index (BMI). There are no data regarding changes in stoma tract length from supine to sitting position or change in this length in relation to BMI. Our aim was to determine if stoma tract length changes significantly from supine and sitting position and if this change is related to BMI.Methods: Consecutive patients undergoing percutaneous feeding
AB264 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
www.giejournal.org
Abstracts tube change from Nov 2006 - Sept 2009 were enrolled. We collected gender, sitting and supine position stoma length, body mass index (BMI), feeding tube type, and any complications. Stoma tract length was measured using a balloon stoma measuring device (AMT, Cleveland, OH). Correlations were made between BMI and stoma tract length in both sitting and supine positions with Spearman’s rank test.Results: 28 patients (24 PEG’s, 4 DPEJ’s) were included, 19 (68%) were female. The mean stoma length in the supine position was 3.6 ⫾ 0.9 cm. The mean stoma length in sitting position was 4.9 ⫾ 1.4 cm. The mean stoma length change from supine to sitting position was 1.53 ⫾ 0.9 cm. Mean BMI was 21.2 ⫾ 4.5 (range 14.9-33.8). Complications included leakage 2/28 (7%) and infection 2/28 (7%). Stoma length in supine position is strongly correlated to BMI r⫽0.65, p⫽0.0002. Stoma length in sitting position is also strongly correlated to BMI, r⫽0.6, p⫽0.0009. Change in stoma tract length is correlated with BMI, r⫽0.43, p⫽ 0.02Conclusions: Stoma tract length is strongly correlated to BMI in both sitting and supine position. PEG stoma tract length changes significantly from supine and sitting position. To prevent complications, most patients should have a longer distance set between internal and external bolsters than is recommended.
M1602 Reduced Risk of Peristomal Infection of Percutaneous Endoscopic Gastrostomy (PEG) by Using Modified Introducer Technique With Gastropexy (Direct Technique): Comparison With the Pull-Through Technique Yoshinobu Saito, Akira Takeda, Atsuo Inoue Background and aim: Peristomal infection is one of the most common complications of Percutaneous endoscopic gastrostomy (PEG). Oropharyngeal bacteria can be brought to the abdominal wall when we use a pull-through technique. A novel extracorporeal technique, modified introducer technique with gastropexy (direct technique), as the instrument doesn’t pass the oral cavity, is expected to reduce the risk of peristomal infection. Since June 2006, we have employed direct technique. Our aim was to assess the preventive effect on peristomal infection of direct technique.Patients and methods: In a single, highvolume center in Japan, data of 538 patients were collected retrospectively from January 1994 to May 2007 for PEG by using pull-through technique (Pull-PEG) and from June 2007 to October 2009 for PEG by using direct technique (DirectPEG). Pull-PEG was performed on 284 patients while Direct-PEG was performed on 254 patients.Results: The incidence of peristomal infection was lower in the Direct-PEG group (1.6%) than in the Pull-PEG Group (7.4%; p⬍0.05).Conclusion: This result suggests that Direct-PEG may be superior to Pull-PEG because of reduced risks of peristomal infection.
M1603 Symptomatic Management of Bowel Obstruction in Advanced Cancer Using Percutaneous Endoscopic Gastrostomy Akira Takeda, Yoshinobu Saito, Satoshi Tanaka, Atsuo Inoue BACKGROUND: Conservative treatment of inoperable bowel obstruction in advanced cancer patients has been known to be effective in controlling the distresses. A number of treatment options are now available for the patients. For intestinal decompression, percutaneous endoscopic gastrostomy (PEG) can be a potential method in place of nasogastric tubing. The aim of this retrospective study was to evaluate the safety of PEG placement in patients with inoperable bowel obstruction. METHODS: A retrospective chart review of all patients who underwent a successful PEG between January 1994 and October 2009 was done. Data included demographics, type of cancer, procedural complications, and survival period for patients. RESULTS: In a total of 538 cases, 40 cases underwent PEG for intestinal decompression. Twenty seven (68%) were men and 13 (32%) were women. The mean age was 68 years (range, 43-82). Underlying cancers included: colorectal (13), gastric cancer (10), pancreatic (7), other gastrointestinal (2) and others (8). Thirty cases (75%) were associated with a complication of ascites and cancerous peritonitis. The PEG procedure was as follows: 14 cases performed using a standard pull-through technique and 26 cases a modified introducer technique. There were 2 procedural complications, 1 major and 1 minor: a gastrostomy through liver (1), and submucoal hematoma (1). Conservative management could deal with these complications. Average survival period after PEG was 87 days (range, 6-392). Seven cases needed a combination therapy with octreotide. These cases were all with lower intestinal obstruction. CONCLUSIONS: These results suggest that PEG could be a substituting method for nasogastirc tubing for intestinal decompression and avoid the distressing symptoms caused by nasogastirc tubing, especially in cases with upper gastrointestinal obstruction.
www.giejournal.org
M1604 Risk Factors Related to Local Recurrence of Early Gastric Cancers After Endoscopic Resection, in Special Reference to Differences Between Early and Late Local Recurrence Keun Man Lee, Jie-Hyun Kim, Sung Ill Jang, Jung Hwan Yu, Jung Soo Park, Chaul Woung Huh, Yong Chan Lee, Hyun Chul Lim, Young Hoon Yoon, Hyojin Park, Sang in Lee Background/Aims: Endoscopic resection (ER) is widely accepted as the standard treatment for early gastric cancer (EGC). The risk of local recurrence after ER is important to validate the clinical outcomes after ER. Thus, we retrospectively analyzed the risk factors related to local recurrence of EGC after ER, in special reference to differences between early and late local recurrence. Methods: From January 2002 to December 2008, 355 lesions in 351 patients were treated by ER (22.8 % conventional EMR; 17.7 % EMR with precut; 59.5 % endoscopic submucosal dissection) in Severance & Gangnam Severance Hospital, Yonsei University College of medicine. ER was performed for EGC based on absolute and extended criteria by Gotada (Gastric cancer, 2000). The clinical and pathologic features of cases with local recurrence of EGC after ER were analyzed in 1-89 months follow-up period. Local recurrence within 1 year after ER was regarded as early local recurrence.Results: The histological complete resection rate was 77.7%. During the follow-up period, a local recurrence was found in 17 cases (1.1 %) with 50.0 % early local recurrence. Female, conventional EMR method, elevated gross type, upper 1/3 location, posterior wall site, signet ring pathology, and piecemeal resection were significantly associated with histological incomplete resection. However, there was no significant risk factor associated with local recurrence in both absolute and extended criteria. When compared between early and late local recurrence after ER, non-eradication rate of Helicobacter pylori was higher in early local recurrence (P⫽0.05). Conclusions: Local recurrence after ER may not be different between absolute and extended criteria for ER in EGC. The eradication of Helicobacter pylori can be helpful to prevent early local recurrence after ER.
M1605 Clinical Experience of Full-Thickness Resection (CLEAN-NET: Combination of Laparoscopic and Endoscopic Approaches to Neoplasia With Non-Exposure Technique) for Early Gastric Cancer With Severe Scar Hironari Shiwaku, Haruhiro Inoue, Hitomi Minami, Hitoshi Satodate, Shin-Ei Kudo INTRODUCTION: ESD (Endoscopic submucosal dissection) becomes widely accepted as a standard endoscopic procedure for early gastric cancer. Marked advancement of endoscopic skill with new devices allows us to perform ESD procedure much easier than before. But we still experience difficult cases due to severe scar of the lesion. For such difficult cases, we conduct laparoscopic local resection (full-thickness resection) assisted by endoscopy and call it ‘CLEANNET’. We introduce the summary and present result of this procedure. AIMS & METHODS: The indication of this procedure is ‘the intra-mucosal cancer within 30 mm in diameter with severe scar’. We experienced 16 cases. The technique of CLEAN-NET is followings. We observe the boundary of the lesion with magnifying Narrow Band Imaging (NBI) System and mark around 10mm outside the margin of the lesion. After sticking a needle knife into gastric wall from inside to confirm the resection range, circumferential incision is made as deep as the submucosal layer from outside laparoscopically (Fig.). Then, full-thickness resection is done by linear stapler. The mucosal layer we left becomes a ‘NET’ not to expose a cancer cell into abdominal cavity. The specimen packed into pouch is withdrawn from 12mm trocar. In the case which the lesion is on smaller or greater curvature, full-thickness resection with lymphedectomy is done en bloc. RESULTS: The mean operation time was 182.1min, and the estimated blood loss was 19.4ml. No case showed positive surgical margin and lymph node metastasis pathologically. There was one case which needed re-operation by laparoscopic surgery due to the deformity of stomach, but now there is no problem. In all cases including that case, there was no apparent problem of resumption after operation. CONCLUSION: CLEAN-NET is a new approach to the cases which ESD procedure is difficult due to severe scar. It enables en bloc and whole-layer excision of lesions, in appropriate operation time, with less bleeding, and with an adequate surgical margin, both vertically and laterally.
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB265