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Pathologic Relationship and Clinical Significance of Magnifying Endoscopy in Scar Lesions After Endoscopic Mucosal Resection for Early Gastric Neoplasm: Prospective Studies in Endoscopy Follow Up
Abstracts
From June 2001 to December 2006, total gastrectomy was performed in 930 patients in National Cancer Center, Korea. A total of 58 patients (6.2%) developed benign stricture at esophagojejunostomy and underwent the TTS-BD. The patients were classified into three groups depending final largest dilator diameter and the session numbers of initial dilation: Group A (n Z 20): final largest luminal diameter of balloon was 1 5 mm or less. Group B (n Z 13): more than 15 mm within 1 session. Group C (n Z 25): more than 15 mm with 2 sessions. Initial success rate (be able to swallow a solid diet after procedure), complication rates, re-stenosis rates according to each group were evaluated. Results: Initial success rates of Group A, B, C were 100% (20/20), 100% (13/13) and 96% (24/25) respectively. The complication was a perforation in Group B (7.7%, 1/13). Re-stenosis rates were 10% (2/20) in Group A, 7.7% (1/13) in Group B, and 0% (0/25) in Group C. All patients were able to intake solid diet more than 6 months after last TTS-BD. Follow-up durations (median, range) except early expired cases caused by tumor recurrence were 108 (30-306), 112 (36-250), 103 (38-262) weeks, respectively. Conclusion: TTSBD up to 15 mm was a safe and effective treatment for the benign anastomosis stricture at esophagojejunostomy after total gastrectomy. Re-stenosis rate was not common and resolved by further 1-2 TTS-BD.
T1687 Safety and Efficacy of Carbon Dioxide (CO2) Insufflation During Endoscopic Submucosal Dissection (ESD) for Gastric Cancer Under Propofol Sedation: A Randomized, Controlled Trial Daisuke Tanioka, Yoshiro Kawahara, Hiroyuki Okada, Ryuta Takenaka, Satoru Yagi, Masafumi Inoue, Seiji Kawano, Takao Tsuzuki, Masahide Kita, Keisuke Hori, Masayuki Uemura, Kazuhide Yamamoto Background/Aims: Endoscopic submucosal dissection (ESD) procedure become popular rapidly, because it enables to remove en bloc large lesion. However, there are a lot of problems in this method (e.g. difficult procedure, many complications, high cost, and etc.). One of the most important problems is time-consuming. Thus, appropriate method of sedation and pain control are needed. We have already reported the utility of propofol sedation for ESD procedure. In addition, several studies have shown that CO2 insufflation instead of air during endoscopy can reduce post procedural pain and discomfort. We applied this CO2 insufflation method for ESD procedure under propofol sedation. We investigated the safety and efficacy of using CO2 insufflation under propofol sedation method for ESD procedure. Patients and Methods: A total of one hundred consecutive gastric cancer patients who treated by ESD procedure in our hospital were randomized to CO2 insufflation or air insufflation. Patients were sedated by propofol under oxygen inhalation (2-3 L/min) by nasotrachial airway. Sedation was provided by a doctor with prior experiences in anesthesia or a specialist anesthetist. In CO2 insufflation group we connected a CO2 cylinder to an endoscopic supply of air device and discharged it in 1.5 L/min. Using a transcutaneous partial pressure of carbon dioxide measuring system (TOSCA500; Radiometer Basel AG, Switzerland), we measured partial pressure of CO2 continuously for all patients. One hour after ESD we evaluated abdominal discomfort of the patients by using visual analogue scale (VAS) (range: 0-100 mm). Results: We carried out fifty ESD procedures using CO2 insafflation and fifty procedures using air insufflation. We excluded one patient in CO2 group and four patients in air group because of perforation. The mean operation times were 119 58 min and 107 46 min, mean partial pressures of CO2 during procedure were 48.8 4.8 mmHg and 50.0 5.5 mmHg in CO2 group and air group, respectively (not significant for each comparison). Average VAS score after ESD in CO2 group was significantly lower than that in air group (14.3 20.5 mm vs. 24.3 25.3 mm, P Z 0.04). We did not experienced complication except of perforation in perioperatively and postoperatively. Conclusion: CO2 insufflation during ESD for gastric cancer under propofol sedation is safety and reduces patient’s abdominal discomfort after procedure.
T1688 Local Recurrence Rate of Gastric Cancer in Ten Years’ Follow Up After Endoscopic Mucosal Resection: A Retrospective Cohort Study Noriyuki Horiki, Fumio Omata, Masayo Tsukamoto, Naoki Ishii, Yoshiyuki Fujita Background: Endoscopic submucosal dissection (ESD) has become one of the standard therapies for early gastric cancer. ESD can be applied to larger lesions compared to conventional endoscopic mucosal resection (EMR). However, ESD requires additional skills and also is more time consuming. To clarify the appropriate usage of ESD versus EMR, this study examined an aspect of EMR efficacy. We evaluated local recurrence rate retrospectively to elucidate the limitation of EMR for larger gastric cancers. Methods: We conducted a retrospective cohort study in a major general hospital in Japan. 127 consecutive patients with early gastric cancer underwent EMR between 1982 and 1994. EMR was performed using a two-channel scope (Olympus 2T 240). Removal of the lesion by EMR was tried en-block in all cases. However, because residual lesion was observed macroscopically, additional treatment such as burning or piece meal EMR had to be done in 80 cases (62%) (non en-block group). EMR could be performed by the method of en-block in 47 cases (38%). Patients in the non en-block group included patients who rejected standard therapy such as abdominal surgery. Data from all cases were followed up until 10 years after the EMR procedure. Data were extracted from the electronic medical record. Results:
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127 consecutive patients (mean age [sd] 68 [10], male gender 77%) were analyzed. The mean [sd] of length and width of lesions were 19.2 [6.5] mm and 16.2 [6.7] mm, respectively. EMR was performed by en-block method in 47 cases (mean age [sd], 65 [10], male gender 78%) and by non-en-block method in 80 cases (mean age [sd], 71 [9.4], male gender 76%). The percentages of well-differentiated carcinoma were 72% and 67% in en-block and non-enblock group, respectively. Area (length times width) [sd] (mm2) of lesions was 264 [132] and 393 [306] in the en-block and in the non-enblock groups, respectively. The proportions of mucosal lesions were 91% and 85% in the en-block and non-en-block groups, respectively. No recurrence was observed in the en-block group. Using the Kaplan-Meier method, local recurrence rate [95%CI] was 11% [6-18] both at 5 years and 10 years. Conclusions: Local recurrence rate of gastric cancer 5 years after EMR was 11% and did not change after another 5 years. Non-en-block EMR is associated with a substantial rate of local recurrence and additional ESD or tight follow up is warranted.
T1689 An Experience for Investigation of Follow-Up Strategy for Incomplete ESD At Single Institute Joo Young Cho, Hyun Gun Kim, Tae Hee Lee, Jin-Oh Kim, Joon Seong Lee, Bong Min Ko, Su Jin Hong, Moon Sung Lee, Chan Sup Shim, Seok R. Choi Background and Aim: Endoscopic submucosal dissection (ESD) allows the direct dissection of the submucosa and has the advantage of permitting en-bloc resection of early gastric cancer (EGC) associated with a minimal risk of lymph node metastasis. Further, recent studies showed the prognosis between ESD and surgical intervention has achieved similarly in well designed EGC groups. Nonetheless, one of the disadvantages of ESD procedure is to go second step of intervention, like, surgical intervention or another trial of ESD procedure because of incomplete resection. The aim of this study was to investigate what kinds of therapeutic modalities has been applied to the patients in incomplete resection group retrospectively. Subjects and Methods: ESD was performed in 647 lesions of gastric tumors from March, 2003 to August, 2007. We evaluated the outcomes of ESD retrospectively in the aspect of curative resection and the follow up treatment after incomplete resection. Results: Of 647 lesions performed ESD, gastric adenoma was seen in 225 lesions (34.8%) and EGC in 422 lesions (65.2%). Of 422 lesions of EGC, 29 lesions were synchronous lesions (6.9%) and 8 lesions were metachronous lesion (1.9%). The mean duration of metachronous lesions was 11.8 month. 3 lesions (0.7%) were recurred after previous ESD (mean 18.6 months after prior resection). Synchronous lesions were initially performed ESD with other lesions simultaneously. Metachronous lesions and recurred lesions were all performed with re-ESD. 567 lesions (87.6%) were removed completely and 80 lesions (12.4%) were resected incompletely. Of the incompletely resected 80 lesions, 24 lesions (30%) underwent operation, 8 lesions (10%) were performed with ablation treatment, 7 lesions (8.8%) were performed with re-ESD, 24 lesions (30%) were regular followup with random biopsy, 17 cases (21.2%) were follow-up loss. Of the 24 lesions performed operation, 9 lesions (37.5%) were residual cancer cell in the pathologic report after operation. There were no recurrence in the non-operated group (mean duration was 13.1 month) except the group of follow up loss. Conclusions: ESD is a relatively safe and effective for removal of gastric cancer in the aspect of recurrence rate (!1%). Various kinds of therapeutic modalities for follow-up in the lesions resected incompletely were applied and the outcomes of follow-up according to different kinds of therapeutic modalities may be requiring long term duration if we consider its effectiveness.
T1690 Pathologic Relationship and Clinical Significance of Magnifying Endoscopy in Scar Lesions After Endoscopic Mucosal Resection for Early Gastric Neoplasm: Prospective Studies in Endoscopy Follow Up Tae Hoon Lee, Il Kwun Chung, Suck-Ho Lee, Ji-Young Park, Jeong Hoon Park, Do Hyun Park, Hong-Soo Kim, Sang-Heum Park, Sun-Joo Kim Background: Magnifying endoscopy (ME) was developed to allow fine examination of various gastrointestinal lesions. However, there have been few studies into the pathologic relationship between the endoscopic features of ME and their clinical significance in scar lesions following endoscopic mucosal resection (EMR). In addition, there is some controversy over whether biopsies should be performed for each endoscopy, where patients have undergone complete EMR. Aim: We evaluated the relationship between the real-time diagnosis of post-EMR scars being observed by ME, and the pathological diagnosis. This research was intended to validate the usefulness of ME as a follow-up method by comparing magnifying and conventional findings with biopsy results. Patients and Methods: During the period November 2006 to August 2007, a total of 81 lesions from 76 patients with gastric neoplasm underwent EMR. We performed endoscopic follow up and histologic evaluation on these cases, 2 months after the EMR. We analyzed the conventional endoscopic characteristics of scar lesions by height, nodularity, color and ulceration, and classified the lesions by four types of pit patterns, and two types of pit regularities through the use of ME. Our findings were compared with histological examinations. Histopathologic components of the lesions (atrophy; intestinal
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB279
Abstracts
metaplasia; fibrosis; congestion, edema or cystic change of gland; lymphoid follicles; and foveolar hyperplasia) were scored by degree, from 0 to 3 point. Results: The minute surface structure of the post-EMR scars, as shown by ME, were classified into four pit patterns, as follows: (I) 29 round pit; (II) 34 short rod or tubular pit; (III) 15 branched or gyrus like pit; and (IV) 3 destroyed pit. The pit arrangement patterns identified were 70 regular and 11 irregular patterns. The two recurrences found were adenoma and high grade adenoma, which showed type IV pit pattern and irregular arrangement through ME (P Z .001). Type IV pit pattern shows a high scoring rate of atrophy and congestion of gland, histologically (2.33, P Z .03 and 1.67, P Z.011, respectively). The positive and negative predictive values for recurrence (type IV), identified by ME, were 66.6% and 100%, respectively. However, CE findings did not show statistically significant results. Conclusion: ME appears to be a helpful diagnostic method for differentiating tumorous and nontumorous lesions in post-EMR scars. Consequently, correct evaluation of ME may reduce unnecessary biopsies in the follow-up period after EMR, in early gastric neoplasm. However, further and larger-scale, long term studies are needed.
T1691 Endoscopic Mucosal Resection for Undifferentiated Early Gastric Cancer - Differential Approach Between Poorly Differentiated Adenocarcinoma and Signet Ring Cell Carcinoma Jie-Hyun Kim, Yong Chan Lee, Hyunki Kim, Kyung Ho Song, Sang Kil Lee, Jae Hee Cheon, Jae Bock Chung Background/Aims: Based on the large scale data by Gotoda (Gastric cancer, 2000) about risk of lymph node metastasis in early gastric cancer (EGC), endoscopic mucosal resection (EMR) has been tried for undifferentiated (UD-) EGC, despite of controversy. We retrospectively analyzed the clinicopathologic outcomes of EMR performed in cases with UD-EGC, in special reference to histopathologic subtypes to examine the feasibility of EMR in UD-EGC. Methods: From January 2001 to April 2007, 59 lesions in 59 patients with UD-EGC (17 poorly differentiated adenocarcinoma (PD); 41 signet ring cell carcinoma (SRC); 1 mucinous adenocarcinoma) were treated by EMR (15 EMR with cap; 9 EMR with precut; 2 EMR with injection and cut technique; 33 endoscopic submucosal dissection) in our hospital. Therapeutic efficacy of EMR was assessed according to the en bloc resection rate, histologically complete resection rate, lateral or vertical cut endpositive (including submucosal invasion) rate, recurrence rate in 3-65 months follow-up period. Results: The mean size of lesions was 13.6 6.8 mm ( SD). The predominant endoscopic gross types of lesions were depressed (15/59: 25.4%), flat (18/59: 30.5%), and elevated (26/59: 44.1%) without concomitant ulcerations. The en bloc resection and histologically complete resection (CR) rates were 84.7% (50/ 59) and 66.1% (39/59) respectively. The en bloc and CR rates in PD were 82.4% and 58.8%; in SRC were 85.4% and 70.7%, respectively. There was no statistically significant differences between PD and SRC (p O 0.05) However, all cases (100%) of histologically incomplete resection (ICR) in PD were vertical cut end-positive while 83.3% (10/12) in SRC was lateral cut end-positive. Recurrence rate was 5.1% (2/39) in CR cases during the follow-up period. The recurred or ICR lesions were successfully treated by salvage operation (11/22: 50%) or endoscopic retreatment (7/22; 31.8%). In operated cases (9/20: 45%) among ICR, 5 cases (55.6%) had no residual cancer cells in surgical specimen and 1 case (11.1%) had lymph node metastasis. When compared CR with ICR cases, there were no significant factors related to CR. Conclusions: EMR might be a good curative treatment option of UDEGC if histologically complete resection. However, differential considerations should be necessary between PD and SRC for CR.
covered and uncovered stents were successfully inserted (70/70 vs 84/84). Clinical success rate was not significantly different in covered and uncovered stent groups (98.6% vs 96.4%). The risk of early stent migration was significantly higher in covered stent than uncovered stent groups (5/69 vs 0/84, P Z 0.019). Early tumor ingrowth and overgrowth rate was not different in both stent groups. The risk of late stent migration was significantly higher in covered stent group than uncovered stent(7/69 vs 0/81, P Z 0.004). Late tumor ingrowth was significantly frequent in uncovered stent than in covered stent group. (2/69 vs 13/81, P Z 0.012). Tumor overgrowth rate was not different in both groups. Stent patent duration and patient survival time were not different according to stent types. Conclusion: Covered and uncovered SEMS insertions are technically feasible and clinically effective for palliative treatment of primary malignant gastroduodenal obstruction. Stent type was not significant factor for the palliative treatment of malignant gastroduodenal obstruction. For prolongation of stent patency, new type stent (combined stent of covered and uncovered type or woven type stent) are necessitated.
T1693 Validity of Magnify NBI for Gastric Intestinal Metaplasia Targeted Biopsy Boonlert Imraporn, Sukprasert Jutaghokiat, Naruemon Wisedopas, Rungsun Rerknimitr, Sombat Treeprasertsuk, Varocha Mahachai, Pinit Kullavanijaya Background: Gastric intestinal metaplasia (GIM) is a premalignant condition for gastric cancer. The gold standard for GIM diagnosis is histology. GIM are scattered and focally located. Random biopsy is quite cumbersome and takes hours, thus targeted biopsy by endoscopic guidance is recommended. However, diagnostic accuracy of targeted biopsy by white light endoscopy is low due to sampling error. Narrow band imaging with magnification endoscopy (NBI-ME) can be applied for more accurate targeted biopsy. However there is little data about the diagnostic accuracy of this technique. Aim: To define the diagnostic accuracy of GIM detection by NBI-ME Methods: 20 patients with previously diagnosed as GIM by random biopsy were enrolled. NBI-ME (Olympus GIF Q160Z) with targeted biopsy for both positive and negative lesions (4 and 2 from antrum and incisura respectively) was done according to endoscopic criteria including light blue crests (LBC), villous pattern (VP) and large long crests (LLC). The specimens were read based on the updated Sydney classification. Results: There were 46/120 specimens with proven positive for GIM. The results are shown in the table. Conclusion: NBI-ME possesses a high accuracy for GIM detection. LBC has the highest sensitivity over VP and LLC. However, if all three criteria are used, the sensitivity and NPV are better.
LBC detected by NBI-ME T1692 Comparison of Uncovered and Covered Stent for Endoscopic Treatment of Inoperable Malignant Gastroduodenal Obstruction Kee Myung Lee, Sang Jo Choi, Jin Hong Kim, Sung Jae Shin, Jae Chul Hwang, Kwang Jae Lee, Byungmoo Yoo, Jae Youn Cheong, Sung Won Cho Background: Self-expandable metallic stents (SEMS) insertion has been simple, safe, and effective palliative treatment for malignant gastric outlet obstruction. Uncovered stents has been reported to have a high rate of tumor ingrowth and covered stents have the disadvantage of stent migration. In most of studies about covered stent, stents were inserted with non-endoscopic method. There has been no comparison study of endoscopic insertion of covered and uncovered stent for malignant gastroduodenal obstruction. The aim of this study is to compare technical and clinical outcome, patency duration, complication rates of covered and uncovered SEMS for the treatment of malignant gastroduodenal obstruction. Patients and Methods: From Jan 1998 to June 2007, patients with symptomatic malignant gastroduodenal obstruction were included. They were not candidate for curative surgery. We excluded the patients with postoperative anastomosis site obstruction and with hemodynamic instability, severe pulmonary insufficiency, or coagulopathy. Technical and clinical success was evaluated. Patients were followed up for clinical outcomes and stent patency (every 1 to 3 months). Results: Covered and uncovered stents were inserted in 70 and 84 patients, respectively. Demographic features of both groups were not different. Most of underlying malignancy of gastroduodenal obstruction was advanced gastric cancer. All of
AB280 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
Validity scores of endoscopic findings Findings
Sensitivity (%)
Specificity (%)
PPV(%)
NPV(%)
Accuracy(%)
LBC VP LLC LBCþVP LBCþLLC All criteria
82.6 32.6 23.9 84.8 86.9 91.3
78.4 93.2 93.2 79.7 77 73
70.3 75 68.8 72.2 70.2 67.7
87.9 69 66.3 89.4 90.5 93.1
80 70 66.7 81.7 80.8 80
T1694 Clinical Significance of Expression of COX-2 and Cadherin in Gastric Cancer Kum Hei Ryu, Ki-Nam Shim, Yang-Hee Joo, Hyun Joo Song, Youn Ju Na, Su Jung Baik, Hae Sun Jung, Ji Min Jung, Chang Yoon Ha, Seong-Eun Kim, Sung-Ae Jung, Sun Young Yi, Kwon Yoo, Kyu Won Chung, Joo-Ho Lee Background/Aims: Cyclooxygenase (COX)-2 disrupts normal cell-to-cell adhesion by down-regulating cadherin and contributes to the enhanced migration and
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From June 2001 to December 2006, total gastrectomy was performed in 930 patients in National Cancer Center, Korea. A total of 58 patients (6.2%) developed benign stricture at esophagojejunostomy and underwent the TTS-BD. The patients were classified into three groups depending final largest dilator diameter and the session numbers of initial dilation: Group A (n Z 20): final largest luminal diameter of balloon was 1 5 mm or less. Group B (n Z 13): more than 15 mm within 1 session. Group C (n Z 25): more than 15 mm with 2 sessions. Initial success rate (be able to swallow a solid diet after procedure), complication rates, re-stenosis rates according to each group were evaluated. Results: Initial success rates of Group A, B, C were 100% (20/20), 100% (13/13) and 96% (24/25) respectively. The complication was a perforation in Group B (7.7%, 1/13). Re-stenosis rates were 10% (2/20) in Group A, 7.7% (1/13) in Group B, and 0% (0/25) in Group C. All patients were able to intake solid diet more than 6 months after last TTS-BD. Follow-up durations (median, range) except early expired cases caused by tumor recurrence were 108 (30-306), 112 (36-250), 103 (38-262) weeks, respectively. Conclusion: TTSBD up to 15 mm was a safe and effective treatment for the benign anastomosis stricture at esophagojejunostomy after total gastrectomy. Re-stenosis rate was not common and resolved by further 1-2 TTS-BD.
T1687 Safety and Efficacy of Carbon Dioxide (CO2) Insufflation During Endoscopic Submucosal Dissection (ESD) for Gastric Cancer Under Propofol Sedation: A Randomized, Controlled Trial Daisuke Tanioka, Yoshiro Kawahara, Hiroyuki Okada, Ryuta Takenaka, Satoru Yagi, Masafumi Inoue, Seiji Kawano, Takao Tsuzuki, Masahide Kita, Keisuke Hori, Masayuki Uemura, Kazuhide Yamamoto Background/Aims: Endoscopic submucosal dissection (ESD) procedure become popular rapidly, because it enables to remove en bloc large lesion. However, there are a lot of problems in this method (e.g. difficult procedure, many complications, high cost, and etc.). One of the most important problems is time-consuming. Thus, appropriate method of sedation and pain control are needed. We have already reported the utility of propofol sedation for ESD procedure. In addition, several studies have shown that CO2 insufflation instead of air during endoscopy can reduce post procedural pain and discomfort. We applied this CO2 insufflation method for ESD procedure under propofol sedation. We investigated the safety and efficacy of using CO2 insufflation under propofol sedation method for ESD procedure. Patients and Methods: A total of one hundred consecutive gastric cancer patients who treated by ESD procedure in our hospital were randomized to CO2 insufflation or air insufflation. Patients were sedated by propofol under oxygen inhalation (2-3 L/min) by nasotrachial airway. Sedation was provided by a doctor with prior experiences in anesthesia or a specialist anesthetist. In CO2 insufflation group we connected a CO2 cylinder to an endoscopic supply of air device and discharged it in 1.5 L/min. Using a transcutaneous partial pressure of carbon dioxide measuring system (TOSCA500; Radiometer Basel AG, Switzerland), we measured partial pressure of CO2 continuously for all patients. One hour after ESD we evaluated abdominal discomfort of the patients by using visual analogue scale (VAS) (range: 0-100 mm). Results: We carried out fifty ESD procedures using CO2 insafflation and fifty procedures using air insufflation. We excluded one patient in CO2 group and four patients in air group because of perforation. The mean operation times were 119 58 min and 107 46 min, mean partial pressures of CO2 during procedure were 48.8 4.8 mmHg and 50.0 5.5 mmHg in CO2 group and air group, respectively (not significant for each comparison). Average VAS score after ESD in CO2 group was significantly lower than that in air group (14.3 20.5 mm vs. 24.3 25.3 mm, P Z 0.04). We did not experienced complication except of perforation in perioperatively and postoperatively. Conclusion: CO2 insufflation during ESD for gastric cancer under propofol sedation is safety and reduces patient’s abdominal discomfort after procedure.
T1688 Local Recurrence Rate of Gastric Cancer in Ten Years’ Follow Up After Endoscopic Mucosal Resection: A Retrospective Cohort Study Noriyuki Horiki, Fumio Omata, Masayo Tsukamoto, Naoki Ishii, Yoshiyuki Fujita Background: Endoscopic submucosal dissection (ESD) has become one of the standard therapies for early gastric cancer. ESD can be applied to larger lesions compared to conventional endoscopic mucosal resection (EMR). However, ESD requires additional skills and also is more time consuming. To clarify the appropriate usage of ESD versus EMR, this study examined an aspect of EMR efficacy. We evaluated local recurrence rate retrospectively to elucidate the limitation of EMR for larger gastric cancers. Methods: We conducted a retrospective cohort study in a major general hospital in Japan. 127 consecutive patients with early gastric cancer underwent EMR between 1982 and 1994. EMR was performed using a two-channel scope (Olympus 2T 240). Removal of the lesion by EMR was tried en-block in all cases. However, because residual lesion was observed macroscopically, additional treatment such as burning or piece meal EMR had to be done in 80 cases (62%) (non en-block group). EMR could be performed by the method of en-block in 47 cases (38%). Patients in the non en-block group included patients who rejected standard therapy such as abdominal surgery. Data from all cases were followed up until 10 years after the EMR procedure. Data were extracted from the electronic medical record. Results:
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127 consecutive patients (mean age [sd] 68 [10], male gender 77%) were analyzed. The mean [sd] of length and width of lesions were 19.2 [6.5] mm and 16.2 [6.7] mm, respectively. EMR was performed by en-block method in 47 cases (mean age [sd], 65 [10], male gender 78%) and by non-en-block method in 80 cases (mean age [sd], 71 [9.4], male gender 76%). The percentages of well-differentiated carcinoma were 72% and 67% in en-block and non-enblock group, respectively. Area (length times width) [sd] (mm2) of lesions was 264 [132] and 393 [306] in the en-block and in the non-enblock groups, respectively. The proportions of mucosal lesions were 91% and 85% in the en-block and non-en-block groups, respectively. No recurrence was observed in the en-block group. Using the Kaplan-Meier method, local recurrence rate [95%CI] was 11% [6-18] both at 5 years and 10 years. Conclusions: Local recurrence rate of gastric cancer 5 years after EMR was 11% and did not change after another 5 years. Non-en-block EMR is associated with a substantial rate of local recurrence and additional ESD or tight follow up is warranted.
T1689 An Experience for Investigation of Follow-Up Strategy for Incomplete ESD At Single Institute Joo Young Cho, Hyun Gun Kim, Tae Hee Lee, Jin-Oh Kim, Joon Seong Lee, Bong Min Ko, Su Jin Hong, Moon Sung Lee, Chan Sup Shim, Seok R. Choi Background and Aim: Endoscopic submucosal dissection (ESD) allows the direct dissection of the submucosa and has the advantage of permitting en-bloc resection of early gastric cancer (EGC) associated with a minimal risk of lymph node metastasis. Further, recent studies showed the prognosis between ESD and surgical intervention has achieved similarly in well designed EGC groups. Nonetheless, one of the disadvantages of ESD procedure is to go second step of intervention, like, surgical intervention or another trial of ESD procedure because of incomplete resection. The aim of this study was to investigate what kinds of therapeutic modalities has been applied to the patients in incomplete resection group retrospectively. Subjects and Methods: ESD was performed in 647 lesions of gastric tumors from March, 2003 to August, 2007. We evaluated the outcomes of ESD retrospectively in the aspect of curative resection and the follow up treatment after incomplete resection. Results: Of 647 lesions performed ESD, gastric adenoma was seen in 225 lesions (34.8%) and EGC in 422 lesions (65.2%). Of 422 lesions of EGC, 29 lesions were synchronous lesions (6.9%) and 8 lesions were metachronous lesion (1.9%). The mean duration of metachronous lesions was 11.8 month. 3 lesions (0.7%) were recurred after previous ESD (mean 18.6 months after prior resection). Synchronous lesions were initially performed ESD with other lesions simultaneously. Metachronous lesions and recurred lesions were all performed with re-ESD. 567 lesions (87.6%) were removed completely and 80 lesions (12.4%) were resected incompletely. Of the incompletely resected 80 lesions, 24 lesions (30%) underwent operation, 8 lesions (10%) were performed with ablation treatment, 7 lesions (8.8%) were performed with re-ESD, 24 lesions (30%) were regular followup with random biopsy, 17 cases (21.2%) were follow-up loss. Of the 24 lesions performed operation, 9 lesions (37.5%) were residual cancer cell in the pathologic report after operation. There were no recurrence in the non-operated group (mean duration was 13.1 month) except the group of follow up loss. Conclusions: ESD is a relatively safe and effective for removal of gastric cancer in the aspect of recurrence rate (!1%). Various kinds of therapeutic modalities for follow-up in the lesions resected incompletely were applied and the outcomes of follow-up according to different kinds of therapeutic modalities may be requiring long term duration if we consider its effectiveness.
T1690 Pathologic Relationship and Clinical Significance of Magnifying Endoscopy in Scar Lesions After Endoscopic Mucosal Resection for Early Gastric Neoplasm: Prospective Studies in Endoscopy Follow Up Tae Hoon Lee, Il Kwun Chung, Suck-Ho Lee, Ji-Young Park, Jeong Hoon Park, Do Hyun Park, Hong-Soo Kim, Sang-Heum Park, Sun-Joo Kim Background: Magnifying endoscopy (ME) was developed to allow fine examination of various gastrointestinal lesions. However, there have been few studies into the pathologic relationship between the endoscopic features of ME and their clinical significance in scar lesions following endoscopic mucosal resection (EMR). In addition, there is some controversy over whether biopsies should be performed for each endoscopy, where patients have undergone complete EMR. Aim: We evaluated the relationship between the real-time diagnosis of post-EMR scars being observed by ME, and the pathological diagnosis. This research was intended to validate the usefulness of ME as a follow-up method by comparing magnifying and conventional findings with biopsy results. Patients and Methods: During the period November 2006 to August 2007, a total of 81 lesions from 76 patients with gastric neoplasm underwent EMR. We performed endoscopic follow up and histologic evaluation on these cases, 2 months after the EMR. We analyzed the conventional endoscopic characteristics of scar lesions by height, nodularity, color and ulceration, and classified the lesions by four types of pit patterns, and two types of pit regularities through the use of ME. Our findings were compared with histological examinations. Histopathologic components of the lesions (atrophy; intestinal
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB279
Abstracts
metaplasia; fibrosis; congestion, edema or cystic change of gland; lymphoid follicles; and foveolar hyperplasia) were scored by degree, from 0 to 3 point. Results: The minute surface structure of the post-EMR scars, as shown by ME, were classified into four pit patterns, as follows: (I) 29 round pit; (II) 34 short rod or tubular pit; (III) 15 branched or gyrus like pit; and (IV) 3 destroyed pit. The pit arrangement patterns identified were 70 regular and 11 irregular patterns. The two recurrences found were adenoma and high grade adenoma, which showed type IV pit pattern and irregular arrangement through ME (P Z .001). Type IV pit pattern shows a high scoring rate of atrophy and congestion of gland, histologically (2.33, P Z .03 and 1.67, P Z.011, respectively). The positive and negative predictive values for recurrence (type IV), identified by ME, were 66.6% and 100%, respectively. However, CE findings did not show statistically significant results. Conclusion: ME appears to be a helpful diagnostic method for differentiating tumorous and nontumorous lesions in post-EMR scars. Consequently, correct evaluation of ME may reduce unnecessary biopsies in the follow-up period after EMR, in early gastric neoplasm. However, further and larger-scale, long term studies are needed.
T1691 Endoscopic Mucosal Resection for Undifferentiated Early Gastric Cancer - Differential Approach Between Poorly Differentiated Adenocarcinoma and Signet Ring Cell Carcinoma Jie-Hyun Kim, Yong Chan Lee, Hyunki Kim, Kyung Ho Song, Sang Kil Lee, Jae Hee Cheon, Jae Bock Chung Background/Aims: Based on the large scale data by Gotoda (Gastric cancer, 2000) about risk of lymph node metastasis in early gastric cancer (EGC), endoscopic mucosal resection (EMR) has been tried for undifferentiated (UD-) EGC, despite of controversy. We retrospectively analyzed the clinicopathologic outcomes of EMR performed in cases with UD-EGC, in special reference to histopathologic subtypes to examine the feasibility of EMR in UD-EGC. Methods: From January 2001 to April 2007, 59 lesions in 59 patients with UD-EGC (17 poorly differentiated adenocarcinoma (PD); 41 signet ring cell carcinoma (SRC); 1 mucinous adenocarcinoma) were treated by EMR (15 EMR with cap; 9 EMR with precut; 2 EMR with injection and cut technique; 33 endoscopic submucosal dissection) in our hospital. Therapeutic efficacy of EMR was assessed according to the en bloc resection rate, histologically complete resection rate, lateral or vertical cut endpositive (including submucosal invasion) rate, recurrence rate in 3-65 months follow-up period. Results: The mean size of lesions was 13.6 6.8 mm ( SD). The predominant endoscopic gross types of lesions were depressed (15/59: 25.4%), flat (18/59: 30.5%), and elevated (26/59: 44.1%) without concomitant ulcerations. The en bloc resection and histologically complete resection (CR) rates were 84.7% (50/ 59) and 66.1% (39/59) respectively. The en bloc and CR rates in PD were 82.4% and 58.8%; in SRC were 85.4% and 70.7%, respectively. There was no statistically significant differences between PD and SRC (p O 0.05) However, all cases (100%) of histologically incomplete resection (ICR) in PD were vertical cut end-positive while 83.3% (10/12) in SRC was lateral cut end-positive. Recurrence rate was 5.1% (2/39) in CR cases during the follow-up period. The recurred or ICR lesions were successfully treated by salvage operation (11/22: 50%) or endoscopic retreatment (7/22; 31.8%). In operated cases (9/20: 45%) among ICR, 5 cases (55.6%) had no residual cancer cells in surgical specimen and 1 case (11.1%) had lymph node metastasis. When compared CR with ICR cases, there were no significant factors related to CR. Conclusions: EMR might be a good curative treatment option of UDEGC if histologically complete resection. However, differential considerations should be necessary between PD and SRC for CR.
covered and uncovered stents were successfully inserted (70/70 vs 84/84). Clinical success rate was not significantly different in covered and uncovered stent groups (98.6% vs 96.4%). The risk of early stent migration was significantly higher in covered stent than uncovered stent groups (5/69 vs 0/84, P Z 0.019). Early tumor ingrowth and overgrowth rate was not different in both stent groups. The risk of late stent migration was significantly higher in covered stent group than uncovered stent(7/69 vs 0/81, P Z 0.004). Late tumor ingrowth was significantly frequent in uncovered stent than in covered stent group. (2/69 vs 13/81, P Z 0.012). Tumor overgrowth rate was not different in both groups. Stent patent duration and patient survival time were not different according to stent types. Conclusion: Covered and uncovered SEMS insertions are technically feasible and clinically effective for palliative treatment of primary malignant gastroduodenal obstruction. Stent type was not significant factor for the palliative treatment of malignant gastroduodenal obstruction. For prolongation of stent patency, new type stent (combined stent of covered and uncovered type or woven type stent) are necessitated.
T1693 Validity of Magnify NBI for Gastric Intestinal Metaplasia Targeted Biopsy Boonlert Imraporn, Sukprasert Jutaghokiat, Naruemon Wisedopas, Rungsun Rerknimitr, Sombat Treeprasertsuk, Varocha Mahachai, Pinit Kullavanijaya Background: Gastric intestinal metaplasia (GIM) is a premalignant condition for gastric cancer. The gold standard for GIM diagnosis is histology. GIM are scattered and focally located. Random biopsy is quite cumbersome and takes hours, thus targeted biopsy by endoscopic guidance is recommended. However, diagnostic accuracy of targeted biopsy by white light endoscopy is low due to sampling error. Narrow band imaging with magnification endoscopy (NBI-ME) can be applied for more accurate targeted biopsy. However there is little data about the diagnostic accuracy of this technique. Aim: To define the diagnostic accuracy of GIM detection by NBI-ME Methods: 20 patients with previously diagnosed as GIM by random biopsy were enrolled. NBI-ME (Olympus GIF Q160Z) with targeted biopsy for both positive and negative lesions (4 and 2 from antrum and incisura respectively) was done according to endoscopic criteria including light blue crests (LBC), villous pattern (VP) and large long crests (LLC). The specimens were read based on the updated Sydney classification. Results: There were 46/120 specimens with proven positive for GIM. The results are shown in the table. Conclusion: NBI-ME possesses a high accuracy for GIM detection. LBC has the highest sensitivity over VP and LLC. However, if all three criteria are used, the sensitivity and NPV are better.
LBC detected by NBI-ME T1692 Comparison of Uncovered and Covered Stent for Endoscopic Treatment of Inoperable Malignant Gastroduodenal Obstruction Kee Myung Lee, Sang Jo Choi, Jin Hong Kim, Sung Jae Shin, Jae Chul Hwang, Kwang Jae Lee, Byungmoo Yoo, Jae Youn Cheong, Sung Won Cho Background: Self-expandable metallic stents (SEMS) insertion has been simple, safe, and effective palliative treatment for malignant gastric outlet obstruction. Uncovered stents has been reported to have a high rate of tumor ingrowth and covered stents have the disadvantage of stent migration. In most of studies about covered stent, stents were inserted with non-endoscopic method. There has been no comparison study of endoscopic insertion of covered and uncovered stent for malignant gastroduodenal obstruction. The aim of this study is to compare technical and clinical outcome, patency duration, complication rates of covered and uncovered SEMS for the treatment of malignant gastroduodenal obstruction. Patients and Methods: From Jan 1998 to June 2007, patients with symptomatic malignant gastroduodenal obstruction were included. They were not candidate for curative surgery. We excluded the patients with postoperative anastomosis site obstruction and with hemodynamic instability, severe pulmonary insufficiency, or coagulopathy. Technical and clinical success was evaluated. Patients were followed up for clinical outcomes and stent patency (every 1 to 3 months). Results: Covered and uncovered stents were inserted in 70 and 84 patients, respectively. Demographic features of both groups were not different. Most of underlying malignancy of gastroduodenal obstruction was advanced gastric cancer. All of
AB280 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
Validity scores of endoscopic findings Findings
Sensitivity (%)
Specificity (%)
PPV(%)
NPV(%)
Accuracy(%)
LBC VP LLC LBCþVP LBCþLLC All criteria
82.6 32.6 23.9 84.8 86.9 91.3
78.4 93.2 93.2 79.7 77 73
70.3 75 68.8 72.2 70.2 67.7
87.9 69 66.3 89.4 90.5 93.1
80 70 66.7 81.7 80.8 80
T1694 Clinical Significance of Expression of COX-2 and Cadherin in Gastric Cancer Kum Hei Ryu, Ki-Nam Shim, Yang-Hee Joo, Hyun Joo Song, Youn Ju Na, Su Jung Baik, Hae Sun Jung, Ji Min Jung, Chang Yoon Ha, Seong-Eun Kim, Sung-Ae Jung, Sun Young Yi, Kwon Yoo, Kyu Won Chung, Joo-Ho Lee Background/Aims: Cyclooxygenase (COX)-2 disrupts normal cell-to-cell adhesion by down-regulating cadherin and contributes to the enhanced migration and
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