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Recurrence Rate and Risk Factors After Endoscopic Mucosal Resection
*M1791 Recurrence Rate and Risk Factors After Endoscopic Mucosal Resection Dong Seok Lee, Chang Keun Park, Chang Min Cho, Young-Oh Kweon, Chang Hun Yang, Yong Hwan Choi, Sung Kook Kim Background/Aim: Endoscopic mucosal resection (EMR) has been widely used as a standard treatment option for gastric mucosal tumors because it was safe, less invasive, and effective. The aim of this study was to assess the recurrence rate and risk factors after EMR. Methods: We analyzed the initial endoscopic findings, EMR results, and follow-up endoscopic findings of 103 patients with 129 lesions who underwent EMR for flat adenoma (74%) or early gastric cancer (EGC) (26%) from January 1999 to August 2003. Mean follow-up duration was 11.7 months. Results: Gastric tumors were resected completely in 87% and by en bloc in 88%. Lesions larger than 2cm, upper part (angle, body, cardia), or macroscopically flat or depressed lesions were more frequently resected incompletely and by piecemeal. Recurrence occurred in 16 of 129 lesions, and 12 of 96 (13%) in flat adenomas and 4 of 33 (12%) in EGCs recurred. Upper part (p<0.001), piecemeal resection (p=0.001), or incomplete resection (p=0.022) lesions recurred more frequently. Location and resection method were significant risk factors for recurrence in multi-variate analysis by logistic regression analysis (respectively, p-value 0.002 and 0.042, regression coefficient 2.102 and 1.994). 13 of 37 (35%) in post-EMR elevated lesions and 3 of 92 (3%) linear ulcer scars on follow-up endoscopy (p<0.001). Conclusion: Recurrence rate was 12% and mean time to recurrence was 8.9 months. Recurrence was closely related to the location, resection method, resection margin, and macroscopic finding on follow-up endoscopy. Recurrence was found at linear ulcer scar on follow-up endoscopy as well as elevated lesions, so biopsy should also be performed on linear ulcer scar on follow-up endoscopy.
*M1793 The Magnified Endoscopic Finding of an Irregular Microvascular Pattern is a Very Useful Marker for Differentiating Between Gastritis and Gastric Cancer: A Prospective Study Kenshi Yao, Akinori Iwashita, Toshiyuki Matsui, Tsuneyoshi Yao, Keisuke Ikeda, Yasuhiro Takagi, Yosuke Kikuchi, Makoto Yorioka, Kanta Kikuma Aim: It is often difficult using standard endoscopy to make an endoscopic diagnosis of the flat type of early gastric cancer that mimics gastritis. We previously reported the magnified endoscopic findings of the microvascular architecture of differentiated type of flat reddened gastric carcinoma (Gastrointest Endosc 2002; 56: 279-84). The aim of this study was to investigate the diagnostic accuracy of these magnified endoscopic findings for differentiating between reddened mucosa due to gastritis and flat reddened gastric cancer, prospectively. Methods: 390 cases were included in this study. The patients received upper gastrointestinal endoscopic examination for the screening of gastric cancer by zoom endoscope GIF-Q240Z (Olympus, Tokyo, Japan). If a flat reddened lesion was detected by non-magnified observation, the lesion was subsequently magnified by a zooming attachment. Immediately after the examination, the following findings which have been reported to be characteristic of carcinoma were recorded. (1) Presence of a demarcation line between the reddened lesion and the surrounding mucosa, (2) Disappearance of a regular subepithelial capillary network pattern of the same shape as that within the surrounding mucosa, and (3) Proliferation of microvessels irregular in both shape and distribution (irregular microvascular pattern). According to the pathological diagnosis, the flat reddened lesions were divided into two groups, i.e. gastritis and carcinoma groups. The incidence and 95% confidence intervals (CI) of these findings were calculated for each of the respective groups. Results: 161 flat reddened lesions from 161 cases were detected. Pathologically, 123 lesions showed only gastritis, while 38 lesions were diagnosed as differentiated carcinoma. The incidence (95% CI) of the magnified endoscopic findings in gastritis vs. carcinoma was (1) 22.8% (15.4-30.2%) vs. 97.4% (92.3100%), (2) 19.5% (12.5-26.5%) vs. 100% and (3) 0.8% (0-2.4%) vs. 97.4% (92.3100%), respectively. As for the differential diagnosis of carcinoma from gastritis, the sensitivity and the specificity of the irregular microvascular pattern were 97.4 and 99.2, respectively. Conclusion: An irregular microvascular pattern visible by magnified endoscopy can be a very useful marker for differentiating between gastritis and carcinoma.
*M1792 Efficacy and Safety of Endoscopic Mucosal Resection Using Precut Method for Treatment of Early Gastric Cancer: Impact of Learning Curve Il Ju Choi, Hee Jin Chang, Hee Sung Kim, Chan Gyoo Kim, Jun Ho Lee, Keun Won Ryu, Young Woo Kim, Jae-Moon Bae Background: Endoscopic mucosal resection (EMR) is a treatment option for early gastric cancer with minimal risk of lymph node metastasis. Precut around a lesion during EMR facilitate en bloc resection which is an important determinant for complete resection of the tumor. We evaluated the efficacy and safety of EMR using precut and cut method (EMR-P) in relation to endoscopist’s experience. Methods: We describe the experience of 60 consecutive early gastric cancer cases which are treated by EMR-P method performed by one endoscopist from January, 2002 to September, 2003. After submucosal injection of 0.25% sodium hyaluronate solution, precut was performed around the lesion with conventional needle knife, and then, resection was performed using direct snaring without exfoliation. The en bloc resection rate, complete resection rate, procedure time, and associated complications were compared between the first 30 cases and the subsequent 30 cases. Results: The en bloc resection rate and the complete resection rate in the whole series were 70% (42/60) and 72% (43/60), respectively. The en bloc resection rate in the first 30 cases was 53% (16/30) and that in the second 30 cases was 87% (26/30) (p=0.010). The complete resection rate in the first half was 60% (18/30) and that in the second half was 83% (25/30) (p=0.084). Residual tumors were found in 7 cases (12%) at follow-up biopsy, 3 in the first half and 4 in the second half. The mean procedure time of the first half was 27.0611.4 min and that of the second half was 20.168.2 min (p=0.01). The mean size of the tumor and that of the resection specimen were not significantly different between the first half and the second half (9.967.3 vs. 10.464.1 mm, 26.167.5 vs. 27.166.9 mm, respectively). Perforation occurred in 3 cases in the first half and in 1 case in the second half. Delayed bleeding that required additional endoscopic treatment occurred in 1 case in each group. Conclusions: EMR-P method is an effective treatment option for early gastric cancer. However, learning curve of about 30 cases might be required to perform efficient and safe EMR-P for early gastric cancer treatment.
VOLUME 59, NO. 5, 2004
*M1794 A New Procedure of En-Bloc Endoscopic Mucosal Resection (EMR) Using Improved Papillotomy Knife (MUCOSECTOME) Kawahara Yoshiro, Shigeatu Fujiki, Yasushi Shiratori Backgrounds: En-bloc resection is beneficial for accurate histological assessment of resected specimen of endoscopic mucosal resection (EMR). Variable EMR methods were developed. Conventional EMR technique or technique using Cap device method (EMRC) is technically simple and convenient but with this procedure the size of specimen obtained from one-piece resection is very limited. Insulated tipped knife procedure (IT knife) has already reported and it is actually useful to some expert endoscopists of it, but sometimes difficult for general endoscopist to use it safely. We newly developed a safe and easy technique of the en-bloc EMR using an improved papillotomy knife (Mucosectome). Device and methods: Mucosectome is an electrosurgical device, which is improved papillotomy knife for EMR. Mucosectome is composed with flexible plastic shaft and cutting wire. Traction applied on the handle manipulates the tip of the Mucosectome to assist in the proper alignment of the cutting wire to the tissue and then procedure itself becomes safe. Results. 35 cases of early gastric cancer patients received EMR using Mucosectome. En bloc resection of the lesion succeeded in 32 cases. The size of the resected specimen varied 20 to 65mm. Dissection of the submucosa was very easily and fastly carried out. Minor bleeding including oozing occurred in 14.2% and no perforation encountered. Conclusion: Here we present a new method of EMR using improved papillotomy knife (Mucosectome), which can realize safer, easier, and less time-consuming EMR compared to previous methods.
GASTROINTESTINAL ENDOSCOPY
P169
*M1793 The Magnified Endoscopic Finding of an Irregular Microvascular Pattern is a Very Useful Marker for Differentiating Between Gastritis and Gastric Cancer: A Prospective Study Kenshi Yao, Akinori Iwashita, Toshiyuki Matsui, Tsuneyoshi Yao, Keisuke Ikeda, Yasuhiro Takagi, Yosuke Kikuchi, Makoto Yorioka, Kanta Kikuma Aim: It is often difficult using standard endoscopy to make an endoscopic diagnosis of the flat type of early gastric cancer that mimics gastritis. We previously reported the magnified endoscopic findings of the microvascular architecture of differentiated type of flat reddened gastric carcinoma (Gastrointest Endosc 2002; 56: 279-84). The aim of this study was to investigate the diagnostic accuracy of these magnified endoscopic findings for differentiating between reddened mucosa due to gastritis and flat reddened gastric cancer, prospectively. Methods: 390 cases were included in this study. The patients received upper gastrointestinal endoscopic examination for the screening of gastric cancer by zoom endoscope GIF-Q240Z (Olympus, Tokyo, Japan). If a flat reddened lesion was detected by non-magnified observation, the lesion was subsequently magnified by a zooming attachment. Immediately after the examination, the following findings which have been reported to be characteristic of carcinoma were recorded. (1) Presence of a demarcation line between the reddened lesion and the surrounding mucosa, (2) Disappearance of a regular subepithelial capillary network pattern of the same shape as that within the surrounding mucosa, and (3) Proliferation of microvessels irregular in both shape and distribution (irregular microvascular pattern). According to the pathological diagnosis, the flat reddened lesions were divided into two groups, i.e. gastritis and carcinoma groups. The incidence and 95% confidence intervals (CI) of these findings were calculated for each of the respective groups. Results: 161 flat reddened lesions from 161 cases were detected. Pathologically, 123 lesions showed only gastritis, while 38 lesions were diagnosed as differentiated carcinoma. The incidence (95% CI) of the magnified endoscopic findings in gastritis vs. carcinoma was (1) 22.8% (15.4-30.2%) vs. 97.4% (92.3100%), (2) 19.5% (12.5-26.5%) vs. 100% and (3) 0.8% (0-2.4%) vs. 97.4% (92.3100%), respectively. As for the differential diagnosis of carcinoma from gastritis, the sensitivity and the specificity of the irregular microvascular pattern were 97.4 and 99.2, respectively. Conclusion: An irregular microvascular pattern visible by magnified endoscopy can be a very useful marker for differentiating between gastritis and carcinoma.
*M1792 Efficacy and Safety of Endoscopic Mucosal Resection Using Precut Method for Treatment of Early Gastric Cancer: Impact of Learning Curve Il Ju Choi, Hee Jin Chang, Hee Sung Kim, Chan Gyoo Kim, Jun Ho Lee, Keun Won Ryu, Young Woo Kim, Jae-Moon Bae Background: Endoscopic mucosal resection (EMR) is a treatment option for early gastric cancer with minimal risk of lymph node metastasis. Precut around a lesion during EMR facilitate en bloc resection which is an important determinant for complete resection of the tumor. We evaluated the efficacy and safety of EMR using precut and cut method (EMR-P) in relation to endoscopist’s experience. Methods: We describe the experience of 60 consecutive early gastric cancer cases which are treated by EMR-P method performed by one endoscopist from January, 2002 to September, 2003. After submucosal injection of 0.25% sodium hyaluronate solution, precut was performed around the lesion with conventional needle knife, and then, resection was performed using direct snaring without exfoliation. The en bloc resection rate, complete resection rate, procedure time, and associated complications were compared between the first 30 cases and the subsequent 30 cases. Results: The en bloc resection rate and the complete resection rate in the whole series were 70% (42/60) and 72% (43/60), respectively. The en bloc resection rate in the first 30 cases was 53% (16/30) and that in the second 30 cases was 87% (26/30) (p=0.010). The complete resection rate in the first half was 60% (18/30) and that in the second half was 83% (25/30) (p=0.084). Residual tumors were found in 7 cases (12%) at follow-up biopsy, 3 in the first half and 4 in the second half. The mean procedure time of the first half was 27.0611.4 min and that of the second half was 20.168.2 min (p=0.01). The mean size of the tumor and that of the resection specimen were not significantly different between the first half and the second half (9.967.3 vs. 10.464.1 mm, 26.167.5 vs. 27.166.9 mm, respectively). Perforation occurred in 3 cases in the first half and in 1 case in the second half. Delayed bleeding that required additional endoscopic treatment occurred in 1 case in each group. Conclusions: EMR-P method is an effective treatment option for early gastric cancer. However, learning curve of about 30 cases might be required to perform efficient and safe EMR-P for early gastric cancer treatment.
VOLUME 59, NO. 5, 2004
*M1794 A New Procedure of En-Bloc Endoscopic Mucosal Resection (EMR) Using Improved Papillotomy Knife (MUCOSECTOME) Kawahara Yoshiro, Shigeatu Fujiki, Yasushi Shiratori Backgrounds: En-bloc resection is beneficial for accurate histological assessment of resected specimen of endoscopic mucosal resection (EMR). Variable EMR methods were developed. Conventional EMR technique or technique using Cap device method (EMRC) is technically simple and convenient but with this procedure the size of specimen obtained from one-piece resection is very limited. Insulated tipped knife procedure (IT knife) has already reported and it is actually useful to some expert endoscopists of it, but sometimes difficult for general endoscopist to use it safely. We newly developed a safe and easy technique of the en-bloc EMR using an improved papillotomy knife (Mucosectome). Device and methods: Mucosectome is an electrosurgical device, which is improved papillotomy knife for EMR. Mucosectome is composed with flexible plastic shaft and cutting wire. Traction applied on the handle manipulates the tip of the Mucosectome to assist in the proper alignment of the cutting wire to the tissue and then procedure itself becomes safe. Results. 35 cases of early gastric cancer patients received EMR using Mucosectome. En bloc resection of the lesion succeeded in 32 cases. The size of the resected specimen varied 20 to 65mm. Dissection of the submucosa was very easily and fastly carried out. Minor bleeding including oozing occurred in 14.2% and no perforation encountered. Conclusion: Here we present a new method of EMR using improved papillotomy knife (Mucosectome), which can realize safer, easier, and less time-consuming EMR compared to previous methods.
GASTROINTESTINAL ENDOSCOPY
P169