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Sa1410 Efficacy of Counter-Traction Techniques for Gastric Endoscopic Submucosal Dissection: a Prospective, Comparative Study
Abstracts pneumoperitoneum (14.5%). The mean time of STER procedure was 56 ⫾ 38 minutes (range 15-200 minutes). Based on univariate and multivariate analysis, tumor size above 30 mm and irregular shape had significant impact on the complete resection rate of STER and on longer procedure times, which were also related to complication rate. Conclusion: STER is an effective and a safe method for the upper-GI SMTs smaller than 50 mm. In tumors with larger size and irregular shape, alternative methods can be discussed. STER for an esophageal leimyoma: A, EUS view of the tumor; B, Endoscopic view of the tumor; C, Endoscopic view of the tumor in the submucosal tunnel; D, The ulcer bed after STER; E, The mucosal entry closed by endoscopic clips; F, The tumor; G, The chest-CT image on the first day after STER; H, The control chest-CT image on the fourth day after STER and the third day after thoracic drainage; I, The endoscopic view during the follow-up in the 6 months after STER.
Sa1408 Usefulness of a Nanoshooter As a Tool for ESD of Narrow Organ Lumen With a TransNasal Endoscope Masakatsu Nakamura*1, Hisakazu Shiroeda1, Tomomitsu Tahara2, Tomoyuki Shibata2, Tomiyasu Arisawa1 1 Gastroenterology, Kanazawa Medical University, Kahoku, Japan; 2 Gastroenterology, Fujita Health University, Toyoake, Japan Background: The duodenal bulb is comprised of a narrow lumen and is considered to be a difficult site for endoscopic submucosal dissection (ESD). For performing ESD of this area with a transnasal endoscope, we have been using a home-made attachment hood (Gastric Cancer 2011 14:378-384). [Objectives]We speculated that this ESD technique employing a transnasal endoscope (TNE) would also be applicable to other hollow organs such as the esophagus (conventionally viewed as an organ for which distal dissection is technically difficult) and the pharynx (where ESD has conventionally been possible only under general anesthesia because of the vomiting reflex). With this expectation, we have developed a Nanoshooter (NS) (Top Co., Ltd.) for use in ESD with TNE. This attachment hood has the following characteristics: (1) equipped with water supply function, (2) equipped with an outlet for aspiration of the water pooled in the hood, and (3) minimal thickness of the attachment site to avoid an excessively large endoscope diameter. We present our data on the usefulness of this NS when used for the esophagus and pharynx, sites at which ESD has conventionally been difficult. Methods: ESD of the esophagus was first carried out in mini-pigs. On the basis of the results obtained, ESD was subsequently performed in patients with mesopharyngeal tumors. TNE used was EG-530N2 (Fujinon), a commercially available product, possessing a tip enabling ESD with a radiofrequency device but having no metallic attachment. Incision and dissection were carried out with a home-made pre-cutting knife. Hemostasis was achieved with home-made hemostasis forceps. ESD technique: Usually, esophageal lesions can be approached only in a direction from the proximal (oral) side to the distal (anal) side. However, the use of TNE allows inversion of the scope within the esophagus, enabling approaches from the distal point of the lesions. This is made possible by the thin and soft nature of the endoscope. Incision and dissection from the anal side are thereby possible, allowing safe and rapid ESD of the lesions at any site. When this technique is applied to cases with pharyngeal tumors, the endoscope is transnasally inserted under non-sedation. A 1:1 mixture of Xylocaine and sodium hyaluronate is topically injected, followed by incision and dissection. Conclusion: ESD with TNE appears to be very useful
www.giejournal.org
as a means of safely resecting esophageal lesions, and is less time-consuming than conventional procedures. This technique is also applicable to non-sedation ESD of the pharynx. Henceforth, ultra-minimally invasive non-sedation ESD of the esophagus, stomach and duodenum will be possible using this technique in high-risk patients with poor cardiopulmonary function. This technique may also give rise to the novel possibility of ultra-minimally invasive treatment in various other fields.
Sa1409 A Novel Submucosal Gel Facilitates ESD With Higher Rates of En Bloc Resection Vinay Chandrasekhara*1, Jillian Haac2, John C. Sigmon2, Aaron J. Small1, Michael L. Kochman1 1 Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, PA; 2Research & Development, Cook Endoscopy, Winston-Salem, NC Background: Endoscopic submucosal dissection (ESD) has been advocated for the treatment of GI luminal lesions due to its higher rate of en bloc resection compared to endoscopic mucosal resection (EMR). ESD has not been widely adopted in Western countries due to a lack of training, availability of necessary equipment, time required to perform the procedure, and higher risk of adverse events. A new gel that provides a durable submucosal lift (⬎60 min) has been developed to facilitate ESD. Aim: To determine if ESD with the Cook Medical gel increases the rate of en bloc resection with a favorable procedure duration and safety profile compared to EMR. Methods: EMR and ESD were performed in 8 Yorkshire pig stomachs in vivo by two interventional endoscopists who routinely perform EMR, but not ESD. A 2 cm length resection target was created using a snare with soft coagulation settings for tissue marking. The endoscopist was instructed to use as much injectate required to elevate and remove the entire lesion, with a goal of en bloc resection. EMR was performed using a submucosal injection of normal saline (NS) and a standard snare. The injectate for ESD utilized a NS starter submucosal bleb followed by submucosal delivery of Cook Medical gel. ESD resections were performed with a Triangle Tip knife (Olympus KD-640L) or a Hook Knife (Olympus KD-620LR). All resections were performed using an ERBE VIO 300 D electrosurgical generator with “Endocut Q” settings. Factors associated with the procedure and adverse event rates were recorded. Results: A total of 24 EMRs and 24 ESDs (6 resections per stomach) were performed. ESD with the Cook Medical gel resulted in a higher rate of en bloc resection (83.3% vs 29.2%, p⬍0.001) with fewer average resection specimens required for complete eradication (1.2⫹/⫺0.5 vs 2.4⫹/⫺1.2, p⫽0.0001) and a larger average surface area for the largest resected specimen (411mm2⫹/⫺175 vs 282mm2⫹/⫺206, p⫽0.03). There was one failed resection with EMR and none with ESD. Total volume of injectate was higher for ESD compared to EMR (6.7mL⫹/⫺0.9 vs 5.9mL⫹/⫺2.7, p⫽0.035). The mean time to perform ESD was higher than EMR (17.6 min⫹/⫺14.6 vs 5.7⫹/⫺3.7, p⬍0.0001). ESD was associated with a higher rate of bleeding (50% vs 4.1%, p⫽0.001) although 9/12 bleeding episodes with ESD were considered minor with spontaneous resolution. Perforation was not significantly higher with ESD (20.8% vs 12.5%, p⫽0.7). There were no identified factors associated with bleeding or perforation with ESD. Conclusions: 1. The Cook Medical gel is a new injectate that appears to facilitate en bloc ESD with larger average resection specimens compared to EMR.2. ESD with the Cook Medical gel requires an average of 12 minutes longer than conventional EMR; however, this is much faster than times reported by ESD experts for similar lesions resected with NS.
Sa1410 Efficacy of Counter-Traction Techniques for Gastric Endoscopic Submucosal Dissection: a Prospective, Comparative Study Jongchan Lee*1, Yunho Jung1, Masayuki Kato1, Mark a. Gromski1, RAM Chuttani1, Kai Matthes1,2 1 Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; 2Anesthesiology, Children’s Hospital Boston, Harvard Medical School, Boston, MA Background: The cutting line visualization is essential to perform an effective and safe gastric endoscopic submucosal dissection (ESD). Various techniques of counter-traction of the submucosal layer have been described. The aim of this study is to evaluate the peroral traction-assisted techniques using the sutured material and external grasping forceps. Method: A total of 66 cases of ESD were performed in fresh ex vivo porcine stomachs. 66 cases were divided into three groups. One is the conventional ESD group (n⫽22), another is the sutured material group (n⫽22), the other is external grasping forceps group (n⫽22). In the sutured material group, a hemoclip fastened with a white suture, was applied at the distal margin of the lesion. During dissection, the sutured material was pulled to the oral side gently. In the external grasping forceps group, a grasping forceps was introduced outside of the endoscope, with assistance of another grasping forceps in the accessory channel. Thereafter it grasped a site of the lesion suitable for counter-traction and it was pulled or pushed for achieving
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB195
Abstracts
good visualization of cutting line during dissection. Main outcome measurements were the cutting line of submucosal layer exposure rate during dissection (primary end point measure), procedure time, specimen size, submucosal injection frequency, and perforation rate (secondary end point measures). Results: The cutting line of submucosal layer exposure rate during dissection was significantly higher in the sutured material group (0.82 ⫾ 0.14 vs 0.44 ⫾ 0.15, P ⫽ .000) and external grasping forceps group (0.85 ⫾ 0.11 vs 0.44 ⫾ 0.15, P ⫽ .001) compared with the conventional ESD group. The mean procedure time was less in the sutured material group (24.2 ⫾ 8.9 minutes vs 35.1 ⫾ 13.2 minutes, P ⫽ .003) and external grasping forceps group (23.0 ⫾ 8.1 minutes vs 35.1 ⫾ 13.2 minutes, P ⫽ .001) compared with the conventional ESD group. Three perforations in the conventional ESD group and one perforation in external grasping forceps group developed. There were no significant differences in specimen size, submucosal injection requirement between the three groups. Conclusions: Counter-traction techniques using suture material or external grasping forceps allows endoscopists to achieve direct visualization of the cutting line of submucosal layer. These techniques are useful for more effective and safer ESD.
Sa1411 The Efficacy of Intralesional Infiltration of Bupivacaine Mixed With Triamcinolone Acetonide for Pain Relief After Endoscopic Submucosal Dissection: a Double-Blind, Three-Armed Randomized Controlled Trial Hyuk Lee*, Jun Chul Park, Sung Kwan Shin, Sang Kil Lee, Yong Chan Lee Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea Background and Aims: Endoscopic submucosal dissection (ESD) is the gold standard technique for performing en bloc resection of large superficial tumors in the upper and lower gastrointestinal tract. Very little is known about the management of epigastric pain after ESD for gastric neoplasm. This study aimed to investigate the utility and safety of intralesional infiltration of bupivacaine mixed with triamcinolone acetonide for pain relief after the operation. Method: This was a double-blind, three-armed randomized, controlled trial of intralesional infiltration of bupivacaine mixed with triamcinolone acetonide (BV-TA) after ESD for early gastric neoplasm, comparing the effectiveness of only bupivacaine infiltration (BV), and with a control group receiving placebo saline only (PL). Patients completed a questionnaire comprising the present pain intensity (PPI) and short-form McGill pain (SF-MP) score at immediate postoperative period, 6, 12, 24 hours after ESD. The primary outcomes variable was PPI measured at 6 hour after ESD. The secondary outcomes variables included pain medication, McGill pain score, complications, second-look endoscopic finding, and length of stay. Result: Ninety-nine patients receiving ESD for early gastric neoplasm participated. There was no significant difference in PPI measured immediately following the operation among three groups. The mean values of 6-hour PPI in BV-TA and BV group was lower than that of PL group (1.88⫾1.22 and 1.48⫾1.15 vs. 2.58⫾1.01, p⫽0.001). 12-hour PPI of BV-TA group (1.09⫾0.90) was lowest among three groups (p⬍0.001). The total 6-hour SF-MP score, especially in sensory domain, was higher in PL group than in BV and BV-TA groups (11.12⫾3.62 vs. 9.27⫾3.51 and 9.24⫾2.55, p⫽0.031), and 12-hour SF-MP score (5.76⫾2.00) was lowest in BV-TA group (p⬍0.001). Tramadol for pain relief was more frequently injected in PL group than BV and BV-TA groups (36.4% vs. 24.2% and 12.1%, p⫽0.071). No difference of length of stay was noted. The distribution of artificial ulcer patterns on second-look endoscopy performed 48 hours following ESD was similar among the groups. In addition, there were no intergroup differences in complications such as postoperative perforation or bleeding. Conclusion: Intralesional infiltration of bupivacaine after ESD was effective for epigastric pain relief at 6-hour postoperatively. Especially, intralesional infiltration of bupivacaine mixed with triamcinolone acetonide was helpful for getting more long-lasting benefit of pain relief after gastric ESD.
Sa1412 Simplified Endoscopic Submucosal Dissection for Resection of Early Gastrointestinal Tumors: a One Year Experience in a Single Tertiary Medical Centre in Northern of Italy Edi Viale, Chiara Notaristefano*, Pier Alberto Testoni San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy Background: gastrointestinal early neoplasm exceeding 20 mm in diameter must often be removed with piecemeal endoscopic mucosal resection (EMR). Endoscopic submucosal dissection (ESD) is a therapeutic procedure developed to enable the en bloc resection regardless of size and shape of lesions, but its technical difficulties, its longer procedure time and increased risk of perforation limit the widespread in the treatment of colorectal and duodenal neoplasms.
Aim: to assess the clinical outcome of ESD with snaring (ESD-S), a simplified modification of ESD in removing early stage of colorectal and duodenal tumors in a single, tertiary-care, referral centre. Patients and Methods: From September 2011 to October 2012 ESD-S was performed in 15 patients (mean age 65 years, SD ⫾ 17.5). They were consecutively enrolled and retrospectively analyzed. All lesions were non peduncolated colorectal and duodenal neoplasia ⱖ 20 mm. Procedures were performed by a single endoscopist and by using a snaring technique. After the injection of glycerol, epinephrine and indigo carmine into the submucosal layer, a circumferential incision was performed using the needle knife, and the neoplasm was resected by snaring. Results: 15 lesions were resected with ESD-S: 5 in duodenum and 10 colonrectum. The mean lesion size was 30 mm (range 20-80 mm). The mean time and SD for ESD-S was 44.7 ⫾ 12.2 minutes. The en bloc resection rate was 93%, only in one case it was not possible because of poor lifting related to submucosal fibrosis from previous biopsies: we obtained two pieces. Two submucosal cancers (sm1) were present: one in duodenum and one in rectum. One intra-procedure bleeding occurred and it required surgical intervention, there were no perforations. Follow up after ESD-S was at 6 and 12 months and a small amount of recurrence duodenal adenoma was evident in one case at 6 months and it was treated with thermal ablation. Conclusions: In our experience ESD-S is a safe, effective and relatively rapid technique for resection of gastrointestinal lesions with a low risk of complications and low incidence of incomplete resections.
Sa1413 Treatment of Gastric Dysplasia and Metaplasia by Endoscopic Radiofrequency Ablation: a Feasibility Study Wai K Leung*1, Daniel K. Tong2, Suet-Yi Leung3, Fion S. Chan2, Teresa Tong1, Ivan F. Hung1, Kent-Man Chu2, Simon Law2 1 Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong; 2Department of Surgery, University of Hong Kong, Hong Kong, Hong Kong; 3Department of Pathology, University of Hong Kong, Hong Kong, Hong Kong Introduction: Patients with pre-neoplastic gastric lesions including intestinal metaplasia (IM) and dysplasia are at increased risk of developing gastric cancer. Endoscopic radiofrequency ablation (RFA) has been successfully used in the eradication of dysplasia and IM associated with Barrett’s esophagus. We tested the feasibility of using RFA for the treatment of dysplasia and IM in the stomach. Methods: Patients who had histologically confirmed gastric dysplasia or IM were recruited. All patients had H. pylori eradicated prior to RFA. Gastroscopy was performed by high definition endoscope with narrow band imaging and chromoendoscopy. Gastric pre-neoplastic lesions should be endoscopically visible, well defined and not raised. Ablation was performed using a HALO90 catheter (Covidien GI Solutions) attached to gastroscope and conducted under direct visualization until the target gastric mucosal lesions were treated. All procedures were performed on an outpatient basis under intravenous sedation. Endoscopy and RFA was repeated at 8 week intervals for a maximum of 3 sessions or when there were no further endoscopically visible lesions. All patients were followed up by endoscopy at 6 and 12 months post-RFA. During follow up examination, reference to previous tattoo marks and video-recordings were made to ensure accurate localization of previous RFA treated lesions. Areas suspicious for dysplasia and/or metaplasia were biopsied for histological examination. The primary outcome was the complete eradication of dysplasia and/or IM. The secondary outcome was improvement in grading of IM as stipulated in updated Sydney Classification. The histological assessment was made by two pathologists who were blinded to the sequences of the biopsy samples. Results: A total of 12 patients were recruited (median age 73 years; 7 male). Four patients had low-grade dysplasia (LGD) and the remaining 8 patients had non-dysplastic IM at baseline. Up to the time of writing this abstract, a total of 25 treatment sessions were applied and 4 patients had completed 3 sessions of RFA. Nine patients, including 2 patients with LGD, had completed their 6month follow up endoscopy and 5 patients had completed their 12-month follow up. Complete eradication of dysplasia was noted in both patients with LGD at baseline (100%). The severity of IM improved in 6 (67%) patients and the remaining 3 patients showed no interval changes on histology at 6-months. At 12-months, 3 (60%) patients had histological improvement in IM. Most patients tolerated the procedure well, except one patient who had a minor mucosal laceration of the cricopharyngeus during insertion of the catheter. Conclusion: Radiofrequency ablation successfully eradicated low-grade dysplasia of the stomach. Gastric IM persisted with RFA treatment, but most showed histological improvement on follow up.
AB196 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
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Sa1408 Usefulness of a Nanoshooter As a Tool for ESD of Narrow Organ Lumen With a TransNasal Endoscope Masakatsu Nakamura*1, Hisakazu Shiroeda1, Tomomitsu Tahara2, Tomoyuki Shibata2, Tomiyasu Arisawa1 1 Gastroenterology, Kanazawa Medical University, Kahoku, Japan; 2 Gastroenterology, Fujita Health University, Toyoake, Japan Background: The duodenal bulb is comprised of a narrow lumen and is considered to be a difficult site for endoscopic submucosal dissection (ESD). For performing ESD of this area with a transnasal endoscope, we have been using a home-made attachment hood (Gastric Cancer 2011 14:378-384). [Objectives]We speculated that this ESD technique employing a transnasal endoscope (TNE) would also be applicable to other hollow organs such as the esophagus (conventionally viewed as an organ for which distal dissection is technically difficult) and the pharynx (where ESD has conventionally been possible only under general anesthesia because of the vomiting reflex). With this expectation, we have developed a Nanoshooter (NS) (Top Co., Ltd.) for use in ESD with TNE. This attachment hood has the following characteristics: (1) equipped with water supply function, (2) equipped with an outlet for aspiration of the water pooled in the hood, and (3) minimal thickness of the attachment site to avoid an excessively large endoscope diameter. We present our data on the usefulness of this NS when used for the esophagus and pharynx, sites at which ESD has conventionally been difficult. Methods: ESD of the esophagus was first carried out in mini-pigs. On the basis of the results obtained, ESD was subsequently performed in patients with mesopharyngeal tumors. TNE used was EG-530N2 (Fujinon), a commercially available product, possessing a tip enabling ESD with a radiofrequency device but having no metallic attachment. Incision and dissection were carried out with a home-made pre-cutting knife. Hemostasis was achieved with home-made hemostasis forceps. ESD technique: Usually, esophageal lesions can be approached only in a direction from the proximal (oral) side to the distal (anal) side. However, the use of TNE allows inversion of the scope within the esophagus, enabling approaches from the distal point of the lesions. This is made possible by the thin and soft nature of the endoscope. Incision and dissection from the anal side are thereby possible, allowing safe and rapid ESD of the lesions at any site. When this technique is applied to cases with pharyngeal tumors, the endoscope is transnasally inserted under non-sedation. A 1:1 mixture of Xylocaine and sodium hyaluronate is topically injected, followed by incision and dissection. Conclusion: ESD with TNE appears to be very useful
www.giejournal.org
as a means of safely resecting esophageal lesions, and is less time-consuming than conventional procedures. This technique is also applicable to non-sedation ESD of the pharynx. Henceforth, ultra-minimally invasive non-sedation ESD of the esophagus, stomach and duodenum will be possible using this technique in high-risk patients with poor cardiopulmonary function. This technique may also give rise to the novel possibility of ultra-minimally invasive treatment in various other fields.
Sa1409 A Novel Submucosal Gel Facilitates ESD With Higher Rates of En Bloc Resection Vinay Chandrasekhara*1, Jillian Haac2, John C. Sigmon2, Aaron J. Small1, Michael L. Kochman1 1 Gastroenterology Division, University of Pennsylvania Health System, Philadelphia, PA; 2Research & Development, Cook Endoscopy, Winston-Salem, NC Background: Endoscopic submucosal dissection (ESD) has been advocated for the treatment of GI luminal lesions due to its higher rate of en bloc resection compared to endoscopic mucosal resection (EMR). ESD has not been widely adopted in Western countries due to a lack of training, availability of necessary equipment, time required to perform the procedure, and higher risk of adverse events. A new gel that provides a durable submucosal lift (⬎60 min) has been developed to facilitate ESD. Aim: To determine if ESD with the Cook Medical gel increases the rate of en bloc resection with a favorable procedure duration and safety profile compared to EMR. Methods: EMR and ESD were performed in 8 Yorkshire pig stomachs in vivo by two interventional endoscopists who routinely perform EMR, but not ESD. A 2 cm length resection target was created using a snare with soft coagulation settings for tissue marking. The endoscopist was instructed to use as much injectate required to elevate and remove the entire lesion, with a goal of en bloc resection. EMR was performed using a submucosal injection of normal saline (NS) and a standard snare. The injectate for ESD utilized a NS starter submucosal bleb followed by submucosal delivery of Cook Medical gel. ESD resections were performed with a Triangle Tip knife (Olympus KD-640L) or a Hook Knife (Olympus KD-620LR). All resections were performed using an ERBE VIO 300 D electrosurgical generator with “Endocut Q” settings. Factors associated with the procedure and adverse event rates were recorded. Results: A total of 24 EMRs and 24 ESDs (6 resections per stomach) were performed. ESD with the Cook Medical gel resulted in a higher rate of en bloc resection (83.3% vs 29.2%, p⬍0.001) with fewer average resection specimens required for complete eradication (1.2⫹/⫺0.5 vs 2.4⫹/⫺1.2, p⫽0.0001) and a larger average surface area for the largest resected specimen (411mm2⫹/⫺175 vs 282mm2⫹/⫺206, p⫽0.03). There was one failed resection with EMR and none with ESD. Total volume of injectate was higher for ESD compared to EMR (6.7mL⫹/⫺0.9 vs 5.9mL⫹/⫺2.7, p⫽0.035). The mean time to perform ESD was higher than EMR (17.6 min⫹/⫺14.6 vs 5.7⫹/⫺3.7, p⬍0.0001). ESD was associated with a higher rate of bleeding (50% vs 4.1%, p⫽0.001) although 9/12 bleeding episodes with ESD were considered minor with spontaneous resolution. Perforation was not significantly higher with ESD (20.8% vs 12.5%, p⫽0.7). There were no identified factors associated with bleeding or perforation with ESD. Conclusions: 1. The Cook Medical gel is a new injectate that appears to facilitate en bloc ESD with larger average resection specimens compared to EMR.2. ESD with the Cook Medical gel requires an average of 12 minutes longer than conventional EMR; however, this is much faster than times reported by ESD experts for similar lesions resected with NS.
Sa1410 Efficacy of Counter-Traction Techniques for Gastric Endoscopic Submucosal Dissection: a Prospective, Comparative Study Jongchan Lee*1, Yunho Jung1, Masayuki Kato1, Mark a. Gromski1, RAM Chuttani1, Kai Matthes1,2 1 Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; 2Anesthesiology, Children’s Hospital Boston, Harvard Medical School, Boston, MA Background: The cutting line visualization is essential to perform an effective and safe gastric endoscopic submucosal dissection (ESD). Various techniques of counter-traction of the submucosal layer have been described. The aim of this study is to evaluate the peroral traction-assisted techniques using the sutured material and external grasping forceps. Method: A total of 66 cases of ESD were performed in fresh ex vivo porcine stomachs. 66 cases were divided into three groups. One is the conventional ESD group (n⫽22), another is the sutured material group (n⫽22), the other is external grasping forceps group (n⫽22). In the sutured material group, a hemoclip fastened with a white suture, was applied at the distal margin of the lesion. During dissection, the sutured material was pulled to the oral side gently. In the external grasping forceps group, a grasping forceps was introduced outside of the endoscope, with assistance of another grasping forceps in the accessory channel. Thereafter it grasped a site of the lesion suitable for counter-traction and it was pulled or pushed for achieving
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB195
Abstracts
good visualization of cutting line during dissection. Main outcome measurements were the cutting line of submucosal layer exposure rate during dissection (primary end point measure), procedure time, specimen size, submucosal injection frequency, and perforation rate (secondary end point measures). Results: The cutting line of submucosal layer exposure rate during dissection was significantly higher in the sutured material group (0.82 ⫾ 0.14 vs 0.44 ⫾ 0.15, P ⫽ .000) and external grasping forceps group (0.85 ⫾ 0.11 vs 0.44 ⫾ 0.15, P ⫽ .001) compared with the conventional ESD group. The mean procedure time was less in the sutured material group (24.2 ⫾ 8.9 minutes vs 35.1 ⫾ 13.2 minutes, P ⫽ .003) and external grasping forceps group (23.0 ⫾ 8.1 minutes vs 35.1 ⫾ 13.2 minutes, P ⫽ .001) compared with the conventional ESD group. Three perforations in the conventional ESD group and one perforation in external grasping forceps group developed. There were no significant differences in specimen size, submucosal injection requirement between the three groups. Conclusions: Counter-traction techniques using suture material or external grasping forceps allows endoscopists to achieve direct visualization of the cutting line of submucosal layer. These techniques are useful for more effective and safer ESD.
Sa1411 The Efficacy of Intralesional Infiltration of Bupivacaine Mixed With Triamcinolone Acetonide for Pain Relief After Endoscopic Submucosal Dissection: a Double-Blind, Three-Armed Randomized Controlled Trial Hyuk Lee*, Jun Chul Park, Sung Kwan Shin, Sang Kil Lee, Yong Chan Lee Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea Background and Aims: Endoscopic submucosal dissection (ESD) is the gold standard technique for performing en bloc resection of large superficial tumors in the upper and lower gastrointestinal tract. Very little is known about the management of epigastric pain after ESD for gastric neoplasm. This study aimed to investigate the utility and safety of intralesional infiltration of bupivacaine mixed with triamcinolone acetonide for pain relief after the operation. Method: This was a double-blind, three-armed randomized, controlled trial of intralesional infiltration of bupivacaine mixed with triamcinolone acetonide (BV-TA) after ESD for early gastric neoplasm, comparing the effectiveness of only bupivacaine infiltration (BV), and with a control group receiving placebo saline only (PL). Patients completed a questionnaire comprising the present pain intensity (PPI) and short-form McGill pain (SF-MP) score at immediate postoperative period, 6, 12, 24 hours after ESD. The primary outcomes variable was PPI measured at 6 hour after ESD. The secondary outcomes variables included pain medication, McGill pain score, complications, second-look endoscopic finding, and length of stay. Result: Ninety-nine patients receiving ESD for early gastric neoplasm participated. There was no significant difference in PPI measured immediately following the operation among three groups. The mean values of 6-hour PPI in BV-TA and BV group was lower than that of PL group (1.88⫾1.22 and 1.48⫾1.15 vs. 2.58⫾1.01, p⫽0.001). 12-hour PPI of BV-TA group (1.09⫾0.90) was lowest among three groups (p⬍0.001). The total 6-hour SF-MP score, especially in sensory domain, was higher in PL group than in BV and BV-TA groups (11.12⫾3.62 vs. 9.27⫾3.51 and 9.24⫾2.55, p⫽0.031), and 12-hour SF-MP score (5.76⫾2.00) was lowest in BV-TA group (p⬍0.001). Tramadol for pain relief was more frequently injected in PL group than BV and BV-TA groups (36.4% vs. 24.2% and 12.1%, p⫽0.071). No difference of length of stay was noted. The distribution of artificial ulcer patterns on second-look endoscopy performed 48 hours following ESD was similar among the groups. In addition, there were no intergroup differences in complications such as postoperative perforation or bleeding. Conclusion: Intralesional infiltration of bupivacaine after ESD was effective for epigastric pain relief at 6-hour postoperatively. Especially, intralesional infiltration of bupivacaine mixed with triamcinolone acetonide was helpful for getting more long-lasting benefit of pain relief after gastric ESD.
Sa1412 Simplified Endoscopic Submucosal Dissection for Resection of Early Gastrointestinal Tumors: a One Year Experience in a Single Tertiary Medical Centre in Northern of Italy Edi Viale, Chiara Notaristefano*, Pier Alberto Testoni San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy Background: gastrointestinal early neoplasm exceeding 20 mm in diameter must often be removed with piecemeal endoscopic mucosal resection (EMR). Endoscopic submucosal dissection (ESD) is a therapeutic procedure developed to enable the en bloc resection regardless of size and shape of lesions, but its technical difficulties, its longer procedure time and increased risk of perforation limit the widespread in the treatment of colorectal and duodenal neoplasms.
Aim: to assess the clinical outcome of ESD with snaring (ESD-S), a simplified modification of ESD in removing early stage of colorectal and duodenal tumors in a single, tertiary-care, referral centre. Patients and Methods: From September 2011 to October 2012 ESD-S was performed in 15 patients (mean age 65 years, SD ⫾ 17.5). They were consecutively enrolled and retrospectively analyzed. All lesions were non peduncolated colorectal and duodenal neoplasia ⱖ 20 mm. Procedures were performed by a single endoscopist and by using a snaring technique. After the injection of glycerol, epinephrine and indigo carmine into the submucosal layer, a circumferential incision was performed using the needle knife, and the neoplasm was resected by snaring. Results: 15 lesions were resected with ESD-S: 5 in duodenum and 10 colonrectum. The mean lesion size was 30 mm (range 20-80 mm). The mean time and SD for ESD-S was 44.7 ⫾ 12.2 minutes. The en bloc resection rate was 93%, only in one case it was not possible because of poor lifting related to submucosal fibrosis from previous biopsies: we obtained two pieces. Two submucosal cancers (sm1) were present: one in duodenum and one in rectum. One intra-procedure bleeding occurred and it required surgical intervention, there were no perforations. Follow up after ESD-S was at 6 and 12 months and a small amount of recurrence duodenal adenoma was evident in one case at 6 months and it was treated with thermal ablation. Conclusions: In our experience ESD-S is a safe, effective and relatively rapid technique for resection of gastrointestinal lesions with a low risk of complications and low incidence of incomplete resections.
Sa1413 Treatment of Gastric Dysplasia and Metaplasia by Endoscopic Radiofrequency Ablation: a Feasibility Study Wai K Leung*1, Daniel K. Tong2, Suet-Yi Leung3, Fion S. Chan2, Teresa Tong1, Ivan F. Hung1, Kent-Man Chu2, Simon Law2 1 Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong; 2Department of Surgery, University of Hong Kong, Hong Kong, Hong Kong; 3Department of Pathology, University of Hong Kong, Hong Kong, Hong Kong Introduction: Patients with pre-neoplastic gastric lesions including intestinal metaplasia (IM) and dysplasia are at increased risk of developing gastric cancer. Endoscopic radiofrequency ablation (RFA) has been successfully used in the eradication of dysplasia and IM associated with Barrett’s esophagus. We tested the feasibility of using RFA for the treatment of dysplasia and IM in the stomach. Methods: Patients who had histologically confirmed gastric dysplasia or IM were recruited. All patients had H. pylori eradicated prior to RFA. Gastroscopy was performed by high definition endoscope with narrow band imaging and chromoendoscopy. Gastric pre-neoplastic lesions should be endoscopically visible, well defined and not raised. Ablation was performed using a HALO90 catheter (Covidien GI Solutions) attached to gastroscope and conducted under direct visualization until the target gastric mucosal lesions were treated. All procedures were performed on an outpatient basis under intravenous sedation. Endoscopy and RFA was repeated at 8 week intervals for a maximum of 3 sessions or when there were no further endoscopically visible lesions. All patients were followed up by endoscopy at 6 and 12 months post-RFA. During follow up examination, reference to previous tattoo marks and video-recordings were made to ensure accurate localization of previous RFA treated lesions. Areas suspicious for dysplasia and/or metaplasia were biopsied for histological examination. The primary outcome was the complete eradication of dysplasia and/or IM. The secondary outcome was improvement in grading of IM as stipulated in updated Sydney Classification. The histological assessment was made by two pathologists who were blinded to the sequences of the biopsy samples. Results: A total of 12 patients were recruited (median age 73 years; 7 male). Four patients had low-grade dysplasia (LGD) and the remaining 8 patients had non-dysplastic IM at baseline. Up to the time of writing this abstract, a total of 25 treatment sessions were applied and 4 patients had completed 3 sessions of RFA. Nine patients, including 2 patients with LGD, had completed their 6month follow up endoscopy and 5 patients had completed their 12-month follow up. Complete eradication of dysplasia was noted in both patients with LGD at baseline (100%). The severity of IM improved in 6 (67%) patients and the remaining 3 patients showed no interval changes on histology at 6-months. At 12-months, 3 (60%) patients had histological improvement in IM. Most patients tolerated the procedure well, except one patient who had a minor mucosal laceration of the cricopharyngeus during insertion of the catheter. Conclusion: Radiofrequency ablation successfully eradicated low-grade dysplasia of the stomach. Gastric IM persisted with RFA treatment, but most showed histological improvement on follow up.
AB196 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
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