- Email: [email protected]
Sa1650 Clinical Outcomes of Endoscopic Resection for Treating Extremely Well Differentiated Intestinal-Type Adenocarcinoma (WHYX Lesion)
Abstracts
is especially high in patients given both anti-platelet agents and anticoagulants, and with such patients precautionary 3rd or 4th EGD is essential. It is also suggested that, when PPIs are given, MPAs reduce post-ESD hemorrhage risk.
operation. Although minor bleeding and a longer procedure time were disadvantages, there were no severe complications. PEG with gastropexy seems to be a safe and feasible method for reducing early complications of PEG.
Sa1647 Clinical and Endoscopic Characteristics of Gastric Tumors Diagnosed in Serial Screening Endoscopy Hyoun Woo Kang*1, Hyoung Jung Na1, Jae Hak Kim1, Jun Kyu Lee1, Yun Jeong Lim1, Moon Soo Koh1, Jin Ho Lee1, Eo-Jin Kim2 1 Internal Medicine, Dongguk University College of Medicine, Goyang, Republic of Korea; 2Pathology, Dongguk University College of Medicine, Goyang, Republic of Korea
Sa1649 Clinical Implication of Endoscopic Gross Appearance in Early Gastric Cancer: Revisited Yoo Mi Park*1, Da Hyun Jung1, Jie-Hyun Kim1, Yong Chan Lee3, Young Hoon Youn1, Hyojin Park1, Sang In Lee1, Jong Won Kim2, Seung Ho Choi2, Woo Jin Hyung4, Sung Hoon Noh4 1 Deparment of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; 2 Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; 3Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; 4Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
Background: Although biennial upper endoscopy is recommended for screening gastric cancer in Korea, there has been little study on the characteristics of clinical and endoscopic characteristics of gastric tumors diagnosed in screening endoscopy. Material and Methods: We retrospectively reviewed clinical and endoscopic characteristics of gastric cancer or adenoma cases which were diagnosed as during serial screening endoscopy and in which prediagnostic endoscopy was negative from October 2005 to July 2011 at our hospital. Clinical characteristics including mean follow up periods and endoscopic characteristics including location, pathology and prediagnostic endoscopic findings were analyzed. Results: A total of 56 lesions with a histologic diagnosis of gastric epithelial neoplasms (31 early gastric cancers, 4 advanced gastric cancers and 21 gastric adenomas) were included. All cases were consecutively treated with endoscopic submucosal dissection or operation. Mean interval between two endoscopies was 688 day (1501775 day), so we divided into less than 2 years group (n⫽33) and more than 2 years groups (n⫽20) by interval between 2 serial examinations. The locations of tumors were antrum 31, body 23 and cardia 2. The initial endoscopic findings were normal 3, gastritis 5, erosion 7, ulcer 7, atrophy 23, and intestinal metaplasia 11. The initial pathologic findings were Helicobacter pylori colonization 68.4% (13/19), neutrophils 52.6 % (10/19), mononuclear cells 84.2% (16/19), atrophy 94.7% (18/19), and intestinal metaplasia 68.8%(11/19). Among 53 cases(except 3 cases due to follow up loss), 3 patients were not cured because of metastasis at the time of diagnosis or recurrence during follow up period. In less than 2 years group, all patients were cured, but in more than 2 years group, 2 patients had distant metastasis at the time of diagnosis and 1 patient had recurrence during follow up period. It showed the statistical difference (p⫽0.022). Conclusions: In conclusions, findings of atrophy during screening upper endoscopy, especially in location of antrum, should necessitate precautious follow up endoscopy. Screening endoscopy for cancer detection may be done within every 2 years.
Sa1648 Percutaneous Endoscopic Gastrostomy With Gastropexy Greatly Reduces the Risk of Peristomal Infection and Eases Pain After the Operation Naoki Okumura*1, Naoko Tsuji1, Norio Yamamoto1, Masatoshi Kudo2 1 Gastroenterology, Sakai Hospital Kinki University Faculty of Medicine, Sakai, Japan; 2Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka sayama, Japan Introduction/Objectives: Peristomal wound infections and pain are common complications of percutaneous endoscopic gastrostomy (PEG). A gastropexy kit consists of two parallel needles with a wire loop and suture thread, and was developed about 20 years ago in Japan. With this kit it is possible to perform a dual gastropexy very easily. PEG with gastropexy has become a very popular technique in Japan. Aims & Methods: The present study aims to assess the advantages and disadvantages of PEG with the gastropexy technique compared to the standard pull method. The study included 178 consecutive patients undergoing PEG in our hospital, and a comparative study was made between the gastropexy group (87 patients) and non-gastropexy group (91 patients). All patients had a blood test and an abdominal CT scan before the procedure. Results: There were no statistical differences between groups with respect to the clinical background, i.e., gender and age distributions, basic illnesses, and albumin. The success rates in both groups were 100%. The rates of patients with erythema in the peristomal area (10% vs. 48%, P⬍0.01), exudates (3% vs. 13%, P⬍0.05) and ulceration (0% vs. 2%) were lower in the gastropexy group. The rate of minor bleeding from the peristomal area was higher in the gastropexy group (11% vs. 2%, P⬍0.05), but no patient required a blood transfusion. Overall procedure times were longer in the gastropexy group (14 min to 72 min with a mean of 31 min compared to 6 min to 77 min with a mean of 23 min, P⬍0.01). The rate of patients who had a fever of 38 degrees or more after the operation was lower in the gastropexy group (14% vs. 35%,P⬍0.001). The 30-day mortality rates were 6% and 5%, respectively, and these deaths were not related to the gastrostomy procedure. Among the patients whom could express their intentions, the rate of patients whom used medication two times or more at the time of pain was lower in the gastropexy group (11% vs. 22%, P⬍0.05). Conclusion: PEG with gastropexy markedly reduces peristomal infection and eases the pain after
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Background/Aims: Macroscopic appearance of early gastric cancer (EGC) is known to reflect growth pattern of the cancer. Thus, endoscopic appearance may have the role as a predictor of clinical behavior of the cancer. The aim of study was to investigate clinical behavior according to endoscopic appearance in EGC. Methods: Between January 2005 and December 2008, 1,845 patients were diagnosed as EGC and underwent surgery. The clinicopathologic characteristics were analyzed according to endoscopic gross appearance. Endoscopic findings were classified by predominant type as elevated, flat and depressed type. Flat and depressed types were categorized into non-elevated type. Results: The proportion of elevated, flat, and depressed type was 16.6%, 28.6%, and 54.8%, respectively. Elevated type was predominant gross appearance in well/moderate differentiation, whereas flat and depressed type in signet ring cell and poorly differentiation respectively. When compared between elevated and non-elevated types, submucosal invasion, lymphovascular invasion (LVI), and lymph node metastasis (LNM) were higher in elevated type than non-elevated type. In differentiated EGC, submucosal invasion, LVI, LNM, and multiplicity were significantly higher in elevated type than non-elevated type. These patterns were significantly common in order from elevated, depressed, and flat type. In undifferentiated EGC, submucosal invasion, LVI, and perineural invasion were significantly higher in elevated type than non-elevated type. These patterns were significantly common in order from elevated, depressed, and flat type. However, LNM was not significantly different according to gross appearance in undifferentiated EGC. Conclusions: Clinical behavior was different according to endoscopic appearance in EGC. Endoscopic appearance of EGC may be helpful to predict clinical behavior, especially differentiated EGC.
Sa1650 Clinical Outcomes of Endoscopic Resection for Treating Extremely Well Differentiated Intestinal-Type Adenocarcinoma (WHYX Lesion) Jun Hee Lee*1, Joon Seong Ahn1, Ja Ryong Jeon1, Yoon Jung Lee1, Ki Joo Kang1, Kyoung-Mee Kim2, Byung Hoon MIN1, Jong Chul Rhee1, Young-Ho Kim1, Jae J Kim1 1 Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; 2Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea Background: Extremely well-differentiated intestinal-type adenocarcinoma of the stomach, also known as “WHYX’ cancer shows surface maturation and mimics intestinal metaplasia. Endoscopically, WHYX cancers demonstrated a vague extent of tumor spread due to pale color changes in both the background atrophic and metaplastic gastric mucosa. However, the clinical outcomes of WHYX cancers after endoscopic resection are unknown. The aim of this study was to evaluate clinical outcomes of WHYX cancers after endoscopic resection. Methods: This study was a retrospective study from January 2009 to December 2010 in a single center. Endoscopically suspected tumor size, final pathological tumor size, endoscopic finding, and clinical outcomes after endoscopic resection were analyzed. Results: Of 872 patients, 17 WHYX cancers were identified. In the endoscopic findings, flat or depressed type was significantly frequent in WHYX cancers (88.2%) compared to others (37.8%) (p⬍0.01). Average size discrepancy between final pathological tumor size and endoscopically suspected tumor size was significantly larger in WHYX cancers (18.35 ⫾ 21.95mm) than others (5.82 ⫾ 7.48mm). The frequency of lateral resection margin involvement was significantly higher in WHYX cancers (29.4% vs 2.5% for non-WHYX cancers) (p⬍0.05) and complete resection was achieved significantly less often in WHYX cancers (47.1% vs 80.4% for non-WHYX cancers) (p⫽0.01). Conclusions: WHYX cancers demonstrated higher frequencies of incomplete resection, especially with positive lateral resection margin caused by vague tumor margin after ESD procedure. Thus, endoscopists should pay particular attention to the
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB233
Abstracts
extent of the tumor on the WHYX cancers. Key Word: Endoscopic submucosal dissection, WHYX, Lateral resection margin, Complete.
Sa1651 Rate of Lymph Node Metastasis and Outcome of Endoscopic Resection for High Grade Dysplasia and Superficial Adenocarcinoma of the Esophagogastric Junction Masayoshi Yamada*1,2, Ichiro Oda1, Satoru Nonaka1, Haruhisa Suzuki1, Shigetaka Yoshinaga1, Yutaka Saito1, Hirokazu Taniguchi2, Shigeki Sekine2, Ryoji Kushima2 1 Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; 2 Pathology Division, National Cancer Center Hospital, Tokyo, Japan Background: In the esophagogastoric junction (EGJ), high grade dysplasia (HGD) and intramucosal adenocarcinoma are generally treated by endoscopic resection (ER). There have been a few reports about ER for minute submucosal adenocarcinoma. The aim of this study is to investigate the possibility of ER for minute submucosal adenocarcinoma based on rate of lymph node metastasis (LNM) of surgical cases and outcome after ER at the EGJ. Material and methods: 1. We reviewed 69 consecutive surgically resected cases of HGD and superficial carcinomas (T1) (M/F⫽56/13, median age 66 years old (33-85), median tumor size 28 mm (7-97), and Barrett’s adenocarcinoma (BA)/non-BA 33/36) and analyzed the rate of LNM.2. We reviewed 78 consecutive endoscopically resected cases (M/F⫽67/11, median age 68 years old (39-88), median tumor size 19mm (3-63), BA/non-BA 32/46) and analyzed the outcome of ER. We defined HGD and adenocarcinoma of the EGJ when the tumor was classified as Siewert type II. Depth of invasion was divided into HGD/mucosa (M) (excluding muscularis mucosae (MM)), MM, submucosa 1 (SM1) (⬍ 500 m into the submucosa) and SM2 (ⱖ 500 m). Histological types were divided into two groups; intestinal or diffuse type, by major histological features. We defined curative resection (CR) as a tumor with HGD/M/MM/SM1, intestinal type, negative for lymphovascular (ly/ v) invasion and negative margins. Results: 1. The rates of LNM were 14.5% (10/ 69) for all cases, 0% (0/5) for M, 14.3% (1/7) for MM, 0% (0/13) for SM1, 20.5% (9/44) for SM2. The rates of LNM were 36.8% (7/19) / 6% (3/50) for positive / negative of the ly/v invasion (p⬍0.01). The rates of LNM were 12.9% (8/62) / 28.6% (2/7) for intestinal / diffuse type, 13.3% (4/30) / 15.4% (6/39) for ⱖ 3cm / ⬍ 3cm in size, 15.2% (5/33) / 13.9% (5/36) for BA / non-BA, respectively. The MM carcinoma with lymph node metastasis had a ly/v invasion.2. En-bloc resection, en-bloc with R0 resection and CR rates were 97.4% (76/78), 82.1% (64/ 78) and 68.0% (53/78), respectively. Median procedure time was 75 minutes (20480). Perforation and stenosis occurred in 1.3% (1/78) and 10.3% (8/78), respectively. All of these cases were treated successfully with endoscopy. None of the patients with CR had recurrence with 3.4 years (0.2-10) of median followup period. The 3-year survival rate of the patients with CR was 100%. However, two patients with non-CR (SM2) died of the disease. One patient had a local recurrence 4 years after additional surgical treatment and another patient, who refused additional surgical treatment, developed lung metastasis 3 years after the ER. Conclusions: ER of superficial adenocarcinoma of EGJ may be indicated for SM1 or less tumor with intestinal type adenocarcinoma. Additional surgical treatment should be subsequently required in cases with ly/v invasion and/or tumor invasion into SM2 after ER.
Sa1652 What are the Unsuccessful Factors of Endoscopic Hemostasis for Upper GI Bleeding? Kouichi Tabei*, Masao Toki, Isamu Kurata, Yasuhito Uchida, Tomohiko Hasue, Kenji Nakamura, Yasuharu Yamaguchi, Shin’Ichi Takahashi Kyorin Univ. School of Medicine, Tokyo, Japan Objective: The efficacy of endoscopic hemostasis for upper GI bleeding is already established. However we also have a few uncontrolled patients required transarterial embolization (TAE) and/or surgical treatment after endoscopic procedure. The purpose of this study was to evaluate the risk factors for endoscopic failure in the view of clinical and endoscopic characteristics. Methods: Between January 1993 and June 2009, endoscopic hemostasis was carried out in 904 patients. These patients were divided into two groups: successful endoscopic hemostasis group (success group) and unsuccessful endoscopic hemostasis group (unsuccess group). The clinical data, endoscopic findings and outcomes of endoscopic treatment were compared between these two groups. The clinical variables (age, gender, smoking, alcohol, NSAID intake, anticoagulant intake, concomitant disease, ulcer history, presence of shock, transfusion over 6 units, inpatient or outpatient status, hemoglobin and serum albumin concentration at endoscopic hemostasis), and endoscopic characteristics of ulcers (size, number and site of ulcers, the severity of initial bleeding) were compared between two groups. Multivariate analysis was performed using a logistic regression model expressed as odds ratio in 95% confidential interval. Results: Among 904 patients, 881 cases (97.5%) were successful with endoscopic procedure (success group). The remaining 23 cases (2.4%) required TAE and/or
surgical operation (unsuccess group). These 23 in unsuccess group consist of 12 cases with duodenal ulcer, 4 cases with gastric ulcer, 3 cases with neoplastic disease, 1 case with aneurysm rupture, 1 case with duodenal diverticulum and 2 cases with ignorance. Twenty one cases in unsuccess group were ultimately treated by TAE (91.3%) and 1 case (4.3%) by operation. These 5 cases (21.7%) died for upper GI bleeding in unsuccess group. Multivariate analysis showed that bleeding lesion existing distal part of duodenal 2nd portion (OR:9.6, 95% CI: 2.437.7, p⬍0.01), elderly patient over 80 years old (OR:8.9, 95% CI: 1-12.4, P⬍0.01), anti-coagulant therapy (OR:7.1, 95% CI: 1.0-17.3, P⫽0.05), presence of shock (OR:5.9, 95% CI:5-20.0, p⬍0.05) were significant risk factor for endoscopic falure. Conclusion: Serious risk of unsuccessful cases required TAE and/or operation after endoscopic hemostasis for GI bleeding can be predicted by checking clinical variables, patients background and endoscopic findings. The endoscopist should consider the treatment strategies such as TAE or operation for the upper GI bleeding patients with above predictive risk factors.
Sa1653 Comparison Among Double-Layered, Uncovered, and Covered Stent for Treatment of Malignant Gastric Outlet Obstruction: Suggestion of Ideal Stent as Initial Intervention Da Hyun Jung*1, Chan Ik Park1, Jie-Hyun Kim1, Yong Chan Lee2, Jaehoon Jahng1, Young Hoon Youn1, Hyojin Park1, Sang In Lee1 1 Deparment of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; 2 Deparment of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea Background/Aims: Self-expandable metal stents (SEMSs) are effective palliation for malignant gastric outlet obstruction. Double-layered (Comvi) SEMSs were developed to overcome limitations of uncovered or covered SEMSs. The aims of study were to evaluate efficacy and safety of Comvi stent compared with uncovered and covered stents, and to determine the factors related to stent patency. Methods: We retrospectively reviewed data from 224 patients (uncovered, 128; covered, 64; Comvi, 32) with gastric cancer who underwent endoscopic SEMSs placement from January 2006 to July 2011. Technical and clinical success rates were evaluated and clinical outcomes were compared according to stent types. Stent ingrowth, migration, and patency were evaluated. Results: Technical and clinical success were achieved in 99.6% and 80.4% without immediate complications. Clinical success rate was not significantly different among uncovered, covered, and Comvi groups. The median stent patency time was 156⫾16.9 days without differences among three groups. The overall 4, 8, 12-week patency rates were 89.4%, 77.3%, and 61.2%, respectively with no differences among three groups. Stent migration was significantly common in order from Comvi, covered, and uncovered stent. However, stent ingrowth was not significantly different among three groups. Chemotherapy significantly lowered re-intervention rates, especially in uncovered stent. Conclusions: Comvi SEMSs was not more effective than other SEMSs. For diminishing early migration and late ingrowth, uncovered SEMSs with chemotherapy may be the most effective initial intervention in gastric outlet obstruction.
Sa1654 Short- and Long-Term Prognosis of Patients With Early Gastric Cancer: Comparative Analysis Between Endoscopic Submucosal Dissection and Surgical Operation Shusei Fukunaga*1, Hirohisa Machida1, Kazunari Tominaga1, Hiroaki Tanaka2, Kazuya Muguruma2, Masaichi Ohira2, Yasuaki Nagami1, Satoshi Sugimori1, Hirotoshi Okazaki1, Tetsuya Tanigawa1, Hirokazu Yamagami1, Kenji Watanabe1, Toshio Watanabe1, Yasuhiro Fujiwara1, Kosei Hirakawa2, Tetsuo Arakawa1 1 Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan; 2Department of Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan Background: Few studies have reported the long-term outcomes of patients with early gastric cancer (EGC) after endoscopic submucosal dissection (ESD). Aim: Herein, we aimed to investigate the short- and long-term outcomes of patients with EGC in comparative analysis between ESD and surgical operation. Patients and methods: In this study, we included 167 patients with EGC who had undergone ESD between 2003 and November 2007, and 120 patients who had undergone surgery (SRG) between 1998 and 2007 at our hospital. The lesions were assigned into the standard indication (SI) and expanded indication (EI) groups after pathological examination, according to the Japanese Treatment Guidelines for gastric cancer. In patients with simultaneous multiple lesions, the first lesion or the dominant lesion (on the basis of size) was evaluated. All patients were followed up for at least 3 years after the treatment. We retrospectively compared the clinical outcomes of ESD for EGC with those of
AB234 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org
is especially high in patients given both anti-platelet agents and anticoagulants, and with such patients precautionary 3rd or 4th EGD is essential. It is also suggested that, when PPIs are given, MPAs reduce post-ESD hemorrhage risk.
operation. Although minor bleeding and a longer procedure time were disadvantages, there were no severe complications. PEG with gastropexy seems to be a safe and feasible method for reducing early complications of PEG.
Sa1647 Clinical and Endoscopic Characteristics of Gastric Tumors Diagnosed in Serial Screening Endoscopy Hyoun Woo Kang*1, Hyoung Jung Na1, Jae Hak Kim1, Jun Kyu Lee1, Yun Jeong Lim1, Moon Soo Koh1, Jin Ho Lee1, Eo-Jin Kim2 1 Internal Medicine, Dongguk University College of Medicine, Goyang, Republic of Korea; 2Pathology, Dongguk University College of Medicine, Goyang, Republic of Korea
Sa1649 Clinical Implication of Endoscopic Gross Appearance in Early Gastric Cancer: Revisited Yoo Mi Park*1, Da Hyun Jung1, Jie-Hyun Kim1, Yong Chan Lee3, Young Hoon Youn1, Hyojin Park1, Sang In Lee1, Jong Won Kim2, Seung Ho Choi2, Woo Jin Hyung4, Sung Hoon Noh4 1 Deparment of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; 2 Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; 3Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; 4Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
Background: Although biennial upper endoscopy is recommended for screening gastric cancer in Korea, there has been little study on the characteristics of clinical and endoscopic characteristics of gastric tumors diagnosed in screening endoscopy. Material and Methods: We retrospectively reviewed clinical and endoscopic characteristics of gastric cancer or adenoma cases which were diagnosed as during serial screening endoscopy and in which prediagnostic endoscopy was negative from October 2005 to July 2011 at our hospital. Clinical characteristics including mean follow up periods and endoscopic characteristics including location, pathology and prediagnostic endoscopic findings were analyzed. Results: A total of 56 lesions with a histologic diagnosis of gastric epithelial neoplasms (31 early gastric cancers, 4 advanced gastric cancers and 21 gastric adenomas) were included. All cases were consecutively treated with endoscopic submucosal dissection or operation. Mean interval between two endoscopies was 688 day (1501775 day), so we divided into less than 2 years group (n⫽33) and more than 2 years groups (n⫽20) by interval between 2 serial examinations. The locations of tumors were antrum 31, body 23 and cardia 2. The initial endoscopic findings were normal 3, gastritis 5, erosion 7, ulcer 7, atrophy 23, and intestinal metaplasia 11. The initial pathologic findings were Helicobacter pylori colonization 68.4% (13/19), neutrophils 52.6 % (10/19), mononuclear cells 84.2% (16/19), atrophy 94.7% (18/19), and intestinal metaplasia 68.8%(11/19). Among 53 cases(except 3 cases due to follow up loss), 3 patients were not cured because of metastasis at the time of diagnosis or recurrence during follow up period. In less than 2 years group, all patients were cured, but in more than 2 years group, 2 patients had distant metastasis at the time of diagnosis and 1 patient had recurrence during follow up period. It showed the statistical difference (p⫽0.022). Conclusions: In conclusions, findings of atrophy during screening upper endoscopy, especially in location of antrum, should necessitate precautious follow up endoscopy. Screening endoscopy for cancer detection may be done within every 2 years.
Sa1648 Percutaneous Endoscopic Gastrostomy With Gastropexy Greatly Reduces the Risk of Peristomal Infection and Eases Pain After the Operation Naoki Okumura*1, Naoko Tsuji1, Norio Yamamoto1, Masatoshi Kudo2 1 Gastroenterology, Sakai Hospital Kinki University Faculty of Medicine, Sakai, Japan; 2Gastroenterology and Hepatology, Kinki University Faculty of Medicine, Osaka sayama, Japan Introduction/Objectives: Peristomal wound infections and pain are common complications of percutaneous endoscopic gastrostomy (PEG). A gastropexy kit consists of two parallel needles with a wire loop and suture thread, and was developed about 20 years ago in Japan. With this kit it is possible to perform a dual gastropexy very easily. PEG with gastropexy has become a very popular technique in Japan. Aims & Methods: The present study aims to assess the advantages and disadvantages of PEG with the gastropexy technique compared to the standard pull method. The study included 178 consecutive patients undergoing PEG in our hospital, and a comparative study was made between the gastropexy group (87 patients) and non-gastropexy group (91 patients). All patients had a blood test and an abdominal CT scan before the procedure. Results: There were no statistical differences between groups with respect to the clinical background, i.e., gender and age distributions, basic illnesses, and albumin. The success rates in both groups were 100%. The rates of patients with erythema in the peristomal area (10% vs. 48%, P⬍0.01), exudates (3% vs. 13%, P⬍0.05) and ulceration (0% vs. 2%) were lower in the gastropexy group. The rate of minor bleeding from the peristomal area was higher in the gastropexy group (11% vs. 2%, P⬍0.05), but no patient required a blood transfusion. Overall procedure times were longer in the gastropexy group (14 min to 72 min with a mean of 31 min compared to 6 min to 77 min with a mean of 23 min, P⬍0.01). The rate of patients who had a fever of 38 degrees or more after the operation was lower in the gastropexy group (14% vs. 35%,P⬍0.001). The 30-day mortality rates were 6% and 5%, respectively, and these deaths were not related to the gastrostomy procedure. Among the patients whom could express their intentions, the rate of patients whom used medication two times or more at the time of pain was lower in the gastropexy group (11% vs. 22%, P⬍0.05). Conclusion: PEG with gastropexy markedly reduces peristomal infection and eases the pain after
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Background/Aims: Macroscopic appearance of early gastric cancer (EGC) is known to reflect growth pattern of the cancer. Thus, endoscopic appearance may have the role as a predictor of clinical behavior of the cancer. The aim of study was to investigate clinical behavior according to endoscopic appearance in EGC. Methods: Between January 2005 and December 2008, 1,845 patients were diagnosed as EGC and underwent surgery. The clinicopathologic characteristics were analyzed according to endoscopic gross appearance. Endoscopic findings were classified by predominant type as elevated, flat and depressed type. Flat and depressed types were categorized into non-elevated type. Results: The proportion of elevated, flat, and depressed type was 16.6%, 28.6%, and 54.8%, respectively. Elevated type was predominant gross appearance in well/moderate differentiation, whereas flat and depressed type in signet ring cell and poorly differentiation respectively. When compared between elevated and non-elevated types, submucosal invasion, lymphovascular invasion (LVI), and lymph node metastasis (LNM) were higher in elevated type than non-elevated type. In differentiated EGC, submucosal invasion, LVI, LNM, and multiplicity were significantly higher in elevated type than non-elevated type. These patterns were significantly common in order from elevated, depressed, and flat type. In undifferentiated EGC, submucosal invasion, LVI, and perineural invasion were significantly higher in elevated type than non-elevated type. These patterns were significantly common in order from elevated, depressed, and flat type. However, LNM was not significantly different according to gross appearance in undifferentiated EGC. Conclusions: Clinical behavior was different according to endoscopic appearance in EGC. Endoscopic appearance of EGC may be helpful to predict clinical behavior, especially differentiated EGC.
Sa1650 Clinical Outcomes of Endoscopic Resection for Treating Extremely Well Differentiated Intestinal-Type Adenocarcinoma (WHYX Lesion) Jun Hee Lee*1, Joon Seong Ahn1, Ja Ryong Jeon1, Yoon Jung Lee1, Ki Joo Kang1, Kyoung-Mee Kim2, Byung Hoon MIN1, Jong Chul Rhee1, Young-Ho Kim1, Jae J Kim1 1 Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; 2Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea Background: Extremely well-differentiated intestinal-type adenocarcinoma of the stomach, also known as “WHYX’ cancer shows surface maturation and mimics intestinal metaplasia. Endoscopically, WHYX cancers demonstrated a vague extent of tumor spread due to pale color changes in both the background atrophic and metaplastic gastric mucosa. However, the clinical outcomes of WHYX cancers after endoscopic resection are unknown. The aim of this study was to evaluate clinical outcomes of WHYX cancers after endoscopic resection. Methods: This study was a retrospective study from January 2009 to December 2010 in a single center. Endoscopically suspected tumor size, final pathological tumor size, endoscopic finding, and clinical outcomes after endoscopic resection were analyzed. Results: Of 872 patients, 17 WHYX cancers were identified. In the endoscopic findings, flat or depressed type was significantly frequent in WHYX cancers (88.2%) compared to others (37.8%) (p⬍0.01). Average size discrepancy between final pathological tumor size and endoscopically suspected tumor size was significantly larger in WHYX cancers (18.35 ⫾ 21.95mm) than others (5.82 ⫾ 7.48mm). The frequency of lateral resection margin involvement was significantly higher in WHYX cancers (29.4% vs 2.5% for non-WHYX cancers) (p⬍0.05) and complete resection was achieved significantly less often in WHYX cancers (47.1% vs 80.4% for non-WHYX cancers) (p⫽0.01). Conclusions: WHYX cancers demonstrated higher frequencies of incomplete resection, especially with positive lateral resection margin caused by vague tumor margin after ESD procedure. Thus, endoscopists should pay particular attention to the
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB233
Abstracts
extent of the tumor on the WHYX cancers. Key Word: Endoscopic submucosal dissection, WHYX, Lateral resection margin, Complete.
Sa1651 Rate of Lymph Node Metastasis and Outcome of Endoscopic Resection for High Grade Dysplasia and Superficial Adenocarcinoma of the Esophagogastric Junction Masayoshi Yamada*1,2, Ichiro Oda1, Satoru Nonaka1, Haruhisa Suzuki1, Shigetaka Yoshinaga1, Yutaka Saito1, Hirokazu Taniguchi2, Shigeki Sekine2, Ryoji Kushima2 1 Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan; 2 Pathology Division, National Cancer Center Hospital, Tokyo, Japan Background: In the esophagogastoric junction (EGJ), high grade dysplasia (HGD) and intramucosal adenocarcinoma are generally treated by endoscopic resection (ER). There have been a few reports about ER for minute submucosal adenocarcinoma. The aim of this study is to investigate the possibility of ER for minute submucosal adenocarcinoma based on rate of lymph node metastasis (LNM) of surgical cases and outcome after ER at the EGJ. Material and methods: 1. We reviewed 69 consecutive surgically resected cases of HGD and superficial carcinomas (T1) (M/F⫽56/13, median age 66 years old (33-85), median tumor size 28 mm (7-97), and Barrett’s adenocarcinoma (BA)/non-BA 33/36) and analyzed the rate of LNM.2. We reviewed 78 consecutive endoscopically resected cases (M/F⫽67/11, median age 68 years old (39-88), median tumor size 19mm (3-63), BA/non-BA 32/46) and analyzed the outcome of ER. We defined HGD and adenocarcinoma of the EGJ when the tumor was classified as Siewert type II. Depth of invasion was divided into HGD/mucosa (M) (excluding muscularis mucosae (MM)), MM, submucosa 1 (SM1) (⬍ 500 m into the submucosa) and SM2 (ⱖ 500 m). Histological types were divided into two groups; intestinal or diffuse type, by major histological features. We defined curative resection (CR) as a tumor with HGD/M/MM/SM1, intestinal type, negative for lymphovascular (ly/ v) invasion and negative margins. Results: 1. The rates of LNM were 14.5% (10/ 69) for all cases, 0% (0/5) for M, 14.3% (1/7) for MM, 0% (0/13) for SM1, 20.5% (9/44) for SM2. The rates of LNM were 36.8% (7/19) / 6% (3/50) for positive / negative of the ly/v invasion (p⬍0.01). The rates of LNM were 12.9% (8/62) / 28.6% (2/7) for intestinal / diffuse type, 13.3% (4/30) / 15.4% (6/39) for ⱖ 3cm / ⬍ 3cm in size, 15.2% (5/33) / 13.9% (5/36) for BA / non-BA, respectively. The MM carcinoma with lymph node metastasis had a ly/v invasion.2. En-bloc resection, en-bloc with R0 resection and CR rates were 97.4% (76/78), 82.1% (64/ 78) and 68.0% (53/78), respectively. Median procedure time was 75 minutes (20480). Perforation and stenosis occurred in 1.3% (1/78) and 10.3% (8/78), respectively. All of these cases were treated successfully with endoscopy. None of the patients with CR had recurrence with 3.4 years (0.2-10) of median followup period. The 3-year survival rate of the patients with CR was 100%. However, two patients with non-CR (SM2) died of the disease. One patient had a local recurrence 4 years after additional surgical treatment and another patient, who refused additional surgical treatment, developed lung metastasis 3 years after the ER. Conclusions: ER of superficial adenocarcinoma of EGJ may be indicated for SM1 or less tumor with intestinal type adenocarcinoma. Additional surgical treatment should be subsequently required in cases with ly/v invasion and/or tumor invasion into SM2 after ER.
Sa1652 What are the Unsuccessful Factors of Endoscopic Hemostasis for Upper GI Bleeding? Kouichi Tabei*, Masao Toki, Isamu Kurata, Yasuhito Uchida, Tomohiko Hasue, Kenji Nakamura, Yasuharu Yamaguchi, Shin’Ichi Takahashi Kyorin Univ. School of Medicine, Tokyo, Japan Objective: The efficacy of endoscopic hemostasis for upper GI bleeding is already established. However we also have a few uncontrolled patients required transarterial embolization (TAE) and/or surgical treatment after endoscopic procedure. The purpose of this study was to evaluate the risk factors for endoscopic failure in the view of clinical and endoscopic characteristics. Methods: Between January 1993 and June 2009, endoscopic hemostasis was carried out in 904 patients. These patients were divided into two groups: successful endoscopic hemostasis group (success group) and unsuccessful endoscopic hemostasis group (unsuccess group). The clinical data, endoscopic findings and outcomes of endoscopic treatment were compared between these two groups. The clinical variables (age, gender, smoking, alcohol, NSAID intake, anticoagulant intake, concomitant disease, ulcer history, presence of shock, transfusion over 6 units, inpatient or outpatient status, hemoglobin and serum albumin concentration at endoscopic hemostasis), and endoscopic characteristics of ulcers (size, number and site of ulcers, the severity of initial bleeding) were compared between two groups. Multivariate analysis was performed using a logistic regression model expressed as odds ratio in 95% confidential interval. Results: Among 904 patients, 881 cases (97.5%) were successful with endoscopic procedure (success group). The remaining 23 cases (2.4%) required TAE and/or
surgical operation (unsuccess group). These 23 in unsuccess group consist of 12 cases with duodenal ulcer, 4 cases with gastric ulcer, 3 cases with neoplastic disease, 1 case with aneurysm rupture, 1 case with duodenal diverticulum and 2 cases with ignorance. Twenty one cases in unsuccess group were ultimately treated by TAE (91.3%) and 1 case (4.3%) by operation. These 5 cases (21.7%) died for upper GI bleeding in unsuccess group. Multivariate analysis showed that bleeding lesion existing distal part of duodenal 2nd portion (OR:9.6, 95% CI: 2.437.7, p⬍0.01), elderly patient over 80 years old (OR:8.9, 95% CI: 1-12.4, P⬍0.01), anti-coagulant therapy (OR:7.1, 95% CI: 1.0-17.3, P⫽0.05), presence of shock (OR:5.9, 95% CI:5-20.0, p⬍0.05) were significant risk factor for endoscopic falure. Conclusion: Serious risk of unsuccessful cases required TAE and/or operation after endoscopic hemostasis for GI bleeding can be predicted by checking clinical variables, patients background and endoscopic findings. The endoscopist should consider the treatment strategies such as TAE or operation for the upper GI bleeding patients with above predictive risk factors.
Sa1653 Comparison Among Double-Layered, Uncovered, and Covered Stent for Treatment of Malignant Gastric Outlet Obstruction: Suggestion of Ideal Stent as Initial Intervention Da Hyun Jung*1, Chan Ik Park1, Jie-Hyun Kim1, Yong Chan Lee2, Jaehoon Jahng1, Young Hoon Youn1, Hyojin Park1, Sang In Lee1 1 Deparment of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; 2 Deparment of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea Background/Aims: Self-expandable metal stents (SEMSs) are effective palliation for malignant gastric outlet obstruction. Double-layered (Comvi) SEMSs were developed to overcome limitations of uncovered or covered SEMSs. The aims of study were to evaluate efficacy and safety of Comvi stent compared with uncovered and covered stents, and to determine the factors related to stent patency. Methods: We retrospectively reviewed data from 224 patients (uncovered, 128; covered, 64; Comvi, 32) with gastric cancer who underwent endoscopic SEMSs placement from January 2006 to July 2011. Technical and clinical success rates were evaluated and clinical outcomes were compared according to stent types. Stent ingrowth, migration, and patency were evaluated. Results: Technical and clinical success were achieved in 99.6% and 80.4% without immediate complications. Clinical success rate was not significantly different among uncovered, covered, and Comvi groups. The median stent patency time was 156⫾16.9 days without differences among three groups. The overall 4, 8, 12-week patency rates were 89.4%, 77.3%, and 61.2%, respectively with no differences among three groups. Stent migration was significantly common in order from Comvi, covered, and uncovered stent. However, stent ingrowth was not significantly different among three groups. Chemotherapy significantly lowered re-intervention rates, especially in uncovered stent. Conclusions: Comvi SEMSs was not more effective than other SEMSs. For diminishing early migration and late ingrowth, uncovered SEMSs with chemotherapy may be the most effective initial intervention in gastric outlet obstruction.
Sa1654 Short- and Long-Term Prognosis of Patients With Early Gastric Cancer: Comparative Analysis Between Endoscopic Submucosal Dissection and Surgical Operation Shusei Fukunaga*1, Hirohisa Machida1, Kazunari Tominaga1, Hiroaki Tanaka2, Kazuya Muguruma2, Masaichi Ohira2, Yasuaki Nagami1, Satoshi Sugimori1, Hirotoshi Okazaki1, Tetsuya Tanigawa1, Hirokazu Yamagami1, Kenji Watanabe1, Toshio Watanabe1, Yasuhiro Fujiwara1, Kosei Hirakawa2, Tetsuo Arakawa1 1 Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan; 2Department of Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan Background: Few studies have reported the long-term outcomes of patients with early gastric cancer (EGC) after endoscopic submucosal dissection (ESD). Aim: Herein, we aimed to investigate the short- and long-term outcomes of patients with EGC in comparative analysis between ESD and surgical operation. Patients and methods: In this study, we included 167 patients with EGC who had undergone ESD between 2003 and November 2007, and 120 patients who had undergone surgery (SRG) between 1998 and 2007 at our hospital. The lesions were assigned into the standard indication (SI) and expanded indication (EI) groups after pathological examination, according to the Japanese Treatment Guidelines for gastric cancer. In patients with simultaneous multiple lesions, the first lesion or the dominant lesion (on the basis of size) was evaluated. All patients were followed up for at least 3 years after the treatment. We retrospectively compared the clinical outcomes of ESD for EGC with those of
AB234 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
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