- Email: [email protected]
Sa1676 Endoscopic Examination of Synchronous or Metachronous Multiple Gastric Tumors After the Initial Endoscopic Submucosal Dissection for Early Gastric Cancer or Gastric Adenoma
Abstracts
as cotherapies resulted in microcytic anemia due to potential bleeding in some patients. Therefore, in those patients, antiulcer therapies even for EPUs may be of considerable practical value.
Sa1672 Hemostatic Forceps As a Rescue Therapy for Bleeding Peptic Ulcer: A Case Series Pei-Yuan Su, Hsu-Heng Yen, Chia-Wei Yang, Shun-Sheng Wu, Wei-Wen Su, Maw-Soan Soon Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan Background: Standard endoscopic management of bleeding peptic ulcer includes the use of injection, thermal coagulation or mechanical clipping. The use of hemostatic forceps has been increased with the widespread use of ESD to control bleeding during the ESD procedure. There are few reports using hemostatic forceps to control peptic ulcer bleeding. Objective: Our aim in this study was to describe the efficacy and complication while using hemostatic forceps as a rescue therapy for bleeding peptic ulcer. Design: Retrospective, single-institution case series. Patients: This study involved 5 patients received hemostatic forceps coagulation as a rescue therapy in our instutition. Intervention Hemostatic forceps as hemostatic tool for bleeding peptic ulcer. Main Outcome Measurements and Results: During Jan 2010 to Oct 2011, 427 patients received endoscopic therapy for bleeding peptic ulcer in our institution. Five patients received hemostasis with hemostatic forceps as a rescue therapy after failure of the standard endoscopic therapy. Four patients had successful hemostasis and one patient received emergent surgery. Limitations: The study is limited in retrospective nature and involved only small case series. To generalization of the outcomes may require more large scale study. Conclusions: Hemostatic forceps is a useful alternative to control peptic ulcer bleeding after failed standard endoscopic treatment. The patients may be prevented from emergent surgery. Further large scale studies are required to confirm our observation.
Sa1673 Feasibility of Endoscopic Submucosal Dissection for Elderly Patients With Early Gastric Cancer Jun Konishi, Nozomu Kobayashi, Ryuzo Sekiguchi Depertment of Diagnostic Imaging, Tochigi Cancer Center, Utunomiya, Japan Background and aim: Endoscopic submucosal dissection (ESD) has been widespread as a standard treatment for early gastric cancer (EGC) in Japan. Although some authors have reported on gastric ESD for elder patients, the efficacy and safety is still unclear. We investigated the feasibility of gastric ESD for elderly patients comparing with non-elderly patients. Methods: A total of 393 EGCs in 343 patients were treated with ESD at our center from April 2005 to march 2009. Elderly patient was defined as 75 year-old or older, and consequently 137 lesions in 121 elderly patients and 255 lesions in 218 nonelderly patients were enrolled. ESD was performed when the lesion was diagnosed as follows: differentiated mucosal cancer without ulcerative change, differentiated mucosal cancer with ulcerative change 3cm or less in size, differentiated minute submucosal cancer 3cm or less in size. We assessed the rate of en bloc resection, complete resection, additional surgery and complications in two groups. Results: The en block resection rate was 94% the in the elderly group (129/137) and 96% in the non-elderly group (250/255), and the curative resection rate was 81% (111/136) in the elderly group and 79% (203/ 255) in the non-elderly group. Of 75 non-curative resection patients, 11 (44%) of elderly patients and 22 (44%) of non-elderly patients received additional surgery. Perforations were observed in 7 (3%) cases in the elderly group and 9 (4%) in non-elderly group, and 4 bleedings(3%) after procedure were observed in the elderly group and 6 (2%) in non-elderly group. There is no significant difference between the two groups. Conclusion: ESD is an efficient and safe technique for elderly patients with EGC.
Sa1674 A Brazilian Designed Self-Expandable Metal Stent (SEMS) for Endoscopic Palliation of Malignant Gastric Outlet Obstruction: Report of 6 Cases Wagner Colaiacovo, Emiliano D. Almodova, Aldenir Fresca, Denise P. Guimaraes, Liza M. Alvarenga, Alessandrino T. Oliveira, Gilberto Fava Endoscopy, Hospital de Câncer de Barretos, Barretos, Brazil Background and Aims: SEMS has been used as a safe alternative to surgery for palliation of malignant gastric outlet obstruction (GOO). Herein we describe the use of a Brazilian designed SEMS (Braile Oncology, Brazil) in the palliative management of 6 patients with unresectable neoplasm obstructing the antro-
www.giejournal.org
pyloric region. Methods: We developed an uncovered SEMS with a novel design funnel shape like and a large luminal diameter to improve gastric emptying of malignant GOO. The stent is made of nitinol where a maximum diameter of 50mm is reached at the proximal end and 30mm at the distal end and 50mm length. The stent is mounted on a delivery system with an outer diameter of 24Fr. All procedures were performed under combined endoscopic and fluoroscopic guidance. The endoscope could be passed through the lesion in all but one case and a stiff guidewire was placed beyond the stricture by using a standard ERCP catheter. Tumor margins were marked by needle injections of radiopaque contrast. Proper stent placement and established patency after deployment was assessed by endoscopy and fluoroscopy. Results: SEMS were placed in 6 consecutives patients (median age, 76.5, range 67-84 years; 3 women and 3 men) with unresecable malignant GOO. Stent implantation was technically successful in 6 (100%) patients. Twenty-four hours post stent placement, fluoroscopic study demonstrated luminal patency and expanded stent in 5 (83.3%) of 6 cases. Clinical success with relief of symptoms was achieved in 5 (83.3%) of 6 cases immediately after placement of SEMS. In one patient, the stent was not fully expanded. There were no procedure-related deaths. The median stent patency period was 85 days (range, 25-260 days). Four patients died (one of distal obstruction and three of caquexia) 25-168 days (median, 84 days) after stent placement. One patient is still alive and has no symptoms 260 days after stent placement. Tumor ingrowth occurred in 2 patients after 25 and 36 days without re-obstruction. One patient had stent oclusion by distal overgrowth on 62 days after the procedure. He was managed by placement of an additional uncovered stent. Conclusion: This novel designed stent appears to be safe and effective approach for the palliation of malignant GOO. Although placement of this new device was successful, through-the-scope (TTS) stent with a design funnel shape like is expected to optimize stent placement with good results on palliation of malignant GOO.
Sa1675 Ex-Vivo Evaluation of a Prototype Submucosal Biopsy Forceps for the Diagnosis of Gastric Gastrointestinal Stromal Tumors Peter Darwin1, Jeffrey Laczek2, Nader Hanna1, William S. Twaddell1 1 University of Maryland, Baltimore, MD; 2Tripler Army Medical Center, Honolulu, HI Background: Pathologic conformation is required for the endoscopic diagnosis of gastrointestinal stromal tumors (GIST). A variety of methods to obtain tissue have been described including endoscopic ultrasound (EUS) guided aspiration, bite on bite cold biopsy and submucosal incision assisted direct biopsy. Each method has potential limitations, including the inability to obtain definitive cytology or mitotic index from aspiration cytology and difficulty sampling submucosal lesions by the bite on bite technique. Aim: Evaluate the ability of a prototype submucosal biopsy forceps to make a histologic diagnosis and mitotic index determination in cases of resected gastric GIST. Methods: Prior to suspected or documented gastric GIST surgical resection, an IRB approved consent was obtained. Post tumor removal, an investigational submucosal biopsy forceps and sheath (Olympus America XB01-998-5/6) was passed under directed vision into the central portion of the lesion. From 3 to 5 passes were placed in formalin for research evaluation. The gross resection specimen was then sectioned and processed for routine histology. A GI pathologist evaluated the research biopsies and a comparison was made to the resection histology. The pathologist was blinded as to the mitotic count for the final resected specimen. Results: In all 3 cases, the research biopsies confirmed a diagnosis of GIST. The mitotic index comparison (research biopsy vs standard final pathology) for each case was; 1/ 25 high power field (hpf) with a final of 7/50, 1 mitosis/26 hpf with a final of 3/50 and 6/50 hpf with a final of 6/50. Based upon the mitotic index from the research biopsies, there would have been no change in tumor risk estimate in 2/3 cases with 1/3 upgraded from very low to moderate. Discussion: In an ex vivo setting, this novel submucosal biopsy forceps was able to obtain tissue to document GIST and provide an accurate mitotic index in 2/3 cases. The finite number of hpf obtained is a limitation of this technique. While additional comparison to other sampling modalities including yield and risks will be needed, this submucosal biopsy forceps has potential to aid in the endoscopic diagnosis of GIST.
Sa1676 Endoscopic Examination of Synchronous or Metachronous Multiple Gastric Tumors After the Initial Endoscopic Submucosal Dissection for Early Gastric Cancer or Gastric Adenoma Tomohiro Kato1,2, Hiroshi Araki2, Fumito Onogi2, Takashi Ibuka2, Akihiko Sugiyama1, Eiichi Tomita1, Hisataka Moriwaki2 1 Gastroenterology, Gifu Municipal Hospital, Gifu-city, Japan; 2 Gastroenterology, Gifu University Hospital, Gifu-city, Japan (Background) Endoscopic submucosal dissection (ESD) has been indicated for early gastric cancer (EGC) and gastric adenoma (GA) to obtain en bloc
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB241
Abstracts
specimens. Synchronous or metachronous tumors have been observed during follow-up after the initial ESD procedure, and it remains unclear when we should perform the endoscopic examination to find new gastric tumors. In this study, we analyzed retrospectively the period between the first and second ESD to try to establish guidelines for the adequate surveillance of new tumors. (Patients and Methods) From September 2002 to May 2010, 1,073 patients of EGA or GA were treated with ESD in Gifu University Hospital and affiliated hospitals under the same protocol. Follow-up endoscopy after ESD was performed at 1, 2, 6, 12 months and annually after ESD. (Results) Thirteen patients (1.2%) were synchronous multiple EGC cases who underwent initial ESD for 2 lesions. Ninety-three patients (8.6%; 75 males, 18 females; average age 72.3 y) underwent a second ESD because of EGC or GA found during the follow-up period. The median period between the initial and second ESD was 6 months. Thirty-one cases (31.3%) were detected within 3 months after the initial ESD, 51 cases (51.5%) within 6 months, and 72 cases (72.7%) within 12 months. The pathological findings at the initial ESD and at the second ESD were as follows: 57 cases (71.1%) were both EGC, 24 cases (23%) were EGC and GA, 9 cases (8.7%) were both GA, and 9 cases were GA and EGA. However, there was no significant difference between pathological findings and the period until the second ESD, or between locations of EGC or GA and the period until the second ESD, or between age, sex of patients and the period until second ESD. (Conclusion) In half of the patients who underwent the initial ESD, new gastric tumors were found within only 6 months, indicating the need for careful followup with early repetition of ESD. Also, we should pay the same attention to patients whose initial tumor was GA as to those with EGA. Further studies are needed.
Sa1677 Clinical Significance of Gastric Atypical Cell on Histologic Finding of Endoscopic Forceps Biopsy Kim So-I1, Kim Jeong Hwan1, Lee Kyung-Ju1, Hong Sung Noh1, Lee Sun-Young1, In Kyung Sung1, Park Hyung Seok1, Hye Seung Han2, Kwon So Young1, Shim Chan Sup1 1 Digestive Disease Center, Konkuk University Medical Center, Seoul, Republic of Korea; 2Department of Pathology, Konkuk University Medical Center, Seoul, Republic of Korea Backgound: Gastric atypical cell on endoscopic forceps biopsy is a borderline lesion between benign and malignant. Definitive management of this lesion remains debatable. We aimed to analyze the final histologic diagnosis for atypical cell on endoscopic forceps biopsy and to examine the discrepancy rate between the final histologic diagnosis and the initial endoscopic diagnosis. Method: The study involved atypical cell that were histologically proven on the basis of forceps biopsy specimens in Konkuk university medical center between April 2008 and September 2010. Atypical cell with regererative atypia was excluded. We reviewed the endoscopic characteristics including lesion size, location, endoscopic appearance, and the final histologic diagnosis. Results: This study involved total twenty seven cases proved atypical cell on initial histology of endoscopic biopsy. The three cases excluded due to follow-up loss. Firstly, of twenty four cases, ten cases underwent ESD and were diagnosed with early gastric cancer (EGC, n⫽9) and adenoma (n⫽1). The other fourteen cases underwent repeated biopsy. After repeated biopsy, four cases diagnosed with EGC and five diagnosed with adenoma underwent ESD, one diagnosed with EGC did operation, and one with gastritis was only monitored. As a result, malignant and premalignant lesions were finally diagnosed in twenty two cases. In addition, twelve cases (50%) showed concordant diagnosis, but eight cases (33%) and four cases (17%) showed upgraded and downgraded diagnosis, respectively, between initial endoscopic diagnosis and final histologic diagnosis. Conclusion: In these cases, the rate of malignant and premalignant lesions was 92%. Additionally, it was difficult to discriminate between malignant lesion and benign lesion by initial endoscopic finding. Therefore, ESD can be considered in patients with atypical cell on endoscopic forceps biopsy.
Sa1678 Duodenal Stents Are Associated With More Durable Patency As Compared to Percutaneous Endoscopic Gastrojejunostomy in the Palliation of Malignant Gastric Outlet Obstruction Ju-En C. Thlick1, Daniel Strand1, James T. Patrie2, Monica Gaidhane1, Michel Kahaleh1, Andrew Y. Wang1 1 Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA;2Division of Biostatistics and Epidemiology, University of Virginia, Charlottesville, VA Introduction: Gastric outlet obstruction (GOO) is a common consequence of advanced gastroduodenal and pancreatic malignancies. In situations where curative surgery is not feasible, surgical gastrojejunostomy (GJ), endoscopic placement of a self-expandable metallic stent (SEMS), and percutaneous endoscopic gastrojejunostomy (PEG-J) are options to provide enteral access and
palliation of symptoms. Surgical GJ and duodenal SEMS have been compared with mixed results (Jeurnink SM et al. J Gastroenterol 2010; Maetani I et al. Endoscopy 2004). However, the duration of patency for duodenal SEMS has not been compared to that of PEG-J in the palliation of patients with malignant GOO. Aim: To compare the patency times of duodenal SEMS and PEG-J in the treatment of GOO caused by advanced unresectable cancers. Methods: A retrospective, single-center, cohort study was conducted that included patients who presented from 8/07 through 10/10 with GOO from unresectable cancer and underwent either placement of an uncovered duodenal SEMS (Duodenal Wallflex, 22 mm x 60-120 mm stents, Boston Scientific, Natick, MA) or a PEG-J (24-Fr PEG with a 12-Fr J-arm, from several vendors). Patients were identified using a hospital database and electronic medical records were reviewed. The Social Security Death Index was queried to obtain mortality data. Aggregate survival/device patency curves were compared via a univariate log-rank Chisquared test. Results: 10 patients (7 men) with a median age of 59.5 years (range: 40-88 years) had 11 duodenal SEMS placed for GOO from various malignancies (pancreatic 7, ampullary 2, gastric 1). 12 patients (6 men) with a median age of 72.5 years (range: 51-91 years) had 12 PEG-J procedures for GOO from various malignancies (pancreatic 6, gastric 2, ampullary 1, metastatic extraintestinal source 3). Post-procedure follow-up with a median duration of 44 days (range: 25-361 days) was available in 80% of patients who had a duodenal SEMS. Postprocedure follow-up with a median duration of 20 days (range: 8-133 days) was available in 75% of patients who underwent PEG-J. Median time from SEMS or PEG-J placement until device failure or death was 49.0 days (range: 27 to 104 days) for the duodenal SEMS group and 28.5 days (range: 15-44 days) for the PEG-J group (P⫽0.057). A Kaplan-Meier analysis demonstrated that patients who received a duodenal SEMS appeared to live longer and/or had more durable enteral access and palliation from symptoms as compared to patients who received a PEG-J (Figure 1). Conclusion: Duodenal SEMS may be associated with longer aggregate patency and survival times as compared to PEG-J in patients with malignant GOO. This study was limited by the small patient populations and may be prone to selection bias due to its retrospective nature. As such, a prospective multi-centered trial is indicated to verify these results.
Figure 8. Kaplan-Meier Analysis Comparing Aggregate Device Patency and Survival In Patients with Duodenal Stents to Those with PEG-J
Sa1679 Endoscopic Findings in Gastric Adenoma With High Grade Dysplasia Suggesting Gastric Cancer Jung Ho Kim, Yoon Jae Kim, Jong Joon Lee, Jun-Won Chung, Kwang An Kwon, Dongkyun Park, Ki-Baik Hahm Department of Gastroenterology, Gachon Univercity of Medicine and Science Gil hospital, Incheon, Republic of Korea Introduction/ These days, Endoscopic submucosal dissection (ESD) was widely used for primary treatment for early gastric cancer. However forceps biopsies may be inadequate for accurate diagnosis of gastric neoplasm. Aim and Methods/ The aim of this study was to elucidate the predicting factor for gastric cancer in patients with gastric adenomas with high grade dysplasia (HGD) at initial endoscopic diagnosis. The medical record of patients who were pathologically confirmed gastric adenomas with HGD at initial diagnostic endoscopy between february 2008 and september 2010 were retrospectively reviewed. In 360 patients who were treated with ESD, 62 patients were included. The endoscopic findings were reviewed for gross type, surface color, surface nodularity, size and ulceration by two endoscopists. Results/ The mean age of
AB242 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
as cotherapies resulted in microcytic anemia due to potential bleeding in some patients. Therefore, in those patients, antiulcer therapies even for EPUs may be of considerable practical value.
Sa1672 Hemostatic Forceps As a Rescue Therapy for Bleeding Peptic Ulcer: A Case Series Pei-Yuan Su, Hsu-Heng Yen, Chia-Wei Yang, Shun-Sheng Wu, Wei-Wen Su, Maw-Soan Soon Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan Background: Standard endoscopic management of bleeding peptic ulcer includes the use of injection, thermal coagulation or mechanical clipping. The use of hemostatic forceps has been increased with the widespread use of ESD to control bleeding during the ESD procedure. There are few reports using hemostatic forceps to control peptic ulcer bleeding. Objective: Our aim in this study was to describe the efficacy and complication while using hemostatic forceps as a rescue therapy for bleeding peptic ulcer. Design: Retrospective, single-institution case series. Patients: This study involved 5 patients received hemostatic forceps coagulation as a rescue therapy in our instutition. Intervention Hemostatic forceps as hemostatic tool for bleeding peptic ulcer. Main Outcome Measurements and Results: During Jan 2010 to Oct 2011, 427 patients received endoscopic therapy for bleeding peptic ulcer in our institution. Five patients received hemostasis with hemostatic forceps as a rescue therapy after failure of the standard endoscopic therapy. Four patients had successful hemostasis and one patient received emergent surgery. Limitations: The study is limited in retrospective nature and involved only small case series. To generalization of the outcomes may require more large scale study. Conclusions: Hemostatic forceps is a useful alternative to control peptic ulcer bleeding after failed standard endoscopic treatment. The patients may be prevented from emergent surgery. Further large scale studies are required to confirm our observation.
Sa1673 Feasibility of Endoscopic Submucosal Dissection for Elderly Patients With Early Gastric Cancer Jun Konishi, Nozomu Kobayashi, Ryuzo Sekiguchi Depertment of Diagnostic Imaging, Tochigi Cancer Center, Utunomiya, Japan Background and aim: Endoscopic submucosal dissection (ESD) has been widespread as a standard treatment for early gastric cancer (EGC) in Japan. Although some authors have reported on gastric ESD for elder patients, the efficacy and safety is still unclear. We investigated the feasibility of gastric ESD for elderly patients comparing with non-elderly patients. Methods: A total of 393 EGCs in 343 patients were treated with ESD at our center from April 2005 to march 2009. Elderly patient was defined as 75 year-old or older, and consequently 137 lesions in 121 elderly patients and 255 lesions in 218 nonelderly patients were enrolled. ESD was performed when the lesion was diagnosed as follows: differentiated mucosal cancer without ulcerative change, differentiated mucosal cancer with ulcerative change 3cm or less in size, differentiated minute submucosal cancer 3cm or less in size. We assessed the rate of en bloc resection, complete resection, additional surgery and complications in two groups. Results: The en block resection rate was 94% the in the elderly group (129/137) and 96% in the non-elderly group (250/255), and the curative resection rate was 81% (111/136) in the elderly group and 79% (203/ 255) in the non-elderly group. Of 75 non-curative resection patients, 11 (44%) of elderly patients and 22 (44%) of non-elderly patients received additional surgery. Perforations were observed in 7 (3%) cases in the elderly group and 9 (4%) in non-elderly group, and 4 bleedings(3%) after procedure were observed in the elderly group and 6 (2%) in non-elderly group. There is no significant difference between the two groups. Conclusion: ESD is an efficient and safe technique for elderly patients with EGC.
Sa1674 A Brazilian Designed Self-Expandable Metal Stent (SEMS) for Endoscopic Palliation of Malignant Gastric Outlet Obstruction: Report of 6 Cases Wagner Colaiacovo, Emiliano D. Almodova, Aldenir Fresca, Denise P. Guimaraes, Liza M. Alvarenga, Alessandrino T. Oliveira, Gilberto Fava Endoscopy, Hospital de Câncer de Barretos, Barretos, Brazil Background and Aims: SEMS has been used as a safe alternative to surgery for palliation of malignant gastric outlet obstruction (GOO). Herein we describe the use of a Brazilian designed SEMS (Braile Oncology, Brazil) in the palliative management of 6 patients with unresectable neoplasm obstructing the antro-
www.giejournal.org
pyloric region. Methods: We developed an uncovered SEMS with a novel design funnel shape like and a large luminal diameter to improve gastric emptying of malignant GOO. The stent is made of nitinol where a maximum diameter of 50mm is reached at the proximal end and 30mm at the distal end and 50mm length. The stent is mounted on a delivery system with an outer diameter of 24Fr. All procedures were performed under combined endoscopic and fluoroscopic guidance. The endoscope could be passed through the lesion in all but one case and a stiff guidewire was placed beyond the stricture by using a standard ERCP catheter. Tumor margins were marked by needle injections of radiopaque contrast. Proper stent placement and established patency after deployment was assessed by endoscopy and fluoroscopy. Results: SEMS were placed in 6 consecutives patients (median age, 76.5, range 67-84 years; 3 women and 3 men) with unresecable malignant GOO. Stent implantation was technically successful in 6 (100%) patients. Twenty-four hours post stent placement, fluoroscopic study demonstrated luminal patency and expanded stent in 5 (83.3%) of 6 cases. Clinical success with relief of symptoms was achieved in 5 (83.3%) of 6 cases immediately after placement of SEMS. In one patient, the stent was not fully expanded. There were no procedure-related deaths. The median stent patency period was 85 days (range, 25-260 days). Four patients died (one of distal obstruction and three of caquexia) 25-168 days (median, 84 days) after stent placement. One patient is still alive and has no symptoms 260 days after stent placement. Tumor ingrowth occurred in 2 patients after 25 and 36 days without re-obstruction. One patient had stent oclusion by distal overgrowth on 62 days after the procedure. He was managed by placement of an additional uncovered stent. Conclusion: This novel designed stent appears to be safe and effective approach for the palliation of malignant GOO. Although placement of this new device was successful, through-the-scope (TTS) stent with a design funnel shape like is expected to optimize stent placement with good results on palliation of malignant GOO.
Sa1675 Ex-Vivo Evaluation of a Prototype Submucosal Biopsy Forceps for the Diagnosis of Gastric Gastrointestinal Stromal Tumors Peter Darwin1, Jeffrey Laczek2, Nader Hanna1, William S. Twaddell1 1 University of Maryland, Baltimore, MD; 2Tripler Army Medical Center, Honolulu, HI Background: Pathologic conformation is required for the endoscopic diagnosis of gastrointestinal stromal tumors (GIST). A variety of methods to obtain tissue have been described including endoscopic ultrasound (EUS) guided aspiration, bite on bite cold biopsy and submucosal incision assisted direct biopsy. Each method has potential limitations, including the inability to obtain definitive cytology or mitotic index from aspiration cytology and difficulty sampling submucosal lesions by the bite on bite technique. Aim: Evaluate the ability of a prototype submucosal biopsy forceps to make a histologic diagnosis and mitotic index determination in cases of resected gastric GIST. Methods: Prior to suspected or documented gastric GIST surgical resection, an IRB approved consent was obtained. Post tumor removal, an investigational submucosal biopsy forceps and sheath (Olympus America XB01-998-5/6) was passed under directed vision into the central portion of the lesion. From 3 to 5 passes were placed in formalin for research evaluation. The gross resection specimen was then sectioned and processed for routine histology. A GI pathologist evaluated the research biopsies and a comparison was made to the resection histology. The pathologist was blinded as to the mitotic count for the final resected specimen. Results: In all 3 cases, the research biopsies confirmed a diagnosis of GIST. The mitotic index comparison (research biopsy vs standard final pathology) for each case was; 1/ 25 high power field (hpf) with a final of 7/50, 1 mitosis/26 hpf with a final of 3/50 and 6/50 hpf with a final of 6/50. Based upon the mitotic index from the research biopsies, there would have been no change in tumor risk estimate in 2/3 cases with 1/3 upgraded from very low to moderate. Discussion: In an ex vivo setting, this novel submucosal biopsy forceps was able to obtain tissue to document GIST and provide an accurate mitotic index in 2/3 cases. The finite number of hpf obtained is a limitation of this technique. While additional comparison to other sampling modalities including yield and risks will be needed, this submucosal biopsy forceps has potential to aid in the endoscopic diagnosis of GIST.
Sa1676 Endoscopic Examination of Synchronous or Metachronous Multiple Gastric Tumors After the Initial Endoscopic Submucosal Dissection for Early Gastric Cancer or Gastric Adenoma Tomohiro Kato1,2, Hiroshi Araki2, Fumito Onogi2, Takashi Ibuka2, Akihiko Sugiyama1, Eiichi Tomita1, Hisataka Moriwaki2 1 Gastroenterology, Gifu Municipal Hospital, Gifu-city, Japan; 2 Gastroenterology, Gifu University Hospital, Gifu-city, Japan (Background) Endoscopic submucosal dissection (ESD) has been indicated for early gastric cancer (EGC) and gastric adenoma (GA) to obtain en bloc
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB241
Abstracts
specimens. Synchronous or metachronous tumors have been observed during follow-up after the initial ESD procedure, and it remains unclear when we should perform the endoscopic examination to find new gastric tumors. In this study, we analyzed retrospectively the period between the first and second ESD to try to establish guidelines for the adequate surveillance of new tumors. (Patients and Methods) From September 2002 to May 2010, 1,073 patients of EGA or GA were treated with ESD in Gifu University Hospital and affiliated hospitals under the same protocol. Follow-up endoscopy after ESD was performed at 1, 2, 6, 12 months and annually after ESD. (Results) Thirteen patients (1.2%) were synchronous multiple EGC cases who underwent initial ESD for 2 lesions. Ninety-three patients (8.6%; 75 males, 18 females; average age 72.3 y) underwent a second ESD because of EGC or GA found during the follow-up period. The median period between the initial and second ESD was 6 months. Thirty-one cases (31.3%) were detected within 3 months after the initial ESD, 51 cases (51.5%) within 6 months, and 72 cases (72.7%) within 12 months. The pathological findings at the initial ESD and at the second ESD were as follows: 57 cases (71.1%) were both EGC, 24 cases (23%) were EGC and GA, 9 cases (8.7%) were both GA, and 9 cases were GA and EGA. However, there was no significant difference between pathological findings and the period until the second ESD, or between locations of EGC or GA and the period until the second ESD, or between age, sex of patients and the period until second ESD. (Conclusion) In half of the patients who underwent the initial ESD, new gastric tumors were found within only 6 months, indicating the need for careful followup with early repetition of ESD. Also, we should pay the same attention to patients whose initial tumor was GA as to those with EGA. Further studies are needed.
Sa1677 Clinical Significance of Gastric Atypical Cell on Histologic Finding of Endoscopic Forceps Biopsy Kim So-I1, Kim Jeong Hwan1, Lee Kyung-Ju1, Hong Sung Noh1, Lee Sun-Young1, In Kyung Sung1, Park Hyung Seok1, Hye Seung Han2, Kwon So Young1, Shim Chan Sup1 1 Digestive Disease Center, Konkuk University Medical Center, Seoul, Republic of Korea; 2Department of Pathology, Konkuk University Medical Center, Seoul, Republic of Korea Backgound: Gastric atypical cell on endoscopic forceps biopsy is a borderline lesion between benign and malignant. Definitive management of this lesion remains debatable. We aimed to analyze the final histologic diagnosis for atypical cell on endoscopic forceps biopsy and to examine the discrepancy rate between the final histologic diagnosis and the initial endoscopic diagnosis. Method: The study involved atypical cell that were histologically proven on the basis of forceps biopsy specimens in Konkuk university medical center between April 2008 and September 2010. Atypical cell with regererative atypia was excluded. We reviewed the endoscopic characteristics including lesion size, location, endoscopic appearance, and the final histologic diagnosis. Results: This study involved total twenty seven cases proved atypical cell on initial histology of endoscopic biopsy. The three cases excluded due to follow-up loss. Firstly, of twenty four cases, ten cases underwent ESD and were diagnosed with early gastric cancer (EGC, n⫽9) and adenoma (n⫽1). The other fourteen cases underwent repeated biopsy. After repeated biopsy, four cases diagnosed with EGC and five diagnosed with adenoma underwent ESD, one diagnosed with EGC did operation, and one with gastritis was only monitored. As a result, malignant and premalignant lesions were finally diagnosed in twenty two cases. In addition, twelve cases (50%) showed concordant diagnosis, but eight cases (33%) and four cases (17%) showed upgraded and downgraded diagnosis, respectively, between initial endoscopic diagnosis and final histologic diagnosis. Conclusion: In these cases, the rate of malignant and premalignant lesions was 92%. Additionally, it was difficult to discriminate between malignant lesion and benign lesion by initial endoscopic finding. Therefore, ESD can be considered in patients with atypical cell on endoscopic forceps biopsy.
Sa1678 Duodenal Stents Are Associated With More Durable Patency As Compared to Percutaneous Endoscopic Gastrojejunostomy in the Palliation of Malignant Gastric Outlet Obstruction Ju-En C. Thlick1, Daniel Strand1, James T. Patrie2, Monica Gaidhane1, Michel Kahaleh1, Andrew Y. Wang1 1 Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA;2Division of Biostatistics and Epidemiology, University of Virginia, Charlottesville, VA Introduction: Gastric outlet obstruction (GOO) is a common consequence of advanced gastroduodenal and pancreatic malignancies. In situations where curative surgery is not feasible, surgical gastrojejunostomy (GJ), endoscopic placement of a self-expandable metallic stent (SEMS), and percutaneous endoscopic gastrojejunostomy (PEG-J) are options to provide enteral access and
palliation of symptoms. Surgical GJ and duodenal SEMS have been compared with mixed results (Jeurnink SM et al. J Gastroenterol 2010; Maetani I et al. Endoscopy 2004). However, the duration of patency for duodenal SEMS has not been compared to that of PEG-J in the palliation of patients with malignant GOO. Aim: To compare the patency times of duodenal SEMS and PEG-J in the treatment of GOO caused by advanced unresectable cancers. Methods: A retrospective, single-center, cohort study was conducted that included patients who presented from 8/07 through 10/10 with GOO from unresectable cancer and underwent either placement of an uncovered duodenal SEMS (Duodenal Wallflex, 22 mm x 60-120 mm stents, Boston Scientific, Natick, MA) or a PEG-J (24-Fr PEG with a 12-Fr J-arm, from several vendors). Patients were identified using a hospital database and electronic medical records were reviewed. The Social Security Death Index was queried to obtain mortality data. Aggregate survival/device patency curves were compared via a univariate log-rank Chisquared test. Results: 10 patients (7 men) with a median age of 59.5 years (range: 40-88 years) had 11 duodenal SEMS placed for GOO from various malignancies (pancreatic 7, ampullary 2, gastric 1). 12 patients (6 men) with a median age of 72.5 years (range: 51-91 years) had 12 PEG-J procedures for GOO from various malignancies (pancreatic 6, gastric 2, ampullary 1, metastatic extraintestinal source 3). Post-procedure follow-up with a median duration of 44 days (range: 25-361 days) was available in 80% of patients who had a duodenal SEMS. Postprocedure follow-up with a median duration of 20 days (range: 8-133 days) was available in 75% of patients who underwent PEG-J. Median time from SEMS or PEG-J placement until device failure or death was 49.0 days (range: 27 to 104 days) for the duodenal SEMS group and 28.5 days (range: 15-44 days) for the PEG-J group (P⫽0.057). A Kaplan-Meier analysis demonstrated that patients who received a duodenal SEMS appeared to live longer and/or had more durable enteral access and palliation from symptoms as compared to patients who received a PEG-J (Figure 1). Conclusion: Duodenal SEMS may be associated with longer aggregate patency and survival times as compared to PEG-J in patients with malignant GOO. This study was limited by the small patient populations and may be prone to selection bias due to its retrospective nature. As such, a prospective multi-centered trial is indicated to verify these results.
Figure 8. Kaplan-Meier Analysis Comparing Aggregate Device Patency and Survival In Patients with Duodenal Stents to Those with PEG-J
Sa1679 Endoscopic Findings in Gastric Adenoma With High Grade Dysplasia Suggesting Gastric Cancer Jung Ho Kim, Yoon Jae Kim, Jong Joon Lee, Jun-Won Chung, Kwang An Kwon, Dongkyun Park, Ki-Baik Hahm Department of Gastroenterology, Gachon Univercity of Medicine and Science Gil hospital, Incheon, Republic of Korea Introduction/ These days, Endoscopic submucosal dissection (ESD) was widely used for primary treatment for early gastric cancer. However forceps biopsies may be inadequate for accurate diagnosis of gastric neoplasm. Aim and Methods/ The aim of this study was to elucidate the predicting factor for gastric cancer in patients with gastric adenomas with high grade dysplasia (HGD) at initial endoscopic diagnosis. The medical record of patients who were pathologically confirmed gastric adenomas with HGD at initial diagnostic endoscopy between february 2008 and september 2010 were retrospectively reviewed. In 360 patients who were treated with ESD, 62 patients were included. The endoscopic findings were reviewed for gross type, surface color, surface nodularity, size and ulceration by two endoscopists. Results/ The mean age of
AB242 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
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