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Strategy of Endoscopic Treatment for Early Gastric Cancer in a Primary Hospital
Abstracts
S1435 Strategy of Endoscopic Treatment for Early Gastric Cancer in a Primary Hospital Naoki Ishii, Noriyuki Horiki, Toshiyuki Itoh, Masayo Tsukamoto, Kendi Yamazaki, Akemi Hashimoto, Motoe Arai, Masataka Maruyama, Yoshiyuki Fujita
S1437 Repeated Endoscopic Examination Six Months After H. Pylori Eradication Could Find Masked Gastric Cancer Makoto Tatewaki, Junko Fujisaki, Etsuo Hoshino, Akiyoshi Ishiyama, Nobue Ueki, Toshiaki Hirasawa, Yorimasa Yamamoto, Tomohiro Tsuchida, Hiroshi Takahashi, Rikiya Fujita
Background: Endoscopic mucosal resection (EMR) is an accepted treatment for early gastric cancer (EGC) associated with a minimal risk of regional lymph node metastasis, and it has been increasingly gaining acceptance in the western countries. Recently, endoscopic submucosal dissection (ESD) has been the treatment of choice in many cases, because it improves the completeness of en-bloc resection of superficial early gastric cancer. We aimed to compare standard EMR with ESD for early gastric cancer treatment to evaluate resected specimens and respectability. Patients and Methods: 82 early gastric cancers (65 men, 17 women, age range 52-86 years) were treated by EMR of the lift and cut technique using double channel scope (GIF-2T240, Olympus, Tokyo, Japan) between Dec 2003 and Nov 2006. 92 early gastric cancers (68 men, 24 women, age range 49-89 years) were treated by ESD using single channel scope (GIF-Q240, Olympus, Tokyo, Japan) and KD-630L (Flex Knife TM, Olympus, Tokyo, Japan). We evaluated the rate of en-bloc resection and the size of the tumors and resected specimens. In the cases of the resection in multiple fragments, resectability was evaluated based on completely reconstructed specimens and the size of the tumor was measured on those specimens. And the largest specimen of multiple fragments was regarded as the size of resected specimens. Informed written consent for EMR and ESD was obtained from all patients. Results: The mean sizes of the resected tumors using EMR and ESD techniques were 8.7 mm (range, 2.0-23 mm) and 13 mm (range, 2.0-50 mm) (P ! 0.05), and the mean size of the resected specimens were 18 mm (range, 9-31 mm) and 31 mm (range, 13-80 mm) (P ! 0.05), respectively. The rates of enbloc resection and complete resection of EMR were 66% (54/82) and 76% (62/82), and those of ESD were 93% (86/92) (P ! 0.05) and 96% (88/92) (P ! 0.05), respectively. Regarding to the size, the confirmation of en-bloc resections could only be confirmed in 58% (37/64) of lesions larger than 5 mm, using standard EMR technique. But in the lesions less than 5 mm, 94% (17/18) was resected en-bloc. Conclusion: Our results demonstrate that Gastric ESD is an effective method for EGC en-bloc resections regardless of the lesion size, but the resection can be performed by standard EMR in smaller lesions (!5 mm).
Background: Detecting early gastric cancer in H. pylori-infected stomach is not easy, when the background gastric mucosa shows severe inflammation with diffuse or patchy redness, edema, and thick mucous. In order to undertake less invasive therapies, such as endoscopic mucosal resection (EMR), it is important to find cancerous lesion(s) as small as possible. Since eradication of H. pylori is known to induce regression of inflamed gastric mucosa, repeated endoscopic examination after eradication could find previously masked cancerous lesion(s). Methods: Twenty-one cases (15 men: 51-88 years old, average 69.7 years of age) of early gastric cancer detected after H. pylori eradication were enrolled in this study. Eradication therapy was performed with LAC regimens (Lansoprazole 60 mg, Clarythromycin 800 mg, and Amoxycillin 1500 mg for 7 days) followed by 13 C-Urea Breath Test. Repeated endoscopic examination with high-resolution endoscopy (Olympus H260) was performed every 3 to 12 months’ intervals after the eradication. Interval period detecting gastric cancer after the eradication and the size of lesion(s) were retrospectively analyzed. Results: Of twenty-one cases, 17 had previous EMR for early gastric cancer (13 cases) or gastric adenoma (4 cases). After H. pylori eradication, inflamed gastric mucosa regressed and thick mucous in the stomach decreased or disappeared in all cases. The mean interval period between detection of gastric cancer and eradication was 6.5 0.9 months (range 2 to 12 months). The mean size of cancer was 8.5 1.6 mm in diameter (range 3 to 18 mm). All cases were treated with EMR and only one case required additional operation due to deep invasion of gastric cancer. Conclusion: Eradication of H. pylori may make it easy to detect small early gastric cancer by regressing inflammation of gastric mucosa. It is highly recommended to perform repeated endoscopic examination at least first 6 months after eradication therapy in patients who had gastric cancer.
S1436 Effectiveness and Validity of Endoscopic Submucosal Dissection (ESD) for Treatment of Early Gastric Carcinomas Shunji Shimaoka, Toru Niihara, Tatsuyuki Nioh, Akio Matsuda, Kotaro Tashiro, Hiromitsu Torimaru, Koichiro Tsukasa, Yoshito Nishimata, Hiroto Nishimata, Sadao Tanaka Background: Endoscopic treatment for early gastric cancer is widely accepted. However, the problem of conventional endoscopic mucosal resection is that enbloc resection is sometimes not successfully achieved for large lesions. To resolve this problem Endoscopic Submucosal Dissection (ESD) has been developed for reliable en bloc resection and is expected to offer an expansion of the criteria for endoscopic treatment. Gotoda et al. proposed the expansion of the criteria based on an estimation from a large number of cases involving the incidence of lymph node metastasis. These criteria have been widely used for the criteria for ESD. Purpose: This study aimed to evaluate the effectiveness and validity of ESD for treatment of early gastric carcinomas. Materials and Methods: One hundred and thirteen patients with early gastric carcinomas treated by ESD at Nanpuh hospital and 317 patients with early gastric carcinomas treated by surgical operation were evaluated. We defined our cases by the time they were treated, the former term and latter term. Results: The rates of en-bloc resection were 72.2% (26/36) in the guideline group and 100% (2/2) in the expansion of criteria group during the former term, 98.1% (52/53) in the guideline group and 89.1% (25/28) in the expansion of criteria group during the latter term, respectively. The rates of complete resection were 63.9% (23/36) in the guideline group and 100% (2/2) in the expansion of criteria group during the former term, 94.3% (50/53) and 82.1% (23/28) during the latter term, respectively. We found no significant differences in the findings during the procedure and post-operative complications between two groups. Twenty-five of the 317 cases with early gastric carcinomas were associated with positive lymph nodes. One intramucosal undifferentiated carcinoma, lesion size 20 mm, without ulceration was associated with lymph node metastasis. These fulfill the expansion of criteria. To evaluate indications for ESD for superficial spreading tumors we sampled 60 cases to examine the rates of submucosal penetration, vascular invasion, lymphatic permeation and lymph node metastasis. It shows that less than 30% of the lesions more than 40 mm in size fulfilled the former criteria. Conclusion: The results of ESD for lesions that corresponded to the expansion of criteria showed that there was not a difference compared with the results for lesions that corresponded to the accepted criteria for guideline lesions. However, care needs to be exercised when treating undifferentiated carcinomas and superficial spreading tumors because of the high level of vascular invasion, lymphatic permeation and lymph node metastasis.
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S1438 A Proposal for Applicability of a Pre-Defined Timing (T-SCORE) to Establish When to Perform An Urgent Endoscopy for Upper Digestive Bleeding Leonardo Tammaro, Maria Carla Di Paolo, Sebastiano Caliendo, Lorella Pallotta The optimal timing of urgent endoscopy for upper digestive bleeding is not established. In 40 to 70% of cases it is performed within 24 hours of admission. For the majority of patients (pts) to wait for 12 or 24 hours an endoscopy does not change their clinical course, but for some pts it is a big difference. We propose the application of a predefined score (T-score) to stratify pts before endoscopy according to simple parameters in order to plan timing of urgent endoscopy (see Table). Aim of this proposal is to improve communication among emergency department doctors and gastroenterologists-endoscopists and allow a better and appropriate planning of upper endoscopies in pts with upper digestive bleeding. Our experience was based on 696 upper digestive endoscopies performed in pts with upper digestive bleeding. Pts were stratified according to T-score in order to undergo endoscopy 1, 2, 6 or 12 hours after presentation. Applying the T-Score 48 pts (7%) underwent endoscopy after 1 hour, 153 pts (22%) after 2 hours, 217 (31%) after 6 hours and 278 (40%) after 12 hours. Only in 15 cases (2%) eventually endoscopy was performed earlier because of a worsening of parameters and therefore a variation of their T-Score. None of the pts died before endoscopy. Our experience has led to this proposal of application of T-Score in different hospitals. Pts presenting upper digestive bleeding will be stratifyed according to T-Score parameters and endoscopy be performed according to relative timing. T-Score definition and relative timing to endoscopy will be applied at Time 0, time of presentation. In pts initially defined as T2 or T3 (endoscopy to be performed after 6 or 12 hours) clinical parameters of T-Score will be assessed again after 2 hours and, if needed, redefined. Four hours after Time 0 clinical parameters and haemoglobin will be assessed again and pts be defined again, if needed. Once performed endoscopy, cause of bleeding will be reported. At the moment a validation of TScore in different hospitals is going on. It will make simple and easy communication among doctors and might prevent legal risks for digestive endoscopists. Table. Score Variable General conditions Pulse/min Systolic blood pressure Haemoglobin (g/dl)
1
2
3
Bad O110 !90 !7
Intermediate 90-110 90-110 7-10
Fairly good !90 O110 O10
Each variable is scored and the total score calculated by simple addition. Score 4, TScore T1A: endoscopy in 1 hour; Score 5-6, T-Score T1B: endoscopy in 2 hours;Score 7-9, T-Score T2: endoscopy in 6 hours; Score 10-12, T-Score T3: endoscopy in 12 hours
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB175
S1435 Strategy of Endoscopic Treatment for Early Gastric Cancer in a Primary Hospital Naoki Ishii, Noriyuki Horiki, Toshiyuki Itoh, Masayo Tsukamoto, Kendi Yamazaki, Akemi Hashimoto, Motoe Arai, Masataka Maruyama, Yoshiyuki Fujita
S1437 Repeated Endoscopic Examination Six Months After H. Pylori Eradication Could Find Masked Gastric Cancer Makoto Tatewaki, Junko Fujisaki, Etsuo Hoshino, Akiyoshi Ishiyama, Nobue Ueki, Toshiaki Hirasawa, Yorimasa Yamamoto, Tomohiro Tsuchida, Hiroshi Takahashi, Rikiya Fujita
Background: Endoscopic mucosal resection (EMR) is an accepted treatment for early gastric cancer (EGC) associated with a minimal risk of regional lymph node metastasis, and it has been increasingly gaining acceptance in the western countries. Recently, endoscopic submucosal dissection (ESD) has been the treatment of choice in many cases, because it improves the completeness of en-bloc resection of superficial early gastric cancer. We aimed to compare standard EMR with ESD for early gastric cancer treatment to evaluate resected specimens and respectability. Patients and Methods: 82 early gastric cancers (65 men, 17 women, age range 52-86 years) were treated by EMR of the lift and cut technique using double channel scope (GIF-2T240, Olympus, Tokyo, Japan) between Dec 2003 and Nov 2006. 92 early gastric cancers (68 men, 24 women, age range 49-89 years) were treated by ESD using single channel scope (GIF-Q240, Olympus, Tokyo, Japan) and KD-630L (Flex Knife TM, Olympus, Tokyo, Japan). We evaluated the rate of en-bloc resection and the size of the tumors and resected specimens. In the cases of the resection in multiple fragments, resectability was evaluated based on completely reconstructed specimens and the size of the tumor was measured on those specimens. And the largest specimen of multiple fragments was regarded as the size of resected specimens. Informed written consent for EMR and ESD was obtained from all patients. Results: The mean sizes of the resected tumors using EMR and ESD techniques were 8.7 mm (range, 2.0-23 mm) and 13 mm (range, 2.0-50 mm) (P ! 0.05), and the mean size of the resected specimens were 18 mm (range, 9-31 mm) and 31 mm (range, 13-80 mm) (P ! 0.05), respectively. The rates of enbloc resection and complete resection of EMR were 66% (54/82) and 76% (62/82), and those of ESD were 93% (86/92) (P ! 0.05) and 96% (88/92) (P ! 0.05), respectively. Regarding to the size, the confirmation of en-bloc resections could only be confirmed in 58% (37/64) of lesions larger than 5 mm, using standard EMR technique. But in the lesions less than 5 mm, 94% (17/18) was resected en-bloc. Conclusion: Our results demonstrate that Gastric ESD is an effective method for EGC en-bloc resections regardless of the lesion size, but the resection can be performed by standard EMR in smaller lesions (!5 mm).
Background: Detecting early gastric cancer in H. pylori-infected stomach is not easy, when the background gastric mucosa shows severe inflammation with diffuse or patchy redness, edema, and thick mucous. In order to undertake less invasive therapies, such as endoscopic mucosal resection (EMR), it is important to find cancerous lesion(s) as small as possible. Since eradication of H. pylori is known to induce regression of inflamed gastric mucosa, repeated endoscopic examination after eradication could find previously masked cancerous lesion(s). Methods: Twenty-one cases (15 men: 51-88 years old, average 69.7 years of age) of early gastric cancer detected after H. pylori eradication were enrolled in this study. Eradication therapy was performed with LAC regimens (Lansoprazole 60 mg, Clarythromycin 800 mg, and Amoxycillin 1500 mg for 7 days) followed by 13 C-Urea Breath Test. Repeated endoscopic examination with high-resolution endoscopy (Olympus H260) was performed every 3 to 12 months’ intervals after the eradication. Interval period detecting gastric cancer after the eradication and the size of lesion(s) were retrospectively analyzed. Results: Of twenty-one cases, 17 had previous EMR for early gastric cancer (13 cases) or gastric adenoma (4 cases). After H. pylori eradication, inflamed gastric mucosa regressed and thick mucous in the stomach decreased or disappeared in all cases. The mean interval period between detection of gastric cancer and eradication was 6.5 0.9 months (range 2 to 12 months). The mean size of cancer was 8.5 1.6 mm in diameter (range 3 to 18 mm). All cases were treated with EMR and only one case required additional operation due to deep invasion of gastric cancer. Conclusion: Eradication of H. pylori may make it easy to detect small early gastric cancer by regressing inflammation of gastric mucosa. It is highly recommended to perform repeated endoscopic examination at least first 6 months after eradication therapy in patients who had gastric cancer.
S1436 Effectiveness and Validity of Endoscopic Submucosal Dissection (ESD) for Treatment of Early Gastric Carcinomas Shunji Shimaoka, Toru Niihara, Tatsuyuki Nioh, Akio Matsuda, Kotaro Tashiro, Hiromitsu Torimaru, Koichiro Tsukasa, Yoshito Nishimata, Hiroto Nishimata, Sadao Tanaka Background: Endoscopic treatment for early gastric cancer is widely accepted. However, the problem of conventional endoscopic mucosal resection is that enbloc resection is sometimes not successfully achieved for large lesions. To resolve this problem Endoscopic Submucosal Dissection (ESD) has been developed for reliable en bloc resection and is expected to offer an expansion of the criteria for endoscopic treatment. Gotoda et al. proposed the expansion of the criteria based on an estimation from a large number of cases involving the incidence of lymph node metastasis. These criteria have been widely used for the criteria for ESD. Purpose: This study aimed to evaluate the effectiveness and validity of ESD for treatment of early gastric carcinomas. Materials and Methods: One hundred and thirteen patients with early gastric carcinomas treated by ESD at Nanpuh hospital and 317 patients with early gastric carcinomas treated by surgical operation were evaluated. We defined our cases by the time they were treated, the former term and latter term. Results: The rates of en-bloc resection were 72.2% (26/36) in the guideline group and 100% (2/2) in the expansion of criteria group during the former term, 98.1% (52/53) in the guideline group and 89.1% (25/28) in the expansion of criteria group during the latter term, respectively. The rates of complete resection were 63.9% (23/36) in the guideline group and 100% (2/2) in the expansion of criteria group during the former term, 94.3% (50/53) and 82.1% (23/28) during the latter term, respectively. We found no significant differences in the findings during the procedure and post-operative complications between two groups. Twenty-five of the 317 cases with early gastric carcinomas were associated with positive lymph nodes. One intramucosal undifferentiated carcinoma, lesion size 20 mm, without ulceration was associated with lymph node metastasis. These fulfill the expansion of criteria. To evaluate indications for ESD for superficial spreading tumors we sampled 60 cases to examine the rates of submucosal penetration, vascular invasion, lymphatic permeation and lymph node metastasis. It shows that less than 30% of the lesions more than 40 mm in size fulfilled the former criteria. Conclusion: The results of ESD for lesions that corresponded to the expansion of criteria showed that there was not a difference compared with the results for lesions that corresponded to the accepted criteria for guideline lesions. However, care needs to be exercised when treating undifferentiated carcinomas and superficial spreading tumors because of the high level of vascular invasion, lymphatic permeation and lymph node metastasis.
www.giejournal.org
S1438 A Proposal for Applicability of a Pre-Defined Timing (T-SCORE) to Establish When to Perform An Urgent Endoscopy for Upper Digestive Bleeding Leonardo Tammaro, Maria Carla Di Paolo, Sebastiano Caliendo, Lorella Pallotta The optimal timing of urgent endoscopy for upper digestive bleeding is not established. In 40 to 70% of cases it is performed within 24 hours of admission. For the majority of patients (pts) to wait for 12 or 24 hours an endoscopy does not change their clinical course, but for some pts it is a big difference. We propose the application of a predefined score (T-score) to stratify pts before endoscopy according to simple parameters in order to plan timing of urgent endoscopy (see Table). Aim of this proposal is to improve communication among emergency department doctors and gastroenterologists-endoscopists and allow a better and appropriate planning of upper endoscopies in pts with upper digestive bleeding. Our experience was based on 696 upper digestive endoscopies performed in pts with upper digestive bleeding. Pts were stratified according to T-score in order to undergo endoscopy 1, 2, 6 or 12 hours after presentation. Applying the T-Score 48 pts (7%) underwent endoscopy after 1 hour, 153 pts (22%) after 2 hours, 217 (31%) after 6 hours and 278 (40%) after 12 hours. Only in 15 cases (2%) eventually endoscopy was performed earlier because of a worsening of parameters and therefore a variation of their T-Score. None of the pts died before endoscopy. Our experience has led to this proposal of application of T-Score in different hospitals. Pts presenting upper digestive bleeding will be stratifyed according to T-Score parameters and endoscopy be performed according to relative timing. T-Score definition and relative timing to endoscopy will be applied at Time 0, time of presentation. In pts initially defined as T2 or T3 (endoscopy to be performed after 6 or 12 hours) clinical parameters of T-Score will be assessed again after 2 hours and, if needed, redefined. Four hours after Time 0 clinical parameters and haemoglobin will be assessed again and pts be defined again, if needed. Once performed endoscopy, cause of bleeding will be reported. At the moment a validation of TScore in different hospitals is going on. It will make simple and easy communication among doctors and might prevent legal risks for digestive endoscopists. Table. Score Variable General conditions Pulse/min Systolic blood pressure Haemoglobin (g/dl)
1
2
3
Bad O110 !90 !7
Intermediate 90-110 90-110 7-10
Fairly good !90 O110 O10
Each variable is scored and the total score calculated by simple addition. Score 4, TScore T1A: endoscopy in 1 hour; Score 5-6, T-Score T1B: endoscopy in 2 hours;Score 7-9, T-Score T2: endoscopy in 6 hours; Score 10-12, T-Score T3: endoscopy in 12 hours
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB175