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Successful Outcomes of Endoscopic Resection for Gastric Adenomas and Early Cancers Located On the Pylorus Ring
Abstracts
deployment of a double-layered combination stent (an outer uncovered and an inner covered stent), three endoscopic clips were applied to fix the proximal end of the enteral stent to the gastric or duodenal mucosa. Main Outcome Measurement: Clinical efficacy, especially migrationResults: Technical and clinical success rate was 100% (20/20) and 90% (18/20), respectively. No stent migration was observed in any of the patients. Four patients (20%) experienced complications such as tumor overgrowth and stent compression. Limitations: Small sample size. Conclusions: Endoscopic clipping for enteral stent placement is effective for prevention of stent migration in patients with malignant gastric outlet obstruction.
the fistula. A long 0 monofilament suture is inserted through trocar and is grasped inside stomach with a snare and pulled out through mouth. The first two steps are then repeated, such that two monofilament sutures traverses the abdominal and gastric walls on either side of the fistula and exits through the mouth. A surgical knot is then made with the two sutures retrieved through the mouth. The ends of the sutures exiting the abdominal wall are pulled such that the knot made outside the mouth is pulled into gastric lumen to close gastric aspect of the fistula. Externally, mucosal bites are taken from fistulous tract using standard biopsy forceps to de-epithelialize the fistulous tract. A surgical knot is made externally to close cutaneous opening. The procedure is repeated to place another suture to close rest of the fistulous opening. IV cephalexin is given for prevention of infection. Result: Enteral feeds were resumed on Day3. No leakeage was noted from fistula. Four weeks later, fistula site remained well healed. DiscussionOur procedure leads to faster closure of fistulas; decreased hospitalization and parenteral nutrition with its complications. This is a safe, cost-effective method for gastrocutaneous fistulas in the elderly compared to surgical or conservative approach.
M1521 Successful Outcomes of Endoscopic Resection for Gastric Adenomas and Early Cancers Located On the Pylorus Ring Do Kim, in Du Jeong, Seok Won Jung, Sung-Jo Bang
M1519 Effectiveness of the Ball Tipped Flush Knife in Endoscopic Submucosal Dissection for the Treatment of GI Neoplasia Takashi Toyonaga, Mariko Man-I, Yoshinori Morita, Hiromu Kutsumi, Hideto Inokuchi, Takeshi Azuma Introduction: We had invented short needle knives that can emit a jet of water from the tip of a sheath (FlushKnife) in 2005 to perform endoscopic submucosal dissection (ESD) more easily, safely, and efficiently. FlushKnife can be considered to be one of the most useful operative instruments for ESD with good resection results of more than 1000 cases. For the further improvement of the operability of the knife and the ability of the hemostasis by the knife itself, we have developed the ball tipped Flush knife (FlushKnife-BT). Aims and Methods: The aim of this study is to examine the effectiveness of FlushKnife-BT, which is the FlushKnife with a ball tip of 0.9 mm in diameter and 3 projecting parts of 1.5, 2, 2.5 mm in length. We treated successive 60 lesions in 52 cases (esophagus; 16, stomach; 32, colorectum; 18) by ESD between March and June 2008. These lesions were subdivided into two subtypes based on the instruments used; FlushKnife (F) group and FlushKnife-BT (BT) group according to the location of esophagus, stomach (Upper body, Middle body, Lower body), and colorectum. We prospectively evaluated the data including the rate of en-block complete resection, diameter of resected specimen and tumor, time required for resection, number of intraoperative bleeding points, number of the point to need hemostatic forceps, rate of perforation and postoperative bleeding. Results: The median diameter of tumor / resected specimen in BT group was 23.5mm [range: 3-55] / 40.0 mm [range: 29-80] and that in F group was 20.0mm [range: 2-44] / 39.0 mm [range: 22-69]. There was no significant difference between two groups. The time required for the resection was 28.7 min. [range: 11.8-58.0] in BT group and 32.0 min. [range: 14.5-83.0] in F group. There was also no significant difference between two groups, but the time in BT group had the tendency to be shorter. The median number of intraoperative bleeding points was 4 [range: 1-11] in BT group and 8[range: 2-20] in F group (p!0.0001). The median number of the point to need hemostatic forceps was 0[range: 0-2] in BT group and 3 [range: 0-10] in F group (p!0.0001). There was no case of perforation nor post operative bleeding. The en-block resection rate and complete resection rate were both 100%. Conclusion: Flushknife-BT has significantly decreased the number of the intraoperative bleeding and the frequency to use the hemostatic forceps in the procedure of ESD. The ball-shaped tip of FlushKnife-BT has enabled to scoop the object in the incision and dissection, the feeling of use was obviously improved. The development of Flushknife-BT is considered to contribute to the wide spread of ESD.
M1520 Endoscopic Suturing of Gastrocutaneous Fistula: A Novel Method Saphwat Eskaros, Vishal Ghevariya, Mahesh Krishnaiah, Sury Anand, Tanya M. George Background: Persistent gastrocutaneous fistula after PEG tube removal is a potential complication in elderly. Studies using argon-beam laser, fibrin sealant and clip placement reported variable success. MethodOn poor surgical candidates, at endoscopy, gastric side of fistula is identified. Cutaneous side is prepped and injected with 1% Lidocaine. An 18F trocar is inserted through abdominal wall near
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Background: Endoscopic resection (ER) is a recognized treatment for early gastric neoplasms and it may result in less morbidity than does incisional surgery, if technically feasible. However, ER is difficult in patients who have gastric neoplasms located on the pylorus ring especially extended from pyloric area to duodenal bulb. The aims of this study were to retrospectively assess the results of ER of gastric adenomas and early cancers located on the pylorus ring. Methods: ER was attempted in 16 patients (8 men, 8 women; median age 64 years) with gastric 5 adenomas or 11 early cancers located on the pylorus ring. After trial of retroflexion within the duodenum for evaluation of tumor extension from pyloric area to duodenal bulb, en bloc resection was attempted by one endoscopist. Endoscopic submucosal dissection (ESD) was attempted for lesions extended to duodenal bulb with the endoscope retroflexed within the duodenum. The en bloc resection rate, histologically complete resection rate, complications and local recurrence were assessed. Results: The success rate of retroflexion within the duodenum and evaluation of the duodenal bulb was 88% (14 of 16) and revealed that 4 cases of tumors (2 adenomas and 2 cancers) were extended from pyloric area to duodenal bulb. Endoscopic mucosal resection was attempted in 6 cases (before 2007) and ESD in 10 including 4 cases of duodenal bulb extension. The complete resection rate was 81.3% (13 of 16), and en bloc resection rate was 75% (12 of 16). In three cases of incomplete resection, two cases were submucosal invasive cancer. The complete resection was possible in 3 of 4 (75%) cases of duodenal bulb extension except one submucosal invasive cancer. Mean size of resected specimens was 26.1 11.0 mm and mean size of the tumors was 13.5 8.2 mm. The average operation time was 48.6 36.9 min, and the mean follow-up period of all patients was 26.3 17.5 months. Major procedure related complication was not found. None of the patients experienced recurrence after ER. Conclusions: Retroflexion of endoscope within the duodenum and ER appears to be feasible and effective treatment for gastric adenomas or early cancers located on the pylorus ring including lesions extended from pyloric area to duodenal bulb.
T1310 Short Double Balloon Enteroscope for ERCP in Patients with Altered Gastrointestinal Anatomy Masaaki Shimatani, Makoto Takaoka, Toshiro Fukui, Kazushige Uchida, Mitsunobu Matsushita, Kazuichi Okazaki Background: ERCP is technically challenging in patients with altered gastrointestinal anatomy. A recently introduced double balloon enteroscope permits the examination of a much longer segment of the small bowel compared with a conventional endoscope, and may be used to perform ERCP in these patients. Objective: Because diagnostic and therapeutic interventions for the pancreatobilliary system in previously operated patients by conventional endoscopes are difficult, we described our experience of ERCP with a short double balloon enteroscope (sDBE; EC-450BI5, FTS, Osaka, Japan) in these patients. Because sDBE has a 2.8mm working channel and working length of 152 cm, all conventional ERCP devices are available. Patients and Methods: Between April 2005 and October 2008, we performed ERCP with the use of sDBE in 69 patients with various anatomic variations (93 procedures; 21 procedures with Billroth II gastorectomy, 22 procedures with pancreatoduoderectomy, 50 procedures with Roux-en-Y total gastorectomy), and evaluated the technique. Result: Deep insertion of the sDBE to the ductal anastomosis or papilla was successful in 90 of 93 procedures (96.8%). Cannulation of the bile duct was successful in 88 of 90 procedures (97.8%). Therapeutic intervention was achieved in all of the 88 procedures of successful biliary cannulation (100%). Endoscopic interventions included calculus extraction (41 procedures), placement of stents (19 plastic and 13 metallic stents), placement of nasobilialy drainage tubes (32 procedures), balloon dilatation of choledochojejunostomy (23 procedures), sphincterotomy (31 procedures), biliary
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB263
deployment of a double-layered combination stent (an outer uncovered and an inner covered stent), three endoscopic clips were applied to fix the proximal end of the enteral stent to the gastric or duodenal mucosa. Main Outcome Measurement: Clinical efficacy, especially migrationResults: Technical and clinical success rate was 100% (20/20) and 90% (18/20), respectively. No stent migration was observed in any of the patients. Four patients (20%) experienced complications such as tumor overgrowth and stent compression. Limitations: Small sample size. Conclusions: Endoscopic clipping for enteral stent placement is effective for prevention of stent migration in patients with malignant gastric outlet obstruction.
the fistula. A long 0 monofilament suture is inserted through trocar and is grasped inside stomach with a snare and pulled out through mouth. The first two steps are then repeated, such that two monofilament sutures traverses the abdominal and gastric walls on either side of the fistula and exits through the mouth. A surgical knot is then made with the two sutures retrieved through the mouth. The ends of the sutures exiting the abdominal wall are pulled such that the knot made outside the mouth is pulled into gastric lumen to close gastric aspect of the fistula. Externally, mucosal bites are taken from fistulous tract using standard biopsy forceps to de-epithelialize the fistulous tract. A surgical knot is made externally to close cutaneous opening. The procedure is repeated to place another suture to close rest of the fistulous opening. IV cephalexin is given for prevention of infection. Result: Enteral feeds were resumed on Day3. No leakeage was noted from fistula. Four weeks later, fistula site remained well healed. DiscussionOur procedure leads to faster closure of fistulas; decreased hospitalization and parenteral nutrition with its complications. This is a safe, cost-effective method for gastrocutaneous fistulas in the elderly compared to surgical or conservative approach.
M1521 Successful Outcomes of Endoscopic Resection for Gastric Adenomas and Early Cancers Located On the Pylorus Ring Do Kim, in Du Jeong, Seok Won Jung, Sung-Jo Bang
M1519 Effectiveness of the Ball Tipped Flush Knife in Endoscopic Submucosal Dissection for the Treatment of GI Neoplasia Takashi Toyonaga, Mariko Man-I, Yoshinori Morita, Hiromu Kutsumi, Hideto Inokuchi, Takeshi Azuma Introduction: We had invented short needle knives that can emit a jet of water from the tip of a sheath (FlushKnife) in 2005 to perform endoscopic submucosal dissection (ESD) more easily, safely, and efficiently. FlushKnife can be considered to be one of the most useful operative instruments for ESD with good resection results of more than 1000 cases. For the further improvement of the operability of the knife and the ability of the hemostasis by the knife itself, we have developed the ball tipped Flush knife (FlushKnife-BT). Aims and Methods: The aim of this study is to examine the effectiveness of FlushKnife-BT, which is the FlushKnife with a ball tip of 0.9 mm in diameter and 3 projecting parts of 1.5, 2, 2.5 mm in length. We treated successive 60 lesions in 52 cases (esophagus; 16, stomach; 32, colorectum; 18) by ESD between March and June 2008. These lesions were subdivided into two subtypes based on the instruments used; FlushKnife (F) group and FlushKnife-BT (BT) group according to the location of esophagus, stomach (Upper body, Middle body, Lower body), and colorectum. We prospectively evaluated the data including the rate of en-block complete resection, diameter of resected specimen and tumor, time required for resection, number of intraoperative bleeding points, number of the point to need hemostatic forceps, rate of perforation and postoperative bleeding. Results: The median diameter of tumor / resected specimen in BT group was 23.5mm [range: 3-55] / 40.0 mm [range: 29-80] and that in F group was 20.0mm [range: 2-44] / 39.0 mm [range: 22-69]. There was no significant difference between two groups. The time required for the resection was 28.7 min. [range: 11.8-58.0] in BT group and 32.0 min. [range: 14.5-83.0] in F group. There was also no significant difference between two groups, but the time in BT group had the tendency to be shorter. The median number of intraoperative bleeding points was 4 [range: 1-11] in BT group and 8[range: 2-20] in F group (p!0.0001). The median number of the point to need hemostatic forceps was 0[range: 0-2] in BT group and 3 [range: 0-10] in F group (p!0.0001). There was no case of perforation nor post operative bleeding. The en-block resection rate and complete resection rate were both 100%. Conclusion: Flushknife-BT has significantly decreased the number of the intraoperative bleeding and the frequency to use the hemostatic forceps in the procedure of ESD. The ball-shaped tip of FlushKnife-BT has enabled to scoop the object in the incision and dissection, the feeling of use was obviously improved. The development of Flushknife-BT is considered to contribute to the wide spread of ESD.
M1520 Endoscopic Suturing of Gastrocutaneous Fistula: A Novel Method Saphwat Eskaros, Vishal Ghevariya, Mahesh Krishnaiah, Sury Anand, Tanya M. George Background: Persistent gastrocutaneous fistula after PEG tube removal is a potential complication in elderly. Studies using argon-beam laser, fibrin sealant and clip placement reported variable success. MethodOn poor surgical candidates, at endoscopy, gastric side of fistula is identified. Cutaneous side is prepped and injected with 1% Lidocaine. An 18F trocar is inserted through abdominal wall near
www.giejournal.org
Background: Endoscopic resection (ER) is a recognized treatment for early gastric neoplasms and it may result in less morbidity than does incisional surgery, if technically feasible. However, ER is difficult in patients who have gastric neoplasms located on the pylorus ring especially extended from pyloric area to duodenal bulb. The aims of this study were to retrospectively assess the results of ER of gastric adenomas and early cancers located on the pylorus ring. Methods: ER was attempted in 16 patients (8 men, 8 women; median age 64 years) with gastric 5 adenomas or 11 early cancers located on the pylorus ring. After trial of retroflexion within the duodenum for evaluation of tumor extension from pyloric area to duodenal bulb, en bloc resection was attempted by one endoscopist. Endoscopic submucosal dissection (ESD) was attempted for lesions extended to duodenal bulb with the endoscope retroflexed within the duodenum. The en bloc resection rate, histologically complete resection rate, complications and local recurrence were assessed. Results: The success rate of retroflexion within the duodenum and evaluation of the duodenal bulb was 88% (14 of 16) and revealed that 4 cases of tumors (2 adenomas and 2 cancers) were extended from pyloric area to duodenal bulb. Endoscopic mucosal resection was attempted in 6 cases (before 2007) and ESD in 10 including 4 cases of duodenal bulb extension. The complete resection rate was 81.3% (13 of 16), and en bloc resection rate was 75% (12 of 16). In three cases of incomplete resection, two cases were submucosal invasive cancer. The complete resection was possible in 3 of 4 (75%) cases of duodenal bulb extension except one submucosal invasive cancer. Mean size of resected specimens was 26.1 11.0 mm and mean size of the tumors was 13.5 8.2 mm. The average operation time was 48.6 36.9 min, and the mean follow-up period of all patients was 26.3 17.5 months. Major procedure related complication was not found. None of the patients experienced recurrence after ER. Conclusions: Retroflexion of endoscope within the duodenum and ER appears to be feasible and effective treatment for gastric adenomas or early cancers located on the pylorus ring including lesions extended from pyloric area to duodenal bulb.
T1310 Short Double Balloon Enteroscope for ERCP in Patients with Altered Gastrointestinal Anatomy Masaaki Shimatani, Makoto Takaoka, Toshiro Fukui, Kazushige Uchida, Mitsunobu Matsushita, Kazuichi Okazaki Background: ERCP is technically challenging in patients with altered gastrointestinal anatomy. A recently introduced double balloon enteroscope permits the examination of a much longer segment of the small bowel compared with a conventional endoscope, and may be used to perform ERCP in these patients. Objective: Because diagnostic and therapeutic interventions for the pancreatobilliary system in previously operated patients by conventional endoscopes are difficult, we described our experience of ERCP with a short double balloon enteroscope (sDBE; EC-450BI5, FTS, Osaka, Japan) in these patients. Because sDBE has a 2.8mm working channel and working length of 152 cm, all conventional ERCP devices are available. Patients and Methods: Between April 2005 and October 2008, we performed ERCP with the use of sDBE in 69 patients with various anatomic variations (93 procedures; 21 procedures with Billroth II gastorectomy, 22 procedures with pancreatoduoderectomy, 50 procedures with Roux-en-Y total gastorectomy), and evaluated the technique. Result: Deep insertion of the sDBE to the ductal anastomosis or papilla was successful in 90 of 93 procedures (96.8%). Cannulation of the bile duct was successful in 88 of 90 procedures (97.8%). Therapeutic intervention was achieved in all of the 88 procedures of successful biliary cannulation (100%). Endoscopic interventions included calculus extraction (41 procedures), placement of stents (19 plastic and 13 metallic stents), placement of nasobilialy drainage tubes (32 procedures), balloon dilatation of choledochojejunostomy (23 procedures), sphincterotomy (31 procedures), biliary
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB263