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The Natural History of Sporadic Duodenal Adenomas and Risk of Synchronous Colonic Adenomas
*M1795 The Natural History of Sporadic Duodenal Adenomas and Risk of Synchronous Colonic Adenomas Alexander C. Ford, Olorunda Rotimi, Simon M. Everett Introduction: There is little information published about sporadic duodenal adenomas. We set out to review our own experience of their natural history and management. Methods: We performed a retrospective review of all cases of sporadic duodenal adenomas diagnosed at the Leeds General Infirmary between 1990 and 2003, identified from histopathology records, with particular emphasis on presentation, treatment, outcome and the incidence of synchronous colonic polyps. Patients with FAP were excluded. Results: We identified 35 patients with sporadic duodenal polyps (16 male, 19 female, median age 65 years). There were 18 tubulovillous, 16 tubular, and 1 villous adenoma. Mild dysplasia was present in 10, moderate in 24, and severe dysplasia in 1. All were diagnosed incidentally (32 at upper GI endoscopy, 3 at ERCP). Of these, 17 were removed (6 surgically, 4 by endoscopic mucosal resection (EMR), 3 snared, 3 during biopsy and 1 by argon photocoagulation). Of the 17 patients who had their polyp removed, 2 had a recurrence (1 treated by EMR, the other kept under surveillance), and all were alive at the time of review (median time from diagnosis 58 months). Amongst the 18 who had no therapy for their polyp, 10 had died (median length of follow-up 43 months). One patient developed a 3cm adenocarcinoma of the first part of the duodenum five months after initial diagnosis and underwent a Whipple’s procedure, but died 12 months later from metastatic disease. The other patients died from unrelated causes. Eleven patients went on to have a colonoscopy, and this revealed a colonic polyp in 5 (3 tubulovillous adenomas, 1 tubular adenoma, 1 metaplastic). Conclusions: Duodenal adenomas usually follow a benign course though have malignant potential and therefore require excision or careful follow up. Most are identified incidentally, and should be carefully sought during upper GI endoscopic examinations. Amongst those who went on to have a colonoscopy almost half were found to have coexistent colonic polyps. Colonoscopy should therefore be performed in these patients.
*M1797 The Comparison of Covered and Uncovered Expandable Metal Stents in the Palliation of Malignant Gastric Outlet Obstruction Yu Kyung Cho, Sang-Woo Kim, Se-Hee Kim, Hae-Won Han, In-Seok Lee, Myung Gyu Choi, In-Sik Chung Background: Reobstruction due to tumor ingrowth has been a major problem of uncovered stents. Membrane covered stents have been developed to overcome this problem, but have showed high stent migration rates. Few comparative studies have been made between covered stents and uncovered stents in malignant gastric outlet obstruction. The aim of our study was to compare the efficacy of covered stents for the palliation of malignant gastric outlet obstruction in a randomized controlled trial. Methods: Twenty-five patients with malignant gastric outlet obstruction with gastric cancer have participated (M:F= 13:12, 65Aˆ611years). The patients were randomly assigned to covered or uncovered nickel-titanium stents. The principal outcome measure was the needs for reintervention due to reobstruction or migration. Secondary end points were the relief of dysphagia measured by the dysphagia score, patients’ satisfaction one week after stenting, and the rate of complication. the mean follow up period was 100Aˆ6106 days. 21/ 25 patients were observed over 2 months or til death. Results: The technical success rate was 100% with no immediate complication. One week after the stent insertion, The dysphagia score improved significantly with both the uncovered (n=12, 2.8Aˆ61.3 to 1.5Aˆ60.8, p=0.03)and covered stents (n=13, 2.9Aˆ61.3 to 1.9Aˆ61.6, p=0.02). One week after the stent insertion, the degree of satisfaction was excellent(7), good(3), fair(1), bad(1) in uncovered stents and excellent(7), good(3), bad(1), very bad(2) in covered stents. The early complication within one week was pain(2), failure of expansion(1) in uncovered stents and pain(2), stent misplacement(1), migration(1) in covered stents. Obstructing tumor ingrowth occurred in 6 patients with uncovered stents (29.7Aˆ622.0days, min.7daysmax.60days) and in 2 patients with covered stents (60,180days) (50%:15%, p=0.07). Reintervention was done in two patients in each group. Stent migration didn’t occurr in patients with uncovered stents, whereas 3 patients with covered stents showed migration (3,15,35days) (p=0.08). And for 2 patients. reintervention was required. Conclusion : Both covered and uncovered expanding metal stents are a safe and efficacious for palliating malignant gastric outlet obstruction. There is no significant difference in the rate of migration or tumor ingrowth between uncovered stents and covered stents. But the time of obstructing tumor ingrowth is longer in covered stents than in uncovered stents.
*M1796 Role of Endoscopic Follow-up After Radical Gastrectomy for Stomach Cancer Yong Soo Kim, Tae II Kim, Yong Chan Lee, Si Young Song, Won Ho Kim, Jae-Bock Chung, Jin-Kyung Kang, Seung Woo Park
*M1798 Endoscopic Mucosal Resection (EMR) for Diffuse-Type Mucosal Gastric Cancer Masaya Inoue, Takuji Gotoda, Roy M. Soetikno, Hisanao Hamanaka, Ichiro Oda, Daizo Saito
Backgound: Upper endoscopy is essential method used for diagnosis and therapy for stomach cancer, and it is also essential tool for surveillance for the patients who underwent radical gastrectomy due to gastric cancer. The endoscopic surveillance for detection of recurrence was usually performed regularily, however, exact recurrence rate and time of recurrence were not well known issues. So there were debates for role of endoscopic follow up after gastrectomy. Material and Method: The aims of study are to evaluate the clinical impact of endoscopic surveillance program and to deduce appropriate endoscopic surveillance schedule. From Jan, 1992 through Dec, 2002, 2995 patients who underwent radical gastrectomy due to stomach cancer were enrolled. The patients had taken annual endoscopic follow up (6-month followed by 1 year interval). We investigated clinical characteristics of patients, stage, operative method (total vs subtotal), time of surveillance endoscopy, and recurrence (endoscopic vs radiologic). Results: Postoperative recurrences were detected by radiologic test and endoscopy in 14.8%(440/2995) and 1.7%(51/2995), respectively. In all of local recurrences, only 17.4% recurrences were detected by endoscopic surveillance. By endoscopic surveillance, only 20 cases(0.67%) of recurrence were detected without evidence of radiologic recurrence. Postoperative recurrence rate was higher in patients with advanced stage and who underwent total gastrectomy. Most of endoscopic recurrences(74.5%) occurred within 2 years after gastrectomy. Conclusion: Routine endoscopic surveillance after radical gastrectomy has very limited role for the detection of recurrence. However, most endoscopic recurrence occurred within 2 years, endoscopic surveillance is warranted by annual base for 2 years and then biennially.
Background:The indication for EMR to treat intestinal-type mucosal gastric cancer (MGC) has been widely accepted in Japan. However, the indication of EMR to resect diffuse-type MGC is considered controversial. Using our surgicalpathology database, we have previously shown that the risk of lymph-node (LN) metastasis was nil in 141 patients with mucosal diffuse-type MGC who had the following pathologic findings: less than 2 cm, without ulcer formation or lymphovascular involvement (95% confidence interval: 0 - 2.6%). We prospectively studied the long-term outcome of patients with diffuse-type MGC who met the same criteria who were treated with EMR. Methods:Our Institutional Review Board approved the study. 51 patients agreed to undergo EMR to treat their diffuse-type MGC. We examined pathological specimen by serial sectioning at 2mm intervals. We defined curative resections when the cancer met the same criteria and when the lateral and vertical margins were free of disease. We informed all patients of their pathological findings, provided information on the risks and benefits of additional surgery, and offered them to have no additional treatment or surgery. Result: 25 patients were considered to have curative resection by EMR. 21 patients decided to have no additional treatment. There was no evidence of LN or distant metastasis, or local recurrence found in patients who had EMR during the follow-up period of median 38 mos (range: 13 to 79 mos). The remaining 4 patients chose gastrectomy with LN dissection. There was no LN metastasis found in patients who had surgery. Conclusions:Our preliminary results suggest that patients with diffuse-type MGC who met the following criteria: mucosal disease, less than 2 cm, without ulcer or lymphovascular involvement may be safely treated using EMR.
P170
GASTROINTESTINAL ENDOSCOPY
VOLUME 59, NO. 5, 2004
*M1797 The Comparison of Covered and Uncovered Expandable Metal Stents in the Palliation of Malignant Gastric Outlet Obstruction Yu Kyung Cho, Sang-Woo Kim, Se-Hee Kim, Hae-Won Han, In-Seok Lee, Myung Gyu Choi, In-Sik Chung Background: Reobstruction due to tumor ingrowth has been a major problem of uncovered stents. Membrane covered stents have been developed to overcome this problem, but have showed high stent migration rates. Few comparative studies have been made between covered stents and uncovered stents in malignant gastric outlet obstruction. The aim of our study was to compare the efficacy of covered stents for the palliation of malignant gastric outlet obstruction in a randomized controlled trial. Methods: Twenty-five patients with malignant gastric outlet obstruction with gastric cancer have participated (M:F= 13:12, 65Aˆ611years). The patients were randomly assigned to covered or uncovered nickel-titanium stents. The principal outcome measure was the needs for reintervention due to reobstruction or migration. Secondary end points were the relief of dysphagia measured by the dysphagia score, patients’ satisfaction one week after stenting, and the rate of complication. the mean follow up period was 100Aˆ6106 days. 21/ 25 patients were observed over 2 months or til death. Results: The technical success rate was 100% with no immediate complication. One week after the stent insertion, The dysphagia score improved significantly with both the uncovered (n=12, 2.8Aˆ61.3 to 1.5Aˆ60.8, p=0.03)and covered stents (n=13, 2.9Aˆ61.3 to 1.9Aˆ61.6, p=0.02). One week after the stent insertion, the degree of satisfaction was excellent(7), good(3), fair(1), bad(1) in uncovered stents and excellent(7), good(3), bad(1), very bad(2) in covered stents. The early complication within one week was pain(2), failure of expansion(1) in uncovered stents and pain(2), stent misplacement(1), migration(1) in covered stents. Obstructing tumor ingrowth occurred in 6 patients with uncovered stents (29.7Aˆ622.0days, min.7daysmax.60days) and in 2 patients with covered stents (60,180days) (50%:15%, p=0.07). Reintervention was done in two patients in each group. Stent migration didn’t occurr in patients with uncovered stents, whereas 3 patients with covered stents showed migration (3,15,35days) (p=0.08). And for 2 patients. reintervention was required. Conclusion : Both covered and uncovered expanding metal stents are a safe and efficacious for palliating malignant gastric outlet obstruction. There is no significant difference in the rate of migration or tumor ingrowth between uncovered stents and covered stents. But the time of obstructing tumor ingrowth is longer in covered stents than in uncovered stents.
*M1796 Role of Endoscopic Follow-up After Radical Gastrectomy for Stomach Cancer Yong Soo Kim, Tae II Kim, Yong Chan Lee, Si Young Song, Won Ho Kim, Jae-Bock Chung, Jin-Kyung Kang, Seung Woo Park
*M1798 Endoscopic Mucosal Resection (EMR) for Diffuse-Type Mucosal Gastric Cancer Masaya Inoue, Takuji Gotoda, Roy M. Soetikno, Hisanao Hamanaka, Ichiro Oda, Daizo Saito
Backgound: Upper endoscopy is essential method used for diagnosis and therapy for stomach cancer, and it is also essential tool for surveillance for the patients who underwent radical gastrectomy due to gastric cancer. The endoscopic surveillance for detection of recurrence was usually performed regularily, however, exact recurrence rate and time of recurrence were not well known issues. So there were debates for role of endoscopic follow up after gastrectomy. Material and Method: The aims of study are to evaluate the clinical impact of endoscopic surveillance program and to deduce appropriate endoscopic surveillance schedule. From Jan, 1992 through Dec, 2002, 2995 patients who underwent radical gastrectomy due to stomach cancer were enrolled. The patients had taken annual endoscopic follow up (6-month followed by 1 year interval). We investigated clinical characteristics of patients, stage, operative method (total vs subtotal), time of surveillance endoscopy, and recurrence (endoscopic vs radiologic). Results: Postoperative recurrences were detected by radiologic test and endoscopy in 14.8%(440/2995) and 1.7%(51/2995), respectively. In all of local recurrences, only 17.4% recurrences were detected by endoscopic surveillance. By endoscopic surveillance, only 20 cases(0.67%) of recurrence were detected without evidence of radiologic recurrence. Postoperative recurrence rate was higher in patients with advanced stage and who underwent total gastrectomy. Most of endoscopic recurrences(74.5%) occurred within 2 years after gastrectomy. Conclusion: Routine endoscopic surveillance after radical gastrectomy has very limited role for the detection of recurrence. However, most endoscopic recurrence occurred within 2 years, endoscopic surveillance is warranted by annual base for 2 years and then biennially.
Background:The indication for EMR to treat intestinal-type mucosal gastric cancer (MGC) has been widely accepted in Japan. However, the indication of EMR to resect diffuse-type MGC is considered controversial. Using our surgicalpathology database, we have previously shown that the risk of lymph-node (LN) metastasis was nil in 141 patients with mucosal diffuse-type MGC who had the following pathologic findings: less than 2 cm, without ulcer formation or lymphovascular involvement (95% confidence interval: 0 - 2.6%). We prospectively studied the long-term outcome of patients with diffuse-type MGC who met the same criteria who were treated with EMR. Methods:Our Institutional Review Board approved the study. 51 patients agreed to undergo EMR to treat their diffuse-type MGC. We examined pathological specimen by serial sectioning at 2mm intervals. We defined curative resections when the cancer met the same criteria and when the lateral and vertical margins were free of disease. We informed all patients of their pathological findings, provided information on the risks and benefits of additional surgery, and offered them to have no additional treatment or surgery. Result: 25 patients were considered to have curative resection by EMR. 21 patients decided to have no additional treatment. There was no evidence of LN or distant metastasis, or local recurrence found in patients who had EMR during the follow-up period of median 38 mos (range: 13 to 79 mos). The remaining 4 patients chose gastrectomy with LN dissection. There was no LN metastasis found in patients who had surgery. Conclusions:Our preliminary results suggest that patients with diffuse-type MGC who met the following criteria: mucosal disease, less than 2 cm, without ulcer or lymphovascular involvement may be safely treated using EMR.
P170
GASTROINTESTINAL ENDOSCOPY
VOLUME 59, NO. 5, 2004