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Tu1728 Effects of Administration of Proton Pump Inhibitor Before Endoscopic Submucosal Dissection for Differentiated Early Gastric Cancer With Ulcer
Abstracts
Tu1725 Predilection Sites of Intestinal Metaplasia in the Stomach: a Retrospective Study Based on Endoscopic Results of 78,335 Cases Xin-Yi Mao, Qing Liu, Hai-Han Zhang, Shun-Fu Xu, Jian-Xia Jiang* Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China Objectives: Gastric intestinal metaplasia (IM) is closely related to the occurrence of intestinal-type gastric carcinoma. This research was aimed to study the predilection sites of IM in the stomach to guide endoscopic biopsy selection to find IM as early as possible, and decrease the canceration rate of stomach ultimately. Methods: Totally 78,335 cases receiving gastroduodenoscope examination, who came from Jiangsu and Anhui provinces of China during 2008-2013, were enrolled in the study. The basic characteristics, biopsy sites and histological information were obtained and analyzed. This study was reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Nanjing Medical University and the committee specifically approved and no informed consent was required since these data were going to be analyzed anonymously. Results: The study showed that IM incidence rate 40% (2,068/6,345) in angulus, 20.24% (11056/54632) in lesser curvature of antrum and 25.48% (276/1083) in corpus, which are significantly higher than other sites in the stomach (P!0.005) (Table 1). Moreover, the severity of IM in lesser curvature of antrum and angulus were worse than great curvature of antrum (Table 2). Furthermore, the severity of acute and chronic inflammation were both higher in lesser curvature than in great curvature of antrum regardless of H. pylori-positive and negative (P!0.05). Conclusion: IM was mostly prone to occur in angulus, the lesser curvature of antrum and corpus. And the severity of inflammation in the lesser curvature of antrum was also higher than the great curvature, which was partially consisting with IM predilection site. Our conclusion was that angulus, the lesser curvature of antrum and corpus should be chosen as regular biopsy sites.Keywords: Intestinal metaplasia, biopsy sites, predilection sites, gastric cancer
The incidence of IM rates in different biopsy sites. Biopsy site
Biopsy (n)
IM (n, %)
c1
P1
72,603 54,632 52,841 4,455 3,285 3,322 1,083 1,153 509 490 6,345 2,724 783 1,179
15,107(20.81) 11,056(20.24) 5,240(9.38) 1,054(23.66) 626(19.00) 497(4.96) 276(25.48) 58(5.03) 49(9.63) 84(17.14) 2,608(40.00) 332(12.19) 241(30.78) 101(8.57)
*
*
Antrum lesser curvature great curvature anterior wall posterior wall Corpus lesser curvature great curvature anterior wall posterior wall Angulus Cardia Pylorus Fundus
!.005
66.51
c2
P2
* * 2224.17 !.005 29.59 !.005 2.68 O.005 * 183.89 53.6 13.3
1,381.03 121.75 46.57 106.23
!.005 !.005 !.005 !.005
* !.005 !.005 !.005
IM incidence was significantly higher in angulus, and antrum than corpus. And within antrum or corpus, IM more easily occurred in lesser curvature than greater curvature. Noet: c1, P1: IM in corpus, angulus, cardia, pylorus, fundus respectively vs. in antrum; c2, P2: IM in different sites vs. in lesser curvature within antrum or corpus. *: The baseline for comparison.
Comparison of IM grade in three main sites using Chi-square test. Biopsy site
Antrum-great curvature * Antrum-lesser curvature Angulus
Biopsy
Mild
Moderate
Severe
n
IM (n,%)
IM (n,%)
IM (n,%)
3,415 (6.12) 6,864 (12.56) 1,236 (19.48)
738 (1.32) 1,759 (3.22) 659 (10.39)
55,841 54,632 6,345
c1
P1
c2
P2
c3
P3
52(0.09) 136(0.25)
1,360.75
!.005
76(1.2)
1470.60
!.005
450. 36 2,131. 80
!.005
39.46
!.005
!.005
338.48
!.005
IM was most severe in angulus, then the lesser curvature of antrum than the great curvature of antrum. Note: c1-3, P1-3: mild, moderate and severe IM in lesser curvature of antrum or angulus vs. in greater curvature of antrum. *: The baseline for comparison.
Tu1726 Predictive Factors for Pain After Endoscopic Resection of Gastric Tumor Seung Young Kim*, Sung Woo Jung, Jong Jin Hyun, Ja Seol Koo, Jong-Jae Park, Hoon Jai Chun, Sang Woo Lee Korea University College of Medicine, Seoul, Korea (the Republic of) Background and Aims: Abdominal pain is a common complaint following an endoscopic resection (ER). The aim of this study was to investigate the predictive factors
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for abdominal pain after an ER. Patients and Methods: Patients who were scheduled to undergo endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for the treatment of gastric adenoma or cancer were prospectively enrolled. Pain score was checked q 6 hours after an ER and any complaint of additional pain was checked with a pain scale (0 to 10). If the pain score exceeded 5, 25mg of IV pethidine was given. Results: Among 162 patients who underwent ER, 70 patients (43.2%) received IV pethidine due to abdominal pain over the scale 5. Female gender (OR, 2.558; p-value, 0.017), lower third location of the tumor (OR, 3.979; p-value, 0.001), and procedures over 60 min (OR, 3.092; p-value, 0.008) were significant predictive factors for pain developed after an ER in the multivariate analysis. Conclusion: Female gender, lower third location of the tumor, and procedures over 60 min were significantly associated with pain after ER. Close management is recommended in patients who are associated with such risks.
Tu1727 Bleeding Risk Assessment Using Forrest Classification After Endoscopic Submucosal Dissection for Gastric Neoplasms Jong Yeul Lee*, Young-Il Kim, Soo-Jeong Cho, Chan Gyoo Kim, Il Ju Choi Center for Gastric Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Korea (the Republic of) Background and Aims: Delayed bleeding seems markedly decrease during the first week after endoscopic submucosal dissection (ESD) for gastric neoplasm. However, it still may occur even after one week of procedure especially in antiplatelet agent users. We aimed to investigate the risk factors for delayed bleeding at post-ESD ulcers using Forrest classification as a surrogate marker. Patients and Methods: Forrest classification of 392 post-ESD ulcers was evaluated at 1st (nZ204) or 2nd (nZ188) week after ESD in 371 patients with 415 gastric neoplasms (323 early gastric cancers and 92 adenomas) at the National Cancer Center Hospital, Korea, between August 2011 and June 2013. Forrest classification was categorized into two groups: increased risk (Forrest Ia-IIc), or low risk (Forrest III). Odds ratios (OR) with 95% confidence intervals (CI) were calculated using logistic regression analysis to determine the risk factors associated with increased risk group. Results: In total, 392 post-ESD ulcers were included, with 1 ulcer (0.3%) being classified as Forrest Ib, 2 (0.5%) as Forrest IIa, 18 (4.6%) as Forrest IIb, 182 (46.4%) as Forrest IIc, and 189 (48.2%) as Forrest III. Increased risk ulcers (Forrest Ia-IIc) were found in 72.1% (147/ 204) at 1st week, but it significantly decreased to 29.8% (56/188) at 2nd week (P ! 0.001). Multivariate analyses showed that 1st week [odds ratio (OR), 7.20 (95% CI, 4.51-11.5)], younger patient age (% 65 years) [OR, 1.99 (95% CI, 1.26-3.14)], middle or upper location of tumor [OR, 2.04 (95% CI, 1.18-3.51)], and larger post-ESD ulcer size (O 4cm) [OR, 1.66 (95% CI, 1.06-2.60)] were significantly associated with increased risk ulcers. Conclusions: Ulcer base 1 week after ESD still have increased risk of bleeding when assessed by Forrest classification. Thus, this finding should be considered in clinical practice and further study to evaluate proper time interval to start medication such as dual antiplatelet agents.
Tu1728 Effects of Administration of Proton Pump Inhibitor Before Endoscopic Submucosal Dissection for Differentiated Early Gastric Cancer With Ulcer Yu Sik Myung*, Su Jin Hong, Hee Jae Jung, Jae Pil Han, Bong Min Ko, Moon Sung Lee Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea (the Republic of) Background and Objectives: Ulcerative early gastric cancer (EGC) repeats improvement and exacerbation of ulceration during its natural course. However, the improvement of ulceration is known to be associated with the usage of antisecretory medication and the depth of invasion. The aim of this study was to evaluate the effect of administration of proton pump inhibitor (PPI) before endoscopic submucosal dissection (ESD) and clinical outcomes in ulcerative EGC. Methods: A total of 136 differentiated EGCs with ulcer which had met the expanded indication for ESD were reviewed between June 2005 and June 2014 retrospectively. Eighty-one patients were administered PPI before ESD and 55 patients were not administered PPI. We compared the rate of ulcer healing and clinical outcomes of ESD including en bloc resection, complete resection, complication and procedure time between two groups (PPI group and non-PPI group). Results: There were no significant differences in patient demographics were observed between the PPI group and non-PPI group. The complete healing rate of ulcer was significantly different between two groups (59.3% vs 23.6%, p!0.001). The procedure time was 38.14.0 and 50.86.8 minutes, respectively (pZ0.047). However, no significant differences were detected in en bloc resection rate, complete resection rate and complications including bleeding and perforation between two groups. Of the 81 patients who administered PPI, rate of complete healing was 71.9%(46/64) in mucosal cancer and 11.8% (2/17) in submucosal cancer, respectively (p!0.001). The multivariated analysis showed that administration of PPI (ORZ7.33, 95% CI 3.02-17.78, p!0.001) and mucosal
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB573
Abstracts
invasion (ORZ22.83, 95% CI 4.80-108.46, p!0.001) were the independent factors to predict complete healing of ulceration. Conclusions: Administration of PPI for differentiated EGC with ulcer which meet the expanded criteria is effective to reduce the procedure time and heal the ulcer lesion. In differenciated EGC meeting the expanded criteria for ESD, complete healing of ulcer after PPI administration suggests mucosal cancer.
Tu1729 Comparison of Once and Twice Daily Intravenous PPI Injections for Prevention of Bleeding After Endoscopic Resections Sung Woo Jung*, Joo Hee Park, Seung Young Kim, Jong Jin Hyun, Ja Seol Koo, Jong-Jae Park, Hoon Jai Chun, Sang Woo Lee Korea University College of Medicine, Seoul, Korea (the Republic of) Background and Aims: Endoscopic resection(ER) is commonly used to remove gastric neoplasms. However, effective treatment dosing or scheduling of proton pump inhibitors (PPI) for the prevention of delayed bleeding after an ER remains unclear. Patients and Methods: One hundred seventy-six patients with gastric adenoma or early gastric cancer were enrolled. After an endoscopic procedure, each subject was randomly assigned to 40 mg q 24 hourrs (once daily group) or 40 mg q 12 hourrs (twice daily group) of IV pantoprazole for 2 days, and subsequently had 40 mg of oral pantoprazole daily. The second-look endoscopy was performed 2 days after an ER to compare the signs of re-bleeding and ulcer status between two groups. Results: Eighty-five patients were treated with 40 mg q 24 hourrs of IV pantoprazole and 91 patients were treated with 40 mg q 12 hourrs of IV pantoprazole. There were no significant differences in the stigmata of early bleeding at the second-look endoscopy (12.1% in once daily group versus 12.0% in twice daily group, pZ0.414) or in the rate of endoscopic hemostatic procedures for the stigmata (30.8% in once daily group versus 32.7% in twice daily group, pZ0.852). Conclusion: Intravenous injections of 40 mg pantoprazole once or twice daily for 2 days after an ER were evenly effective for the prevention of early bleeding.
Clinical characteristics En bloc resection rate, % Adverse events Intraoperative complication, no. Bleeding, Mucosal injury Pneumoperitoneum Postoperative complication, no. Pneumothorax combined with subcutaneous emphysema Pleural effusion combined with pneumonitis Pleural effusion combined with focal atelectasis Subphrenic infection Histopathologic evaluation Pathological diagnosis Leiomyoma Gastrointestinal stromal tumor Glomus tumor Nerve sheath tumor, Calcifying fibrous tumor Complete resection rate, %
100%
1 0 6 3 2 1 1
18 11 1 1 1 100
Tu1730 Clinical Impact of Submucosal Tunneling Endoscopic Resection for the Treatment of Gastric Submucosal Tumors Originating From the Muscularis Propria Layer Quan-Lin Li, Jian-Wei Hu, Chen Zhang, Mei-Dong Xu*, Li-Qing Yao, Ping-Hong Zhou Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China Background: Submucosal tunneling endoscopic resection (STER) can be adequately adopted as an effective treatment for subumucosal tumors (SMTs) originating from the muscularis propria (MP) layer at the esophagus and cardia. However, it has been seldom used for gastric SMTs. Our purpose was to evaluate the clinical impact of STER for gastric SMTs arising from the MP layer. Methods: Thirty-two patients with gastric SMTs from the MP layer were retrospectively identified from a prospectively maintained database including a total of 403 consecutive patients with STER. The main outcome measurements were complete resection rate, adverse events, local recurrence and distant metastases during follow-up. Results: Of the 32 lesions, 12 were located in the gastric corpus close to the cardia, 3 in the gastric fundus close to the cardia, 6 in the lesser curvature of the gastric corpus, and 11 in the greater curvature of the gastric antrum. STER was successfully performed in all patients with en bloc resection of tumors. The mean tumor size was 2.3 cm (range 1.0-5.0 cm). The complete resection rate was 100%. The operation time ranged from 25 to 125 min (mean, 51.8 min). All complications related to STER were successfully managed with conservative treatments. Local recurrence or distant metastasis did not occur during a follow-up period of 6-32 months. Conclusion: STER is a safe and effective therapeutic strategy for eligible gastric SMTs originating from the MP layer. Submucosal tunneling in the stomach may be more challenging than that in the esophagus, but does not increase procedure-related adverse events or prevent successful STER for eligible gastric SMTs.
Clinical characteristics Sex (female/male), no. Mean patient age (range), y Tumor location, no. Gastric fundus close to the cardia Gastric corpus close to the cardia Lesser curvature of the gastric corpus Greater curvature of the gastric antrum Procedure-related parameters Mean diameter of lesion (range), cm Mean procedure time (range), min
14/18 48.1 (31-73) 3 12 6 11 2.3 (1-5) 51.8 (25-125)
AB574 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Submucosal tunneling endoscopic resection (STER) procedure for a submucosal tumor (SMT) in the gastric antrum. a A SMT in the gastric antrum. b The tumor originated from the muscularis propria layer. c A latitudinal mucosal incision was made. d Submucosal tunnel was created and it was more difficult in the stomach than in the esophagus. e, f The tumor was dissected under direct view. g The defect of gastric wall after tumor resection. h The mucosal entry was closed. i The resected specimen.
Tu1731 Safe Definitive Endoscopic Management of High-Risk Polypoid Lesions of the Foregut Using Combined Volume Reduction and the Loop and Leave Technique John Walker, Suraj Gupta, Hani Jarawan, Joshua Penfield, David Klibansky, Douglas A. Howell* Pancreaticobilary Center, Maine Medical Center, Portland, ME Background: Large hyperplastic foregut polyps typically arise from chronically inflamed mucosa, present with bleeding or pain from prolapse, and have a !2% malignant potential. When malignancy is present, neoplasia is usually focal and lymph node involvement and metastases are rare. Due to the highly vascular nature of these polyps and low risk for malignancy, removal for histology is both dangerous and unnecessary in most cases, especially in those with comorbidities. Challenges include inability to fully encircle lesions to secure the stalks even with large snares, presence of thick stalks that cannot be clipped, and difficult positioning. A comprehensive, safe, and simple technique of management has not been established for these high-risk patients (pts). We propose a technique of combined volume reduction by epinephrine (epi) injection of the stalk and subsequent placement
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Tu1725 Predilection Sites of Intestinal Metaplasia in the Stomach: a Retrospective Study Based on Endoscopic Results of 78,335 Cases Xin-Yi Mao, Qing Liu, Hai-Han Zhang, Shun-Fu Xu, Jian-Xia Jiang* Department of Gastroenterology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China Objectives: Gastric intestinal metaplasia (IM) is closely related to the occurrence of intestinal-type gastric carcinoma. This research was aimed to study the predilection sites of IM in the stomach to guide endoscopic biopsy selection to find IM as early as possible, and decrease the canceration rate of stomach ultimately. Methods: Totally 78,335 cases receiving gastroduodenoscope examination, who came from Jiangsu and Anhui provinces of China during 2008-2013, were enrolled in the study. The basic characteristics, biopsy sites and histological information were obtained and analyzed. This study was reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Nanjing Medical University and the committee specifically approved and no informed consent was required since these data were going to be analyzed anonymously. Results: The study showed that IM incidence rate 40% (2,068/6,345) in angulus, 20.24% (11056/54632) in lesser curvature of antrum and 25.48% (276/1083) in corpus, which are significantly higher than other sites in the stomach (P!0.005) (Table 1). Moreover, the severity of IM in lesser curvature of antrum and angulus were worse than great curvature of antrum (Table 2). Furthermore, the severity of acute and chronic inflammation were both higher in lesser curvature than in great curvature of antrum regardless of H. pylori-positive and negative (P!0.05). Conclusion: IM was mostly prone to occur in angulus, the lesser curvature of antrum and corpus. And the severity of inflammation in the lesser curvature of antrum was also higher than the great curvature, which was partially consisting with IM predilection site. Our conclusion was that angulus, the lesser curvature of antrum and corpus should be chosen as regular biopsy sites.Keywords: Intestinal metaplasia, biopsy sites, predilection sites, gastric cancer
The incidence of IM rates in different biopsy sites. Biopsy site
Biopsy (n)
IM (n, %)
c1
P1
72,603 54,632 52,841 4,455 3,285 3,322 1,083 1,153 509 490 6,345 2,724 783 1,179
15,107(20.81) 11,056(20.24) 5,240(9.38) 1,054(23.66) 626(19.00) 497(4.96) 276(25.48) 58(5.03) 49(9.63) 84(17.14) 2,608(40.00) 332(12.19) 241(30.78) 101(8.57)
*
*
Antrum lesser curvature great curvature anterior wall posterior wall Corpus lesser curvature great curvature anterior wall posterior wall Angulus Cardia Pylorus Fundus
!.005
66.51
c2
P2
* * 2224.17 !.005 29.59 !.005 2.68 O.005 * 183.89 53.6 13.3
1,381.03 121.75 46.57 106.23
!.005 !.005 !.005 !.005
* !.005 !.005 !.005
IM incidence was significantly higher in angulus, and antrum than corpus. And within antrum or corpus, IM more easily occurred in lesser curvature than greater curvature. Noet: c1, P1: IM in corpus, angulus, cardia, pylorus, fundus respectively vs. in antrum; c2, P2: IM in different sites vs. in lesser curvature within antrum or corpus. *: The baseline for comparison.
Comparison of IM grade in three main sites using Chi-square test. Biopsy site
Antrum-great curvature * Antrum-lesser curvature Angulus
Biopsy
Mild
Moderate
Severe
n
IM (n,%)
IM (n,%)
IM (n,%)
3,415 (6.12) 6,864 (12.56) 1,236 (19.48)
738 (1.32) 1,759 (3.22) 659 (10.39)
55,841 54,632 6,345
c1
P1
c2
P2
c3
P3
52(0.09) 136(0.25)
1,360.75
!.005
76(1.2)
1470.60
!.005
450. 36 2,131. 80
!.005
39.46
!.005
!.005
338.48
!.005
IM was most severe in angulus, then the lesser curvature of antrum than the great curvature of antrum. Note: c1-3, P1-3: mild, moderate and severe IM in lesser curvature of antrum or angulus vs. in greater curvature of antrum. *: The baseline for comparison.
Tu1726 Predictive Factors for Pain After Endoscopic Resection of Gastric Tumor Seung Young Kim*, Sung Woo Jung, Jong Jin Hyun, Ja Seol Koo, Jong-Jae Park, Hoon Jai Chun, Sang Woo Lee Korea University College of Medicine, Seoul, Korea (the Republic of) Background and Aims: Abdominal pain is a common complaint following an endoscopic resection (ER). The aim of this study was to investigate the predictive factors
www.giejournal.org
for abdominal pain after an ER. Patients and Methods: Patients who were scheduled to undergo endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for the treatment of gastric adenoma or cancer were prospectively enrolled. Pain score was checked q 6 hours after an ER and any complaint of additional pain was checked with a pain scale (0 to 10). If the pain score exceeded 5, 25mg of IV pethidine was given. Results: Among 162 patients who underwent ER, 70 patients (43.2%) received IV pethidine due to abdominal pain over the scale 5. Female gender (OR, 2.558; p-value, 0.017), lower third location of the tumor (OR, 3.979; p-value, 0.001), and procedures over 60 min (OR, 3.092; p-value, 0.008) were significant predictive factors for pain developed after an ER in the multivariate analysis. Conclusion: Female gender, lower third location of the tumor, and procedures over 60 min were significantly associated with pain after ER. Close management is recommended in patients who are associated with such risks.
Tu1727 Bleeding Risk Assessment Using Forrest Classification After Endoscopic Submucosal Dissection for Gastric Neoplasms Jong Yeul Lee*, Young-Il Kim, Soo-Jeong Cho, Chan Gyoo Kim, Il Ju Choi Center for Gastric Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Korea (the Republic of) Background and Aims: Delayed bleeding seems markedly decrease during the first week after endoscopic submucosal dissection (ESD) for gastric neoplasm. However, it still may occur even after one week of procedure especially in antiplatelet agent users. We aimed to investigate the risk factors for delayed bleeding at post-ESD ulcers using Forrest classification as a surrogate marker. Patients and Methods: Forrest classification of 392 post-ESD ulcers was evaluated at 1st (nZ204) or 2nd (nZ188) week after ESD in 371 patients with 415 gastric neoplasms (323 early gastric cancers and 92 adenomas) at the National Cancer Center Hospital, Korea, between August 2011 and June 2013. Forrest classification was categorized into two groups: increased risk (Forrest Ia-IIc), or low risk (Forrest III). Odds ratios (OR) with 95% confidence intervals (CI) were calculated using logistic regression analysis to determine the risk factors associated with increased risk group. Results: In total, 392 post-ESD ulcers were included, with 1 ulcer (0.3%) being classified as Forrest Ib, 2 (0.5%) as Forrest IIa, 18 (4.6%) as Forrest IIb, 182 (46.4%) as Forrest IIc, and 189 (48.2%) as Forrest III. Increased risk ulcers (Forrest Ia-IIc) were found in 72.1% (147/ 204) at 1st week, but it significantly decreased to 29.8% (56/188) at 2nd week (P ! 0.001). Multivariate analyses showed that 1st week [odds ratio (OR), 7.20 (95% CI, 4.51-11.5)], younger patient age (% 65 years) [OR, 1.99 (95% CI, 1.26-3.14)], middle or upper location of tumor [OR, 2.04 (95% CI, 1.18-3.51)], and larger post-ESD ulcer size (O 4cm) [OR, 1.66 (95% CI, 1.06-2.60)] were significantly associated with increased risk ulcers. Conclusions: Ulcer base 1 week after ESD still have increased risk of bleeding when assessed by Forrest classification. Thus, this finding should be considered in clinical practice and further study to evaluate proper time interval to start medication such as dual antiplatelet agents.
Tu1728 Effects of Administration of Proton Pump Inhibitor Before Endoscopic Submucosal Dissection for Differentiated Early Gastric Cancer With Ulcer Yu Sik Myung*, Su Jin Hong, Hee Jae Jung, Jae Pil Han, Bong Min Ko, Moon Sung Lee Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University School of Medicine, Bucheon, Korea (the Republic of) Background and Objectives: Ulcerative early gastric cancer (EGC) repeats improvement and exacerbation of ulceration during its natural course. However, the improvement of ulceration is known to be associated with the usage of antisecretory medication and the depth of invasion. The aim of this study was to evaluate the effect of administration of proton pump inhibitor (PPI) before endoscopic submucosal dissection (ESD) and clinical outcomes in ulcerative EGC. Methods: A total of 136 differentiated EGCs with ulcer which had met the expanded indication for ESD were reviewed between June 2005 and June 2014 retrospectively. Eighty-one patients were administered PPI before ESD and 55 patients were not administered PPI. We compared the rate of ulcer healing and clinical outcomes of ESD including en bloc resection, complete resection, complication and procedure time between two groups (PPI group and non-PPI group). Results: There were no significant differences in patient demographics were observed between the PPI group and non-PPI group. The complete healing rate of ulcer was significantly different between two groups (59.3% vs 23.6%, p!0.001). The procedure time was 38.14.0 and 50.86.8 minutes, respectively (pZ0.047). However, no significant differences were detected in en bloc resection rate, complete resection rate and complications including bleeding and perforation between two groups. Of the 81 patients who administered PPI, rate of complete healing was 71.9%(46/64) in mucosal cancer and 11.8% (2/17) in submucosal cancer, respectively (p!0.001). The multivariated analysis showed that administration of PPI (ORZ7.33, 95% CI 3.02-17.78, p!0.001) and mucosal
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB573
Abstracts
invasion (ORZ22.83, 95% CI 4.80-108.46, p!0.001) were the independent factors to predict complete healing of ulceration. Conclusions: Administration of PPI for differentiated EGC with ulcer which meet the expanded criteria is effective to reduce the procedure time and heal the ulcer lesion. In differenciated EGC meeting the expanded criteria for ESD, complete healing of ulcer after PPI administration suggests mucosal cancer.
Tu1729 Comparison of Once and Twice Daily Intravenous PPI Injections for Prevention of Bleeding After Endoscopic Resections Sung Woo Jung*, Joo Hee Park, Seung Young Kim, Jong Jin Hyun, Ja Seol Koo, Jong-Jae Park, Hoon Jai Chun, Sang Woo Lee Korea University College of Medicine, Seoul, Korea (the Republic of) Background and Aims: Endoscopic resection(ER) is commonly used to remove gastric neoplasms. However, effective treatment dosing or scheduling of proton pump inhibitors (PPI) for the prevention of delayed bleeding after an ER remains unclear. Patients and Methods: One hundred seventy-six patients with gastric adenoma or early gastric cancer were enrolled. After an endoscopic procedure, each subject was randomly assigned to 40 mg q 24 hourrs (once daily group) or 40 mg q 12 hourrs (twice daily group) of IV pantoprazole for 2 days, and subsequently had 40 mg of oral pantoprazole daily. The second-look endoscopy was performed 2 days after an ER to compare the signs of re-bleeding and ulcer status between two groups. Results: Eighty-five patients were treated with 40 mg q 24 hourrs of IV pantoprazole and 91 patients were treated with 40 mg q 12 hourrs of IV pantoprazole. There were no significant differences in the stigmata of early bleeding at the second-look endoscopy (12.1% in once daily group versus 12.0% in twice daily group, pZ0.414) or in the rate of endoscopic hemostatic procedures for the stigmata (30.8% in once daily group versus 32.7% in twice daily group, pZ0.852). Conclusion: Intravenous injections of 40 mg pantoprazole once or twice daily for 2 days after an ER were evenly effective for the prevention of early bleeding.
Clinical characteristics En bloc resection rate, % Adverse events Intraoperative complication, no. Bleeding, Mucosal injury Pneumoperitoneum Postoperative complication, no. Pneumothorax combined with subcutaneous emphysema Pleural effusion combined with pneumonitis Pleural effusion combined with focal atelectasis Subphrenic infection Histopathologic evaluation Pathological diagnosis Leiomyoma Gastrointestinal stromal tumor Glomus tumor Nerve sheath tumor, Calcifying fibrous tumor Complete resection rate, %
100%
1 0 6 3 2 1 1
18 11 1 1 1 100
Tu1730 Clinical Impact of Submucosal Tunneling Endoscopic Resection for the Treatment of Gastric Submucosal Tumors Originating From the Muscularis Propria Layer Quan-Lin Li, Jian-Wei Hu, Chen Zhang, Mei-Dong Xu*, Li-Qing Yao, Ping-Hong Zhou Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China Background: Submucosal tunneling endoscopic resection (STER) can be adequately adopted as an effective treatment for subumucosal tumors (SMTs) originating from the muscularis propria (MP) layer at the esophagus and cardia. However, it has been seldom used for gastric SMTs. Our purpose was to evaluate the clinical impact of STER for gastric SMTs arising from the MP layer. Methods: Thirty-two patients with gastric SMTs from the MP layer were retrospectively identified from a prospectively maintained database including a total of 403 consecutive patients with STER. The main outcome measurements were complete resection rate, adverse events, local recurrence and distant metastases during follow-up. Results: Of the 32 lesions, 12 were located in the gastric corpus close to the cardia, 3 in the gastric fundus close to the cardia, 6 in the lesser curvature of the gastric corpus, and 11 in the greater curvature of the gastric antrum. STER was successfully performed in all patients with en bloc resection of tumors. The mean tumor size was 2.3 cm (range 1.0-5.0 cm). The complete resection rate was 100%. The operation time ranged from 25 to 125 min (mean, 51.8 min). All complications related to STER were successfully managed with conservative treatments. Local recurrence or distant metastasis did not occur during a follow-up period of 6-32 months. Conclusion: STER is a safe and effective therapeutic strategy for eligible gastric SMTs originating from the MP layer. Submucosal tunneling in the stomach may be more challenging than that in the esophagus, but does not increase procedure-related adverse events or prevent successful STER for eligible gastric SMTs.
Clinical characteristics Sex (female/male), no. Mean patient age (range), y Tumor location, no. Gastric fundus close to the cardia Gastric corpus close to the cardia Lesser curvature of the gastric corpus Greater curvature of the gastric antrum Procedure-related parameters Mean diameter of lesion (range), cm Mean procedure time (range), min
14/18 48.1 (31-73) 3 12 6 11 2.3 (1-5) 51.8 (25-125)
AB574 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 5S : 2015
Submucosal tunneling endoscopic resection (STER) procedure for a submucosal tumor (SMT) in the gastric antrum. a A SMT in the gastric antrum. b The tumor originated from the muscularis propria layer. c A latitudinal mucosal incision was made. d Submucosal tunnel was created and it was more difficult in the stomach than in the esophagus. e, f The tumor was dissected under direct view. g The defect of gastric wall after tumor resection. h The mucosal entry was closed. i The resected specimen.
Tu1731 Safe Definitive Endoscopic Management of High-Risk Polypoid Lesions of the Foregut Using Combined Volume Reduction and the Loop and Leave Technique John Walker, Suraj Gupta, Hani Jarawan, Joshua Penfield, David Klibansky, Douglas A. Howell* Pancreaticobilary Center, Maine Medical Center, Portland, ME Background: Large hyperplastic foregut polyps typically arise from chronically inflamed mucosa, present with bleeding or pain from prolapse, and have a !2% malignant potential. When malignancy is present, neoplasia is usually focal and lymph node involvement and metastases are rare. Due to the highly vascular nature of these polyps and low risk for malignancy, removal for histology is both dangerous and unnecessary in most cases, especially in those with comorbidities. Challenges include inability to fully encircle lesions to secure the stalks even with large snares, presence of thick stalks that cannot be clipped, and difficult positioning. A comprehensive, safe, and simple technique of management has not been established for these high-risk patients (pts). We propose a technique of combined volume reduction by epinephrine (epi) injection of the stalk and subsequent placement
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