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W1423: Human Hybrid Endoscopic and Laparoscopic Management of Gastroesophageal Junction Tumors
Abstracts
T1620 Endomicroscopy Is Able to Identify Superficial but Not Deep Intestinal Metaplasia of the Gastric Mucosa Ralf Kiesslich, Maximilian Sehn, Lee Guan Lim, Arthur Hoffman, Martin Goetz, Thorsten Hansen, Peter R. Galle Introduction: Patients with atrophic gastritis and intestinal metaplasia (IM) face an increased risk for gastric cancer. The presence of IM can macroscopically not be visualized. Thus, aim of the current study was to investigate the value of confocal laser endomicroscopy or intensive histological mapping for diagnosing intestinal metaplasia.Methods: Patients with known intestinal metaplasia were re-invited for EGD using fluorescein guided confocal laser endomicroscopy (Pentax, Japan). Initially random biopsies were performed at 5 predefined areas within the stomach [2x antrum, 2x corpus, 1x angulus; 2 biopies per site] (Histological analysis 1). Subsequently endomicroscopy was performed in the same region with at least 1 cm distance from the biopsied area. Confocal images from the surface up to 250 m (deepest imaging plane depth) were recorded and immediately in vivo judgment for the presence of IM was made (Endomicroscopic analysis). Exact targeted biopsies from the endomicroscopically investigated areas were performed (Histological analysis 2). Histological specimens were stained with H&E and PAS. The presence, amount and location of intestinal metaplasia were judged. Outcome analysis was performed for the three different analyses.Results: 15 patients were finally included [6 male, mean age 58.6 years]. Outcome analyses (see table).Disagreement between endomicroscopy and histology was seen if IM was present only in deeper parts of the mucosa (⬎250m) and if less than 5 goblet cells were seen per field of view (475 x 475m).Conclusions:Endomicroscopy enables the in vivo identification of goblet cells within the superficial gastric mucosa which defines intestinal metaplasia and rightly identifies patients with IM as accurately as conventional histology. However, conventional histology was able to identify significantly more sites with IM, which reflect the fact that almost half of the IM was present only in deeper parts of the mucosa, which could not be reached endomicroscopically.
nⴝ15
No. of pts. with IM
Sites with IM
Sensitivity (per site)
Specificity (per site)
Histology 1 Histology 2 Endomicroscopy
10 9 8
24 20 12 (p⫽0.034)
40%
92.6%
consists of a main chamber and a cover. The main chamber has a negative image of the micro-spike structure. The biopsied tissue is efficiently detached from the micro-spike by inserting the micro-spike into the negative structure. The cover prevents the detached tissue from being lost. A 400 m diameter hole array is microfabricated on the top and bottom layers of the collection tool for exchanging paraffin liquid to the main chamber and keeping the detached tissue from a paraffin embedding process.The in vivo experiment of tissue biopsy is performed in gastro intestines of an anesthetized pig with minimally invasive micro-spike. The biopsied tissue is detached from micro-spike with proposed tissue collection tool and the cover replaces micro-spike to keep the detached tissue. After that, the tissue collection tool keeping the tissue is processed through the conventional histopathological procedure.RESULTS:Fine histopathological photomicrographs are acquired using the developed tissue collection tool with the conventional histopathological procedure. The photomicrographs acquisition rate rises to 90 % from 10 % due to the proposed tool. These experimental results show that the paraffin-based tissue collection tool and micro-spike are applicable to the medical practice.
W1423 Human Hybrid Endoscopic and Laparoscopic Management of Gastroesophageal Junction Tumors Sagar Garud, Eric M. Paul, S. Scott Davis, Richard Kraus, Melinda M. Lewis, David Kooby, Field Willingham Introduction: Gastroesophageal junction (GEJ) mass lesions which are too large for endoscopic resection may be considered for surgical resection. Even for relatively small masses, GEJ lesions may require subtotal or total gastrectomy. Total gastrectomy is associated with long term implications in quality of life. A resection-sparing hybrid laparoscopic and endoscopic technique was developed for the management of GEJ tumors. Methods: Patients in whom a GEJ mass was deemed unresectable by the referring gastroenterologist as well as the tertiary care gastroenterologist and who were surgical candidates were offered a hybrid resection. Pre-operative EGD, EUS with FNA, and CT scan were obtained for all patients. The patients were taken to the operating room and placed under general anesthesia. An optically viewing trocar was placed through the umbilicus. Two additional ports each were placed in the left and the right abdomen. The stomach was mobilized laparoscopically, and a two channel therapeutic gastroscope was introduced. A 5.5 cm needle tip snare was advanced through the gastroscope. The tumor was manipulated into the snare with laparascopic assistance and resected. The tumor was retrieved endoscopically and sent for pathologic examination. Results: Three patients were offered hybrid resection for GEJ mass lesions. In two of three patients (Table 1) the gastroesophageal junction masses were removed successful with the combined laparoscopic and endoscopic technique. In the third patient, despite creation of laparoscopic gastrotomies, the mass lesion was too large for a hybrid approach. The third patient underwent a partial gastrectomy. Three of three patients had an uneventful recovery with no post-operative morbidity. Conclusion: The hybrid technique was safe and feasible in three human patients with GEJ mass lesions too large for conventional endoscopic resection. Two of three patients consented for total gastrectomy were spared an open surgery and gastric resection. With further study, the pre-operative characteristics of lesions resectable with a hybrid approach will be refined. Table 1: Patient characteristics and results
T1621 Paraffin-Based Tissue Collection Tool for Micro-Spike Biopsy, Applicable to the Conventional Histopathological Procedure Hyo-Young Jeong, Kyo-in Koo, Sangmin Lee, Jae-Won Ban, Ho-Soo Park, Seok-Jun Hong, Seungmin Bang, Si Young Song, Dongil D. Cho BACKGROUND:In 2005, we presented a novel micro-spike for the minimal invasive biopsy using the microelectromechanical systems(MEMS) technology. The micro-spike forks the intestinal wall and extracts tissues by retaining them between the barbed shanks of the micro-spike. In 2006, we developed a tailored catheter for the micro-spike biopsy. In over the 30 in vivo pig experiments, there has been no intestinal puncture during the micro-spike biopsy operations. Bleeding was observed in only approximately 13%. Despite the fact that the micro-spike allows performing the biopsy function with minimal invasiveness, the acquisition rate of histopathological tissue images has been approximately 10%. The principal cause is that it is difficult to detach the biopsied tissue from the micro-spike. Another cause is that the detached tissue is easily lost in the subsequent histopathological procedure.OBJECTIVES:This paper presents a paraffin-based tissue collection tool for the micro-spike biopsy which is applicable to the conventional histopathological procedure. Using the proposed tissue collection tool, the biopsied tissue is efficiently detached from the microspike, and well protected from various solution exchanges in the subsequent histopathological procedure.METHODS:The proposed tissue collection tool is fabricated with paraffin, using the MEMS technology. The tissue collection tool
AB324 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
Patient Age/ Lesion No. Gender Size 1 2 3
Preliminary Pathology
Laparoendoscopic resection Final pathology
62/ F 2.6 cm x Adenoma with high Successful Intramucosal 2.3 cm x grade dysplasia carcinoma 1.4 cm 62/ F 3.3 cm x Non-diagnostic Successful Hyperplastic 1.9 cm x polyp 1.6 cm 63/ M 4.8 cm x Gastrointestinal Unsuccessful. Gastrointestinal 4.2cm x stromal tumor (GIST) Underwent partial stromal tumor 2.4 cm gastrectomy (GIST)
W1424 Factors Associated With Esophageal Stricture Development Following Endoscopic Mucosal Resection for Neoplastic Barrett’s Esophagus Jason J. Lewis, Joel H. Rubenstein, Amit G. Singal, Cyrus R. Piraka Introduction: Endoscopic mucosal resection (EMR) for neoplastic Barrett’s esophagus is gaining favor over esophagectomy, demonstrating similar survival advantage with less morbidity. Esophageal strictures are a common complication of EMR. Symptomatic stricture formation has been reported with EMR, photodynamic therapy and combination therapy in 13-37% of patients. Predictors of stricture development have been examined in patients treated with
www.giejournal.org
T1620 Endomicroscopy Is Able to Identify Superficial but Not Deep Intestinal Metaplasia of the Gastric Mucosa Ralf Kiesslich, Maximilian Sehn, Lee Guan Lim, Arthur Hoffman, Martin Goetz, Thorsten Hansen, Peter R. Galle Introduction: Patients with atrophic gastritis and intestinal metaplasia (IM) face an increased risk for gastric cancer. The presence of IM can macroscopically not be visualized. Thus, aim of the current study was to investigate the value of confocal laser endomicroscopy or intensive histological mapping for diagnosing intestinal metaplasia.Methods: Patients with known intestinal metaplasia were re-invited for EGD using fluorescein guided confocal laser endomicroscopy (Pentax, Japan). Initially random biopsies were performed at 5 predefined areas within the stomach [2x antrum, 2x corpus, 1x angulus; 2 biopies per site] (Histological analysis 1). Subsequently endomicroscopy was performed in the same region with at least 1 cm distance from the biopsied area. Confocal images from the surface up to 250 m (deepest imaging plane depth) were recorded and immediately in vivo judgment for the presence of IM was made (Endomicroscopic analysis). Exact targeted biopsies from the endomicroscopically investigated areas were performed (Histological analysis 2). Histological specimens were stained with H&E and PAS. The presence, amount and location of intestinal metaplasia were judged. Outcome analysis was performed for the three different analyses.Results: 15 patients were finally included [6 male, mean age 58.6 years]. Outcome analyses (see table).Disagreement between endomicroscopy and histology was seen if IM was present only in deeper parts of the mucosa (⬎250m) and if less than 5 goblet cells were seen per field of view (475 x 475m).Conclusions:Endomicroscopy enables the in vivo identification of goblet cells within the superficial gastric mucosa which defines intestinal metaplasia and rightly identifies patients with IM as accurately as conventional histology. However, conventional histology was able to identify significantly more sites with IM, which reflect the fact that almost half of the IM was present only in deeper parts of the mucosa, which could not be reached endomicroscopically.
nⴝ15
No. of pts. with IM
Sites with IM
Sensitivity (per site)
Specificity (per site)
Histology 1 Histology 2 Endomicroscopy
10 9 8
24 20 12 (p⫽0.034)
40%
92.6%
consists of a main chamber and a cover. The main chamber has a negative image of the micro-spike structure. The biopsied tissue is efficiently detached from the micro-spike by inserting the micro-spike into the negative structure. The cover prevents the detached tissue from being lost. A 400 m diameter hole array is microfabricated on the top and bottom layers of the collection tool for exchanging paraffin liquid to the main chamber and keeping the detached tissue from a paraffin embedding process.The in vivo experiment of tissue biopsy is performed in gastro intestines of an anesthetized pig with minimally invasive micro-spike. The biopsied tissue is detached from micro-spike with proposed tissue collection tool and the cover replaces micro-spike to keep the detached tissue. After that, the tissue collection tool keeping the tissue is processed through the conventional histopathological procedure.RESULTS:Fine histopathological photomicrographs are acquired using the developed tissue collection tool with the conventional histopathological procedure. The photomicrographs acquisition rate rises to 90 % from 10 % due to the proposed tool. These experimental results show that the paraffin-based tissue collection tool and micro-spike are applicable to the medical practice.
W1423 Human Hybrid Endoscopic and Laparoscopic Management of Gastroesophageal Junction Tumors Sagar Garud, Eric M. Paul, S. Scott Davis, Richard Kraus, Melinda M. Lewis, David Kooby, Field Willingham Introduction: Gastroesophageal junction (GEJ) mass lesions which are too large for endoscopic resection may be considered for surgical resection. Even for relatively small masses, GEJ lesions may require subtotal or total gastrectomy. Total gastrectomy is associated with long term implications in quality of life. A resection-sparing hybrid laparoscopic and endoscopic technique was developed for the management of GEJ tumors. Methods: Patients in whom a GEJ mass was deemed unresectable by the referring gastroenterologist as well as the tertiary care gastroenterologist and who were surgical candidates were offered a hybrid resection. Pre-operative EGD, EUS with FNA, and CT scan were obtained for all patients. The patients were taken to the operating room and placed under general anesthesia. An optically viewing trocar was placed through the umbilicus. Two additional ports each were placed in the left and the right abdomen. The stomach was mobilized laparoscopically, and a two channel therapeutic gastroscope was introduced. A 5.5 cm needle tip snare was advanced through the gastroscope. The tumor was manipulated into the snare with laparascopic assistance and resected. The tumor was retrieved endoscopically and sent for pathologic examination. Results: Three patients were offered hybrid resection for GEJ mass lesions. In two of three patients (Table 1) the gastroesophageal junction masses were removed successful with the combined laparoscopic and endoscopic technique. In the third patient, despite creation of laparoscopic gastrotomies, the mass lesion was too large for a hybrid approach. The third patient underwent a partial gastrectomy. Three of three patients had an uneventful recovery with no post-operative morbidity. Conclusion: The hybrid technique was safe and feasible in three human patients with GEJ mass lesions too large for conventional endoscopic resection. Two of three patients consented for total gastrectomy were spared an open surgery and gastric resection. With further study, the pre-operative characteristics of lesions resectable with a hybrid approach will be refined. Table 1: Patient characteristics and results
T1621 Paraffin-Based Tissue Collection Tool for Micro-Spike Biopsy, Applicable to the Conventional Histopathological Procedure Hyo-Young Jeong, Kyo-in Koo, Sangmin Lee, Jae-Won Ban, Ho-Soo Park, Seok-Jun Hong, Seungmin Bang, Si Young Song, Dongil D. Cho BACKGROUND:In 2005, we presented a novel micro-spike for the minimal invasive biopsy using the microelectromechanical systems(MEMS) technology. The micro-spike forks the intestinal wall and extracts tissues by retaining them between the barbed shanks of the micro-spike. In 2006, we developed a tailored catheter for the micro-spike biopsy. In over the 30 in vivo pig experiments, there has been no intestinal puncture during the micro-spike biopsy operations. Bleeding was observed in only approximately 13%. Despite the fact that the micro-spike allows performing the biopsy function with minimal invasiveness, the acquisition rate of histopathological tissue images has been approximately 10%. The principal cause is that it is difficult to detach the biopsied tissue from the micro-spike. Another cause is that the detached tissue is easily lost in the subsequent histopathological procedure.OBJECTIVES:This paper presents a paraffin-based tissue collection tool for the micro-spike biopsy which is applicable to the conventional histopathological procedure. Using the proposed tissue collection tool, the biopsied tissue is efficiently detached from the microspike, and well protected from various solution exchanges in the subsequent histopathological procedure.METHODS:The proposed tissue collection tool is fabricated with paraffin, using the MEMS technology. The tissue collection tool
AB324 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
Patient Age/ Lesion No. Gender Size 1 2 3
Preliminary Pathology
Laparoendoscopic resection Final pathology
62/ F 2.6 cm x Adenoma with high Successful Intramucosal 2.3 cm x grade dysplasia carcinoma 1.4 cm 62/ F 3.3 cm x Non-diagnostic Successful Hyperplastic 1.9 cm x polyp 1.6 cm 63/ M 4.8 cm x Gastrointestinal Unsuccessful. Gastrointestinal 4.2cm x stromal tumor (GIST) Underwent partial stromal tumor 2.4 cm gastrectomy (GIST)
W1424 Factors Associated With Esophageal Stricture Development Following Endoscopic Mucosal Resection for Neoplastic Barrett’s Esophagus Jason J. Lewis, Joel H. Rubenstein, Amit G. Singal, Cyrus R. Piraka Introduction: Endoscopic mucosal resection (EMR) for neoplastic Barrett’s esophagus is gaining favor over esophagectomy, demonstrating similar survival advantage with less morbidity. Esophageal strictures are a common complication of EMR. Symptomatic stricture formation has been reported with EMR, photodynamic therapy and combination therapy in 13-37% of patients. Predictors of stricture development have been examined in patients treated with
www.giejournal.org