Rarity of Severe Bleeding and Perforation in Endoscopic Ultrasound-Guided Fine Needle Aspiration for Submucosal Tumors

Background

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an established procedure for the pathological diagnosis of gastrointestinal submucosal tumors (SMTs). Although bleeding and perforation are potentially severe complications of EUS-FNA, the incidences and severities of these complications have not yet been fully evaluated because of their relative rarity.

Aim

The purpose of this study was to evaluate the incidences and mortality of severe bleeding and perforation in patients who underwent EUS-FNA for SMTs.

Methods

The records of 1,135 consecutive patients who underwent EUS-FNA for SMTs at 219 hospitals, with low- to high-volume, were reviewed using a Japanese nationwide administrative database.

Results

Of the targeted lesions 73.5 % were located in the stomach, 13.4 % in the esophagus, 8.2 % in the duodenum, and 4.9 % at other sites. Five patients (0.44 %) experienced severe bleeding requiring red blood cell transfusion or endoscopic treatment, with none experiencing perforation. Only one patient (0.09 %) died in-hospital within 30 days of EUS-FNA (0.09 %), with death not associated with bleeding or perforation.

Conclusions

EUS-FNA is safe in evaluating SMTs, with low risks of bleeding and perforation.     

Preprocedural Rabeprazole Treatment Before Endoscopic Submucosal Dissection for Gastric Neoplasms

Background

The maximal effect of proton pump inhibitors (PPI) is reported to take 5 days. However, most current protocols start PPI on the day of gastric endoscopic submucosal dissection (ESD).

Aims

We aimed to evaluate the benefit of 5 days pretreatment with oral PPI before ESD to prevent bleeding.

Methods

This was a prospective randomized controlled trial. Patients were administered oral rabeprazole 20 mg or placebo twice daily for 5 days before ESD. Intravenous pantoprazole 40 mg was administered 2 h before ESD and at postprocedure day 1, and then oral rabeprazole 20 mg was administered once daily. Follow-up endoscopy was performed on days 1 and 30. Forty-eight-hour measurement of intragastric pH was performed in 26 patients. The primary endpoint was major bleeding related to ESD.

Results

One-hundred and twenty patients were enrolled. Of these, 45 in the pretreatment and 53 in the placebo group were analyzed. Each group had three cases of major bleeding. There were no significant differences in the ulcer healing rate. Intragastric pH percentage times greater than 4, 5, and 6 were 86.61 ± 19.45 %, 83.30 ± 22.06 %, and 76.86 ± 25.35 %, respectively, in the pretreatment and 85.54 ± 19.45 %, 84.08 ± 27.11 %, and 81.53 ± 27.81 %, respectively, in the placebo group, without significant differences.

Conclusions

Preprocedural administration of rabeprazole offers no additional benefit over postprocedural administration alone in preventing major bleeding after gastric ESD.     

Endoscopic Muscularis Excavation for Subepithelial Tumors of the Esophagogastric Junction Originating from the Muscularis Propria Layer

Background

Because of complicating anatomic factors, endoscopic submucosal dissection is seldom performed in subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.

Aim

This study was designed to evaluate the feasibility of endoscopic muscularis excavation for treating subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.

Methods

Between December 2008 and December 2011, 68 patients with subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer were treated with endoscopic muscularis excavation. Key steps of the procedure included the following: (1) injecting a mixture solution into the submucosal layer after making several dots around the tumor; (2) making a cross incision of the overlying mucosa, and excavating the tumor from the muscularis propria layer; (3) closing the artificial ulcer with clips after tumor removal.

Results

The mean tumor size was 16.2 mm (range 7–35 mm). Endoscopic muscularis excavation was successfully performed in 65 out of 68 cases (success rate 95.6 %). Pathological diagnosis of these tumors included leiomyoma (39 out of 68) and gastrointestinal stromal tumor (29 out of 68). Perforation occurred in seven patients (10.3 %). No massive bleeding or delayed bleeding occurred. The median follow-up period after the procedure was 23 months (range 6–42 months). No residual or recurrent tumor was detected and no stricture occurred in patients during the follow-up period.

Conclusions

Endoscopic muscularis excavation is a safe, effective and feasible procedure for providing accurate histopathologic evaluation and curative treatment for subepithelial tumors of the esophagogastric junction originating from the muscularis propria layer.     

Half-Dose Rabeprazole Has an Equal Efficacy to Standard-Dose Rabeprazole on Endoscopic Submucosal Dissection-Induced Ulcer

Background

Although endoscopic submucosal dissection (ESD)-induced ulcers heal faster and recur less often than non-iatrogenic gastric ulcers, the optimal dosage and duration of proton pump inhibitor treatment for ESD-induced ulcers remain unclear.

Aims

To evaluate the efficacy of half-dose rabeprazole on endoscopic submucosal dissection-induced ulcer compared with standard dose rabeprazole.

Methods

The study was a prospective randomized controlled double-blind trial at a single tertiary hospital. A total of 80 patients who underwent ESD for gastric neoplasia were enrolled. Of these patients, 10 were not followed to completion. Final analysis included the remaining 70 patients. Rabeprazole 20 or 10 mg, depending on randomization, was given orally for 4 weeks after ESD.

Results

Of the 70 patients, 45 (64 %) were men, and the median age was 65.2 ± 9.7 years. The mean ESD-induced ulcer area was 673 mm². No significant differences in ulcer area reduction ratio (p = 0.49) or ulcer-related symptoms (p = 0.91) were observed between the two groups at 4 weeks after ESD.

Conclusion

For ESD-induced ulcers, treatment with 10 mg of rabeprazole daily produces a similar outcome as 20 mg of rabeprazole with regard to healing efficacy and symptom resolution.     

Efficacy and Safety of Endoscopic Submucosal Dissection for Superficial Squamous Esophageal Neoplasia: A Meta-Analysis

Background and Aims

Although endoscopic submucosal dissection (ESD) has grown popular in resecting lesions in the stomach, the application of ESD to the esophagus has been limited by greater technical difficulty. An increasing number of series have recently reported the application of ESD to esophageal lesions. The aim of the present systemic review and meta-analysis was to evaluate the efficacy and safety of ESD for esophageal lesions.

Methods

Comprehensive literature searches (1999–2012) were performed on studies that reported ESD for the removal of esophageal neoplasia. Primary outcome measures were pooled estimates of complete resection rate and en bloc resection rate. Secondary outcome measures were pooled estimates of complication rates.

Results

A total of 15 studies provided data on 776 ESD-treated lesions. The pooled estimate of complete resection rate was 89.4 % (95 % CI 86.2–91.9 %). The pooled estimate of en bloc resection was 95.1 % (95 % CI 92.6–96.8 %). The pooled estimates of complications of ESD such as bleeding, perforation, and stenosis were 2.1, 5.0, and 11.6 %, respectively.

Conclusions

ESD appeared to be an extremely effective technique to achieve complete resection of esophageal neoplasia. The very low rate of complications also shows the potential safety of this approach.     

Comparison of Clinical Outcomes Among Different Endoscopic Resection Methods for Treating Colorectal Neoplasia

Background/Aim

Endoscopic treatments of colorectal neoplasms have yet to be standardized. This study aimed to compare efficacy and tolerability of different endoscopic resection methods for colorectal epithelial tumors.

Methods

Patients with non-pedunculated colorectal tumors undergoing endoscopic treatments were consecutively enrolled, and their medical records were reviewed retrospectively. The resection methods were classified into three groups: endoscopic mucosal resection with circumferential precutting (EMR-P), endoscopic submucosal dissection with snaring (ESD-S), and endoscopic submucosal dissection alone (ESD). We compared en bloc resection, pathological complete resection, and complications associated with these methods.

Results

Overall, 206 lesions from 203 patients were included in the study (mean size 25.2 ± 10.1 mm). The number of lesions treated with EMR-P, ESD-S, and ESD was 91 (44.2 %), 57 (27.7 %), and 58 (28.2 %), respectively. There was a significant difference in both the en bloc resection rates (EMR-P, 61.5 %; ESD-S, 64.9 %; ESD, 96.6 %; p = 0.001) and complete resection rates (EMR-P, 51.6 %; ESD–S, 54.4 %; ESD, 75.9 %; p = 0.009). Bleeding and perforation were less frequently observed in the EMR-P group. In the subgroup-analysis of lesions less than 20 mm, however, these differences were not observed.

Conclusions

All endoscopic resection methods, including EMR-P, ESD-S, and ESD, were effective and safe for the treatment of colorectal neoplasms. Technically demanding ESD with high en bloc and complete resection rate should be reserved for the suspicious cancer lesion, which requires the precise histological evaluation. EMR-P with good feasibility can be considered an alternative to ESD for the lesions less than 20 mm.     

The Risk Factors for Discrepancy After Endoscopic Submucosal Dissection of Gastric Category 3 Lesion (Low Grade Dysplasia)

Background

Treatment with endoscopic submucosal dissection (ESD) for gastric category 3 lesion (low grade dysplasia, LGD) diagnosed by endoscopic forceps biopsy (EFB) is controversial.

Aims

The purpose of the present study was to validate the use of ESD for gastric LGD diagnosed by EFB and to evaluate predictable factors for pathologic upgrade diagnosis to category 4 (high grade dysplasia, HGD) or 5 (early gastric cancer, EGC) lesions.

Methods

Between November 2008 and October 2011, a retrospective analysis of a prospective database was conducted at a single tertiary referral center. A total of 218 ESD procedures were carried out for gastric LGD lesions identified by EFB. The under-diagnosis rate by EFB and the predictable factors for upgrade diagnosis to category 4 or 5 lesions were analyzed.

Results

Pathologic discrepancy between EFB and surgical resection was 20.1 % (44/218). Thirty eight lesions (17.4 %) were diagnosed HGD or EGC by ESD. Gastric HGD lesions were 14 cases (6.4 %) and EGC lesions were 24 cases (23 mucosal and 1 submucosal cancer) (11.0 %). Multivariate analysis revealed that lesion diameter more than 1 cm (OR 3.496 [95 % CI 1.375–8.849]), surface redness (OR 6.493 [95 % CI 2.557–16.666]) and nodular surface (OR 2.762 [95 % CI 1.237–6.172]) were significant risk factors.

Conclusions

Endoscopic resection can be recommended if a LGD lesion has risk factors such as a size of 1 cm or greater, surface redness or surface nodulariy. For lesions without the risk factors, follow-up endoscopy may be recommended.     

A Water-Jet Videoendoscope May Reduce Operation Time of Endoscopic Submucosal Dissection for Early Gastric Cancer

Background

One of the problems with endoscopic submucosal dissection (ESD) for early gastric cancer is that it prolongs procedure time considerably.

Aim

The purpose of this study was to investigate whether a videoendoscope with water-jet function shortened the time of ESD for early gastric cancer.

Methods

A total of 82 early gastric cancers that were intramucosal, differentiated-type adenocarcinoma ≤2 cm, without ulcer or scar, in 75 consecutive patients were investigated. Three supervised resident endoscopists participated as operators. After stratification by the operator and tumor location, the lesions were randomly assigned to the water-jet videoendoscope or a conventional videoendoscope groups. An insulated tipped knife was used for the ESD procedure. Total operation time was evaluated as a primary endpoint.

Results

The median (25–75th percentile) total operation time for the water-jet videoendoscope group was 51 (33–87) minutes, which was shorter than the 62 (43–88) minutes for the conventional videoendoscope, but it did not reach significance (P = 0.201). Multivariate analysis revealed that the water-jet videoendoscope (OR 3.0, P = 0.046), tumor size ≤14 mm (OR 3.2, P = 0.040) and antral tumor (OR 4.5, P = 0.046) were significantly associated with short (≤60 min) operation time.

Conclusions

The water-jet videoendoscope may reduce operation time of ESD for early gastric cancer, compared with conventional videoendoscope. A large-scale multicenter trial is warranted to clarify the efficacy of the water-jet videoendoscope for gastric ESD.     

Risk factors for vertical incomplete resection in endoscopic submucosal dissection as total excisional biopsy for submucosal invasive colorectal carcinoma

Purpose

Endoscopic submucosal dissection (ESD) for colorectal tumor is a minimally invasive treatment. Histologic information obtained from the entire ESD specimen is important for therapy selection in submucosal invasive colorectal carcinoma (SMca). This study aimed to identify risk factors for vertical incomplete resection (vertical margin-positive [VM+]) when ESD was performed as total excisional biopsy for SMca.

Methods

From June 2003 through December 2011, 78 SMca cases were resected by ESD at Hiroshima University Hospital. Patient and tumor characteristics, intraoperative variables, and histopathology were compared between the VM+ group and the vertical complete resection (vertical margin-negative) group. The ability of magnifying endoscopy (ME) and endoscopic ultrasonography (EUS) to predict VM+ was assessed.

Results

ESD resulted in VM+ in eight cases (10.3 %), with a greater percentage invading to a depth of ≥2,000 vs. <2,000 μm (P?=?0.047). Severe submucosal fibrosis was found in five of the eight cases (62.5 %, P?=?0.017). Poor differentiation was seen at the deepest invasive portion in six cases (75.0 %), and two of six cases had an invasion depth <2,000 μm. Of 39 EUS cases, 36 not showing deep invasion close to the muscularis propria were completely resected by ESD.

Conclusions

Submucosal fibrosis and poor differentiation at the deepest invasive portion may be risk factors for VM+ in colorectal ESD for tumors with submucosal deep invasion. ME plus EUS is more likely to help determine whether ESD is indicated as complete total excisional biopsy for SMca.     

Outcome of endoscopic submucosal dissection for colorectal tumors in elderly people

Background

Endoscopic submucosal dissection (ESD) has been reported to be effective for the en bloc resection of large colorectal tumors. Our study investigated whether ESD was suitable for elderly people with large colorectal tumors in terms of its invasiveness.

Patients and methods

We studied 119 colorectal tumors that were treated with ESD at Kyoto Prefectural University of Medicine or Nara City Hospital between 2006 and 2009. We classified each patient as either elderly, i.e., more than 75 years old, or non-elderly, i.e., less than 75 years old. Thirty-two of the cases were classified as elderly. Performance status, tumor size, operation time, rate of en bloc resection, histopathological diagnosis, complications, and hospital stay after ESD were analyzed retrospectively in both groups.

Results

In the elderly group, the average tumor size was 32.6 mm; the average operation time, 96 min; the rate of en bloc resection, 81.2%; the rate of perforation, 3.1%; and hospital stay after ESD, 5.1 days. Histopathological diagnosis for 16 tumors was adenoma; for 13, carcinoma with invasion into the mucosa; and for three, carcinoma with invasion into the submucosa. There were no statistical differences between the two groups in any of these data. The case with perforation was treated conservatively without urgent surgery in the elderly group.

Conclusions

ESD for colorectal tumors resulted in favorable rates of en bloc resection in elderly people. Perforation occurred in elderly people, but these patients were cured with conservative treatment. ESD is a safe and minimally invasive treatment for elderly people with colorectal tumors.     

Risk Factors and Prognosis of Pulmonary Complications After Endoscopic Submucosal Dissection for Gastric Neoplasia

Background

Hospital-acquired pneumonia after an endoscopic submucosal dissection (ESD) can prolong the patient’s stay in the hospital, leading to greater healthcare costs. However, little is known of the characteristics and risk factors associated with this complication.

Aims

To analyze the clinical features of pneumonia after ESD and to suggest a treatment plan.

Methods

This was a retrospective study in which the cases of 1,661 consecutive patients who underwent ESD for 1,725 lesions between January 2008 and June 2011 were reviewed.

Results

Of the 1,661 patients who underwent ESD during the study period, 38 were subsequently diagnosed with pneumonia, and an additional 18 patients exhibited lung consolidation, based on chest radiography, without respiratory signs or symptoms. The remaining 1,605 patients showed neither lung consolidation on chest radiography nor respiratory signs/symptoms. Continuous propofol infusion with intermittent or continuous administration of an opioid [odds ratio (OR) 4.498, 95 % confidence interval (CI) 2.267–8.923], a procedure time of >2 h (OR 2.900, 95 % CI 1.307–6.439), male gender (OR 2.835, 95 % CI 1.164–6.909), and age >75 years (OR 2.765, 95 % CI 1.224–6.249) were independent risk factors for pneumonia after ESD. In patients with only lung consolidation (without respiratory signs and symptoms), the length of hospital stay and prognosis were not affected by antibiotics use.

Conclusions

Deep sedation under continuous propofol infusion with opioid injection during ESD may be a risk factor for pneumonia.     

The efficacy of endoscopic submucosal dissection for colorectal tumors extending to the dentate line

Purpose

Although endoscopic submucosal dissection (ESD) is becoming the mainstay of the treatment strategies, rather than surgical treatment, for colorectal tumors extending to the dentate line, ESD is technically more difficult. This study was aimed at assessing the usefulness of ESD for the treatment of colorectal tumors extending to the dentate line.

Methods

This study included 531 patients with colorectal tumors who underwent colorectal ESD between 2008 and 2015. They were divided into three groups: rectal tumors extending to the dentate line (anorectal group), those not extending to the dentate line (proximal rectal group), and colonic tumors (colonic group), and a retrospective comparative analysis was carried out.

Results

Of the total patients, 18 (3.4%) had lesions extending to the dentate line area. The procedure times were 103.4 ± 84.0, 80.4 ± 64.3, and 71.8 ± 52.3 min, respectively (P = 0.0318). All the patients in the anorectal group were operated by operators who had performed at least 20 colorectal ESDs (P < 0.0001). No significant difference among the three groups was found in the en bloc resection rate, complete resection rate, or curative resection rate. Although no significant difference in the incidence of perforation was observed among the three groups, intraoperative bleeding was observed in 61% of the patients in the anorectal group (P < 0.0001).

Conclusions

ESD is an effective treatment strategy for colorectal tumors extending to the dentate line. However, it seems that anorectal ESD, which is technically more difficult than colorectal ESD, should be performed by operators with ample experience in performing ESD.

     

Risk factors for complications of endoscopic submucosal dissection in gastric tumors: analysis of 478 lesions

Purpose

Endoscopic submucosal dissection (ESD) technique has facilitated en bloc removal of widely spread lesions from the stomach. This retrospective study aimed to determine factors associated with serious complications of ESD.

Methods

Between December 2001 and March 2007, we have performed ESD for 478 lesions in 436 patients. We experienced 39 patients with post-operative bleeding and 17 patients with perforation. Risk factors of patients who received ESD in gastric mucosal tumors for complications were evaluated, focusing on resected size, location, scar lesions, operation time, and experience of endoscopists. We evaluated the patients’ background characteristics including sex, age, body mass index (kg/m²), drug history of anticoagulant, and underlying diseases including cerebrovascular disorder, ischemic heart disease, liver dysfunction, renal dysfunction, hyperuricemia, hypertension and diabetes mellitus.

Results

Multivariate analysis indicated a risk factor for perforation was long operation time. Multivariate analysis indicated a significant risk factor for post-operative bleeding was size of the resected tumor.

Conclusions

This study indicated risk factors for serious complications of ESD. Large resected tumor size was a risk factor for post-operative bleeding, while long operation time was a risk factor for perforation. Information regarding operation risk factors should be useful for planning strategies for ESD.     

Endoscopic submucosal dissection as a treatment for gastric noninvasive neoplasia: a multicenter study by Osaka University ESD Study Group

Background

Treatment with endoscopic submucosal dissection (ESD) for gastric noninvasive neoplasia (NIN) diagnosed by endoscopic forceps biopsy specimen, whether as a follow-up or ??total incisional biopsy??, is controversial. To validate the use of ESD for total incisional biopsy in NIN, we examined the underdiagnosis rate of NIN and the rates of complication associated with ESD.

Methods

This is a cross-sectional multicenter retrospective study from 10 hospitals. Subjects diagnosed with NIN (equivalent to category 3 or 4.1 of the Vienna classification) by endoscopic forceps biopsy and treated with ESD were included. From March 2003 to December 2009, a total of 468 subjects were included and analyzed. The underdiagnosis rate was defined as the proportion of lesions diagnosed with adenocarcinoma after ESD. We assessed the complete en-bloc resection rate and the complication rate of ESD.

Results

Among the 468 subjects with NIN, 205 were diagnosed with adenocarcinoma after ESD, with an underdiagnosis rate of 44% (95% confidence interval: 39?C49%). Two submucosal cancer lesions had invaded beyond 500???m and one had lymphatic involvement. The complete en-bloc resection rate was 97%. The incidences of post-ESD bleeding, perforation, and serious complications were 5.5, 4.7, and 0.43%, respectively. There were no procedure-related deaths.

Conclusions

In this large-scale, multicenter cross-sectional study, over 40% of the noninvasive gastric neoplasia specimens were determined to have adenocarcinoma, and the ESD-related complication rate was relatively low. Therefore, ESD was useful and may be a therapeutic option for gastric NIN.     

A Multicenter Survey of the Management After Gastric Endoscopic Submucosal Dissection Related to Postoperative Bleeding

Background and Aims

Bleeding is a major complication after gastric endoscopic submucosal dissection (ESD). An evidence-based strategy for postoperative care related to delayed bleeding is required. We conducted a multicenter survey to assess the current status of management after gastric ESD.

Methods

A total of 1,814 gastric epithelial neoplasms in 2009 at ten tertiary referral centers were enrolled. The current status of the management after gastric ESD (use of an antisecretory drug, food intake, and second-look endoscopy) at participating hospitals was assessed. Furthermore, the rate of post-ESD bleeding and the differences in each parameter were retrospectively analyzed.

Results

Postoperative bleeding occurred in 100 cases (5.5%), which included 62 cases of bleeding within 24?h after ESD. In all of the hospitals, proton pump inhibitors (PPIs) were used. The median administration period was 56?days (range 14?C60?days). Food intake was resumed from postoperative day (POD) 1 in 4 hospitals and from POD 2 in 6 hospitals. Second-look endoscopy was performed for almost all cases, fewer cases, and rarely or none in 6, 2, and 2 hospitals, respectively. The day of second-look endoscopy varied among hospitals. There was no statistical relationship between the postoperative bleeding rate and the differences in these three parameters.

Conclusions

Post-ESD management (duration of PPI use, resumption of food intake, and performance of second-look endoscopy) varied among the medical centers; thus, randomized controlled trials are required for an optimal strategy after gastric ESD.     

Clinicopathologic differences of mesenchymal submucosal tumors between the esophagogastric junction and the upper stomach

Objective

We compared the clinicopathologic features between mesenchymal tumors located in the esophagogastric junction (EGJ) and upper stomach, that had been removed surgically.

Methods

Thirty-five patients with a submucosal tumor (SMT) of the stomach, including the EGJ, were surgically treated over the last decade. Of these, 23 patients with SMTs located in the upper third of the stomach (n = 15; UG-group) and EGJ (n = 8; EGJ-group) were studied.

Results

The mean age was younger in the EGJ-group than in the UG-group, and the EGJ-group frequently showed symptoms. Histopathologically, 4 gastrointestinal stromal tumors (GISTs) and 4 leiomyomas were observed in the EGJ-group, while 14 GISTs and one schwannoma were observed in the UG-group (p = 0.0096). Two tumors macroscopically showed a horseshoe or spiral type in the EGJ-group, while all tumors showed a ball/ball-like appearance in the UG-group. Regarding surgical procedures, 7 patients underwent laparotomy in the EGJ-group, while 9 patients underwent laparoscopic surgery in the UG-group. The mean operating time was longer and operative bleeding was greater in the EGJ-group than in the UG-group, respectively (p = 0.0015 and p = 0.0095). Postoperative complications were frequently observed in the EGJ-group. The EGJ-group showed no patients with recurrence and/or metastasis after surgery, while three cases with GISTs had them in the UG-group. In GISTs, the mean mitotic index of the UG-group was relatively more than that of the EGJ-group and a case was classified into the high-risk group, although there was no significance in the risk classification between the two groups.

Conclusion

SMTs included GISTs and leiomyomas in the EGJ, while the majority demonstrated GISTs in the upper stomach. SMTs of the EGJ were removed by a tailored approach to prevent recurrence as well as postoperative complications. The biological behavior of GISTs may be different between the EJG and stomach.     

Preventing Stricture Formation by Covered Esophageal Stent Placement After Endoscopic Submucosal Dissection for Early Esophageal Cancer

Objective

We aimed to evaluate the efficacy and safety of fully covered esophageal stent placement for preventing esophageal strictures after endoscopic submucosal dissection (ESD).

Methods

Twenty-two patients with a mucosal defects that exceeded 75 % of the circumference of the esophagus after ESD treatment for superficial esophageal squamous cell carcinomas were grouped according to the type of mucosal defect and randomized to undergo fully covered esophageal stent placement post-ESD (group A, n = 11) or no stent placement (group B, n = 11). In group A, the esophageal stents were removed 8 weeks post-ESD. Endoscopy was performed when patients reported dysphagia symptoms and at 12 weeks post-ESD in patients without symptoms. Savary–Gilliard dilators were used for bougie dilation in patients experiencing esophageal stricture in both groups, and we compared the rates of post-ESD strictures and the need for bougie dilation procedures.

Results

The proportion of patients who developed a stricture was significantly lower in group A (18.2 %, n = 2) than in group B (72.7 %, n = 8) (P < 0.05). Moreover, the number of bougie dilation procedures was significantly lower in group A (mean 0.45, range 0–3) than in group B (mean 3.9, range 0–17) (P < 0.05). The two patients in group A who experienced stricture also had stent displacement.

Conclusions

Esophageal stents are a safe and effective method of preventing esophageal strictures in cases where >75 % of the circumference of the esophagus has mucosal defects after ESD treatment for early esophageal cancer.     

Defective Mucosal Movement at the Gastroesophageal Junction in Patients with Gastroesophageal Reflux Disease

Background

Little is known about the role of muscularis mucosa at the gastroesophageal junction (GEJ).

Aim

To evaluate the movement of the mucosa/muscularis-mucosa/submucosa (MMS) at the GEJ in normal subjects and in patients with gastroesophageal reflux disease (GERD).

Methods

Gastroesophageal junctions of 20 non-GERD subjects and 10 patients with GERD were evaluated during 5 mL swallows using two methods: in high-resolution endoluminal ultrasound and manometry, the change in the GEJ luminal pressures and cross-sectional area of esophageal wall layers were measured; in abdominal ultrasound, the MMS movement at the GEJ was analyzed.

Results

Endoluminal ultrasound: In the non-GERD subjects, the gastric MMS moved rostrally into the distal esophagus at 2.17 s after the bolus first reached the GEJ. In GERD patients, the gastric MMS did not move rostrally into the distal esophagus. The maximum change in cross-sectional area of gastroesophageal MMS in non-GERD subjects and in GERD patients was 289 % and 183 %, respectively. Abdominal ultrasound: In non-GERD subjects, the gastric MMS starts to move rostrally significantly earlier and to a greater distance than muscularis propria (MP) after the initiation of the swallow (1.75 vs. 3.00 s) and (13.97 vs. 8.91 mm). In GERD patients, there is no significant difference in the movement of gastric MMS compared to MP (6.74 vs. 6.09 mm). The independent movement of the gastric MMS in GERD subjects was significantly less than in non-GERD subjects.

Conclusion

In non-GERD subjects, the gastric MMS moves rostrally into the distal esophagus during deglutitive inhibition and forms a barrier. This movement of the MMS is defective in patients with GERD.     

Evaluation of hemostasis with soft coagulation using endoscopic hemostatic forceps in comparison with metallic hemoclips for bleeding gastric ulcers: a prospective, randomized trial

Background

Endoscopic high-frequency soft coagulation, recently developed in Japan, is available for the management of gastric bleeding in cases of bleeding gastric ulcers and bleeding during endoscopic submucosal dissection. The aim of this study was to evaluate the efficacy of hemostasis with soft coagulation for bleeding gastric ulcers by comparing it with hemoclips in a prospective, randomized trial.

Methods

During the period of April 2006 to March 2008, 96 patients that had gastric ulcers with bleeding or nonbleeding visible vessels were enrolled in this study. All of the 96 patients were randomly divided into two groups: endoscopic hemostasis with soft coagulation (Group I) or endoscopic hemoclipping (Group II).

Results

A total of 41 (85%) out of 48 patients in Group I and 38 (79%) out of 48 patients in Group II were successfully treated with soft coagulation or clipping alone, respectively. The endoscopic hemostasis rate for the initial modality in combination with another endoscopic procedure performed after the initial method was 98% in both groups. One patient in Group I (2%) and five patients in Group II (10%) experienced recurrent bleeding. The time required to achieve hemostasis was shorter in Group I compared with Group II (9.2 ± 11.1 vs. 13.6 ± 9.4 min; P < 0.05).

Conclusions

This study revealed that soft coagulation is as effective as hemoclipping for treating bleeding gastric ulcers. The time required to achieve hemostasis was shorter with the soft coagulation procedure.     

Endoscopic Therapy with 2-Octyl-cyanoacrylate for the Treatment of Gastric Varices

Background

Gastric variceal bleeding is associated with significant morbidity and mortality and limited endoscopic therapeutic options.

Aim

The aim of this study was to evaluate the short- and long-term efficacy and safety of endoscopic therapy with 2-octyl-cyanoacrylate in patients with gastric variceal bleeding.

Methods

A single-center retrospective review of patients receiving endoscopic therapy for gastric variceal hemorrhage. Patient demographics, laboratory, and procedural data were collected. Patients were followed to death, liver transplantation, or last follow-up. Success rates were defined as immediate control of bleeding; early re-bleeding (1–7 days), short-term re-bleeding (1–12 weeks), overall survival, and serious procedure complications.

Results

A total of 41 patients (39 with cirrhosis) underwent 54 cyanoacrylate injections during study period. Mean age was 57 and 73 % were males. Twenty-four (58.5 %) patients had failed or were deemed ineligible for transjugular intra-hepatic portosystemic shunt, and 5 % were done for primary prophylaxis. Immediate hemostasis was achieved in five active bleeders. During a median survival time of 117 days, early re-bleeding was seen in 1 (2.4 %), short-term re-bleeding in five patients (12 %), and varices were eradicated in 15 (46.8 %) patients on follow-up. Mean MELD score at the time of the first injection was 17.1 ± 7.8. Mean volume injected was 3.4 cc and median number of varices injected per session was one. Eight patients died during the long-term follow-up: metastatic cancer (2), infections (3), liver failure (1), and re-bleeding (2). There were no serious procedure-related complications.

Conclusions

Endoscopic cyanoacrylate therapy appears effective and safe for treatment of patients with bleeding from gastric varices or high-risk stigmata.