Endoscopic mucosal resection of early gastric cancer： Experiences in Korea

Endoscopic mucosal resection （EMR） has been established as one of the treatment options for early gastric cancer （EGC）. However, there are many uncertain areas such as indications of EIR, best treatment methods, management of complications and follow-up methods after the procedure. Host studies on this topic have been carried out by researchers in Japan. In Korea, gastric cancer is the most common malignant disease, and the second leading cause of cancer death. In these days, EIR for EGC is widely performed in many centers in Korea. In this review, we will provide an overview of the bechniques and outcomes of EIR in Korea.     

Gastric polypoid lesions： Analysis of 150 endoscopic polypectomy specimens from 91 patients

AIM: To analyze gastric polypoid lesions in our patient-population with respect to histopathologic features and demographic, clinical, and endoscopic characteristics of patients. METHODS: Clinical records and histopathologic reports of patients with gastric polypoid lesions were analyzed retrospectively. All lesions had been totally removed by either endoscopic polypectomy or hot biopsy forceps. The histopathologic slides were re-evaluated by the same histopathologist. RESULTS: One-hundred and fifty gastric polypoid lesions were identified in 91 patients. There were 53 (58%) women and 38 (42%) men with a median age of 53 (range, 31 to 82) years. The most frequent presenting symptom was dyspepsia that was observed in 35 (38.5%) patients. Symptoms were mostly related to various associated gastric abnormalities such as chronic gastritis or H pylori infection rather than polypoid lesion itself. Polypoid lesions were commonly located in the antrum followed by cardia. Out of 150 lesions, 80 (53%) had the largest dimensions less than or equal to 5 mm and only 7 were pedunculated. The frequencies of hyperplastic polyps, foveolar hyperplasia, and fundic gland polyps were 46%, 18%, and 14% respectively. We also detected gastritis varioliformis in 12 specimens, lymphoid follicles in 9, 4 adenomatous polyps in 4, polypoid lesions with edematous mucosa in 4, inflammatory polyps in 3, and carcinoid tumor in 1. Adenomatous changes were observed within two hyperplastic polyps and low grade dysplasia in one adenoma. Histopathologic evaluation of the surrounding gastric mucosa demonstrated chronic gastritis in 72 (79%) patients and H pylori infection in 45 (49%). CONCLUSION: Hyperplastic polyps are the most frequently encountered subtype of gastric polypoid lesions. They are usually associated with chronic gastritis or H pylori gastritis. Contrary to the previous belief, they may harbour adenomatous changes or dysplastic foci. Therefore, endoscopic polypectomy seems as a safe and fast procedure for both diagnosis and treatment of gastric polypoid lesions at the same session. In addition, edematous mucosa may appear misleadingly as a polypoid lesion in some instances and it can be ruled out only by histopathologic examination.     

Endoscopic findings and pathologic characteristics of gastric eosinophilic granuloma： A report of 18 patients

INTRODUCTION Gastric eosinophilic granuloma (GEG) is characterized by pathological changes including eosinophil cells infiltrated into the submucous layer and muscular layer of the stom- ach. Its etiology is still unknown. The patients are prone to be mis…     

Conventional colonoscopy and magnified chromoendoscopy for the endoscopic histological prediction of diminutive colorectal polyps： A single operator study

AIM: To accurately differentiate the adenomatous from the non-adenomatous polyps by colonoscopy. METHODS: All lesions detected by colonoscopy were first diagnosed using the conventional view followed by chromoendoscopy with magnification. The diagnosis at each step was recorded consecutively. All polyps were completely removed endoscopically for histological evaluation. The accuracy rate of each type of endoscopic diagnosis was evaluated, using histological findings as gold standard. RESULTS: A total of 240 lesions were identified, of which 158 (65.8%) were non-neoplastic and 82 (34.2%) were adenomatous. The overall diagnostic accuracy of conventional view, and chromoendoscopy with magnification was 76.3% (183/240) and 95.4% (229/240), respectively (P< 0.001) CONCLUSION: The combination of colonoscopy and magnified chromoendoscopy is the most reliable non-biopsy method for distinguishing the non-neoplastic from the neoplastic lesions.     

Management of choledocholithiasis： Comparison between laparoscopic common bile duct exploration and intraoperative endoscopic sphincterotomy

AIM：Choledocholithiasis is present in 5 to 10 percent of patients who have cholelithiasis. In the area of laparoscopic cholecystectomy (LC), laparoscopic common bile duct exploration (LCBDE) and intraoperative endoscopic sphincterotomy (IOES) have been used to treatcholedo cholithiasis. The purpose of this study was to compare the clinical outcomes and hospital costs of LCBDE with IOES. METHODS: Between November 1999 and October 2002, patients with choledocholithiasis undergoing LC plus LCBDE (Group A, n=45) were retrospectively compared to those undergoing LC plus IOES (Group B, n=57) at a single institution. RESULTS: Ductal stone clearance rates were equivalent for the two groups (88% versus 89%, P=0.436). The conversion rate was higher for Group B (8.8% versus 4.4%,P=0.381), as was the morbidity (12.3% versus 6.7%, P=0.336). There were no other significant differences between the two groups. The complications were mainly related to endoscopic sphincterotomy (ES), and the hospital costs were significantly increased in this subset of Group B (median, 23 910 versus 14 955 RMB yuan, P=0.03). Although hospital stay was longer in Group A (median, 7 versus 6 days, P=0.041), the patients in Group A had a significantly decreased cost of hospitalization compared with those in Group B (median, 11 362 versus 15 466 RMB yuan, P=0.000). CONCLUSION: The results demonstrate equivalent ductal stone dearance rates for the two groups. LCBDE management appears safer, and is associated with a significantly decreased hospital cost. The findings suggest LCBDE for choledocholithiasis is a better option.     

Usefulness of magnifying endoscopy in post-endoscopic resection scar for early gastric neoplasm： A prospective short-term follow-up endoscopy study

AIM： To investigate the relationship between postendoscopic resection （ER） scars on magnifying endoscopy （ME） and the pathological diagnosis in order to validate the clinical significance of ME. METHODS： From January, 2007 to June, 2008, 124 patients with 129 post-ER scar lesions were enrolled. Mucosal pit patterns on ME were compared with conventional endoscopy （CE） findings and histological results obtained from targeted biopsies. RESULTS： CE findings showed nodular scars （53/129）, erythematous scars （85/129）, and ulcerative scars （4/129）. The post-ER scars were classified into four pit patterns of sulci and ridges on ME： （ Ⅰ ） 47 round; （Ⅱ） 54 short rod or tubular; （Ⅲ） 19 branched or gyrus-like;and （Ⅳ） 9 destroyed pits. Sensitivity and specificity were 88.9% and 62.5%, respectively, by the presence of nodularity on CE. Erythematous lesions were high sensitivity （100%）, but specificity was as low as 36.7%. The range of the positive predictive va ue （PPV） on CE was as low as 10.6%-25%. Nine type N pit patterns were diagnosed as tumor lesions, and 120 cases of type Ⅰ-Ⅲ pit patterns revealed non-neoplastic lesions. Thus, the sensitivity, specificity, and the PPV of ME were 100%. CONCLUSION： ME findings can detect the presence of tumor in post-ER scar lesions, and make evident the biopsy target site in short-term follow-up. Further large-scale and long-term studies are needed to determine whether ME can replace endoscopic biopsy.     

Differences in endoscopic classification of early colorectal carcinoma between China and Japan： A comparative study

AIM: To compare the differences in the endoscopic classification of early colorectal carcinoma (CRC) betweenJapan and China.METHODS: Ten cases of early CRC were included in the study. After reviewing the color pictures of these cases, 5Japanese endoscopists and 5 Chinese endoscopists made their classificatory diagnosis individually using the current Japanese classification, and indicated their findings on which the diagnosis was based.RESULTS: Some lesions diagnosed by the Japanese endoscopists as Ⅱa or Ⅱa plus Ⅱc, were classified as Is or Isp by the Chinese endoscopists. For superficial lesions consisting of elevation plus central depression, Ⅱa plus depression, Ⅱa plus Ⅱc or Ⅱc plus Ⅱa were classified according to the ratio of elevated area/depressed area.However, international as well as interobserver difference still existed in the classification of such lesions. In addition,most Chinese endoscopists overlooked slightly depressed part on the top of a protruded lesion. Laterally spreading tumor, a special type of Ⅱa, was identified as LST by some Japanese endoscopists.CONCLUSION: Discrepancies on macroscopic classification for early CRC do exist between Japanese and Chinese endoscopists, which are found not only in terminology but also in recognition of some lesions. In order to develop a universal classification, it needs for international communication and cooperation.     

Selection criteria for preoperative endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy and endoscopic treatment of bile duct stones： Results of a retrospective,single center study between 1996-2002

AIM: The optimal treatment for bile duct stones (in terms of cost, complications and accuracy) is unclear. The aim of our study was to determine the predictive factors for preoperative endoscopic retrograde cholangiopancreatography (ERCP).METHODS: Patients undergoing preoperative ERCP (≤90 d before laparoscopic cholecystectomy) were evaluated in this retrospective study from the 1^st of January 1996 to the 31^st of December 2002. The indications for ERCP were elevated serum bilirubin, elevated liver function tests (LFT), dilated bile duct (≥8 mm) and/or stone at US examination, coexisting acute pancreatitis and/or acute pancreatitis or jaundice in patient‘s history. Suspected prognostic factors and the combination of factors were compared to the result of ERCRRESULTS: Two hundred and six preoperative ERCPs were performed during the observed period. The rate of successful cannulation for ERC was (97.1%). Bile duct stones were detected in 81 patients (39.3%), and successfully removed in 79 (97.5%). The number of prognostic factors correlated with the presence of bile duct stones. The positive predictive value for one prognostic factor was 1.2%, for two 43%,for three 72.5%, for four or more 91.4%.CONCLUSION: Based on our data preoperative ERCP is highly recommended in patients with three or more positive factors (high risk patients). In contrast, ERCP is not indicated in patients with zero or one factor (low risk patients).Preoperative ERCP should be offered to patients with two positive factors (moderate risk patients), however the practice should also be based on the local conditions (e.g.skill of the endoscopist, other diagnostic tools).     

Endoscopic ultrasonography in preoperative staging of gastric cancer： determination of tumor invasion depth, nodal involvement and surgical resectability

AIM: Current study was aimed to evaluate the usefulness of EUS in TNM staging of gastric cancer by comparing EUS preoperative staging with pathological findings, and the preliminary exploration of possible reasons for overstaging and understaging phenomenon was especially intended. METHODS: A total of 35 patients with histologically confirmed gastric adenocarcinoma were referred to EUS and staged preoperatively by using the TNM system. The preoperative endosonographic results were compared with the histopathological staging. RESULTS: The overall accuracy of EUS for determination of the T stage was 80.0 %, and for T1, T2, T3, and T4 was 100 %, 71.4 %, 87.5 % and 72.7 %, respectively. For N stage, EUS had the accuracy of 68.6 %, with sensitivity and specificity of 66.7 % and 73.7 %, respectively. Resectability was predicted with sensitivity and specificity of 87.5 % and 100 %, respectively. CONCLUSION: EUS is an accurate staging modality in most cases, with a few exceptions of overstaging and understaging. Patients with gastric cancers can benefit from preoperative EUS staging for establishing individualized therapy. However, EUS criteria to differentiate benign from malignant nodes still need to be further defined by future studies.     

Current concept on the pathogenesis of inflammatory bowel disease-crosstalk between genetic and microbial factors： Pathogenic bacteria and altered bacterial sensing or changes in mucosal integrity take ＂toll＂ ？

The pathogenesis of inflammatory bowel disease(IBD)is only partially understood.Various environmentaland host(e.g.genetic-,epithelial-,immune and non-immune)factors are involved.It is a multifactorialpolygenic disease with probable genetic heterogeneity.Some genes are associated with IBD itself,while othersincrease the risk of ulcerative colitis(UC)or Crohn's disease(CD)or are associated with disease locationand/or behaviour.This review addresses recent advancesin the genetics of IBD.The article discusses the currentinformation on the crosstalk between microbial andgenetic factors(e.g.NOD2/CARD15,SLC22A46A5 andDLG5).The genetic data acquired in recent years help inunderstanding the pathogenesis of IBD and can identify anumber of potential targets for therapeutic intervention.In the future,genetics may help more accurately diagnoseand predict disease course in IBD.     

胃上皮内瘤变内镜活组织检查与内镜切除标本病理结果差异分析

目的 分析比较我国胃镜活组织检查（简称活检）和内镜下切除病理诊断胃上皮内瘤变的可靠性。 方法 回顾性分析2010年1月至2015年3月北京协和医院胃镜活检病理诊断为胃上皮内瘤变的98例患者,包括20例低级别上皮内瘤变（LGIN）,65例高级别上皮内瘤变（HGIN）和13例早期胃癌（EGC）。患者均行内镜下切除,结合患者临床资料,对活检病理与内镜下切除病理差异率、临床特征和差异因素进行分析。 结果 20例活检病理为LGIN的患者,内镜下切除后有12例病理结果较活检病理进展,其中7例HGIN（差异率35.0％,7／20）,5例EGC（25.0％,5／20）。活检病理诊断HGIN的65例患者,内镜切除后38例诊断为EGC（58.5％,38／65）,4例诊断为LGIN（6.2％,4／65）。13例活检诊断为EGC者切除后病理维持原诊断。活检病理和内镜切除病理诊断的总体差异率为55.1％（54／98）。病变直径＞2 cm,病变表面充血是活检和内镜切除病理差异的主要因素（P＜0.05）。 结论 内镜活检病理诊断胃上皮内瘤变的可靠性欠佳,内镜下切除不仅是治疗胃上皮内瘤变的主要手段,也是明确组织学诊断的一个重要方法。     

Flat gastric polyps: results of forceps biopsy, endoscopic mucosal resection, and long-term follow-up

OBJECTIVE: Histological examination of specimens obtained by forceps biopsy sampling of gastric polyps is of limited accuracy, and their management on this basis is therefore controversial. The aim of this prospective study was to assess the value of forceps biopsy sampling in establishing the correct diagnosis revealed by endoscopic mucosal resection (EMR). The complication rate of EMR was also determined. MATERIAL AND METHODS: Subjects with gastric polyps of epithelial origin, of at least 0.5 cm in diameter, and not associated with polyposis syndromes, were included in the study. Between 1994 and 2004, 56 gastric polyps in 44 patients (30 F, 14 M, mean age 67 years) met the inclusion criteria. Indigo carmine dye staining and electronic magnification were used in all cases. Following forceps biopsy sampling, 56 EMRs were performed. The histological results of the forceps biopsy and the resected specimens were analyzed. RESULTS: The initial forceps biopsies identified in situ carcinoma in 3 cases, adenoma with no dysplasia in 19, adenoma with low-grade dysplasia in 2, adenoma with moderate-grade dysplasia in 6, adenoma with high-grade dysplasia in 7, and hyperplastic lesions in 19 cases. The histological examination of the resected polyps revealed in situ carcinoma in 5 cases, carcinoid in 1, gastrointestinal stromal tumor in 1, adenoma with no dysplasia in 14, adenoma with low-grade dysplasia in 3, adenoma with moderate-grade dysplasia in 9, adenoma with high-grade dysplasia in 1, hyperplastic lesions in 21, and no diagnosis in 1 case. Complete agreement between the histological results on the forceps biopsy sample and on the ectomized polyp was seen in only 31 (55.3%) polyps. There were important disagreements in 12 cases. In 14 neoplastic and 1 hyperplastic polyps, the degree of dysplasia seen on histological examination of the forceps biopsy specimens differed from that observed for the resected specimens. Post-mucosectomy bleeding was observed in 3 patients, all of whom were successfully treated endoscopically. CONCLUSIONS: Forceps biopsy is not sufficiently reliable for the identification of gastric polyps. These lesions should be fully resected by EMR for a final diagnosis and (depending on the lesion size and type) possibly definitive treatment.     

Flat gastric polyps: Results of forceps biopsy,endoscopic mucosal resection,and long-term follow-up

Objective. Histological examination of specimens obtained by forceps biopsy sampling of gastric polyps is of limited accuracy, and their management on this basis is therefore controversial. The aim of this prospective study was to assess the value of forceps biopsy sampling in establishing the correct diagnosis revealed by endoscopic mucosal resection (EMR). The complication rate of EMR was also determined. Material and methods. Subjects with gastric polyps of epithelial origin, of at least 0.5?cm in diameter, and not associated with polyposis syndromes, were included in the study. Between 1994 and 2004, 56 gastric polyps in 44 patients (30?F, 14?M, mean age 67 years) met the inclusion criteria. Indigo carmine dye staining and electronic magnification were used in all cases. Following forceps biopsy sampling, 56 EMRs were performed. The histological results of the forceps biopsy and the resected specimens were analyzed. Results. The initial forceps biopsies identified in situ carcinoma in 3 cases, adenoma with no dysplasia in 19, adenoma with low-grade dysplasia in 2, adenoma with moderate-grade dysplasia in 6, adenoma with high-grade dysplasia in 7, and hyperplastic lesions in 19 cases. The histological examination of the resected polyps revealed in situ carcinoma in 5 cases, carcinoid in 1, gastrointestinal stromal tumor in 1, adenoma with no dysplasia in 14, adenoma with low-grade dysplasia in 3, adenoma with moderate-grade dysplasia in 9, adenoma with high-grade dysplasia in 1, hyperplastic lesions in 21, and no diagnosis in 1 case. Complete agreement between the histological results on the forceps biopsy sample and on the ectomized polyp was seen in only 31 (55.3%) polyps. There were important disagreements in 12 cases. In 14 neoplastic and 1 hyperplastic polyps, the degree of dysplasia seen on histological examination of the forceps biopsy specimens differed from that observed for the resected specimens. Post-mucosectomy bleeding was observed in 3 patients, all of whom were successfully treated endoscopically. Conclusions. Forceps biopsy is not sufficiently reliable for the identification of gastric polyps. These lesions should be fully resected by EMR for a final diagnosis and (depending on the lesion size and type) possibly definitive treatment.     

内镜下黏膜切除术治疗胃肠道息肉样病变的70例临床分析

目的 探讨内镜下黏膜切除术（ endoscopic mucosal resection,EMR） 在切除胃肠道息肉中的应用价值.方法 回顾性分析70例（82枚息肉）行EMR治疗胃肠道息肉的临床资料.结果 30例患者40枚胃息肉及40例患者42枚结肠息肉经EMR 治疗后,病变均完整切除,无出血、感染和穿孔等并发症发生.结论 EMR是临床上治疗胃肠道息肉的一种安全有效的内镜治疗手段,值得临床推广.     

Discrepancy between endoscopic forceps biopsy and endoscopic resection in esophageal intraepithelial neoplasia

正Objective To analyze the histopathologic characteristics of specimens collected during endoscopic resection(ER)and to compare biopsy specimens from patients with esophageal intraepithelial neoplasia(IEN)or early esophageal cancer(EEC).Methods From January 2014to April 2017,a total of 182 lesions diagnosed as IEN or EEC by endoscopic forceps biopsy(EFB)were enrolled.     

Disposable endoscopic biopsy forceps: comparison with standard forceps of sample size and adequacy of specimen

Disposable biopsy forceps have recently been introduced into the field of endoscopy. We have analyzed biopsy size and histologic interpretation of samples obtained with the disposable forceps and compared them to those obtained with reusable forceps. In the 18 patients studied, 49 samples were collected with the reusable forceps and 47 samples with the disposable. Biopsy sites included the colorectum in 50%, esophagus in 22%, small bowel in 17%, and stomach in 11% of the patients. We found that statistically smaller samples were collected by the disposable biopsy forceps than by the reusable (2.48 +/- 1.11 mm versus 1.99 +/- 0.55 mm, p = 0.006). The smaller biopsy size with disposable forceps was not clinically important since all but one of 47 specimens were interpreted as adequate for histologic diagnosis. The convenience, potential cost savings, and prevention of the spread of communicable agents afforded by disposable biopsy forceps make them a possible alternative to conventional forceps in some clinical settings.     

Histopathologic discrepancies between endoscopic forceps biopsy and endoscopic resection specimens in nonampullary duodenal epithelial tumors

For patients with nonampullary duodenal epithelial tumors (NADETs), endoscopic forceps biopsy results that reflect the final histopathologic results of the entire lesion are indispensable for accurate diagnosis and appropriate treatment modality selection. This study aimed to investigate the histopathologic discrepancies between endoscopic forceps biopsy and endoscopic resection specimens in NADETs and to elucidate the factors contributing to such discrepancies.This retrospective observational study included 105 patients (105 lesions) who underwent endoscopic resection for NADETs at the Pusan National University Hospital between May 2006 and October 2019. NADETs were classified as low-grade intraepithelial neoplasms (LGINs), high-grade intraepithelial neoplasms (HGINs), or adenocarcinomas. Following slide reviews, the histopathologic concordance between endoscopic forceps biopsy and endoscopic resection specimens was assessed for each case.The histopathologic discrepancy rate between endoscopic forceps biopsy and endoscopic resection specimens was 19.0% (20/105 lesions). Among the 20 diagnostically discordant lesions, up- and downgrade of the histopathologic diagnosis occurred in 17 and 3 lesions, respectively. The predominant discrepancies involved upgrades from LGIN to HGIN (n = 14) and upgrades from LGIN to adenocarcinomas (n = 2). The 3 downgraded cases included 2 from LGIN to inflammation and 1 from HGIN to LGIN. In the multivariate analyses, the old age (>67 years) was the only factor significantly associated with histopathologic upgrade (odds ratio 4.553, 95% confidence interval 1.291–15.939; P = .018).Considerable histopathologic discrepancies were observed between endoscopic forceps biopsy and endoscopic resection specimens in NADETs. Older age was significantly associated with these discrepancies.