Carbon dioxide insufflation in esophageal endoscopic submucosal dissection reduces mediastinal emphysema: A randomized,double-blind,controlled trial

AIM To assess the efficacy of CO2 insufflation for reduction of mediastinal emphysema(ME) immediately after endoscopic submucosal dissection(ESD).METHODS A total of 46 patients who were to undergo esophageal ESD were randomly assigned to receive either CO2 insufflation(CO2 group, n = 24) or air insufflation(Air group, n = 22). Computed tomography(CT) was carried out immediately after ESD and the next morning. Pain and abdominal distention were chronologically recorded using a 100-mm visual analogue scale(VAS). The volume of residual gas in the digestive tract was measured using CT imaging. RESULTS The incidence of ME immediately after ESD in the CO2 group was significantly lower than that in the Air group(17% vs 55%, P = 0.012). The incidence of ME the next morning was 8.3% vs 32% respectively(P= 0.066). There were no differences in pain scores or distention scores at any post-procedure time points. The volume of residual gas in the digestive tract immediately after ESD was significantly smaller in the CO2 group than that in the Air group(808 m L vs 1173 m L, P = 0.013).CONCLUSION CO2 insufflation during esophageal ESD significantly reduced postprocedural ME. CO2 insufflation also reduced the volume of residual gas in the digestive tract immediately after ESD, but not the VAS scores of pain and distention.     

Safety and curative ability of endoscopic submucosal dissection for superficial esophageal cancers at least 50 mm in diameter

Background and Aim: Limited data are available regarding the use of endoscopic submucosal dissection (ESD) for superficial esophageal cancers ≥50 mm in diameter. The aim of the present study was to investigate the safety and success of ESD for superficial esophageal cancers ≥50 mm. Methods: A total of 39 patients with superficial esophageal squamous cell carcinoma ≥50 mm were treated with ESD at Osaka Medical Center for Cancer and Cardiovascular Diseases between January 2004 and April 2011, and were analyzed in a retrospective study. Results: En bloc resection was achieved in all patients. One mediastinal emphysema without perforation occurred during the procedure. Stricture developed in 11 of 39 patients, requiring a median of five endoscopic balloon dilatation procedures. Thirty‐three clinical epithelial or lamina propria mucosal cancers were treated by ESD with curative intent, of which invasion into the muscularis mucosa or deeper was detected in seven and lymphovascular involvement in three. The en bloc resection rate was 100% with a tumor‐free margin achieved in 92% of lesions. The curative resection and complication rates during ESD were 70% and 2.5%, respectively. Conclusion: ESD achieved a high en bloc resection rate of 92% with a tumor‐free margin. Curative resection rate of ESD in patients with clinical epithelial or lamina propria mucosal cancers was not low at 70%. However, the risk of stricture must be taken into account when considering the use of ESD in lesions ≥50 mm.     

Clinical features and treatment of patients with esophageal cancer and a history of gastrectomy: a multicenter,questionnaire survey in Kyushu,Japan

It is still controversial whether patients with a history of gastrectomy have high risk of esophageal carcinogenesis. On the other hand, the treatment strategy for esophageal cancer patients after gastrectomy is complicated. The association between histories of gastrectomy and esophageal carcinogenesis was retrospectively analyzed, and the treatment of esophageal cancer patients after gastrectomy was evaluated based on questionnaire data collected from multiple centers in Kyushu, Japan. The initial subject population comprised 205 esophageal cancer patients after gastrectomy. Among them, 108 patients underwent curative surgical treatment, and 70 patients underwent chemoradiation therapy (CRT). The time between gastrectomy and esophageal cancer development was longer in peptic ulcer patients (28.3 years) than in gastric cancer patients (9.6 years). There were no differences in the location of esophageal cancer according to the gastrectomy reconstruction method. There were no significant differences in the clinical background characteristics between patients with and without a history of gastrectomy. Among the 108 patients in the surgery group, the 5‐year overall survival rates for stages I (n = 30), II (n = 18), and III (n = 60) were 68.2%, 62.9%, and 32.1%, respectively. In the CRT group, the 5‐year overall survival rate of stage I (n = 29) was 82.6%, but there were no 5‐year survivors in other stages. The 5‐year overall survival rate of patients with CR (n = 33) or salvage surgery (n = 10) was 61.2% or 36%, respectively. For the treatment of gastrectomized esophageal cancer patients, surgery or CRT is recommended for stage I, and surgery with or without adjuvant therapy is the main central treatment in advanced stages, with surgery for stage II, neoadjuvant therapy + surgery for stage III, and CRT + salvage surgery for any stage, if the patient's condition permits.     

Evaluation of esophageal varices on liver computed tomography: Receiver operating characteristic analyses of the performance of radiologists and endoscopists

Background and Aim: Recent liver multi‐detector row computed tomography (MDCT) always covers the distal esophagus with an excellent image quality. The aim of this study was to compare the performance of faculty abdominal radiologists with those of radiology residents and endoscopists for the detection of esophageal varices and high‐risk esophageal varices on liver MDCT. Methods: A total of 104 cirrhotic patients that had undergone liver MDCT 4 weeks or less before an upper endoscopy were evaluated. Two faculty abdominal radiologists, two radiology residents, and two endoscopists independently interpreted all of the CT images to detect the presence of esophageal varices and high‐risk (grade 2 or 3) esophageal varices. With endoscopic grading as the reference standard, their performances were compared by using receiver operating characteristic (ROC) curve analysis. Results: The areas under the ROC curves for the detection of esophageal varices indicated better performance of the abdominal radiologists (A_z = 0.868), compared with the radiology residents (A_z = 0.798) (P = 0.007) and endoscopists (A_z = 0.784) (P = 0.006). For the detection of high‐risk esophageal varices, however, the performance of the abdominal radiologists (A_z = 0.914) was similar to those of radiology residents (A_z = 0.900) and endoscopists (A_z = 0.907) (each P > 0.05). Conclusions: Experienced readers have a better ability to detect esophageal varices on liver MDCT, but had no higher performance to evaluate high‐risk esophageal varices. As the accuracy of detecting high‐risk esophageal varices with clinical relevance on liver MDCT is excellent, even by endoscopists, the evaluation of esophageal varices from a recent liver MDCT may be useful to avoid the use of low‐yield endoscopy.     

Advantages of endoscopic submucosal dissection versus endoscopic oblique aspiration mucosectomy for superficial esophageal tumors

Background and Aim: In the treatment of superficial esophageal tumors (SET), en bloc histologically‐complete resection reduces the risk of local recurrence. Endoscopic oblique aspiration mucosectomy (EOAM) and endoscopic submucosal dissection (ESD) have been applied to resect SET. The aim of this study was to retrospectively determine whether ESD is more advantageous than EOAM for SET. Methods: In the present study, there was a total of 122 patients in whom 162 SET were resected endoscopically at Hiroshima University Hospital. EOAM (83 lesions/63 patients) or ESD (79 lesions/59 patients) was performed. En bloc histologically‐complete resection rates, operation time, complications, and the local recurrence rate were studied. Results: In SET > 20 mm, the en bloc histologically‐complete resection rate was significantly higher with ESD than with EOAM (94% vs 42%, P < 0.001). In SET of 16–20 mm, the rate tended to be higher with ESD than with EOAM (100% vs 81%, P = 0.08). In SET < 15 mm, the rates did not differ significantly between groups. The average operation time was significantly longer for ESD than for EOAM, regardless of tumor size (49.7 ± 33.0 min vs 19.1 ± 6.1 min, P < 0.001). Complication rates did not differ significantly between groups. The local recurrence rate was significantly lower with ESD than with EOAM (0%, mean observation period: 18.9 months vs 9%, mean observation period: 30.7 months, P = 0.03). Conclusion: Although increased operation time with ESD remains problematic, SET >15 mm should be treated with ESD to reduce local recurrence. In lesions ≤15 mm, EOAM might be preferable, especially in high‐risk patients.     

Intentional examination of esophagus by narrow‐band imaging endoscopy increases detection rate of cervical inlet patch

Foci of heterotopic gastric mucosa have been identified at different sites in the human body and the most common location is the proximal esophagus which is referred to as cervical inlet patch (CIP). The true prevalence of CIP varies and it is usually incidental findings during endoscopy. Because CIP is always asymptomatic, it was believed to be of little clinical relevance. However, emerging studies have described the acid‐secreting characteristics of heterotopic gastric mucosa and associations of CIP with gastroesophageal reflux disease (GERD). In addition, complications such as stricture, fistula, infection, mucosal hyperplasia, and malignant transformation have been reported. In this study, we investigated the prevalence of CIP, its associations with clinical manifestations, and the effect of intentional screening upper esophagus by magnifying endoscopy‐narrow‐band imaging (ME‐NBI) system. Consecutive healthy adults who underwent panendoscopy were separated into two groups. Patients in group I (n = 471) were examined by an endoscopist who intended to find CIPs by ME‐NBI. Patients in group II (n = 428) were examined by two endoscopists who were unaware of the study and performed white‐light imaging endoscopy. Participants provided questionnaires on GERD‐related symptoms. Higher CIP prevalence (11.7% vs. 1.9%, P < 0.0001) and longer duration of esophageal examination (mean ± standard deviation, 17.50 ± 12.40 vs. 15.24 ± 10.78 seconds, P = 0.004) were noted in group I than in group II. Analyzing group I patients revealed the higher prevalences of reflux symptoms (32.7% vs. 18.3%, P = 0.013) and erosive esophagitis (43.6% vs. 25.5%, P = 0.005) in patients with CIP than in those without. CIP was not associated with globus or dysphagia symptoms. More small CIPs (<5 mm) were detected by ME‐NBI than by white‐light imaging (85.3% vs. 41.4%, P = 0.001). In conclusion, CIP prevalence was not low under intentional ME‐NBI examination of the upper esophagus. The clinical relevance of CIP and its association with GERD require further investigation.     

Comparing endoscopic submucosal dissection with transanal resection for non-invasive rectal tumor: a retrospective study

Background and Aim: Endoscopic submucosal dissection (ESD) is an alternative to transanal resection (TAR) in treating rectal adenomas, intramucosal cancers, and superficial submucosal cancers. The purpose of this study is to compare the clinical efficacy between ESD and TAR for non‐invasive rectal tumors. Methods: Between January 1998 and December 2006, 85 patients with preoperative diagnosis of non‐invasive rectal tumors were treated by ESD or TAR. En‐bloc resection, local recurrence, complication, procedure time, and hospital stay were evaluated retrospectively using a prospectively‐completed database. Results: Mean resection sizes were 40 mm and 39 mm in diameter for the ESD and TAR groups, respectively. En‐bloc resections with a negative resection margin were achieved in 67% (35/52) of the ESD group, which was significantly higher than the 42% (14/33) in the TAR group. Sixty‐three lesions were diagnosed as curative resection, histopathologically. There was no local recurrence in the ESD group, but five local recurrences developed in the TAR group. Two rectal perforations, one minor delayed bleeding, and one subcutaneous emphysema in the ESD group were successfully managed conservatively. There were one minor delayed bleeding and two anesthesia‐related complications in the TAR group. The ESD group had a shorter hospital stay than the TAR group (4.9 days vs 7 days), but a longer procedure time (131 min vs 63 min). Conclusion: ESD was more effective than TAR in treating non‐invasive rectal tumors, with a lower recurrence rate and shorter hospital stay.     

USE OF SHORT NEEDLE KNIFE FOR ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION

Background: The emergence of endoscopic submucosal dissection (ESD) has enabled en bloc resection of lesions, which were conventionally difficult. However, ESD has problems of technical difficulty and high incidence of complications. In order to improve the procedure of marking and submucosal dissection in the esophagus, we modified and adjusted the standard needle knife to a short needle knife having a tip portion with a projection length of 1.5 mm. Methods: We treated 20 esophageal lesions with ESD using the short needle knife. We marked around the lesion with the short needle knife and performed mucosal incision of the entire circumference with a needle knife and an IT knife, then dissected the submucosal layer with the short needle knife. A Hook knife was also used in situations where muscular layers were located in the front‐view Results: Complete en bloc resection was performed in all 20 cases. The diameter of lesions ranged from 3 to 65 mm (median, 20 mm), and that of resected specimens ranged from 28 to 90 mm (median, 47 mm). Submucosal dissection was completed with the short needle knife alone in 13 cases in 20 (65%), and in seven cases (35%), in combination with so‐called Hook knife. The procedure was complicated in one patient with mediastinal emphysema. Conclusions: The short needle knife proved to be useful and safe in clear marking and submucosal dissection of esophageal lesions. It allows greater flexibility in the angle of insertion, and enables more effective and safer procedures because its full length can be inserted into the submucosa and fixed.     

Diagnosis of undifferentiated type early gastric cancers by magnification endoscopy with narrow-band imaging

Background and Aims: The diagnostic use of magnification endoscopy with narrow‐band imaging (ME‐NBI) to assess histopathologically undifferentiated‐type early gastric cancers (UD‐type EGCs) is not well elucidated. The purpose of this study was to examine the comparative relationship between ME‐NBI images and histopathological findings in UD‐type EGCs. Methods: We analyzed 78 consecutive cases of UD‐type EGCs ≤ 20 mm in diameter that underwent ME‐NBI ≤ 2 weeks prior to resection. The ME‐NBI images were compared with histopathological findings following either endoscopic submucosal dissection (ESD) or surgery. Applying the comparative results, we prospectively evaluated the success of identifying the lateral extent of UD‐type EGCs resected by ESD in additional consecutive cases. Results: Lesions with preserved but irregular surface microstructures (S‐type based on ME‐NBI) showed mucosal atrophy and corresponded histologically to the non‐whole‐layer type of intramucosal cancer (24/24, 100%). Lesions with an irregular microvasculature type (V‐type, for example, corkscrew pattern) or mixed type upon ME‐NBI corresponded histopathologically to the non‐whole‐layer type of intramucosal cancer (15/54, 27.8%), the whole‐layer type of intramucosal cancer (27/54, 50.0%) or submucosal (sm) invasion cancer (12/54, 22.2%). Applying these comparative results, we used ME‐NBI to successfully predict the lateral extent of cancer, which corresponded to the histopathological lateral extent in all 18 additional consecutive UD‐type EGCs resected by ESD. Conclusions: ME‐NBI images of UD‐type EGCs were very closely related to the histopathological findings. Thus, ME‐NBI can be useful in the pretreatment assessment of the histopathological patterns of cancer development and the lateral extent of such lesions.     

Endoscopic submucosal dissection for superficial esophageal neoplasms using the stag beetle knife

Endoscopic submucosal dissection (ESD) is an accepted standard treatment for early gastric cancer but is not widely used in the esophagus because of technical difficulties. To increase the safety of esophageal ESD, we used a scissors‐type device called the stag beetle (SB) knife. The aim of this study was to determine the efficacy and safety of ESD using the SB knife. We performed a single‐center retrospective, uncontrolled trial. A total of 38 lesions were excised by ESD from 35 consecutive patients who were retrospectively divided into the following two groups according to the type of knife used to perform ESD: the hook knife (hook group) was used in 20 patients (21 lesions), and the SB knife (SB group) was used in 15 patients (17 lesions). We evaluated and compared the operative time, lesion size, en bloc resection rate, pathological margins free rate, and complication rate in both groups. The operative time was shorter in the SB group (median 70.0 minutes [interquartile range, 47.5–87.0]) than in the hook group (92.0 minutes [interquartile range, 63.0–114.0]) (P = 0.019), and the rate of complications in the SB group was 0% compared with 45.0% in the hook group (P = 0.004). However, the lesion size, en bloc resection rate, and pathological margins free rate did not differ significantly between the two groups. In conclusion, ESD using the SB knife was safer than that using a conventional knife for superficial esophageal neoplasms.     

内镜黏膜下隧道法剥离术治疗早期食管癌伴黏膜下层纤维化的临床观察

目的评价内镜黏膜下隧道法剥离术（endoscopic submucosal tunnel dissection,ESTD）治疗早期食管癌伴黏膜下层纤维化的效果和安全性。方法2015年6月—2018年2月间,在江苏省苏北人民医院消化内科采用ESTD或内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）治疗,术后病理证实病灶＜1/3食管管周,且伴有黏膜下层纤维化的早期食管癌病例87例纳入回顾性分析,按纤维化程度分成轻度纤维化60例（ESTD 31例、ESD 29例）和重度纤维化27例（ESTD 16例、ESD 11例）,比较同一纤维化程度时两种手术方式的剥离速度、整块切除率、完全切除率,以及出血、肌层损伤、穿孔、颈部皮下气肿和术后狭窄的发生率。结果对于伴有轻度黏膜下层纤维化的早期食管癌患者,ESTD的整块切除率[96.8%（30/31）比82.8%（24/29）,P＜0.05]和完全切除率[96.8%（30/31）比75.9%（22/29）,P＜0.05]明显高于ESD,固有肌层损伤发生率明显低于ESD[6.5%（2/31）比17.2%（5/29）,P＜0.05],剥离速度、术中出血发生率、穿孔发生率、术后狭窄发生率与ESD比较差异均无统计学意义（P均＞0.05）,两种手术方式均无术后迟发性出血和颈部皮下气肿发生。对于伴有重度黏膜下层纤维化的早期食管癌患者,ESTD的剥离速度快于ESD[（12.3±2.8）mm2/min比（7.1±3.2）mm2/min],整块切除率、完全切除率、术后狭窄发生率与ESD相近,术中出血发生率[12.5%（2/16）比54.5%（6/11）]、固有肌层损伤发生率[18.8%（3/16）比54.5%（6/11）]、穿孔发生率[6.3%（1/16）比27.3%（3/11）]、颈部皮下气肿发生率[6.3%（1/16）比27.3%（3/11）]低于ESD,两种手术方式均无术后迟发性出血发生。术后12个月2例行ESD和1例行ESTD患者局部复发,术后24个月1例行ESTD患者发生异时癌。结论ESTD能安全、有效切除伴有黏膜下层纤维化的早期食管癌。对于伴有轻度黏膜下层纤维化者,ESTD的优势主要体现在治疗效果方面;对于伴有重度黏膜下层纤维化者,ESTD的优势主要体现在治疗安全性方面。     

Influence of endoscopic submucosal dissection on serum levels of pepsinogens in patients with early gastric cancer

Background: The serum levels of pepsinogens (PG) have been considered to be a useful marker for assessing the risk of metachronous gastric cancer in patients who undergo endoscopic submucosal dissection. However, the influence of endoscopic submucosal dissection (ESD) on serum levels of PG has not yet been examined. The aim of this study was to examine whether the level of PG after ESD can be used to predict the risk of metachronous cancer. Patients and Methods: The study included of 100 consecutive patients who underwent ESD for gastric cancer at Hirosaki University Hospital from September 2009 to February 2011. Serum levels of PG I and II on the day before and after ESD were compared. Stool antigen test was also performed to examine the presence of Helicobacter pylori infection. Results: The mean serum level of PG I before and after ESD was 34.3 ± 31.6 ng/mL and 70.5 ± 100.0 ng/mL (P < 0.001), respectively. PG I/II ratio before and after ESD was 2.40 ± 1.51 and 2.79 ± 1.70 (P < 0.001). The serum level of PG I and the PG I/II ratio were significantly changed after ESD, regardless of the use of proton pump inhibitor, Helicobacter pylori infection or the location of the tumor. Conclusions: ESD treatment modulates the serum level of PG I and significantly increases the PG I/II ratio. Serum levels of PG should be measured before the ESD procedure is performed to predict the risk of developing metachronous gastric cancer after ESD.     

Results of chemoradiotherapy for stage I esophageal cancer in medically inoperable patients compared with results in operable patients

The purpose of the present study was to evaluate long‐term results of chemoradiotherapy for clinical T1b‐2N0M0 esophageal cancer and to compare outcomes for operable and inoperable patients. Patients with stage I esophageal cancer (Union for International Cancer Control [UICC] 2009), excluding patients with cT1a esophageal cancer, were studied. All patients had histologically proven squamous cell carcinoma. Operable patients received cisplatin and 5‐fluorouracil with concurrent radiotherapy of 60 Gy including a 2‐week break. Inoperable patients received nedaplatin and 5‐fluorouracil with concurrent radiotherapy of 60–70 Gy without a pause. End‐points were overall survival rate (OS), cause‐specific survival rate (CSS), progression‐free survival rate (PFS), and locoregional control rate (LC). Thirty‐seven operable patients and 30 medically inoperable patients were enrolled. There was a significant difference in only age between the operable group and inoperable group (P = 0.04). The median observation period was 67.9 months. In all patients, 5‐year OS, CSS, PFS, and LC were 77.9%, 91.5%, 66.9%, and 80.8%, respectively. Comparison of the operable group and inoperable group showed that there was a significant difference in OS (5‐year, 85.5% vs. 68.7%, P = 0.04), but there was no difference in CSS, PFS, or LC. Grade 3 or more late toxicity according to Common Terminology Criteria for Adverse Events v 3.0 was found in seven patients. Even in medically inoperable patients with stage I esophageal cancer, LC of more than 80% can be achieved with chemoradiotherapy. However, OS in medically inoperable patients is significantly worse than that in operable patients.     

Predictive factors for esophageal stenosis after endoscopic submucosal dissection for superficial esophageal cancer

Endoscopic submucosal dissection (ESD) has been utilized as an alternative treatment to endoscopic mucosal resection for superficial esophageal cancer. We aimed to evaluate the complications associated with esophageal ESD and elucidate predictive factors for post‐ESD stenosis. The study enrolled a total of 42 lesions of superficial esophageal cancer in 33 consecutive patients who underwent ESD in our department. We retrospectively reviewed ESD‐associated complications and comparatively analyzed regional and technical factors between cases with and without post‐ESD stenosis. The regional factors included location, endoscopic appearance, longitudinal and circumferential tumor sizes, depth of invasion, and lymphatic and vessel invasion. The technical factors included longitudinal and circumferential sizes of mucosal defects, muscle disclosure and cleavage, perforation, and en bloc resection. Esophageal stenosis was defined when a standard endoscope (9.8 mm in diameter) failed to pass through the stenosis. The results showed no cases of delayed bleeding, three cases of insidious perforation (7.1%), two cases of endoscopically confirmed perforation followed by mediastinitis (4.8%), and seven cases of esophageal stenosis (16.7%). Monovalent analysis indicated that the longitudinal and circumferential sizes of the tumor and mucosal defect were significant predictive factors for post‐ESD stenosis (P < 0.005). Receiver operating characteristic analysis showed the highest sensitivity and specificity for a circumferential mucosal defect size of more than 71% (100 and 97.1%, respectively), followed by a circumferential tumor size of more than 59% (85.7 and 97.1%, respectively). It is of note that the success rate of en bloc resection was 95.2%, and balloon dilatation was effective for clinical symptoms in all seven patients with post‐ESD stenosis. In conclusion, the most frequent complication with ESD was esophageal stenosis, for which the sizes of the tumor and mucosal defect were significant predictive factors. Although ESD enables large en bloc resection of esophageal cancer, practically, in cases with a lesion more than half of the circumference, great care must be taken because of the high risk of post‐ESD stenosis.     

Effect of Endoscopic Submucosal Dissection for Superficial Esophageal Neoplasms and Risk Factors for Postoperative Stricture

Endoscopic submucosal dissection (ESD) enables wider tumor resection compared with endoscopic mucosal resection and en bloc resection of superficial esophageal neoplasms. However, ESD may cause difficult-to-treat stricture of the esophagus, and therefore, prediction of and measures against postoperative esophageal stricture are critical. The aim of this study was to evaluate the effect of ESD on superficial esophageal neoplasms and identify risk factors associated with esophageal stricture after ESD.This study included 165 lesions in 120 patients with superficial esophageal neoplasms, including cancer and neoplasia, who underwent ESD from 2009 to 2013.The complete resection rate of superficial esophageal neoplasms by ESD was 90.9%. After ESD, 22 subjects (18.3%) had symptomatic esophageal stricture, 12 (10.0%) had aspiration pneumonia of grade 2, and 7 (5.8%) had mediastinal emphysema of grade 2. Comparison of the 22 subjects with stricture with the 98 subjects without stricture showed significant differences in the rate of resection of >75% of the esophageal circumference, rate of whole circumference resection, and the required time for resection. The tumor size and the size of the resected tissue sample also differed between the 2 groups. The groups did not differ in age, sex, alcohol intake, and smoking; location, macroscopic, and histological tumor findings; chest pain; or use of anticoagulants for comorbidities. In multivariate analysis, tumor size and whole circumference resection were independent risk factors for stricture. Furthermore, in 45 subjects with resection of >75% of the esophageal circumference, whole resection of the esophagus was the only independent risk factor for stricture.This study suggests that ESD has a strong therapeutic effect on superficial esophageal neoplasms; however, a greater extent of resection of the esophagus increases the risk of postoperative esophageal stricture. Preventive measures against development of postoperative stricture require further study.     

USEFUL ENDOSCOPIC ULTRASONOGRAPHY TO ASSESS THE EFFICACY OF NEOADJUVANT THERAPY FOR ADVANCED ESOPHAGEAL CARCINOMA: BASED ON THE RESPONSE EVALUATION CRITERIA IN SOLID TUMORS

Objective: The aim of the present study was to assess the usefulness of endoscopic ultrasonography (EUS) for evaluating the efficacy of neoadjuvant therapy for advanced esophageal carcinoma based on the Response Evaluation Criteria in Solid Tumors (RECIST). Patients and Methods: Sixty‐two patients with advanced esophageal carcinoma underwent surgical resection after neoadjuvant therapy. The maximal tumor thickness was measured by EUS before and after neoadjuvant therapy, and the percent reduction was compared with the pathological response. Based on the RECIST, PD‐SD (progressive disease‐stable disease) was defined as < 30% reduction of tumor thickness on EUS, PR (partial response) as ≥ 30% reduction of tumor thickness, and CR (complete response) as no detectable tumor (100%). Results: The percent reduction of the thickness of Grade 0–1, Grade 2 and Grade 3 tumor was 11.5 ± 21.0%, 48.2 ± 17.0% and 74.9 ± 21.1%, respectively. There were significant differences in the extent of reduction among the three groups. Based on the RECIST, 80% of Grade 0–1 cases, 91% of Grade 2 cases and 22% of Grade 3 cases were PD‐SD, PR, and CR according to EUS, respectively. EUS correctly identified 80% of non‐responders and 94% of responders. Conclusions: The percentage reduction of tumor thickness on EUS closely reflected the pathological evaluation. EUS evaluation based on the RECIST seems to be useful for monitoring neoadjuvant therapy in patients with esophageal carcinoma.     

The extent of emphysema in patients with COPD

Background and Aims: The global initiative for COPD (GOLD) adopted the degree of airway obstruction as a measure of the severity of the disease. The objective of this study was to apply CT to assess the extent of emphysema in patients with chronic obstructive pulmonary disease (COPD) and relate this extent to the GOLD stage of airway obstruction. Materials and Methods: We included 209 patients with COPD. COPD was defined as FEV₁/FVC < 0.70 and no reversibility to β₂‐agonists. All patients were current smokers with a smoking history of ≥20 pack‐years. Patients were assessed by lung function measurement and visual and quantitative assessment of CT, from which the relative area of emphysema below ?910 Hounsfield units (RA‐910) was extracted. Results: Mean RA‐910 was 7.4% (n = 5) in patients with GOLD stage I, 17.0% (n = 119) in stage II, 24.2% (n = 79) in stage III and 33.9% (n = 6) in stage IV. Regression analysis showed a change in RA‐910 of 7.8% with increasing severity according to GOLD stage (P < 0.001). Combined visual and quantitative assessment of CT showed that 184 patients had radiological evidence of emphysema, whereas 25 patients had no emphysema. Conclusion: The extent of emphysema increases with increasing severity of COPD and most patients with COPD have emphysema. Tissue destruction by emphysema is therefore an important determinant of disease severity in COPD. Please cite this paper as: Shaker SB, Stavngaard T, Hestad M, Bach KS, Tonnesen P and Dirksen A. The extent of emphysema in patients with COPD. The Clinical Respiratory Journal 2009; 3: 15–21.     

Multidetector CT in patients with esophageal stent as a palliative treatment for stenosing esophageal cancer: A feasibility study

Objective. The self-expanding metallic stent (SEMS) is widely used in the palliative treatment of stenosing esophageal cancer. Multidetector computed tomography (MDCT) allows volumetric investigation including virtual endoscopy. The aim of this study was to determine the feasibility of MDCT follow-up of esophageal SEMS and to describe the imaging patterns encountered as well as correlating them with fibroscopic evaluation. Material and methods. Thirteen consecutive patients (10 M, mean age 64 years) with esophageal SEMS as a palliative treatment underwent MDCT for recurrent dysphagia (n=7), chest pain and fever (n=1) or follow-up without symptoms (n=5). Patency and esophageal wall patterns were studied and compared with diagnosis by fibroscopy. Results. No metallic artefact related to the SEMS was observed. At the SEMS level, MDCT revealed a tissular lump (n=1), a thin recurrent layer of tissue (n=1), extrinsic compression (n=1), fluid stasis (n=7) and intussusception of the gastric wall into the SEMS (n=4). The esophageal wall was analyzed by MDCT (peripheral thickening around the stent (n=8), tumor overgrowth under or above the SEMS level (n=8)) and showed tracheal compression (n=3). At the level of the SEMS, fibroscopy showed tumor recurrence (n=2), a thin recurrent layer of tissue (n=1), a distorted SEMS (n=1) and a tumor overgrowth under or above the SEMS level (n=6). In comparison with fibroscopy, MDCT satisfactorily diagnosed the SEMS patency in 92% of cases and the esophageal wall in 73%. Conclusions. Morphology, patency of the SEMS and analysis of the esophageal wall can be performed by MDCT with a good degree of accuracy as compared to fibroscopy. In such patients in palliative care, a non-invasive investigation is worth promoting as a first-line procedure.     

Relation between grade II hypertensive retinopathy and coronary artery disease in treated essential hypertensives

It is known that in advanced hypertensive retinopathy, which changes advanced hypertensive retinopathy (Grade III or IV), there is a strong relation between retinal microvascular lesions and cardiac and macrovascular markers of target organ damage (TOD). The prevalence of grade II hypertensive retinopathy and its relationship to cardiovascular risk factors remain controversial. The subjects, a total of 437 hypertensive patients, were divided into three groups according to modified Keith, Wagener, and Barker (KWB) classification by two ophthalmologists: Grade 0 with normal retinal change (N = 169, 38.7%), Grade I with arteriolar narrowing (N = 215, 49.1%), Grade II with arteriovenous crossings (N = 49, 11.2%). The prevalence of Grade I and Grade II hypertensive retinopathy was significantly higher than that of advanced hypertensive retinopathy. The grade of hypertensive retinopathy was related to age, duration of hypertension, coronary artery disease (CAD), and left ventricular hypertrophy (LVH). The prevalence of LVH and CAD in Grade II was significantly higher than in Grade I and Grade 0. The hypertensive retinopathy Grade II was significantly correlated with LVH (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.21-4.44, p < 0.05) and CAD (OR 4.2, 95% CI 1.97-8.95, p-<-0.001). Grade I and Grade II hypertensive retinopathy are frequently observed in hypertensive patients compared to Grade III and IV patients. We concluded that Grade II hypertensive retinopathy is closely related to CAD and should therefore not be ignored.     

Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: Review of the literature and recommendations from experts

Prevention therapy is recommended for lesions >1/2 of the esophageal circumference. Locoregional steroid injection is recommended for lesions >1/2–3/4 of the esophageal circumference and oral steroids are recommended for lesions >1/2 of the subtotal circumference. For lesions of the entire circumference, oral steroid combined with injection steroid is considered. Endoscopic balloon dilatation (EBD) is the first choice of treatment for stricture after esophageal endoscopic submucosal dissection (ESD). Radical incision and cutting or self‐expandable metallic stent can be considered for refractory stricture after EBD. In case of intraoperative perforation during esophageal ESD, endoscopic clip closure should be initially attempted. Surgery is considered for treatment of delayed perforation. Current standard practice for prevention of delayed bleeding after gastric ESD includes prophylactic coagulation of vessels on post‐ESD ulcers and giving proton pump inhibitors. Chronic kidney disease stage 4 or 5, multiple antithrombotic drug use, anticoagulant use, and heparin bridging therapy are high‐risk factors for delayed bleeding after gastric ESD. Intraoperative perforation during gastric ESD is initially managed by endoscopic clip closure. If endoscopic clip closure is difficult, other methods such as over‐the‐scope clip (OTSC), polyglycolic acid (PGA) sheet shielding etc. are attempted. Delayed perforation usually requires surgical intervention, but endoscopic closure by OTSC or PGA sheet may be considered. Resection of three‐quarters of the circumference is a risk factor for stenosis after gastric ESD. Giving prophylactic local steroid injection and/or oral steroid is reported, but effectiveness has not been fully verified as has been done for esophageal stricture. The main management method for gastric stenosis is EBD but it may cause perforation.