Endoscopic therapy for gastric stromal tumors originating from the muscularis propria

AIM: To explore endoscopic therapy methods for gastric stromal tumors originating from the muscularis propria.METHODS: For 69 cases diagnosed as gastric stromal tumors originating from the muscularis propria, three types of endoscopic therapy were selected, based on the size of the tumor. These methods included endoscopic ligation and resection (ELR), endoscopic submucosal excavation (ESE) and endoscopic full-thickness resection (EFR). The wound surface and the perforation of the gastric wall were closed with metal clips. Immunohistostaining for CD34, CD117, Dog-1, S-100 and smooth muscle actin (SMA) was performed on the resected tumors.RESULTS: A total of 38 cases in which the tumor size was less than 1.2 cm were treated with ELR; three cases were complicated by perforation, and the perforations were closed with metal clips. Additionally, 18 cases in which the tumor size was more than 1.5 cm were treated with ESE, and no perforation occurred. Finally, 13 cases in which the tumor size was more than 2.0 cm were treated with EFR; all of the cases were complicated by artificial perforation, and all of the perforations were closed with metal clips. All of the 69 cases recovered with medical treatment, and none required surgical operation. Immunohistostaining demonstrated that among all of the 69 gastric stromal tumors diagnosed by gastroscopy, 12 cases were gastric leiomyomas (SMA-positive), and the other 57 cases were gastric stromal tumors.CONCLUSION: Gastric stromal tumors originating from the muscularis propria can be treated successfully with endoscopic techniques, which could replace certain surgical operations and should be considered for further application.     

Peri-operative heparin: a possible adjuvant to surgery in colo-rectal cancer?

Analysis of data from a randomised trial of adjuvant razoxane involving 603 patients with colo-rectal cancer having curative surgery is reported. The results show that razoxane was ineffective but peri-operative subcutaneous heparin treatment apparently conferred a statistically significant improvement in survival at 5 years, or equivalently a reduction in the risk of death. This beneficial effect is apparent in both razoxane treated and control patients and is not explained by demonstrable differences between heparin and non-heparin treated patients in the distribution of known prognostic factors. Adjustment for these factors slightly increased the apparent magnitude of the beneficial effect.

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Résumé L'analyse des résultats d'une étude randomisée sur le traitement adjuvant par Razoxane et comprenant 603 patients porteurs d'un cancer colo-rectal ayant eu une chirurgie curatrice est reportée. Les résultats montrent que le Razoxane était inefficient mais que le traitement péri-opératoire par Héparine sous cutanée montrait apparemment une amélioration statistiquement significative dans la survie à 5 ans ou de façon équivalente une réduction du risque de mort. Cet effet bénéfique est apparent dans les deux groupes de patients traités par Razoxane et contrôles et n'est pas expliqué par une différence de la distribution des facteurs pronostiques connus entre les patients héparinés ou non héparinés. L'ajustement de ces facteurs augmente légèrement l'ampleur apparente de cet effet bénéfique.

     

Clinical merit of subdividing gastric cancer according to invasion of the muscularis propria

BACKGROUND/AIMS: In TNM classification, carcinoma that has invaded the muscularis propria (mp) and cancer that has invaded the subserosa are both categorized as T2 cancer. However, some mp gastric cancer patients have a good postoperative course, similar to that of early gastric cancer patients. We performed a retrospective analysis of 74 patients with mp gastric cancer, based on the depth of mp invasion. METHODOLOGY: The clinicopathologic features of 74 cases of gastric cancer invading the mp (but no further) were subdivided according to depth of invasion, retrospectively reviewed and compared with surgical features of 165 patients with gastric cancer invading the submucosa (sm gastric cancer). For each tumor, we evaluated the degree of tumor invasion in the mp layer at a magnification of x100, using the section that showed the greatest extent of invasion. The patients were classified into 2 groups: mp1, tumor was limited to the first of the 3 mp layers; mp2, tumor had expanded beyond the first layer. RESULTS: Of the 74 mp gastric cancer patients, 30 were classified as mp1 and 44 were classified as mp2. Patients with mp1 gastric cancer had significantly more macroscopic signs of early gastric cancer, a lower frequency of lymph node metastasis, and a higher rate of operative cure than patients with mp2 gastric cancer. The incidence of lymph node metastasis among mp1 gastric cancer patients was almost equal to that of the 165 sm gastric cancer patients. The 5-year survival rate of mp1 patients was significantly better than that of mp2 patients (p<0.05), but was similar to that of the 165 sm gastric cancer patients (84%) (p<0.05). CONCLUSIONS: There were clear differences in clinical features between the mp1 and mp2 gastric cancer patients. Subdivision of mp gastric cancer according to depth of invasion may enable more precise prognosis and treatment of mp gastric cancer patients. The clinicopathological findings and surgical outcome of the mp1 patients were similar to those of the sm gastric cancer patients. Thus, mp1 patients may require treatment that is similar to treatment administered to patients with early gastric cancer.     

Submucosal tunneling endoscopic resection: An effective and safe therapy for upper gastrointestinal submucosal tumors originating from the muscularis propria layer

AIM To evaluate the effectiveness and safety of submucosal tunneling endoscopic resection(STER) and compare its outcomes in esophageal and cardial submucosal tumors(SMTs) of the muscularis propria(MP) layer.METHODS From May 2012 to November 2017, 173 consecutive patients with upper gastrointestinal(GI) SMTs of the MP layer underwent STER. Overall, 165 patients were included, and 8 were excluded. The baseline characteristics of the patients and SMTs were recorded. The en bloc resection rate, complete resection rate,residual rate, and recurrence rate were calculated to evaluate the effectiveness of STER, and the complication rate was recorded to evaluate its safety. Effectiveness and safety outcomes were compared between esophageal and cardial SMTs.RESULTS One hundred and twelve men and 53 women with a mean age of 46.9 ± 10.8 years were included. The mean tumor size was 22.6 ± 13.6 mm. Eleven SMTs were located in the upper esophagus(6.7%), 49 in the middle esophagus(29.7%), 46 in the lower esophagus(27.9%), and 59 in the cardia(35.7%). Irregular lesions accounted for 48.5% of all lesions. STER achieved an en bloc resection rate of78.7%(128/165) for GI SMTs with an overall complication rate of 21.2%(35/165).All complications resolved without intervention or were treated conservatively without the need for surgery. The en bloc resection rates of esophageal and cardial SMTs were 81.1%(86/106) and 72.1%(42/59), respectively(P = 0.142), and the complication rates were 19.8%(21/106) and 23.7%(14/59), respectively,(P =0.555). The most common complications for esophageal SMTs were gas-related complications and fever, while mucosal injury was the most common for cardial SMTs.CONCLUSION STER is an effective and safe therapy for GI SMTs of the MP layer. Its effectiveness and safety are comparable between SMTs of the esophagus and cardia.     

内镜下结扎剥离术在切除胃固有肌层来源小肿瘤中的应用价值初探

目的初步探讨内镜下结扎剥离技术治疗胃固有肌层来源小肿瘤的有效性和安全性。方法对33例患有胃固有肌层来源1cm以下肿瘤的患者进行内镜下结扎剥离治疗。用皮圈结扎瘤体,之后用钩刀或IT刀对瘤体进行剥离,直到瘤体完全或部分剥离出来,标本送组织学检查,创面以金属夹和医用胶封闭。分别于术后1周、1个月、3个月、6个月、12个月进行内镜检查观察瘤体脱落情况及创面愈合情况。结果33个病例中,25个瘤体内镜下部分剥离,8个瘤体内镜下完整剥离,33个瘤体均随着皮圈套完整脱落,所有病例均获得了确切的病理学诊断。1例患者出现自限性的出血,未出现穿孔等并发症。术后随访3—18个月,无复发患者。结论内镜下结扎剥离是治疗胃固有肌层来源肿瘤安全、有效,而且相对简单的技术,优势在于为病变提供了组织病理学诊断。     

Gastric carcinoma confined to the Muscularis propria: how can we detect, evaluate, and cure intermediate-stage carcinoma of the stomach?

OBJECTIVE: The most important surgical strategy for advanced gastric cancer is its detection at the curative stage. The aim of this study was to characterize the curable intermediate-stage gastric carcinomas. METHODS: Of 1120 consecutive patients who underwent gastric resection for primary gastric cancer from 1979 through 1996, 94 patients were histologically diagnosed as having cancer confined to the muscularis propria (mp cancer), analyzed clinicopathologically, and compared with patients with early and serosal cancers. RESULTS: The operative incidence of mp cancer was around 8% among cases of gastrectomy, and the ratio of mp cancer to advanced cancer began to increase in 1991. Mp cancer was at a statistically intermediate stage, between early and serosal cancers in terms of symptoms, surgical curability (96%), size and histology of the tumor, and the rate of lymph node metastasis (46%). Preoperative assessments of tumor depth were unclear using radiology and endoscopy; however, 35% of 31 cases studied were diagnosed precisely by endoscopic ultrasonography (EUS). Accuracy of lymph node metastasis diagnosis was the same (65%) by preoperative EUS and by surgeon; however, sensitivity of the surgeon's assessment was higher (69% vs 38%) and specificity of EUS was higher (83% vs 39%). The 5-yr survival rate was 85%, which was significantly better than that of serosal cancer and similar to that of early cancer. Patient outcome was not affected by lymph node metastasis or macroscopic type of tumor. CONCLUSIONS: Mp cancer should be considered an intermediate-stage cancer. Surgery with level 2 lymph node dissection should provide a cure rate similar to that for early cancer.     

Prostasin: a possible candidate gene for human hypertension

BackgroundProstasin, a serine protease, is suggested to be a novel mechanism regulating the epithelial sodium channel (ENaC) expressed in the distal nephron. This study aimed to evaluate whether the human prostasin gene is a novel candidate gene underlying blood pressure (BP) elevation.MethodsIn a sample of healthy African-American (AA) and European-American (EA) twin subjects aged 17.6 +/- 3.3 years (n = 920, 45% AAs), race-specific tagging single-nucleotide polymorphisms (tSNPs) were identified to tag all the available SNPs +/- 2 kb up- and downstream of the prostasin gene from HapMap at r(2) of 0.8-1.0. Selection yielded four tSNPs in AAs and one in EAs, with one tSNP (rs12597511: C to T) present in both AAs and EAs.ResultsFor rs12597511, CT and TT genotypes exhibited higher systolic BP (SBP) than CC genotype (115.9 +/- 1.1 mm Hg vs. 113.7 +/- 0.6 mm Hg, P = 0.025 (AAs); and 110.7 +/- 0.5 mm Hg vs. 109.6 +/- 0.6 mm Hg, P = 0.115 (EAs)). CT and TT genotypes compared with CC genotype showed a significant increase in diastolic BP (DBP) in both racial groups (62.5 +/- 0.7 mm Hg vs. 60.4 +/- 0.4 mm Hg, P = 0.003 (AAs); and 58.2 +/- 0.3 mm Hg vs. 56.7 +/- 0.4 mm Hg, P = 0.007 (EAs)). Furthermore, there was an increase in radial pulse wave velocity (PWV) in subjects with CT and TT genotype as compared with those with CC genotype (6.5 +/- 0.1 vs. 6.1 +/- 0.1 m/s, P < 0.0001) (EAs); and 6.7 +/- 0.1 vs. 6.6 +/- 0.1 m/s, P = 0.354 (AAs)). Analyses combining AAs and EAs consistently demonstrated a statistical significance of rs12597511 on all the phenotypes including SBP/DBP and PWV.ConclusionGenetic variation of the prostasin gene may be implicated in the development of hypertension in youths.American Journal of Hypertension (2008). doi 10.1038/ajh.2008.224American Journal of Hypertension (2008); 21, 9, 1028-1033. doi 10.1038/ajh.2008.224.     

Surgical adjuvant therapy for rectal cancer: Present options

Recent advances have been made with the publication of the results of GITSG and NCCTG trials, which demonstrated the significant improvement of survival by combined postoperative radiochemotherapy protocols for Stage II and III rectal cancer. These data show that systemic chemotherapy has a decisive role to play in this policy. Some of the advantages of preoperative irradiation compared with postoperative radiation therapy consist of the improvement of resectability of T4 tumors and the anal preservation for low-lying cancers. These data suggest that preoperative chemoradiotherapy should be applied not only to T4 tumors but also to all T3 tumors even when the transrectal extension is limited. The most usual protocol combines 5-fluorouracil (300–350 mg/m²/day) and leucovorin (20 mg/m₂/day) for 5 days, followed by radiation therapy (30–35 Gy in 10 fractions within 12–15 days), with surgery taking place 4 to 8 weeks later, after the tumor has been restaged. Systemic therapy is continued for four more months. T2 cancers should not be excluded from the benefit of preoperative irradiation.     

Ligation‐assisted endoscopic enucleation for treatment of esophageal subepithelial lesions originating from the muscularis propria: a preliminary study

An innovative ligation‐assisted endoscopic enucleation (EE‐L) technique was developed for the diagnosis and treatment of esophageal subepithelial lesions (smaller than 12 mm) originating from muscularis propria by combining endoscopic band ligation and endoscopic enucleation techniques. The aim of the study was to evaluate efficacy and safety of EE‐L technique in the treatment of esophageal subepithelial lesions (smaller than 12 mm) originating from muscularis propria. Forty‐seven esophageal subepithelial lesions (smaller than 12 mm) originating from the muscularis propria in 44 patients were treated with EE‐L between September 2010 and September 2012. The lesion was first aspirated into the transparent cap attached to the tip of endoscope. The elastic band was then released around its base. The purpose of ligation was to force the lesion to assume a polypoid form with a pseudostalk. Endoscopic enucleation was then performed until the tumor was completely enucleated from muscularis propria using a hook knife and forceps. All tumors (median diameter: 8.2 ± 2.3 mm, range: 4–12 mm) were enucleated completely. Histopathology identified 45 tumors (95.7%) as leiomyoma, 2 (4.3%) tumors as gastrointestinal stromal tumor with very low risk. The mean time of the EE‐L procedure was 12.5 ± 4.6 minutes (range: 6–23 minutes). Two patients experienced self‐limiting, non‐life‐threatening hemorrhage after EE‐L. No perforation and massive hemorrhage requiring further endoscopic or surgical intervention occurred. There were no recurrences during the 6–24 months follow‐up period. EE‐L offers the option of localized treatment of small esophageal muscularis propria tumors (smaller than 12 mm) with relatively few complications and low mortality, and provides the advantage of allowing a histopathological diagnosis. All the resected lesions in this study had a benign pathology.     

Laparoscopy-assisted endoscopic full-thickness resection for gastric subepithelial tumors originated from the muscularis propria layer: a pilot study with literature review

Objective: Laparoscopy-assisted endoscopic full-thickness resection (LAEFTR) has been suggested as an alternative to laparoscopic wedge resection in the treatment of gastric subepithelial tumors (SETs). It is expected to minimize the resection of the tissue surrounding the tumors and maintain the function of the remnant stomach. Here, we performed a prospective pilot study to evaluate the efficacy of laparoscopy-assisted endoscopic full-thickness resection (LAEFTR) for patients with gastric SETs.

Material and methods: We enrolled twelve patients who were diagnosed with gastric SETs with an intraluminal growth pattern or which is located in the gastric antrum between October 2011 and September 2013. LAEFTR was performed endoscopically using an endoscopic knife to make an incision half way around the tumor circumference and a laparoscopic resection around the remaining tumor circumference, followed by its laparoscopic removal. The feasibility, safety, and effectiveness of LAEFTR for gastric SETs were evaluated.

Results: The median size of the tumors in twelve patients was 22?mm (21–33). Of the 12 patients, 8 received LAEFTR, while the others underwent conventional laparoscopic wedge resection, since their tumor outlines were clearly visible in laparoscopic view. In 8 patients who underwent LAEFTR, the mean total operation time (endoscopic procedure time/laparoscopic procedure time) were 117 (37/41) min. The tumors were completely resected with clear margin, and there was no perioperative and postoperative complications.

Conclusions: LAEFTR currently seems to be the ideal treatment modality of intraluminal gastric SETs where their resection margins are difficult to define under laparoscopic guidance alone.     

Neoadjuvant and adjuvant therapy in relation to surgery for colorectal liver metastases

Liver resection is associated with prolonged survival in patients with colorectal liver metastases. At diagnosis, 15-20% of patients have resectable colorectal liver metastases whereas other patients have too advanced disease to enable surgical treatment and receive chemotherapy. In patients undergoing resection of colorectal liver metastases, disease relapse occurs in up to 70%. Therefore, a combined approach including preoperative or postoperative chemotherapy or both has been tested to improve outcome after surgery. In patients with unresectable colorectal liver metastases, chemotherapy is initially the sole treatment option. The considerable improvement of the efficacy of anticancer agents has contributed to increase the response rate in patients with advanced colorectal cancer. In case of major response to chemotherapy, surgery with curative intent can be offered to patients with initially unresectable liver metastases.     

Single-incision laparoscopic colorectal surgery for cancer: State of art

A number of clinical trials have demonstrated that the laparoscopic approach for colorectal cancer resection provides the same oncologic results as open surgery along with all clinical benefits of minimally invasive surgery. During the last years, a great effort has been made to research for minimizing parietal trauma, yet for cosmetic reasons and in order to further reduce surgery-related pain and morbidity. New techniques, such as natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopy (SIL) have been developed in order to reach the goal of “scarless” surgery. Although NOTES may seem not fully suitable or safe for advanced procedures, such as colectomies, SIL is currently regarded as the next major advance in the progress of minimally invasive surgical approaches to colorectal disease that is more feasible in generalized use. The small incision through the umbilicus allows surgeons to use familiar standard laparoscopic instruments and thus, perform even complex procedures which require extraction of large surgical specimens or intestinal anastomosis. The cosmetic result from SIL is also better because the only incision is made through the umbilicus which can hide the wound effectively after operation. However, SIL raises a number of specific new challenges compared with the laparoscopic conventional approach. A reduced capacity for triangulation, the repeated conflicts between the shafts of the instruments and the difficulties to achieve a correct exposure of the operative field are the most claimed issues. The use therefore of this new approach for complex colorectal procedures might understandingly be viewed as difficult to implement, especially for oncologic cases.     

Single-incision laparoscopic surgery to treat hepatopancreatobiliary cancer: A technical review

Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site surgery, was launched to minimize incisional traumatic effects in the 1990s. Minor SILS, such as cholecystectomies, have been gaining in popularity over the past few decades. Its application in complicated hepatopancreatobiliary (HPB) surgeries, however, has made slow progress due to instrumental and technical limitations, costs, and safety concerns. While minimally invasive abdominal surgery is pushing the boundaries, advanced laparoscopic HPB surgeries have been shown to be comparable to open operations in terms of patient and oncologic safety, including hepatectomies, distal pancreatectomies (DP), and pancreaticoduodenectomies (PD). In contrast, advanced SILS for HPB malignancy has only been reported in a few small case series. Most of the procedures involved minor liver resections and DP; major hepatectomies were rarely described. Single-incision laparoscopic PD has not yet been reported. We herein review the published SILS for HPB cancer in the literature and our three-year experience focusing on the technical aspects.     

Long-term risk of breast cancer recurrence: the need for extended adjuvant therapy

Background: All women with early breast cancer, even those with small tumors and negative nodes, remain at appreciable risk of recurrence after surgery over the subsequent 10–15 years. In women with tumors expressing estrogen receptors and/or progesterone receptors, standard systemic adjuvant therapy is 5 years of tamoxifen, which substantially reduces the risk of recurrence and breast cancer-related death. Tamoxifen efficacy benefits are limited to 5 years of treatment, presumably a consequence of acquired tamoxifen resistance. The third-generation aromatase inhibitors, which are highly selective and potent in suppressing whole-body estrogen synthesis in postmenopausal women, are being investigated as alternative or complementary treatments to tamoxifen. For treatment beyond adjuvant tamoxifen for 5 years, letrozole is the only aromatase inhibitor for which clinical trial data were reported. That trial, MA.17, evaluated letrozole as extended adjuvant treatment following standard adjuvant tamoxifen in postmenopausal women with predominantly estrogen receptor—and/or progesterone receptor—positive early breast cancer. Results: Compared with placebo, letrozole markedly reduced the residual risk of recurrence, by 42%, and the improvement in disease-free survival was irrespective of patient nodal status. A significant improvement in overall survival has already been seen in the patients at highest risk, those with positive nodes. Conclusion: On the basis of these results, extended adjuvant letrozole is recommended for all patients completing 5 years of adjuvant tamoxifen, including women generally considered at minimal risk.     

Effect of a clinical pathway after laparoscopic surgery for colorectal cancer

BACKGROUND/AIMS: The purpose of this study was to evaluate whether implementation of a clinical pathway (CP) reduces length of stay after laparoscopic surgery for colorectal carcinoma. METHODOLOGY: We retrospectively reviewed 330 patients with colorectal carcinoma who underwent laparoscopic surgery between 2002 and 2006. The patients were divided into 2 groups: no clinical pathway patients in 2002-03 (Group A) and those managed with clinical pathway in 2004-06 (Group B). Patients in Group B were planned to be discharged and return home within postoperative day 8, with use of CP. RESULTS: There was no mortality in either group. In Group B, the rate of patients who started solid food within postoperative day 3 was significantly higher than in Group A for both colon carcinoma (96.7 vs. 82.8%, p = 0.001) and rectal carcinoma (94.2 vs. 65.5%, p = 0.001). The rate of patients discharged within postoperative day 8 was significantly higher in Group B than in Group A (98.5 vs. 64.8%, p = 0.001), although there were more advanced cases in Group B. CONCLUSIONS: The implementation of clinical pathway has led to the standardization of patient care and considerable decrease in length of stay after laparoscopic surgery for colorectal carcinoma.