Esophageal granular cell tumors: Report of 9 cases and a literature review

Esophageal granular cell tumors (GCTs) are rare tumors of the esophagus. We evaluated the clinical and pathologic features of 9 esophageal GCT patients (5 men and 4 women) from our institute and reviewed the related disease literature. Patient age ranged from 25 to 53 years (mean: 41 years). All the patients were asymptomatic or presented with non-specific symptoms. Most GCTs occurred in the distal esophagus and were less than 6 mm in diameter. Computational analysis showed that the average gray-scale endoscopic ultrasound images of esophageal GCTs were greater than that of esophageal leiomyomas. Eight patients were treated by endoscopic resection, and 1 patient underwent surgical excision. No post-therapy recurrence or metastasis developed during follow-up (mean: 36.4 mo, range: 1-72 mo).     

Argon plasma coagulation for superficial esophageal squamous-cell carcinoma in high-risk patients

AIM: To evaluate the usefulness and safety of argon plasma coagulation (APC) for superficial esophageal squamous-cell carcinoma (SESC) in high-risk patients. METHODS: We studied 17 patients (15 men and 2 women, 21 lesions) with SESC in whom endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and open surgery were contraindicated from March 1999 through February 2009. None of the patients could tolerate prolonged EMR/ESD or open surgery because of severe concomitant disease (e.g., liver cirrhosis, cerebral infarction, or ischemic heart disease) or scar formation after EMR/ESD and chemoradiotherapy. After conventional endoscopy, an iodine stain was sprayed on the esophageal mucosa to determine the lesion margins. The lesion was then ablated by APC. We retrospectively studied the treatment time, number of APC sessions per site, complications, presence or absence of recurrence, and time to recurrence.RESULTS: The median duration of follow-up was 36 mo (range: 6-120 mo). All of the tumors were macroscopically classified as superficial and slightly depressed type (0-Ⅱc). The preoperative depth of invasion was clinical T1a (mucosal cancer) for 19 lesions and clinical T1b (submucosal cancer) for 2. The median treatment time was 15 min (range: 10-36 min). The median number of treatment sessions per site was 2 (range: 1-4). The median hospital stay was 14 d (range: 5-68 d). Among the 17 patients (21 lesions), 2 (9.5%) had recurrence and underwent additional APC with no subsequent evidence of recurrence. There were no treatment-related complications, such as bleeding or perforation. CONCLUSION: APC is considered to be safe and effective for the management of SESC that cannot be resected endoscopically because of underlying disease, as well as for the control of recurrence after EMR and local recurrence after chemoradiotherapy.     

Single center experience of laparoscopic vs. open resection for gastrointestinal stromal tumors of the stomach

BACKGROUND/AIMS: With better understanding of disease biology and technological advances, an increasing number of gastric gastrointestinal stromal tumors (GISTs) are being resected laparoscopically. We assessed our management of gastric GISTs in our institution. METHODOLOGY: Prospectively collected data from 13 patients who underwent surgery for gastric gastrointestinal stromal tumors over an 18-month period were analyzed with respect to operative and oncological outcomes. Seven patients underwent open resection and 6 patients had laparoscopic resection. RESULTS: The tumors were evenly distributed in both groups in whom the median age was 68 years in the open group vs. 70 years in the laparoscopic group. The median operating time was 132 min in the open group and 110 min in the laparoscopic group and patients who had a laparoscopic resection had a shorter hospital stay (4 days versus 11 days). Patients in the open group had a larger tumor the patients in the laparoscopic group (11.5 x 6 x 4 cm vs. 5 x 4 x 3 cm). No patient had evidence of recurrence at median follow-up of 9 months. CONCLUSIONS: Patients with small gastric GISTs can be safely resected with a laparoscopic approach, offering a quicker operation and shorter hospital stay. A laparoscopic approach does not alter risk of early local or distant recurrence.     

Factors associated with early recurrence after curative surgery for gastric cancer

AIM: To characterize patterns of gastric cancer recurrence and patient survival and to identify predictors of early recurrence after surgery.METHODS: Clinicopathological data for 417 consecutive patients who underwent curative resection for gastric cancer were retrospectively analyzed. Tumor and node status was reclassified according to the 7th edition of the American Joint Committee on Cancer tumor-node-metastasis classification for carcinoma of the stomach. Survival data came from both the patients' follow-up records and telephone followups.Recurrent gastric cancer was diagnosed based on clinical imaging, gastroscopy with biopsy, and/or cytological examination of ascites, or intraoperative findings in patients who underwent reoperation.Predictors of early recurrence were compared in patients with pT1 and pT2-4a stage tumors. Pearson's χ 2 test and Fisher's exact test were used to compare differences between categorical variables. Survival curves were constructed using the Kaplan-Meier method and compared via the log-rank test. Variables identified as potentially important for early recurrence using univariate analysis were determined by multivariate logistic regression analysis.RESULTS: Of 417 gastric cancer patients, 80(19.2%)were diagnosed with early gastric cancer and the remaining 337(80.8%) were diagnosed with locally advanced gastric cancer. After a median follow-up period of 56 mo, 194 patients(46.5%) experiencedrecurrence. The mean time from curative surgery to recurrence in these 194 patients was 24 ± 18 mo(range, 1-84 mo). Additionally, of these 194 patients,129(66.5%) experienced recurrence within 2 years after surgery. There was no significant difference in recurrence patterns between early and late recurrence(P 0.05 each). For pT1 stage gastric cancer, tumor size(P = 0.011) and pN stage(P = 0.048) were associated with early recurrence of gastric tumors.Patient age, pT stage, pN stage, Lauren histotype,lymphovascular invasion, intraoperative chemotherapy,and postoperative chemotherapy were independent predictors of early recurrence in patients with pT2-4a stage gastric cancer(P 0.05 each).CONCLUSION: Age, pT stage, pN stage, Lauren histotype, lymphovascular invasion, intraoperative chemotherapy, and postoperative chemotherapy are independent factors influencing early recurrence of pT2-4a stage gastric cancer.     

Intrahepatic biliary cystadenoma: a need for radical resection

BACKGROUND: Intrahepatic biliary cystadenoma (IBC) is a rare liver tumour, which has strong tendency to recur and malignant potential as it can progress to cystadenocarcinoma (IBCa). METHODS: From June 2003 to December 2006, four patients diagnosed with hepatic cystadenoma were operated on our Liver Surgical Unit. All patients were females with median age of 51 years (range 45-63 years). Liver resections included three left and one right hepatectomies. In two patients, IBC was diagnosed by abdominal imaging and serum tumour markers but the rest of the patients were initially misdiagnosed as simple cysts, treated by laparoscopic fenestration and referred to our unit after cyst recurrence. RESULTS: In all cases, the pathology report was consistent with liver cystadenomas. The postoperative course was uneventful and the median hospital stay was 8 days (range 5-12 days). In a median 18-month follow-up (range 2-40 months), all patients are alive and free of recurrence. CONCLUSION: Liver cystadenomas can be easily misdiagnosed with other hepatic cystic lesions. An aggressive surgical approach is recommended, due to their malignant potential and high recurrence rate after fenestration.     

Gastrointestinal stromal tumors in a cohort of Chinese patients in Hong Kong

AIM: To investigate the prevalence and clinical pattern of gastrointestinal stromal tumors (GISTs) in Hong Kong Chinese, and to assess the impact of introduction of CD117 on the disease incidence. METHODS: From the database of the Department of Pathology of Yan Chai Hospital, 47 patients, with GISTs from September 1995 to December 2003 were included in this study. Ten GISTs were diagnosed before the introduction of CD117. The clinical features, tumor characteristics, and treatment were analyzed. Factors predicting tumor related death or recurrence were studied with Cox proportional hazard model. RESULTS: The patients included 26 males and 21 females, with a mean age of 66.6 years (SD 13.1, range 29-87 years). The estimated prevalence of GISTs was 13.4-15.6 per 100 000 people, with an annual incidence of 1.68-1.96 per 100 000 people. The annual incidence of GISTs before and after the introduction of CD117 was 1.1 per 100 000 people and 2.1 per 100 000 people respectively. Stomach (34 patients, 72.3%) was the most common location for the tumor, followed by the small intestine (8 patients, 17.0%), esophagus (2 patients, 4.3%), omentum (2 patients, 4.3%) and colon (1 patient, 2.1%). Thirty-one patients (66%) had complete tumor resection. Eleven out of 16 deaths (23%) were tumor-related. The median survival time was 26 mo. Five-year survival rate was 61.3%. The significant factors associated with tumor-related death or recurrence were incomplete resection, tumor size 5 cm or above, invasion to the adjacent organ or presence of metastasis. CONCLUSION: The incidence of GIST in Hong Kong is comparable to that in the United States but lower than that in Finland. The true incidence of GISTs could be underestimated before the introduction of CD117. Incomplete resection, tumor size 5 cm or above, invasion to the adjacent organ or presence of metastasis are factors predicting tumor-related death or recurrence.     

Laparoscopic spleen-preserving distal pancreatectomy for pancreatic neoplasms: A retrospective study

AIM: To describe the clinical characteristics, technical procedures, and outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy (LSPDP) for benign and malignant pancreatic neoplasms.METHODS: The clinical data of 38 patients who underwent LSPDP in the Sir Run Run Shaw Hospital between January 2003 and August 2013 were analyzed retrospectively. Surgical techniques for LSPDP included preservation of the splenic artery and vein (Kimura’s technique) and ligation of the splenic pedicle with preservation of the short gastric vessels (Warshaw’s technique).RESULTS: There were no conversions to open surgery in the 38 patients. Splenic vessels were conserved during spleen-preserving pancreatectomy, except in two patients who underwent resection of the splenic vessels and preservation only of the short gastric vessels. The mean operation time was 123.2 ± 52.4 min, the mean intraoperative blood loss was 78.2 ± 39.5 mL, and the mean postoperative hospital stay was 7.6 ± 2.9 d. The overall rate of postoperative complications was 18.4% (7/38), and the rate of clinical pancreatic fistula was 13.2% (5/38). All postoperative complications were treated conservatively. The postoperative pathological diagnoses were 22 cases of benign pancreatic disease and 16 cases of borderline or low-grade malignant lesions. During a median follow-up of 38 mo (range: 5-133 mo), no recurrence was observed.CONCLUSION: LSPDP is a safe, feasible and effective procedure for the treatment of benign and low-grade malignant tumors of the distal pancreas.     

Duodenum-preserving resection and Roux-en-Y pancreatic jejunostomy in benign pancreatic head tumors

This study was conducted to explore the feasibility of partial pancreatic head resection and Roux-en-Y pancreatic jejunostomy for the treatment of benign tumors of the pancreatic head(BTPH). From November 2006 to February 2009, four patients(three female and one male) with a mean age of 34.3 years(range: 21-48 years) underwent partial pancreatic head resection and Roux-en-Y pancreatic jejunostomy for the treatment of BTPH(diameters of 3.2-4.5 cm) using small incisions(5.1-7.2 cm). Preoperative symptoms include one case of repeated upper abdominal pain, one case of drowsiness and two cases with no obvious preoperative symptoms. All four surgeries were successfully performed. The mean operative time was 196.8 min(range 165-226 min), and average blood loss was 138.0 m L(range: 82-210 m L). The mean postoperative hospital stay was 7.5 d(range: 7-8 d). In one case, the main pancreatic duct was injured. Pathological examination confirmed that one patient suffered from mucinous cystadenoma, one exhibited insulinoma, and two patients had solid-pseudopapillary neoplasms. There were no deaths or complications observed during the perioperative period. All patients had no signs of recurrence of the BTPH within a follow-up period of 48-76 mo and had good quality of life without diabetes. Partial pancreatic head resection with Roux-en-Y pancreatic jejunostomy is feasible in selected patients with BTPH.     

Prognostic factors and outcome of resected patients for gastrointestinal stromal tumors

BACKGROUND/AIMS: The aim of this study was to analyze the outcome of 33 patients with primary gastrointestinal stromal tumors (GISTs) who were observed and treated in a single teaching hospital and followed up prospectively. METHODOLOGY: Thirty-three GISTs patients (21 male; 12 female; mean age: 57 +/- 12 years; range: 23-76 years) between June 1994 and October 2004, were reviewed retrospectively. Patient, tumor, and treatment variables were analyzed to identify patterns of tumor relapse and factors affecting survival. RESULTS: Of 33 patients, 30 patients (91%) had primary tumor without metastasis, and all of them underwent complete surgical resection of gross disease. Three patients (9%) had metastasis. Among patients radically resected, the 5-year actuarial survival rate was 85%, and the disease-free survival was 76%. Among patients resected for cure, there were 6 recurrences. The mean time to recurrence was 22 +/- 11 months (range: 4-36 months), and liver was the prevalent site for relapsing disease (n = 5; 83%). After recurrence, survival at 2 and 3 years was 44% and 0%, respectively. CONCLUSIONS: GISTs are uncommon sarcomas. Tumor recurrence tends to be intra-abdominal. Investigational protocols are indicated to reduce the rate of recurrence after resection and to improve the outcome for patients with GIST.     

Elective operation after acute complicated diverticulitis: Is it still mandatory?

AIM: To investigate recurrence rates, patterns and complications after nonoperatively managed complicated diverticulitis (CD).METHODS: A retrospective study of patients treated for CD was performed. CD was defined on computed tomography by the presence of a localized abscess, pelvic abscess or extraluminal air. For follow-up, patients were contacted by telephone. Numbers of elective surgeries, recurrences and abdominal pain were analyzed.RESULTS: A total of 114 patients (median age 57 years (range 29-97)), were admitted for CD. Nine patients required surgical intervention for failure of conservative therapy (Hartmann’s procedure: n = 6; resection and colorectal anastomosis: n = 3). Of the 105 remaining patients, 24 (22.9%) underwent elective sigmoid resection. The 81 (71%) non-operated patients were all contacted after a median follow-up of 32 mo (4-63). Among them, six had developed a recurrent episode of diverticulitis at a median follow-up of 12 mo (6-36); however, no patient required hospitalization. Sixty-eight patients (84%) were asymptomatic and 13 (16%) had recurrent abdominal pain.CONCLUSION: Conservative policy is feasible and safe in 71% of cases, with a low medium-term recurrence risk.     

Prognosis and follow-up of 135 patients with ischemic colitis over a five-year period

AIM:To study the prognosis(recurrence and mortality)of patients with ischemic colitis(IC).METHODS:This study was conducted in four Spanish hospitals,participants in the Ischemic Colitis in Spain study We analyzed prospectively 135 consecutive patients who met criteria for definitive or probable IC according to Brandt criteria,and follow up these patients during the next five years,retrospectively.Long-term results(recurrence and mortality)were evaluated retrospectively after a median interval of 62 mo(range54-75 mo).RESULTS:Estimated IC recurrence rates were 2.9%,5.1%,8.1%and 9.7%at years 1,2,3 and 5 years,respectively.Five-year survival was 69%(93 of 135)and 24%(10 of 42 patients)died for causes related to the IC.Among these 10 patients,8 died in their first episode at hospital(4 had gangrenous colitis and 4 fulminant colitis)and 2 due to recurrence.CONCLUSION:The five-year recurrence rate of IC was low.On the other hand,mortality during follow-up was high and was not associated with ischemic colitis.     

Clinicopathological,treatment, and prognosis study of 43 gastric neuroendocrine carcinomas

AIM To provide more information and therapeutic methods about gastric neuroendocrine carcinomas(G-NECs) which occur rarely but are highly malignant and clinically challenging.METHODS We retrospectively analyzed the clinicopathological characteristics, treatments, and prognosis of 43 G-NEC patients at our hospital between January 2007 and December 2014. The diagnosis was based on the 2010 World Health Organization criteria.RESULTS Forty-three G-NECs containing 39 small cell carcinomas and 4 large cell NECs with Ki67 60% were included in this study, accounting for only 0.95% of all gastric carcinomas. The median patient age was 62 years (range, 33-82) and the male-to-female ratio was 4.4:1. All patients underwent surgery, including 38 curative resections and 5 palliative resections. Among these 43 patients, nearly half(48.84%) of these tumors were located in the cardiac region of the stomach, regional lymph node metastasis was found in 31 cases(72.09%), and liver metastasis was found in 6 cases(13.95%). Follow-up information was got for 40 patients. Twentythree die of this disease with a median survival of 31 mo(range 1-90). The 1-year, 2-year, 3-year, and 5-year survival rate was 77.50%, 57.04%, 44.51%, and 35.05%, respectively. Survival was better in patients with tumor located in the cardiac region of the stomach, less than 7 lymph nodes metastasis and no liver metastasis. Five patients did not undergo postoperative chemotherapy, and the median survival time for these patients was 15 mo. For the remaining 34 patients who received postoperative chemotherapy, the median survival time was 44 mo and those received etoposide, cisplatin, and Paclitaxel survived the best. One patient with resected liver metastasis who received postoperative Capecitabine plus Oxaliplatin and Paclitaxel systemic chemotherapy plus octreotide LAR(30 mg intramuscularly, every 4 wk, for 2 years) has survived for 74 mo with no recurrence.CONCLUSION G-NECs are mostly nonfunctioning, which lead to a delay in detection. Local and/or distant metastases were noticed in most patients when diagnosed, and they required postoperative medical treatment. Adjuvant etoposide, cisplatin plus Paclitaxel systemic chemotherapy is recommended for these patients.     

Tumors of the angle of Treitz: A single-center experience

AIM:To explore the feasibility and oncologic outcomes of segmental jejunal resection on the left side of the mesenteric vessels in patients with tumors of the angle of Treitz using data from a single center.METHODS:Thirteen patients with tumors of the angle of Treitz who underwent surgery at our institution were prospectively followed.A segmental jejunal resection on the left side of the mesenteric vessels was performed in all patients.Formalin-fixed and paraffin-embedded tumor samples were examined.The primary end point of this analysis was disease-free survival.RESULTS:In this study,there were 8 males and 5females(mean age,50.1 years;range,36-74 years).The mean tumor size was 8.1 cm(range,3.2-15 cm).Histologic examination showed 11 gastrointestinal stromal tumors(GISTs)and 2 adenocarcinomas.Five of the GIST patients presented with potential low risk,and 6presented with intermediate and high risk,according to the National Institutes of Health criteria.One potentially high-risk patient showed tumor progression at 46 mo and died 52 mo after surgery.One patient with locally advanced adenocarcinoma received neoadjuvant chemotherapy and adjuvant radiotherapy,but the disease progressed,and the patient died 9 mo after surgery.One GIST patient without progression died 16 mo after surgery because of a postoperative intestinal obstruction.The median overall survival rate was 84.6 mo,and the median disease-free survival rate was 94.5 mo.CONCLUSION:The overall survival of patients with tumors of the angle of Treitz was encouraging even when the tumor size was relatively large.A segmental resection on the left side of the mesenteric vessels is considered to be a reliable and curative option for tumors of the angle of Treitz.     

Comparison between different reconstruction routes in esophageal squamous cell carcinoma

AIM:To compare postoperative complications and prognosis of esophageal squamous cell carcinoma patients treated with different routes of reconstruction. METHODS:After obtaining approval from the Medical Ethics Committee of the Sun Yat-Sen University Cancer Center, we retrospectively reviewed data from 306 consecutive patients with histologically diagnosed esophageal squamous cell carcinoma who were treated between 2001 and 2011. All patients underwent radical McKeown-type esophagectomy with at least two-field lymphadenectomy. Regular follow-up was performed in our outpatient department. Postoperative complica-tions and long-term survival were analyzed by treatment modality, baseline patient characteristics, and operative procedure. Data from patients treated via the retrosternal and posterior mediastinal routes were compared. RESULTS:The posterior mediastinal and retrosternal reconstruction routes were employed in 120 and 186 patients, respectively. Pulmonary complications were the most common complications experienced during the postoperative period (46.1% of all patients; 141/306). Compared to the retrosternal route, the posterior mediastinal reconstruction route was associated with a lower incidence of anastomotic stricture (15.8% vs 27.4%, P = 0.018) and less surgical bleeding (242.8 ± 114.2 mL vs 308.2 ± 168.4 mL, P 0.001). The median survival time was 26.8 mo (range:1.6-116.1 mo). Upon uni/multivariate analysis, a lower preoperative albumin level (P = 0.009) and a more advanced pathological stage (pT; P = 0.006; pN; P 0.001) were identified as independent factors predicting poor prognosis. The reconstruction route did not influence prognosis (P = 0.477). CONCLUSION:The posterior mediastinal route of reconstruction reduces incidence of postoperative complications but does not affect survival. This route is recommended for resectable esophageal squamous cell carcinoma.     

内镜黏膜下挖除术治疗食管固有肌层肿瘤

目的探讨内镜黏膜下挖除术（ESE）治疗食管固有肌层肿瘤的临床价值。方法回顾性分析2008年12月至2010年12月27例行ESE治疗的食管固有肌层肿瘤患者的资料,评价治疗的可行性、安全性和疗效。结果27例患者共29个病灶,病变直径0．5—3．0cm,平均（1．25±0．70）cm。切除率96．3％（26／27）,1例患者中转手术治疗。中位手术时间74（30～120）min。术后病理诊断平滑肌瘤26例,间质瘤1例。2例术中穿孔伴气胸,金属夹夹闭创面后予胸腔闭式引流,未行开胸手术修补。中位随访时间12（3～27）个月,未见复发病例。结论对于直径小于3．0cm、腔内生长为主的食管固有肌层肿瘤,ESE治疗具有安全、有效的特点,并可提供完整的病理学诊断资料,进一步扩大了内镜治疗的范围。     

腹腔镜食管裂孔疝修补联合胃底折叠术20例临床分析

目的探讨腹腔镜手术治疗食管裂孔疝的可行性、临床应用价值及安全性。 方法选取2012年3月至2017年9月,淄博市中心医院行腹腔镜食管裂孔疝修补联合胃底折叠术20例患者的临床资料,并评价其临床和预后效果。 结果20例患者均顺利完成腹腔镜手术,无中转开腹病例,行Nissen术患者16例、Toupet术4例,20例患者均使用不吸收线修补,7例患者使用U型补片。手术时间95~180 min,平均150 min;术中出血量30~70 ml,平均40 ml;术后24~48 h进流质饮食,术后临床症状均得到有效缓解,无严重并发症及死亡病例,1例胸骨后疼痛患者术后当晚症状消失,3例患者术后3 d出现吞咽困难及进固体食物时轻度哽噎感,经饮食教育2周后症状均得到缓解;4例患者术后1周出现腹泻,给予对症治疗后1周症状缓解;3例患者术后2周反酸症状复发,应用抑酸药物后症状缓解;术后住院时间3~7 d,平均4.1 d;20例患者均得到随访,随访时间3个月至5年,平均2.6年,无死亡病例,无解剖学复发病例,手术结果满意率95.0%。 结论腹腔镜微创手术治疗食管裂孔疝,充分体现了创伤小、恢复快、安全可行、疗效可靠的特点,具有推广价值。     

Laparoscopic total mesorectal excision with natural orifice specimen extraction

AIM:To introduce transvaginal or transanal specimen extraction in laparoscopic total mesorectal excision surgery to avoid an abdominal incision. METHODS:Between January 2009 and December 2011,21 patients with rectal cancer underwent laparoscopic radical resection and the specimen was retrieved by two different ways:transvaginal or transanal rectal removal.Transvaginal specimen extraction approach was strictly limited to elderly post-menopausal women who need hysterectomy.Patients aged between 30 and 80 years,with a body mass index of less than 30 kg/m2, underwent elective surgery.The surgical technique and the outcomes related to the specimen extraction,such as duration of surgery,length of hospital stay,and the complications were retrospectively reviewed. RESULTS:Laparoscopic resection using a natural orifice removal approach was successful in all of the 21 patients.Median operating time was 185 min(range,122-260 min)and the estimated blood loss was 48 mL. The mean length of hospital stay was 7.5 d(range,2-11 d).One patient developed postoperative ileus and had an extended hospital stay.The patient complained of minimal pain.There were no postoperative complications or surgery-associated death.The mean size of the lesion was 2.8 cm(range,1.8-6.0 cm),and the mean number of lymph nodes harvested was 18.7(range, 8-27).At a mean follow-up of 20.6 mo(range,10-37 mo),there were no functional disorders associated with the transvaginal and transanal specimen extraction. CONCLUSION:Transvaginal or transanal extraction in L-TME is a safe and effective procedure.Natural orifice specimen extraction can avoid the abdominal wall incision and its potential complications.     

Efficacy and safety of endoscopic prophylactic treatment with undiluted cyanoacrylate for gastric varices

AIM:To evaluate the efficacy and safety of undiluted N-butyl-2 cyanoacrylate plus methacryloxysulfolane(NBCM)as a prophylactic treatment for gastric varices(GV)bleeding.METHODS:This prospective study was conducted at a single tertiary-care teaching hospital between October 2009 and March 2013.Patients with portal hypertension(PH)and GV,with no active gastrointestinal bleeding,were enrolled in primary prophylactic treatment with NBCM injection without lipiodol dilution.Initial diagnosis of GV was based on endoscopy and confirmed with endosonography(EUS); the same procedure was used after treatment to confirm eradication of GV.After puncturing the GV with a regular injection needle,1 mL of undiluted NBCM was injected intranasally into GV.The injection was repeated as necessary to achieve eradication or until a maximum total volume of 3 mL of NBCM had been injected.Patients were followed clinically and evaluated with endoscopy at 3,6 and 12 mo.Later follow-ups were performed yearly.The main outcome measures were efficacy(GV eradication),safety(adverse events related to cyanoacrylate injection),recurrence,bleeding from GV and mortality related to GV treatment.RESULTS:A total of 20 patients(15 male)with PH and GV were enrolled in the study and treated with undiluted NBCM injection.Only 2(10%)patients had no esophageal varices(EV); 18(90%)patients were treated with endoscopic band ligation to eradicate EV before inclusion in the study.The patients were followed clinically and endoscopically for a median of 31 mo(range:6-40 mo).Eradication of GV was observed in all patients(13 patients were treated with 1 session and 7 patients with 2 sessions),with a maximum injected volume of 2 mL NBCM.One patient had GV recurrence,confirmed by EUS,at 6-mo follow-up,and another had late recurrence with GV bleeding after 35 mo of follow-up; overall,GV recurrence was observed in 2 patients(10%),after 6 and 35 mo of follow-up,and GV bleeding rate was 5%(1 patient).Mild epigastric pain was reported by 3 patients(15%).No mortality or major complications,including embolism,or damage to equipment were observed.CONCLUSION:Endoscopic injection with NBCM,without lipiodol,may be a safe and effective treatment for primary prophylaxis of gastric variceal bleeding.     

Esophageal variceal ligation for acute variceal bleeding: results of three years' follow-up.

BACKGROUND/AIMS: Endoscopic variceal ligation is widely accepted as the optimum endoscopic treatment for esophageal variceal hemorrhage. However, the rebleeding course and long-term outcome of patients with esophageal variceal hemorrhage after ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation. METHODS: Twenty-one liver cirrhotic patients with endoscopically proven esophageal variceal hemorrhage were treated by endoscopic variceal ligation. These patients received regular follow-up and detailed clinical assessment of at least 24 months. RESULTS: Twenty-one eligible patients were followed up for a mean of 44.45 months (range 33.5-64 months). The mean number of sessions required to obtain eradication was 3.57+/-1.99 (range 1-8). Esophageal varices could be obliterated within 11.57+/-6.8 weeks (range 3-30). The percentage of variceal recurrence during follow-up was 57.14% (12/21) after endoscopic variceal ligation. Recurrence were observed in a mean of 34 months (median 29 months). Rebleeding from esophageal varices appeared in four patients (19.04%). The appearance rates of portal hypertensive gastropathy and fundal gastric varices after varice obliteration were found to be 45.45% (5/11) and 25% (3/12), respectively. CONCLUSIONS: Based on the results of long-term follow-up of endoscopic variceal ligation, although the percentage of variceal recurrence was high, endoscopic ligation achieved variceal obliteration faster and in fewer treatment sessions. Furthermore, endoscopic variceal ligation had a lower rate of rebleeding and of development of fundal gastric varices, but high portal hypertensive gastropathy.     

Endoscopy-based management decreases the risk of postoperative recurrences in Crohn's disease

AIM: To investigate whether an endoscopy-based management could prevent the long-term risk of postoperative recurrence.METHODS: From the pathology department database, we retrospectively retrieved the data of all the patients operated on for Crohn's disease(CD) in our center(1986-2015). Endoscopy-based management was defined as systematic postoperative colonoscopy(median time after surgery = 9.5 mo) in patients with no clinical postoperative recurrence at the time of endoscopy. RESULTS: From 205 patients who underwent surgery, 161 patients(follow-up 6 mo) were included. Endoscopic postoperative recurrence occurred in 67.6%, 79.7%, and 95.5% of the patients, respectively 5, 10 and 20 years after surgery. The rate of clinical postoperative recurrence was 61.4%, 75.9%, and 92.5% at 5, 10 and 20 years, respectively. The rate of surgical postoperative recurrence was 19.0%, 38.9% and 64.7%, respectively, 5, 10 and 20 years after surgery. In multivariate analysis, previous intestinal resection, prior exposure to anti-TNF therapy before surgery, and fistulizing phenotype(B3) were postoperative risk factors. Previous perianal abscess/fistula(other perianal lesions excluded), were predictive of only symptomatic recurrence. In multivariate analysis, an endoscopy-based management(n = 49/161) prevented clinical(HR = 0.4, 95%CI: 0.25-0.66, P 0.001) and surgical postoperative recurrence(HR = 0.30, 95%CI: 0.13-0.70, P = 0.006).CONCLUSION: Endoscopy-based management should be recommended in all CD patients within the first year after surgery as it highly decreases the long-term risk of clinical recurrence and reoperation.