Additional Endoscopic Treatment Research Articles

WEO Newsletter.

WEO Newsletter.

Additional endoscopic treatments for patients with positive lateral margins after endoscopic resection of early esophageal squamous cell carcinoma.

There are currently no well-established treatment strategies for early esophageal squamous cell carcinoma (ESCC) for patients with only positive lateral margin (LM+) following endoscopic resection (ER). The present study aimed to find a treatment strategy for patients with early ESCC with non-curative resection (non-CR) and only LM+ following ER. In total, 511 patients with early ESCC treated at the Fourth Hospital of Hebei Medical University (Shijiazhuang, China) with ER were retrospectively analyzed, 41 of which (8%) were patients with only LM+ after non-CR. Of these, 28 patients received re-ER and 13 received additional surgical treatment. The clinicopathological characteristics of patients were analyzed and those who underwent additional surgery vs. re-ER were compared. Residual cancer cells were found in 27 patients (27/41, 65.9%) following re-ER or additional surgery. A significant increase in residual cancer cells was observed in patients with poorly differentiated cancer and patients with multiple LM+ (P=0.03 and P=0.015, respectively). Older patients and patients with single LM+ tended to choose re-ER (P=0.023 and P=0.038, respectively). In addition, there were three cases (3/13, 23.1%) of lymph node metastasis in the additional surgery group. However, within the limited follow-up time (mean, 36.1±24.1 months), no recurrence or metastasis was found in the remaining patients. The results showed that re-ER may be a more suitable additional therapy compared with surgery for patients with LM+ following non-CR, at least in the medium-term.

Are Newer Extracorporeal Shock Wave Lithotripsy Models Truly Improving Pancreatolithiasis Lithotripsy Performance? A Japanese Single-Center Study Using Endoscopic Adjunctive Treatment.

Many Japanese institutions use electromagnetic extracorporeal shock wave lithotripsy (ESWL) systems for treating pancreatic duct stones. However, there are no reports on direct comparisons between recent electromagnetic lithotripters. This study aimed to verify whether the new electromagnetic lithotripter can improve the efficiency of pancreatic stone fragmentation, and to clarify the role of combined endoscopic treatment on the clearance of pancreatic duct stones. We retrospectively identified 208 patients with pancreatolithiasis who underwent endoscopic adjunctive treatment after pancreatic ESWL at a single Japanese center over a 17-year period. We evaluated the outcome data of this procedure performed with SLX-F2 (last 2 years; group A) and Lithostar/Lithoskop (first 15 years; group B), as well as additional endoscopic treatments for pancreatolithiasis. We also performed logistic regression analysis to detect various factors associated with the procedure. For pancreatic head stones, ESWL disintegration was achieved in 93.7% of group A patients and 69.0% of group B patients (p=0.004), and adjunctive endoscopic treatment removed stones in 96.8% of group A patients and 73.0% of group B patients (p=0.003). Multivariate analysis revealed that lithotripter type (odds ratio, 6.99; 95% confidence interval, 1.56 to 31.33; p<0.01) and main pancreatic duct stricture (odds ratio, 2.87; 95% confidence interval, 1.27 to 6.45; p<0.01) were significant factors for ESWL fragmentation. The SLX F2 showed high performance in fragmenting the pancreatic duct stones. In addition, endoscopic adjunctive treatment improved the overall success rate of the procedure. The improved ESWL lithotripter has many advantages for patients undergoing pancreatic lithotripsy treatment.

Therapeutic approach to non-curative resection after endoscopic treatment in early gastric cancer

Background: Endoscopic resection is indicated for early or superficial gastrointestinal neoplasms with a negligible risk of lymph node metastasis. This procedure could preserve the organ while allowing en bloc resection of tumors, irrespective of the size and location of the lesion. Histological evaluation of the resected specimen determines whether curative resection, which implies a favorable long-term outcome, was achieved. If the resected specimen reveals non-curative, additional treatment is necessary as it is strongly associated with recurrence.Current Concepts: Surgical resection is recommended after non-curative resection of gastrointestinal neoplasms. However, rather than surgical resection, additional endoscopic treatment can be recommended if non-curative resection is solely because of the positive involvement at the horizontal resection margin without any other findings compatible with the non-curative resection criteria.Discussion and Conclusion: Adopting precise indications of endoscopic resection is important to reduce the risk of non-curative resection. If curative resection is not achieved after endoscopic resection, additional treatment should be considered to prevent local recurrence as well as lymph node metastasis.

Usefulness of endoscope-assisted surgery under exoscopic view in skull base surgery: A technical note.

Background: The use of the exoscope has been increasing in the field of neurosurgery, as it can set the visual axis freely, enabling the surgeon to operate in a comfortable posture. Although endoscope-assisted surgery for compensation of insufficient surgical field is useful under the microscope, we report that using an endoscope in exoscopic surgery is safer and more useful.Methods: The exoscope used was ORBEYE. All surgical procedures were performed exoscopically from the beginning of the surgery. When endoscopic observation was required during the operation, the endoscope was inserted under observation by an exoscope. The exoscopic screen was 4K-3D and endoscopic screen was 4K-2D, the operation was performed while observing both screens at the same time. The endoscope was held manually or by a mechanical holder.Results: Twenty-two cases, including 14 requiring microvascular decompression (MVD) and eight requiring tumor removal, were performed by endoscopic-assisted exoscopic surgery. The endoscope could be inserted safely because its relationship with the surrounding structure could be observed under the exoscope, and the operator could observe both screens without moving the head. Fourteen of 22 patients required additional endoscopic treatment. Satisfactory two-handed operation was performed in 13 cases. Symptomatology disappeared in all cases of MVD, and sufficient tumor resection was achieved.Conclusion: Exoscopic surgery provides excellent surgical view that is not inferior to conventional microsurgery. As a large space can be secured between the scope and the surgical field, it is safer and easier to manipulate the endoscope under the exoscope.

Efficacy and safety of endoscopic papillectomy: a multicenter, retrospective, cohort study on 227 patients.

Background:Endoscopic papillectomy is a minimally invasive treatment for benign tumors of the ampulla of Vater or early ampullary carcinoma. However, reported recurrence rates are significant and risk factors for recurrence are unclear.Objective:The aims of this study were to evaluate the efficacy and safety of endoscopic papillectomy and to identify risk factors for recurrence and adverse events.Methods:All patients who underwent endoscopic papillectomy at five tertiary referral centers between January 2008 and December 2018 were included. Recurrence was defined as the detection of residue on one of the follow-up endoscopies. Treatment success was defined as the absence of tumor residue on the last follow-up endoscopy.Results:A total of 227 patients were included. The resections were en bloc in 64.8% of cases. The mean lesion size was 20 mm (range: 3–80) with lateral extension in 23.3% of cases. R0 resection was achieved in 45.3% of cases. The recurrence rate was 30.6%, and 60.7% of recurrences were successfully treated with additional endoscopic treatment. Finally, treatment success was achieved in 82.8% of patients with a median follow-up time of 22.3 months. R1 resection, intraductal invasion, and tumor size > 2 cm were associated with local recurrence. Adverse events occurred in 36.6% of patients and included pancreatitis (17.6%), post-procedural hemorrhage (11.0%), perforation (5.2%), and biliary stenosis (2.6%). The mortality rate was 0.9%.Conclusion:Endoscopic papillectomy is an effective and relatively well-tolerated treatment for localized ampullary tumors. In this series, R1 resection, intraductal invasion, and lesion size > 2 cm were associated with local recurrence.

Long-term Outcomes of Additional Endoscopic Treatments for Patients with Positive Lateral Margins after Endoscopic Submucosal Dissection for Early Gastric Cancer.

Background/AimsIt is uncertain whether additional endoscopic treatment may be chosen over surgery in patients with positive lateral margins (pLMs) as the only non-curative factor after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We aimed to compare the long-term outcomes of additional endoscopic treatments in such patients with those of surgery and elucidate the clinicopathological factors that could influence the treatment selection.MethodsA total of 99 patients with 101 EGC lesions undergoing additional treatment after non-curative ESD with pLMs as the only non-curative factor were analyzed. Among them, 25 (27 lesions) underwent ESD, 29 (29 lesions) underwent argon plasma coagulation (APC), and 45 (45 lesions) underwent surgery. Clinicopathological characteristics and long-term outcomes were compared.ResultsResidual tumor was found in 73.6% of cases. The presence of multiple pLMs was associated with higher risk of residual tumor (p=0.046). During a median follow-up of 58.9 months, recurrent or residual lesions after additional ESD and APC were found in 4% (1/25) and 6.8% (2/29) of patients, respectively. However, all were completely cured with surgery or repeated ESD. There were no extragastric recurrences after additional endoscopic treatment. Lymph node metastasis was identified after additional surgery in one (2.2%) patient with an EGC showing histological heterogeneity.ConclusionsGiven the favorable long-term outcomes, additional ESD or APC may be an acceptable choice for patients with pLMs as the only non-curative factor after ESD for EGC. However, clincopathological characteristics such as multiple pLMs and histological heterogeneity should be considered in the treatment selection.

Nonrecurrence Rate of Underwater EMR for ≤20-mm Nonampullary Duodenal Adenomas: A Multicenter Prospective Study (D-UEMR Study)

Endoscopic resection of nonampullary duodenal adenoma is often challenging, and its technique has not yet been standardized. To overcome the practical difficulty of conventional endoscopic mucosal resection, underwater endoscopic mucosal resection (UEMR) was recently developed; therefore, we investigated the effectiveness and safety of UEMR for nonampullary duodenal adenoma. A multicenter, prospective cohort study was conducted at 21 institutions in Japan. We enrolled patients with no more than 2 nonampullary duodenal adenomas ≤20 mm in size, who were planned to undergo UEMR. After UEMR, follow-up endoscopies were scheduled at 2 and 12 months after the procedure, and biopsy specimens were taken from the post-UEMR scars. The primary endpoint was the proportion of patients with histologically proven nonrecurrence at follow-up endoscopy and biopsy. A total of 155 patients with 166 lesions underwent UEMR. One patient with a non-neoplastic lesion in the resected specimen and 10 patients with 10 lesions who were lost to follow-up were excluded. Finally, 144 patients with 155 lesions who received all follow-up endoscopies were analyzed for the primary endpoint. The proportion of patients with proven nonrecurrence was 97.2% (n= 140 of 144; 95% confidence interval, 92.8%-99.1%) which exceeded the predefined threshold value (92%). Two cases of delayed bleeding (1.2%) occurred and they were successfully managed by clips. All recurrences were successfully treated by additional endoscopic treatment. This multicenter, prospective cohort study demonstrated effectiveness and safety of UEMR for nonampullary duodenal adenomas ≤20 mm in size. (University Hospital Medical Network Clinical Trials Registry, Number: UMIN000030414).

Long-term Outcomes of Undifferentiated-Type Early Gastric Cancer with Positive Horizontal Margins after Endoscopic Resection

Background/AimsThis study examined the long-term outcomes of undifferentiated-type early gastric cancer (UD EGC) with positive horizontal margins (HMs) after endoscopic resection (ER) and compared them between additional surgery and nonsurgical management.MethodsFrom 2005 to 2015, a total of 1,124 patients with UD EGC underwent ER at 18 tertiary hospitals in Korea. Of them, 92 patients with positive HMs as the only noncurative factor (n=25) or with both positive HMs and tumor size >2 cm (n=67) were included. These patients underwent additional surgery (n=40), underwent additional endoscopic treatment (n=6), or were followed up without further treatment (n=46).ResultsNo lymph node (LN) metastasis was found in patients who underwent additional surgery. During a median follow-up of 57.7 months (interquartile range, 27.6 to 68.8 months), no LN or distant metastases or gastric cancer-related deaths occurred in the overall cohort. At baseline, the residual cancer rate was 57.8% (26/45) after additional surgery or ER. The 5-year local recurrence rate was 33.6% among patients who were followed up without additional treatment. The 5-year overall survival rates were 95.0% and 87.8% after additional surgery and nonsurgical management (endoscopic treatment or close follow-up), respectively (log-rank p=0.224). In the multivariate Cox regression analysis, nonsurgical management was not associated with an increased risk of mortality.ConclusionsUD EGC with positive HMs after ER may have favorable long-term outcomes and a very low risk of LN metastasis. Nonsurgical management may be suggested as an alternative, particularly for patients with old age or chronic illness. (Gut Liver 2021;15-731)

Su1072 ENDOSCOPIC MANAGEMENT OF RESIDUAL OR RECURRENT NEOPLASIA FOLLOWING PIECEMEAL ENDOSCOPIC MUCOSAL RESECTION IS EFFICACIOUS.

Endoscopic mucosal resection (EMR) is the primary treatment method for complex colon polyps. Current guidelines recommend surveillance colonoscopy at 6 months following piecemeal EMR due to residual or recurrent neoplasia (RN) rate of up to 15%. There is limited data on management outcomes when RN occurs. The primary aim of this study was to evaluate the efficacy of endoscopic management of RN following EMR. We conducted a retrospective cohort study of patients who had RN on surveillance colonoscopy following EMR of a large colon polyp by 3 gastroenterologists with EMR expertise at a single center between 2010 and June 2019. The primary outcome was successful resolution of the RN, defined as at least one surveillance colonoscopy without neoplasia seen at the EMR site. Among 483 polyps resected in 407 patients, RN was identified on first surveillance colonoscopy (SC1) in 59 cases (12.2%). Four cases of RN were not felt amenable to endoscopic resection and referred to surgery. Endoscopic resection was performed in the remaining 55 cases (Table). The majority (91%) of RN had visibly abnormal tissue at the prior EMR site; only 9% had RN diagnosed on biopsy of an apparently normal scar. Resection was performed utilizing a variety of techniques: underwater EMR (12.7%), hot EMR (36.4%), cold EMR (5.5%), snare resection (16.4%), and cold forceps (29.1%), respectively. Adjunctive therapies were used in 45.5% of resections, with APC in 30.9%, cold forceps in 20.0%, hot avulsion in 7.3%, and soft coagulation in 3.6% of cases. Additional follow up surveillance colonoscopy data until RN was resolved was available for 44 cases. One patient had intramucosal adenocarcinoma within RN pathology on their second surveillance colonoscopy (SC2) and was referred for surgical management. The majority (70.5%) had no RN at SC2, while 27.3% required additional endoscopic treatment of RN with subsequent resolution on further surveillance colonoscopy (Figure). In total, 89.6% of patients with RN were confirmed to have been successfully treated. Among the 472 polyps resected with EMR with sufficient follow up, endoscopic treatment of the polyp was successful in 98.9% of cases. Although recurrent or residual neoplasia is common after piecemeal polypectomy, it is adequately treated in nearly all patients. Use of multiple resection modalities may be necessary for successful treatment based on our observations. Thus, concerns for RN should not significantly impact decision to perform EMR for colorectal polyps.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Impact of Endoscopic Vacuum Therapy with Low Negative Pressure for Esophageal Perforations and Postoperative Anastomotic Esophageal Leaks

Introduction: Management of esophageal anastomotic leaks (AL) and esophageal perforations (EP) remains difficult and often requires an interdisciplinary treatment modality. For primary endoscopic management, self-expanding metallic stent (SEMS) placement is often considered first-line therapy. Recently, endoscopic vacuum therapy (EVT) has emerged as an alternative or adjunct for management of these conditions. So far, data for EVT in the upper gastrointestinal-tract is restricted to single centre, non-randomized trials. No studies on optimal negative pressure application during EVT exist. The aim of our study is to describe our centre’s experience with low negative pressure (LNP) EVT for these indications over the past 5-years. Patients and Methods: Between January 2014 and December 2018, 30 patients were endoscopically treated for AL (n = 23) or EP (n = 7). All patients were primarily treated with EVT and LNP between –20 and –50 mm Hg. Additional endoscopic treatment was added when EVT failed. Procedural and peri-procedural data, as well as clinical outcomes including morbidity and mortality, were analysed. Results: Clinical successful endoscopic treatment of EP and AL was achieved in 83.3% (n = 25/30), with 73.3% success using EVT alone (n = 22/30). Mean treatment duration until leak closure was 16.1 days (range 2–58 days). Additional treatment modalities for complete leak resolution was necessary in 10% (n = 3/30), including SEMS placement and fibrin glue injection. Mean hospital stay for patients with EP was shorter with 33.7 days compared to AL with 54.4 days (p = 0.08). Estimated preoperative 10-year overall survival (Charlson comorbidity score) was 39.4% in patients with AL and 59.9% in patients with EP (p = 0.26). A mean of 5.1 EVT changes (range 1–12) was needed in EP and 3.6 changes (range 1–13) in AL to achieve complete closure, switch to other treatment modality, or reach endoscopic failure (p = 0.38). Conclusion: LNP EVT enables effective minimally – invasive endoluminal leak closure from anastomotic esophageal leaks and EP in high-morbid patients. In this study, EVT was combined with other endoscopic treatment options such as SEMS placement or fibrin glue injection in order to achieve leak or perforation closure in the vast majority of patients (83.3%). Low aspiration pressures led to slower but still sufficient clinical results.

Yield of capsule endoscopy in obscure gastrointestinal bleeding: A comparative study between premenopausal and menopausal women.

AIMTo evaluate differences in capsule endoscopy (CE) performed in the setting of obscure gastrointestinal bleeding (OGIB) among premenopausal women (PMW) and menopausal women (MW).METHODSRetrospective, single-center study, including female patients submitted to CE in the setting of OGIB between May 2011 and December 2016. Patients were divided into 2 groups according to age, considering fertile age as ≤ 55 years and postmenopausal age as > 55 years. The diagnostic yield (DY), the rebleeding rate and the time to rebleed were evaluated and compared between groups. Rebleeding was defined as a drop of Hb > 2 g/dL or need for transfusional support or presence of melena/hematochezia.RESULTSA hundred and eighty three female patients underwent CE for OGIB, of whom 30.6% (n = 56) were PMW and 69.4% (n = 127) were MW. The DY was 30.4% in PMW and 63.8% in MW. The most common findings were angiodysplasias in both groups (PMW: 21.4%, MW: 44.9%) (P = 0.003). In PMW, only 1.8% required therapeutic endoscopy. In 17.3% of MW, CE findings led to additional endoscopic treatment. Rebleeding at 1, 3 and 5 years in PMW was 3.6%, 10.2%, 10.2% and 22.0%, 32.3% and 34.2% in MW. Postmenopausal status was significantly associated with higher DY (P < 0.001), TY (P = 0.003), rebleeding (P = 0.031) and lower time to rebleed (P = 0.001).CONCLUSIONPMW with suspected OGIB are less likely to have significant findings in CE. In MW DY, need for endoscopic treatment and rebleeding were significantly higher while time to rebleed was lower.

Biliary Decompression in Malignant Obstructive Jaundice

Aim. Determination of optimal method and study of results of minimally invasive biliary decompression in neoplastic obstructive jaundice. Materials and Methods. Biliary decompression was performed in 59 patients who were divided into groups of percutaneous drainage (n = 33) and transpapillary stenting (n = 26). In the second stage priority tactic of transpapillary biliary decompression was used in the prospective group of patients (n = 159). Results. Transpapillary and/or percutaneous biliary drainage was performed in all patients. There was high efficiency of cholestasis syndrome relief (serum bilirubin levels decreased by 39.2%, 53.9% and 77.0% at 3, 7 and 14 day after surgery respectively). Lower incidence of complications was revealed in patients after transpapillary decompression (n = 2; 7.7%) compared with percutaneous technique (n = 10; 30.3%, p = 0.032). Herewith clinical effectiveness and mortality were similar (p = 0.316). In the prospective group of 159 patients transpapillary stenting (n = 107; 63%) was ineffective in 31 case (29.9%), that required additional endoscopic treatment (n = 12) or percutaneous biliary drainage (n = 19). Mortality rate was 13.8% (22 patients). Conclusion. Endoscopic transpapillary stenting can be recommended in malignant obstructive jaundice management because of low incidence of complications and equal effectiveness and mortality. Percutaneous biliary drainage with primary or delayed recanalization of malignant stricture should be done if transpapillary stenting is impossible due to technical or anatomical aspects. The algorithm provides differentiated approach to choice of biliary decompression method and improves treatment outcomes.

Long-term outcomes after noncurative endoscopic resection of early gastric cancer: the optimal time for additional endoscopic treatment

We aimed to evaluate long-term outcomes with noncurative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) and surveillance strategies such as the optimal time for additional endoscopic treatment in patients with noncurative ESD. Of 2527 patients who underwent gastric ESD for EGC, 512 (20.3%) patients with noncurative resection were reviewed. Noncurative resection is defined as positive resected margins on histology, lymphovascular infiltration, or beyond the expanded criteria for ESD. The mean ± standard deviation follow-up duration was 79.0 ± 55.7 months. A total of 264 patients (51.6%) and 50 patients (9.8%) underwent surgery and endoscopic treatment after noncurative resection, respectively, whereas 198 patients (38.7%) were observed. Cancer-specific survival and disease-free survival rates were significantly different among the surgery, other endoscopic treatment, and observation groups (96.7%, 86.8%, and 86.2%, respectively; P=.030; and 92.5%, 73.6%, and 63.0%, respectively; P< .001). When patients who underwent surgery were excluded, the disease-free survival rate of recurrence was not significantly different between the endoscopic treatment and observation groups (73.6% vs 63.0%; P= .548). To exclude the potential for the presence of lymph node metastasis, we further analyzed disease-free survival of local recurrence by comparing the patients with only a positive lateral resection margin. The disease-free survival rate was higher in the endoscopic treatment group than in the observation group (89.2% vs 69.1%; P= .023). Moreover, additional endoscopic treatment within 3 months showed significant associations with lower risk of local recurrence on multivariate analysis (hazard ratio, 0.017; 95% confidence interval, 0.002-0.260; P= .003). In patients with noncurative ESD, additional surgery showed a better long-term outcome; moreover, when a positive lateral resection margin was the only noncurative factor, additional endoscopic treatment within 3 months could be considered to improve disease-free survival.

Can further gastrectomy be avoided in patients with incomplete endoscopic resection?

Endoscopic resection (ER) is a widely accepted treatment for patients with early gastric cancer (EGC) with no lymph node metastasis. Occasionally, however, additional surgery is needed due to an incomplete resection. The purpose of this study was to detect clinical factors which might identify patients at greater risk of additional surgery after ER and to suggest an alternative treatment strategy for these patients. This study retrospectively analyzed 350 patients with gastric cancer who underwent radical gastrectomy and lymphadenectomy after ER in a single institution between July 2004 and July 2014. Risk factors for incomplete resection were identified using binary logistic multiple regression tests and a classification and regression tree analysis. Residual cancer cells were found in the remnant stomach or lymph node in 96 patients (27.4%). In multivariate analysis, lymphovascular invasion (p<0.001, odds ratio [OR] 5.619) and depth of invasion greater than the second submucosal layer (SM2) (p<0.01, OR 3.224) were independent risk factors for lymph node metastasis. Positive resection margin (p<0.001, OR 7.565), depth of invasion to mucosa (M) and the first submucosal layer (SM1) (p<0.001, OR 4.219), and size over 3cm (p<0.029, OR 2.306) were significant risk factors for residual tumor in the remnant stomach. Of 106 patients who had invasion of the M or SM1 without lymphatic invasion at the time of ER, residual cancer was found in 53 patients. Of these 53 patients, 50 (94.3%) had residual cancer in the mucosal layer and only one had lymph node metastasis. In patients with EGC with M or SM1 invasion without lymphovascular invasion at the time of ER, who had an incomplete resection, additional endoscopic treatment or close monitoring can be performed instead of additional surgery, especially in patients who are unable to tolerate gastrectomy, for example elderly patients or those with comorbidities.

Prospective pilot study of fully covered self-expandable metal stents for refractory benign pancreatic duct strictures: long-term outcomes.

Background and study aims: Background and study aims: Temporary placement of a fully covered self-expandable metal stent (FCSEMS) has recently emerged as a treatment option for pancreatic duct strictures due to chronic pancreatitis refractory to conventional plastic stenting. However, there are no data about long-term outcomes with this therapeutic option. The aims of the current study were to estimate the feasibility, safety, efficacy, and long-term outcomes of temporary FCSEMS placement for refractory pancreatic duct strictures. Patients and methods: This was a prospective, single-center feasibility study. Ten patients with refractory pancreatic duct strictures due to chronic pancreatitis underwent FCSEMS placement for 3 months. We evaluated the rate of recurrent symptoms after stent removal during long-term follow-up, as well as adverse events (AEs). Results: Two patients required early (within 1 week) stent removal because of intolerable pain or pancreatitis. In the remaining 8 patients, the recurrence rate of any symptoms after FCSEMS removal was 63% during 35 months of follow up. The causes of recurrent symptoms were as follows: recurrence of stricture in 2; stent-induced stricture in 1; impaction of pancreatic stones in 1; and development of a pseudocyst in 1. When limited to stricture, the recurrence rate was 38%. Additional endoscopic treatments were required in 4 patients: a second FCSEMS placement in 1; plastic stent (PS) placement in 1; stone extraction in 1; and endoscopic ultrasound–guided pseudocyst drainage in 1. Asymptomatic stent migration occurred in 2 patients. Suppurative pancreatic ductitis due to food impaction in the FCSEMS occurred in 2 patients, and endoscopic pancreatic duct drainage was performed. Stent-induced ductal changes developed in 2 patients and PS treatment was required in 1 patient for pain relief. Conclusion: The FCSEMS appears to be a feasible and potentially effective option for the management of refractory pancreatic duct strictures due to chronic pancreatitis during long-term follow-up. AEs including post-procedure pain, stent-induced ductal changes, migration, and ductitis are issues that need to be resolved.

Outcomes of endoscopic treatment of second recurrences of large nonpedunculated colorectal adenomas.

Piecemeal endoscopic mucosal resection (EMR) of large nonpedunculated colorectal adenomas is associated with significant recurrence rates. After salvage endoscopic treatment of recurrences, there is a significant rate of second recurrences. There is a paucity of data on the efficacy and safety of continued endoscopic treatment after a second recurrence. Consecutive patients with recurrent adenomas after initial piecemeal EMR of nonpedunculated colorectal adenomas >2cm were reviewed. We assessed the feasibility, safety and efficacy of continued endoscopic treatment in these patients. Sixty-four patients with 70 recurrent lesions were identified. All were retreated endoscopically. Follow-up colonoscopy (mean interval 6.4months) was performed on 62/70 lesions (89%), and a second recurrence was found in 21/62 (34%). One patient underwent surgery for a circumferential adenoma of the ileocecal valve. The other 20 lesions were treated endoscopically. Follow-up colonoscopy was performed on 15/20 (75%) and demonstrated a third recurrence in 3/15 (20%). One was a deep T1 cancer; curative surgery was performed. The other two patients each had one additional endoscopic treatment and both had no recurrence on subsequent colonoscopy. There were two complications: Both were delayed bleeds after treatment of the first recurrence. A mean of 1.3 endoscopic procedures was required to achieve a cure (range 1-3) for recurrent adenomas after piecemeal EMR. Endoscopic treatment of patients with second recurrences is safe and effective, but is associated with a significant rate of additional recurrences. Continued endoscopic treatment of patients with multiple recurrences is associated with high cure rates, low complication rates and a low risk of progression to malignancy.

PD22-08 MALE ANTERIOR URETHRAL STRICTURES ARE COMMONLY TREATED WITHOUT IMAGING OR BEING OFFERED URETHROPLASTY

You have accessJournal of UrologyTrauma/Reconstruction: Urethral Reconstruction (including Stricture) III1 Apr 2015PD22-08 MALE ANTERIOR URETHRAL STRICTURES ARE COMMONLY TREATED WITHOUT IMAGING OR BEING OFFERED URETHROPLASTY Justin De Grado, Rachel Quinn, and Joel Gelman Justin De GradoJustin De Grado More articles by this author , Rachel QuinnRachel Quinn More articles by this author , and Joel GelmanJoel Gelman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1450AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We evaluated the percentage of urethral stricture patients presenting to our institution who had prior internal urethrotomy (IU) or dilation without prior imaging and/or being offered open reconstruction during informed consent. METHODS After IRB approval, we prospectively collected data on all adult patients seen from April 2011 – January 2014 who were previously evaluated and/or treated for anterior stricture disease. We identified 103 men, and evaluated demographics, disease related information, medical records, outside imaging, and whether the patient was imaged and/or offered urethroplasty prior to treatment. RESULTS Ninety-one patients (88%) had been previously treated prior to being evaluated at our institution. Of the 91 men, 76 (84%) were treated without imaging. Of these 76 patients, 51 had IU as their initial treatment. Forty-three of the 51 had multiple procedures (range 2-5). The other 25 of the 91 treated patients were dilated. Fifteen had multiple (range 2-7) dilations. Only 13/58 (22%) who had multiple procedures had imaging after one or more failures prior to additional endoscopic treatment. Of the 91 patients who underwent prior treatment, 82 (90%) of them were treated with IU or dilation without being offered urethroplasty, and 57/82 had multiple dilations and/or IUs without being informed that urethral reconstruction was a treatment option. CONCLUSIONS While urethral imaging to define stricture characteristics including length, location and number is generally recommended prior to treatment in major textbooks and published literature, the vast majority of men diagnosed with urethral strictures via cystoscopy were treated (often repeatedly) endoscopically without prior imaging. Moreover, 90% of men with urethral strictures were treated with single and more often multiple endoscopic procedures without being offered urethroplasty as a treatment option. This is of interest given that recent literature suggests the success rate of IU is very low, the cure rate of repeated dilations and IUs approaches 0, and open urethroplasty offers cure rates of 90-98+ %. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e479 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Justin De Grado More articles by this author Rachel Quinn More articles by this author Joel Gelman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Retroflexion-assisted endoscopic mucosal resection: a useful and safe method for removal of low rectal laterally spreading tumors.

Lesions below or involving the dentate line cannot be removed by standard forward-viewing endoscopic mucosal resection (EMR). Data about retroflexion technique applied during EMR for low rectal laterally spreading tumors (LSTs) are quite limited. Therefore, we aimed to determine the efficacy and safety of retroflexion-assisted EMR (REMR) for the removal of large LSTs from the lower rectum. EMR employing a complete retroflexion technique was performed in 49 consecutive patients (28 men, 21 women; mean age 51.8 years) with low rectal LSTs that were considered unresectable by conventional forward-viewing EMR due to the narrow and poor endoscopic view. Colonoscopy follow-up data were collected after resection. The low rectal LSTs had a median size of 51 mm (range 30-85 mm). All the tumors were successfully resected in two sessions (median procedure time 57.4 min, range 29-126 min). Procedure-related early bleeding occurred in 14 patients, and delayed hemorrhage occurred in four patients. Serious complications such as perforation or anal dysfunction were not observed, and any procedure-related bleeding was well controlled. The median follow-up period was 8.4 months (range 3-36 months). Nine patients (nine out of 49, 18.4%) experienced recurrence based on follow-up colonoscopy examinations, and the recurrent lesion was completely eradicated by additional endoscopic treatments. This is the first pilot study to evaluate the efficacy and safety of REMR for removal of low rectal LSTs. The short-term outcomes observed in this study indicate that REMR is a valuable method for the removal of low rectal LSTs. However, further studies evaluating the long-term efficacy and comparing REMR with other interventional therapies are needed.

Single-center early experience of optical coherence tomography (OCT) for evaluation of high-grade dysplasia or early cancer in Barrett's esophagus.

56 Background: Barrett’s esophagus is a well-known risk factor for esophageal cancer. Surveillance esophagogastroduodenoscopy (EGD) and procedures like endoscopic mucosal resection (EMR) and radio frequency ablation (RFA) are adopted to mitigate risk of evolution to high grade dysplasia and cancer. Newer imaging modalities are expected to improve diagnostic accuracy and guide management. Here we describe our early experience with optical coherence tomography (OCT) which is an near infra-red light imaging technique for diagnosing high grade dysplasia and early stage cancer in patients with Barrett’s esophagus. Methods: Patients who underwent EGD and diagnosed with Barrett’s esophagus and endoscopic features worrisome for high grade dysplasia or early cancer were selected for the procedure. Patients underwent OCT for further characterizations of these lesions. Clinical and endoscopic findings, imaging studies and OCT findings were recorded and analyzed. Results: 5 patients were studied in this early series and details are tabulated below. (OCT images will accompany final presentation.) Conclusions: Early detection of high grade lesions and early cancer with image directed therapy in Barrett’s esophagus may positively impact survival. Our early experience suggests OCT is helpful in detecting cryptic dysplastic changes, especially in the aftermath of previous ablation and can guide additional endoscopic treatment. Further studies are necessary to determine efficacy of such an approach. [Table: see text]