Additional Endoscopic Treatment Research Articles

Eosinophilic esophagitis: From pathophysiology to treatment.

Eosinophilic esophagitis (EoE) is a chronic immune disease, characterized by a dense eosinophilic infiltrate in the esophagus, leading to bolus impaction and reflux-like symptoms. Traditionally considered a pediatric disease, the number of adult patients with EoE is continuously increasing, with a relatively higher incidence in western countries. Dysphagia and food impaction represent the main symptoms complained by patients, but gastroesophageal reflux-like symptoms may also be present. Esophageal biopsies are mandatory for the diagnosis of EoE, though clinical manifestations and proton pump inhibitors responsiveness must be taken into consideration. The higher prevalence of EoE in patients suffering from atopic diseases suggests a common background with allergy, however both the etiology and pathophysiology are not completely understood. Elimination diets are considered the first-line therapy in children, but this approach appears less effective in adults patients, who often require steroids; despite medical treatments, EoE is complicated in some cases by esophageal stricture and stenosis, that require additional endoscopic treatments. This review summarizes the evidence on EoE pathophysiology and illustrates the safety and efficacy of the most recent medical and endoscopic treatments.

The Efficacy of Self-Expanding Metal Stents for Malignant Colorectal Obstruction by Noncolonic Malignancy with Peritoneal Carcinomatosis

Although self-expanding metal stents for colorectal obstruction is preferred over emergency surgery, the efficacy of self-expanding metal stents in patients with malignant colorectal obstruction by a noncolonic malignancy with peritoneal carcinomatosis has not been demonstrated. The aim of this study was to evaluate the survival and long-term clinical outcome of self-expanding metal stents as the initial interventional approach in patients with malignant colorectal obstruction due to a noncolonic malignancy with peritoneal carcinomatosis. This is a retrospective study. This study was conducted at 2 tertiary care academic medical centers in South Korea. The patients were included who underwent self-expanding metal stent insertion for palliation of a malignant colorectal obstruction by a noncolonic malignancy with peritoneal carcinomatosis between July 2004 and January 2010. Inclusion criteria were incurable status, noncolorectal cancer, obstructive symptoms and/or signs, and colonoscopic findings of obstruction. The survival and success rate of patients undergoing self-expanding metal stents insertion was assessed. Twenty patients were included during the study period. Technical success of self-expanding metal stents was achieved in 18/20 (90.0%) patients, and obstructive symptoms were resolved within 72 hours in 17/20 (85.0%) patients. Ten patients (10/20, 50%) did not need further intervention during the follow-up period after the first stent insertion. Eight patients ultimately underwent surgery during the follow-up period. One of the remaining 2 patients underwent additional endoscopic treatment without surgery. Another patient refused further intervention and thus received conservative management. Mean event-free survival was 119.0 days, and the mean overall survival of the included patients was 156.3 days. The number of study patients was small. Self-expanding metal stent insertion appears to be a reasonable first-treatment option in patients with malignant colorectal obstruction by noncolonic malignancy with peritoneal carcinomatosis.

58 Management of Differentiated-Type Early Gastric Cancer After Non-Curative Endoscopic Submucosal Dissection With a Positive Lateral Margin or Piecemeal Resection: a Retrospective Analysis

After non-curative endoscopic submucosal dissection (ESD) for differentiated-type early gastric cancer (EGC), if a positive lateral margin (LM) or piecemeal resection is the only non-curative factor, non-surgical management (close observation or immediate additional endoscopic treatment) can be performed instead of gastrectomy due to the negligible risk of metastasis. However, the most appropriate management is unknown because of limited research.

Outcome of endoscopic resection tracheoplasty for treating lambdoid tracheal stomal stenosis

To evaluate the efficacy of endoscopic resection tracheoplasty (ERT) for treating post-tracheotomy stomal stenosis caused by inward collapse of tracheal ring remnants. Prospective observational study. Between 2007 and 2012, we treated 40 patients with "lambdoid" tracheal deformity with a two-staged minimally invasive procedure undertaken using suspension microtracheoscopy and high-frequency jet ventilation. The first procedure entailed CO₂ laser photoablation of collapsed tracheal rings and dilatation. The second procedure, performed 6 to 8 weeks later, involved ablation of residual structural obstruction, removal of granulation tissue, and intralesional corticosteroid injection. Perioperative patient and lesion characteristics and results of treatment were assessed. There were 22 males and 18 females, and mean age at first treatment was 59 years. There were 17 cases of scarring at the postero-lateral tracheal groove (trachealis blunting), and 22 patients had age-adjusted Charlson comorbidity scores greater than 4. All patients without trachealis blunting were successfully managed endoscopically, with only one patient requiring one additional endoscopic treatment. Seven patients with trachealis blunting needed additional treatment, and four patients had tracheal resection (P = 0.013). All patients were decannulated, and 75% of patients achieved good dyspnea outcomes. Patients with low morbidities were significantly more likely to achieve good dyspnea outcomes (P < 0.027). There were no treatment-related worsenings of voice or swallowing. ERT is an effective minimally invasive treatment for intubation-related lambdoid tracheal stenosis. It achieves a successful outcome while avoiding the risks associated with open surgery. We recommend its more widespread use for treating patients with this condition.

Repeatedly Recurrent Colon Cancer Involving the Appendiceal Orifice after Endoscopic Piecemeal Mucosal Resection: A Case Report

Local recurrence after endoscopic piecemeal mucosal resection (EPMR) for colorectal tumors is a crucial issue. However, such recurrence is usually detected within one year and cured with additional endoscopic treatment, which makes EPMR acceptable. Herein, we report a rare case of repeatedly recurrent colon cancer involving the appendiceal orifice after EPMR, which was not cured with additional endoscopic treatments. A 67-year-old man was referred to us for endoscopic treatment of a 25 mm cecal tumor spreading to the appendiceal orifice in May 2002. The tumor was resected with EPMR, showing well differentiated intramucosal adenocarcinoma with a positive lateral cut margin of tubular adenoma. Endoscopic surveillance was conducted and the first local recurrence was detected in August 2006. Although we resected it endoscopically, the second local recurrence was found in September 2007 and we removed it with endoscopic resection again. However, the third local recurrence was detected in March 2008. Although endoscopic resection was performed also for the third recurrence, curative resection was not achieved. In February 2009, laparoscopic assisted colectomy was performed and histopathological examination showed well differentiated adenocarcinoma with deep submucosal invasion. This case is important in considering indication for endoscopic resection in colorectal tumors involving the appendiceal orifice.

Transgastrically placed endoscopic vacuum-assisted closure system as an addition to transgastric necrosectomy in necrotizing pancreatitis (with video)

Endoscopic transluminal débridement of infected pancreatic necrosis has been proved to be an important alternative to surgical débridement. Recently, endoscopic vacuum-assisted closure (EVAC) has been described as a new effective treatment option in upper intestinal anastomotic leaks. To test whether the EVAC can be applied to transgastrically accessible infected cavities. Single-center case study. Academic medical center. Two patients with necrotizing pancreatitis. Successful closure of leak. We successfully applied EVAC to treat transgastrically accessible necrotic cavities. Small case number. EVAC might be an important additional endoscopic treatment option for infected pancreatic necrosis, especially if established endoscopic treatment options fail.

OC-142 Hemospray for non-variceal upper gastrointestinal bleeding: results of the seal dataset (survey to evaluate the application of hemospray in the luminal tract)

IntroductionHemospray is an endoscopic haemostatic agent licensed for use in non-variceal upper gastrointestinal bleeding (UGIB). It has been shown to be effective in achieving haemostasis in bleeding peptic ulcers in...

Clinical outcomes of endoscopic submucosal dissection and endoscopic mucosal resection for laterally spreading tumors larger than 20 mm

Colorectal laterally spreading tumors (LST) > 20 mm are usually treated by endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR). Endoscopic piecemeal mucosal resection (EPMR) is sometimes required. The aim of our study was to compare the outcomes of ESD and EMR, including EPMR, for such LST. A total of 269 consecutive patients with a colorectal LST > 20 mm were treated endoscopically at our hospital from April 2006 to December 2009. We retrospectively evaluated the complications and local recurrence rates associated with ESD, hybrid ESD (ESD with EMR), EMR, and EPMR. ESD and EMR were performed successfully for 89 and 178 LST, respectively: 61 by ESD; 28 by hybrid ESD; 70 by EMR; and 108 by EPMR. Between-group differences in perforation rates were not significant. Local recurrence rates in cases with curative resection were as follows: 0% (0/56) in ESD; 0% (0/27) in hybrid ESD; 1.4% (1/69) in EMR; and 12.1% (13/107) in EPMR; that is, significantly higher in EPMR. No metastasis was seen at follow up. The recurrence rate for EPMR yielding ≥ three pieces was significantly high (P < 0.001). All 14 local recurrent lesions were adenomas that were cured endoscopically. As for safety, ESD/hybrid ESD is equivalent to EMR/EPMR. ESD/hybrid ESD is a feasible technique for en bloc resection and showed no local recurrence. Although local recurrences associated with EMR/EPMR were seen, which were conducted based on our indication criteria, all local recurrences could obtain complete cure by additional endoscopic treatment.

Comparison of endoscopic submucosal dissection and endoscopic mucosal resection for large colorectal tumors

Endoscopic mucosal resection (EMR) is the standard procedure for treatment of colorectal tumors. Endoscopic submucosal dissection (ESD) can be performed for resection of larger tumors, but has not been studied in the colorectum because of technical difficulties and complications. We compared outcomes and complications after resection of colorectal tumors larger than 20 mm diameter by ESD and EMR. We retrospectively studied 104 colorectal tumors treated with EMR from 1995 to 2004, and 85 colorectal tumors treated with ESD from 2005 to 2009. We compared the tumor location, shape, size, procedure time, en bloc resection rate, recurrence rate, and associated complications between the treatments. Tumors treated with ESD were larger (31.6 ± 9.0 vs. 25.5 ± 6.8 mm, P<0.001), incurred a longer procedure time (87.2 ± 49.7 vs. 29.4 ± 26.1 min, P<0.001), had a higher en bloc resection rate [71 of 85 tumors (83.5%) vs. 50 of 104 tumors (48.1%), P<0.001], and had a lower recurrence rate [one of 84 tumors (1.2%) vs. 16 of 104 tumors (15.4%); P=0.002] compared with EMR. Perforation occurred in five (5.9%) cases after ESD and in none after EMR (P=0.04). Postoperative bleeding occurred in two (2.4%) and three (2.9%) cases after ESD and EMR (P=not significant), respectively. Although 11 of 16 cases with recurrence after EMR were cured by additional endoscopic treatment, three cases required surgery. The only recurrence after ESD was in one patient who developed perforation after snare EMR. Despite its longer procedure time and higher perforation rate, ESD resulted in a higher en bloc resection rate and lower recurrence rate for larger colorectal tumors compared with EMR.

Clinical Features of Gastroduodenal Ulcer in Japanese Patients Taking Low-Dose Aspirin

The risks of peptic ulcer complications increase in association with low-dose aspirin (LDA) use. The endoscopic findings and clinical features of gastroduodenal ulcer have not been thoroughly investigated in patients taking LDA. We classified 1,041 gastroduodenal ulcer patients into three groups [patients taking LDA (group A), patients taking nonaspirin nonsteroidal anti-inflammatory drug (NSAID) (group N), and patients taking neither aspirin nor nonaspirin NSAID (group C)] and 241 bleeding gastroduodenal ulcer patients into three corresponding groups (groups a, n, and c). We investigated the clinical features, endoscopic characteristics, and endoscopic treatment of the hemorrhagic lesion in the gastroduodenal ulcer patients taking LDA and compared them with those of the other groups. The frequency of bleeding events such as hematemesis, melena, and anemia was significantly higher in group A and N than in group C. The percentage of ulcers located in the antrum was higher in group A and N than in group C, and also higher in group a and n than in group c. The percentage of ulcers located in the body, fundus, and cardia was significantly higher in the bleeding patients than in all gastroduodenal ulcer patients. The percentage of cases that required additional endoscopic treatment in group a was higher than in group c. Duration of hospitalization of group a was significantly longer than that of group c. These results indicate that it is very important to prevent LDA-induced gastroduodenal ulcer complications, including bleeding.

Pre-Treatment Predictors of Esophageal Stricture Formation Following Photodynamic Therapy for Barrett's Esophagus with High-Grade Dysplasia

Introduction: The major local adverse effect of photodynamic therapy (PDT) with porfimer sodium is esophageal stricture formation. The exact cause of stricture formation is not known but might be influenced by treatment variables including treatment length, light dosimetry and use of a centering balloon. This study was performed to assess whether pre-treatment variables, including prior endoscopic therapy for Barrett's esophagus (BE), are associated with post-PDT stricture formation. Methods: Data were reviewed for all patients who have undergone PDT with porfimer sodium for BE with high-grade dysplasia at our institution since 1997. Exclusion criteria included palliative PDT for adenocarcinoma stage T2 or greater and PDT for squamous cell carcinoma. Results: 113 patients underwent 158 PDT courses (75 patients treated with a single PDT course, 32 patients with 2 courses, 5 patients with 3 courses, and 1 patient with 4 courses). 81% were male and 99% were Caucasian, with a mean age of 70.3 at the time of index PDT. 83% of patients received additional endoscopic treatment for BE, including 28 who underwent endoscopic mucosal resection (EMR) prior to PDT. The incidence of stricture formation following index PDT was 15% (17/113). When all PDT courses were considered, the overall incidence of stricture was 23% (36/158). Stricture rate was significantly higher following a second PDT course compared with index PDT (45% versus 15%, [P = 0.0002]). Of the 17 patients who developed stricture following index PDT, 6 underwent a second PDT course, with 3 developing recurrent stricture. There was no association between age, gender, or body-mass index and development of post-PDT stricture. There was no association between prior EMR and post-PDT stricture. Patients who developed stricture had longer length BE pre-treatment than those who did not develop stricture (8.3 cm versus 5.7 cm [P = 0.005] for index PDT only; 7.5 cm versus 5.7 cm [P = 0.004] for all PDT courses). Length of BE and multiple PDT courses were independent predictors of post-PDT stricture in a stepwise logistic regression analysis controlling for treatment variables, including treatment length. Conclusions: Endoscopic therapy for BE frequently requires multiple courses of PDT or PDT as one component in a multimodality approach. EMR has gained use as a neoadjuvant therapy, and does not appear to influence the likelihood of stricture development following porfimer sodium PDT. Our data demonstrate an increased risk of stricture following multiple PDT courses. Our data also suggest an association between post-PDT stricture and length of BE, but not treatment length.

Risk factors for local recurrence of superficial esophageal cancer after treatment by endoscopic mucosal resection

The aim of this study was to elucidate the risk factors for local recurrence after endoscopic mucosal resection (EMR) treatment for superficial esophageal cancer (SEC). We performed a retrospective analysis of the clinical course of 62 patients with 64 SECs that were treated by EMR between 1993 and 2004. Follow-up examinations by chromoscopy with iodine solution and biopsy were performed 3 months, 6 months, 12 months, and then annually after EMR. Local recurrence was defined as a histologically confirmed finding of cancer cells at the site of the preceding EMR. The contributions of lesion-related and procedure-related factors to local recurrence were analyzed retrospectively. Local recurrence was detected in 14/64 SECs 3-36 months after EMR. Of the lesion-related factors we assessed, local recurrence was found to be more frequent in SECs with a larger diameter (P = 0.01), larger circumferential spread (P = 0.04), or deeper invasion (P = 0.04), although the last two factors failed to demonstrate statistical significance after correction for multiple testing. Piecemeal resection did not increase the risk of local recurrence (P = 0.11), but the need for adjunctive coagulation therapy was found to increase the risk of local recurrence (P = 0.06). Larger SECs are associated with a higher risk of local recurrence after EMR. In patients with residual lesions, coagulation therapy does not seem to be adequate as additional endoscopic treatment.

Result of Endoscopic Ureteroureterostomy with Holmium:YAG Laser for Complete Ureteral Obstruction

Complete ureteral obstruction after pelvic surgery is traditionally managed by open repair. Recent advances in endoscopic instruments and techniques have improved the efficacy with which these conditions are treated. Here, we describe our experiences with a holmium:YAG laser in the endoscopic management of complete ureteral obstruction. Retrograde endoscopic ureteroureterostomy using a Ho:YAG laser was performed on five patients with complete ureteral obstruction having a mean length of 0.9 +/- 0.2 cm after gynecologic surgery. The obliterated segment was incised with a 550-microm fiber through a rigid ureteroscope and under fluoroscopic guidance. Afterward, balloon dilatation was performed. A 7F/14F endopyelotomy stent was maintained for a mean time of 7 weeks, and follow-up was conducted via radiologic imaging. Recanalization was possible in all five patients immediately. One month after the initial operation, one patient exhibited a normal ureteral passage, and three other patients exhibited partial ureteral stricture. The remaining patient was lost to follow-up. Of the three patients with partial strictures, two evidenced no stricture after additional endoscopic treatment(s), and the remaining patient eventually underwent open repair. Overall, three of four (75%) patients exhibited normal excretory function without any open surgery and were symptom free with a mean follow-up time of 45 months (range 23-67 months). Although the number of patients in this study was small, it appears that endoscopic ureteroureterostomy with a Ho:YAG laser may constitute a valuable option for the treatment of complete short ureteral obstructions.

Endoscopic treatment of high-grade dysplasia and early stage cancer in Barrett's esophagus

The aim of this study was to prospectively evaluate endoscopic resection (ER) combined with photodynamic therapy (PDT) for the treatment of selected patients with early neoplasia in Barrett's esophagus. Patients with Barrett's esophagus and neoplastic lesions <2 cm in diameter and no sign of submucosal infiltration, positive lymph nodes, or distant metastasis underwent diagnostic ER (cap technique). Patients with a T1sm tumor in the resection specimen were referred for surgery; those with a T1m or a less invasive tumor underwent additional endoscopic therapy (ER, PDT, and/or argon plasma coagulation [APC]), or they were followed. PDT was performed with 5-aminolevulinic acid and a light dose of 100 J/cm 2 at lambda = 632 nm. Thirty-three patients underwent diagnostic ER. Endoscopic treatment was not performed in 5 patients, who underwent surgery (4 T1sm; 1, patient preference). Five patients were immediately entered into a follow-up protocol, and 23 received additional endoscopic treatment (13 additional ER, 19 PDT, 3 APC). Endoscopic treatment was successful in 26/28 patients; no severe complication was observed. During follow-up (median 19 months, range 13-24 months), 5/26 patients had a recurrence of high-grade dysplasia: all were successfully re-treated with ER. At the end of follow-up, 26/33 originally enrolled patients (79%) and 26/28 endoscopically treated patients (93%) were in local remission. Endoscopic therapy is safe and effective for selected patients with early stage neoplasia in Barrett's esophagus.

Chirurgische Therapie von Gallengangverletzungen nach laparoskopischer Cholezystektomie. Welchen Einfluss auf den Langzeitverlauf hat die gleichzeitige Verletzung der Arteria hepatica dextra?

Bile duct injuries are the most dreaded complication associated with laparoscopic cholecystectomy. Recent collective reviews have outlined the management of bile duct injuries, but only few have reported on the significance of concomitant injuries of the right hepatic artery. This study was conducted to compare the outcome of patients with isolated bile duct injuries and patients with additional vascular injuries. From January 1990 to February 2002, a total of 54 patients with bile duct injuries during laparoscopic cholecystectomy were surgically treated in our institution. In 46 patients a Roux-Y hepaticojejunostomy was performed. Eight patients underwent other surgical procedures and were not included in the statistical analysis. 11 patients had a concomitant vascular injury. Multivariate analysis was performed to evaluate the impact of vascular injuries. The rate of postoperative biliary complications was 21.7 % for all patients. Patients with combined bile duct and hepatic arterial injuries had a higher risk for the development of a biliary complication (6 of 11 patients (54.5 %) versus 4 of 35 patients (11.4 %); p = 0.006). After a median follow-up time of 61 months (range, 2-164 months) a successful overall outcome was achieved in 42 of 46 patients (91.3 %), which included the patients who required additional endoscopic or surgical treatment after primary reconstruction. The long-term outcome was successful in 9 of 11 patients (81.8 %) with combined bile duct and hepatic arterial injuries and in 33 of 35 patients (94.3 %) with solitary bile duct injury. The outcome of patients with combined bile duct and arterial injuries is worse than in patients with isolated bile duct injuries. We therefore recommend the evaluation of patients with major bile duct injuries for additional vascular injuries. Vascular reconstruction should be performed when ever possible in early recognised injuries to prevent late complications.

Management and outcome of patients with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy

Background Recent collective reviews have described the management and outcome of bile duct injuries during laparoscopic cholecystectomy. However, few have reported on the clinical significance of concomitant right hepatic arterial injuries. This study was conducted to examine the correlation of combined bile duct and vascular injuries and to evaluate the impact of these injuries on patient morbidity. Methods From January 1990 to February 2002, a total of 54 patients with bile duct injuries during laparoscopic cholecystectomy were surgically treated in our institution. In 46 patients a Roux-en- Y hepaticojejunostomy was performed. Eleven patients had a concomitant vascular injury. Arterial reconstruction was performed in addition to Roux-en- Y hepaticojejunostomy in 2 patients. Eight patients underwent other surgical procedures and were not included in the statistical analysis. To evaluate the impact of vascular injuries, univariate and multivariate analysis was performed. Results The rate of postoperative biliary complications was 21.7% for all patients. Univariate and multivariate analysis identified 2 risk factors for the development of biliary complications after reconstructive surgery: (1) combined bile duct and hepatic arterial injuries (6 of 11 patients [54.5%] vs 4 of 35 patients [11.4%]; P = .006) and (2) surgical repair in active peritonitis (8 of 13 patients [61.5%] vs 2 of 33 [6.1%]; P <.001). In the other, late referred patients with concomitant right hepatic arterial injury, the distal part of the artery was not exposable. After a median follow-up time of 44.6 months (range, 2 to 143.5 months) a successful outcome was achieved in 42 of 46 patients (91.3%), which included the patients who required additional endoscopic or surgical treatment after primary reconstruction. Conclusions The outcome of bile duct reconstruction is worse in patients with concomitant arterial injuries. We therefore recommend the assessment of patients with major bile duct injuries for additional vascular injuries. Further studies are needed to evaluate the importance of hepatic arterial revascularization in early recognized injuries to the long-term outcome of bile duct reconstructions.

Efficacy and Safety of Endoscopic Mucosal Resection Using Precut Method for Treatment of Early Gastric Cancer: Impact of Learning Curve

Background: Endoscopic mucosal resection (EMR) is a treatment option for early gastric cancer with minimal risk of lymph node metastasis. Precut around a lesion during EMR facilitate en bloc resection which is an important determinant for complete resection of the tumor. We evaluated the efficacy and safety of EMR using precut and cut method (EMR-P) in relation to endoscopist's experience. Methods: We describe the experience of 60 consecutive early gastric cancer cases which are treated by EMR-P method performed by one endoscopist from January, 2002 to September, 2003. After submucosal injection of 0.25% sodium hyaluronate solution, precut was performed around the lesion with conventional needle knife, and then, resection was performed using direct snaring without exfoliation. The en bloc resection rate, complete resection rate, procedure time, and associated complications were compared between the first 30 cases and the subsequent 30 cases. Results: The en bloc resection rate and the complete resection rate in the whole series were 70% (42/60) and 72% (43/60), respectively. The en bloc resection rate in the first 30 cases was 53% (16/30) and that in the second 30 cases was 87% (26/30) (p=0.010). The complete resection rate in the first half was 60% (18/30) and that in the second half was 83% (25/30) (p=0.084). Residual tumors were found in 7 cases (12%) at follow-up biopsy, 3 in the first half and 4 in the second half. The mean procedure time of the first half was 27.0±11.4 min and that of the second half was 20.1±8.2 min (p=0.01). The mean size of the tumor and that of the resection specimen were not significantly different between the first half and the second half (9.9±7.3 vs. 10.4±4.1 mm, 26.1±7.5 vs. 27.1±6.9 mm, respectively). Perforation occurred in 3 cases in the first half and in 1 case in the second half. Delayed bleeding that required additional endoscopic treatment occurred in 1 case in each group. Conclusions: EMR-P method is an effective treatment option for early gastric cancer. However, learning curve of about 30 cases might be required to perform efficient and safe EMR-P for early gastric cancer treatment.

Clinical Outcome of Endoscopic Aspiration Mucosectomy for Early Stage Gastric Cancer

Endoscopic mucosal resection is an established treatment option for early stage gastric cancer. However, several problems with endoscopic mucosal resection remain to be solved, such as appropriate treatment for recurrence and incomplete tumor resection. The outcome for patients undergoing endoscopic aspiration mucosectomy was evaluated retrospectively to determine factors associated with complete resection and tumor recurrence. Between May 1995 and Dec 2002, endoscopic aspiration mucosectomy was performed in 271 patients with early stage gastric cancers up to 20mm in diameter that were well or moderately differentiated adenocarcinoma. All were superficial lesions without ulceration, distinct signs of submucosal invasion, or a poorly demarcated border. En bloc or piecemeal resection was performed. Follow-up endoscopy was performed at 2, 6, 12, 18, and 24months and thereafter once per year. Outcome and factors associated with complete resection and tumor recurrence were assessed. 167 patients(62%) underwent en bloc resection and 104(38%) piecemeal resection. The rate of complete resection was 81.2%. The mean longest diameter of the resected specimens was 22Ã,±15mm. In patients with tumors completely resected, there was no recurrence after en bloc resection. Patients with incompletely resected intramucosal lesions underwent additional endoscopic treatment. Cancer recurred in 5 patients (1.8%), all of whom had lesions measuring more than 13mm in diameter. Endoscopic aspiration mucosectomy is safe and useful for the management of early stage gastric cancer. Further improvement in outcome requires mor accurate preoperative diagnosis and postoperative histopathologic evaluation. Patients with incompletely resected lesions should undergo aggressive additional treatment.

Addition of a second endoscopic treatment following epinephrine injection improves outcome in high-risk bleeding ulcers

Background & Aims: Endoscopic therapy reduces the rebleeding rate, the need for surgery, and the mortality in patients with peptic ulcer and active bleeding or visible vessel. Injection of epinephrine is the most popular therapeutic method. Guidelines disagree on the need for a second hemostatic procedure immediately after epinephrine; although it seems to reduce further bleeding, its effects on morbidity, surgery rates, and mortality remain unclear. The aim of this study was to perform a systematic review and meta-analysis to determine whether the addition of a second procedure improves hemostatic efficacy and/or patient outcomes after epinephrine injection. Methods: An extensive search for randomized trials comparing epinephrine alone vs. epinephrine plus a second method was performed in MEDLINE and EMBASE and in the abstracts of the AGA Congresses between 1990 and 2002. Selected articles were included in a meta-analysis. Results: Sixteen studies including 1673 patients met inclusion criteria. Adding a second procedure reduced the further bleeding rate from 18.4% to 10.6% (Peto odds ratio 0.53, 95% CI: 0.40–0.69) and emergency surgery from 11.3% to 7.6% (OR: 0.64, 95% CI: 0.46–0.90). Mortality fell from 5.1% to 2.6% (OR: 0.51, 95% CI: 0.31–0.84). Subanalysis showed that the risk of further bleeding decreased regardless of which second procedure was applied. In addition, the risk was reduced in all subgroups, although reduction was more evident in high-risk patients and when no scheduled follow-up endoscopies were performed. Conclusions: Additional endoscopic treatment after epinephrine injection reduces further bleeding, need for surgery, and mortality in patients with bleeding peptic ulcer.

Clinical outcome of endoscopic aspiration mucosectomy for early stage gastric cancer

Background: Endoscopic mucosal resection is an established treatment option for early stage gastric cancer. However, several problems with endoscopic mucosal resection remain to be solved, such as appropriate treatment for recurrence and incomplete tumor resection. The outcome for patients undergoing endoscopic aspiration mucosectomy (endoscopic mucosal resection) by a modification of the cap-fitted technique was evaluated retrospectively to determine factors associated with complete resection and tumor recurrence. Methods: Endoscopic mucosal resection was performed in 106 patients with early stage gastric cancers up to 20 mm in diameter that were well or moderately differentiated adenocarcinoma. All were superficial lesions without ulceration, distinct signs of submucosal invasion, or a poorly demarcated border. En bloc (tumors <10 mm in diameter) or piecemeal (tumors 10-20 mm in diameter) resection was performed. Follow-up endoscopy was performed at 2, 6, 12, 18, and 24 months and thereafter once per year. Outcome and factors associated with complete resection and tumor recurrence were assessed retrospectively. Results: Sixty-eight patients (64%) underwent en bloc resection and 38 (36%) piecemeal resection. The mean longest dimension (SD) of the resected lesions was significantly greater after piecemeal resection (12.3 [4.0] mm) than after en bloc resection (7.6 [4.0] mm; p < 0.01). In patients with tumors completely resected, there was no recurrence after either en bloc or piecemeal resection. Six of 8 patients found to have submucosal invasion after endoscopic mucosal resection underwent surgery. Patients with incompletely resected intramucosal lesions underwent additional endoscopic treatment. Cancer recurred in 3 patients (2.8%), all of whom had lesions measuring more than 15 mm in diameter. Conclusions: Endoscopic mucosal resection is safe and useful for the management of early stage gastric cancer. Further improvement in outcome requires more accurate preoperative diagnosis and postoperative histopathologic evaluation. Patients with incompletely resected lesions should undergo aggressive additional treatment. (Gastrointest Endosc 2002;56:708-13.)