Follow-up Endoscopic Examination Research Articles

Outcome after colorectal full-thickness resection and management of recurrence.

Background and study aims Endoscopic full-thickness resection (eFTR) allows treatment of "difficult to resect" lesions not amenable to conventional endoscopic methods. Efficacy and safety of the system have already been proven in numerous studies. Follow-up data on outcome of colorectal eFTR and management of recurrences are still rare. Patients and methods All patients undergoing colorectal eFTR at our institution with at least one endoscopic follow-up examination were retrospectively analyzed. The primary endpoint was the rate of recurrent or residual lesions (RRLs) and the secondary endpoint was the rate of late adverse events (AEs). We further aimed to identify risk factors for RRLs and to describe their management. Results Between November 2014 and 2021, 141 patients underwent eFTR at University Medical Center Freiburg. Ninety-one patients fulfilled the inclusion criteria. Indications for eFTR were non-lifting adenoma (n = 65), subepithelial tumors (n = 18) and early carcinoma (n = 8). The median follow-up period was 17 months (range, 2-86). The overall RRL rate was 9.9% (9/91). A significant proportion of RRLs (6/9, 66%) were detected late. All RRLs occurred in the group of non-lifting adenoma, corresponding to a RRL rate of 13.8% in this subgroup. Thirty-three percent (3/9) were initially treated by hybrid eFTR. Of the RRLs, 66.6% could were successfully treated endoscopically. On χ2 analysis, the hybrid eFTR technique ( P = 0.006) was associated with a higher rate of RRL. No late AEs occurred. Conclusions The rate of RRL after colorectal eFTR is low and the majority could be treated endoscopically. For non-lifting adenomas and early carcinomas, close follow-up is mandatory to detect late recurrence. Long-term outcomes after hybrid eFTR need further investigation.

Surgical repair of rectovaginal fistula by combined transanal and transvaginal endoscopy: a case report

The common causes of rectovaginal fistula include obstetric trauma, local infection, and rectal surgery, while rectovaginal fistula following hemorrhoid surgery is extremely rare. Rectovaginal fistulae (RVF) rarely heal without intervention. Surgical treatment is usually performed, but the optimal surgical method remains controversial. The patient was a 37-year-old woman who was transferred to our hospital due to an unsuccessful repair of a rectovaginal fistula after hemorrhoid surgery in a local hospital. The next day after admission, she had prophylactic ileostomy, fecal diversion and combined treatment with cephalosporin antibiotic to create a clean postoperative area. However, there was still fecal outflow from the vagina, with no significant reduction in excretion compared to previous surgery. Digestive endoscopy confirmed a failure of the repair for rectovaginal fistula. Therefore, preventive ileostomy was continued to reduce the accumulation of bacteria in the fistula and control the inflammation. After 8 weeks, the endoscopic fistula inflammation disappeared, and the condition of endoscopic surgery was considered to be mature. Subsequently, a new surgical method combining transanal endoscopy and transvaginal endoscopy was performed. After 12 weeks of surgery, a follow-up endoscopic examination showed that the fistula had been repaired and healed. During the 1-year follow-up, no serious complication was encountered, no recurrence was found, and the repair effect was satisfactory. In conclusion, a new technique combining transanal endoscopy and transvaginal endoscopy can effectively be used for the surgical repair of rectovaginal fistula after a hemorrhoid operation.

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Novel balloon compression-assisted endoscopic injection sclerotherapy and endoscopic variceal ligation in the treatment of esophageal varices: a prospective randomized study

BackgroundHerein, our group designed a novel technology, termed balloon compression-assisted endoscopic injection sclerotherapy (bc-EIS), which was applied to improve the efficiency of eradicating esophageal varices (EVs). The present study aimed to compare the rate of eradication and efficacy between bc-EIS and endoscopic variceal ligation (EVL) in the management of EVs.MethodsNinety-five patients with esophageal variceal bleeding (EVB) were randomly assigned to receive bc-EIS or ligation alone. Additional treatment sessions were held 1 month later and then at 3-month intervals until eradication of the varices was achieved. Endoscopic follow-up examinations were carried out at 6-month intervals in the absence of recurrence or immediately if there was any recurrent bleeding.ResultsThe mean physical injection points per session were 2.89 ± 0.79, and the mean volume of lauromacrogol used per session was 17.74 ± 7.09 ml in the bc-EIS group. The mean band per session was 6.13 ± 0.86. The rate of eradication after one to three rounds of bc-EIS was obviously higher than that of the EVL group (89.36%, 97.87%, and 100% vs. 37.5%, 43.75%, and 47.92%, respectively). Retrosternal pain or discomfort in the bc-EIS group was slightly lower than that in the EVL group (23.4%, 11/47 vs. 31.25%, 15/48). Two and five patients showed mild abdominal bloating and distension between the bc-EIS and EVL groups, respectively (2/47, 4.26% vs. 5/48, 10.42% P > 0.05). Nausea and vomiting were reported in one patient (1/47, 2.13%) in the bc-EIS group and three patients (3/48, 6.25%) in the EVL group. However, there were no statistically significant differences between the two groups (P > 0.05). No fatal or severe complications, such as esophageal perforation, esophageal stricture or ectopic embolism, were observed.ConclusionThe bc-EIS method was effective in eradicating EVs and was accompanied by fewer complications.

Simple and reliable transhiatal reconstruction after laparoscopic proximal gastrectomy with lower esophagectomy for Siewert type II tumors: y-shaped overlap esophagogastric tube reconstruction.

Despite the increasing incidence of adenocarcinoma of the esophagogastric junction, laparoscopic proximal gastrectomy with lower esophagectomy (PGLE) is not widely accepted owing to the lack of standardized reconstruction techniques. In this study, we developed a new reconstruction method named y-shaped overlap esophagogastric tube reconstruction, which reproduces an angle of His and a pseudo-fornix, to be used in laparoscopic transhiatal PGLE. This study aimed to determine the feasibility of this novel reconstruction method. This retrospective study included the analysis of short- and mid-term surgical outcomes of 30 consecutive patients with Siewert type II esophagogastric junction adenocarcinoma who underwent laparoscopic PGLE with y-shaped overlap esophagogastric tube reconstruction from April 2015 to August 2020. A novel method was used to form a 6-cm pseudo-fornix and an angle of His using the distal esophagus and a long gastric tube. The median operation time was 369min, and the median blood loss was 28mL. The median follow-up period after surgery was 37months. Although two patients experienced postoperative anastomotic leakage, none of the patients developed stenosis. One patient experienced moderate reflux symptoms, whereas four patients developed moderate reflux esophagitis based on the 1-year follow-up endoscopic examination; the condition of all patients could be efficiently controlled with medication. The short- and mid-term surgical outcomes of y-shaped overlap esophagogastric tube reconstruction reflected the feasibility of this simple technique and suggested its potential utility as a reconstruction alternative for Siewert type II tumors.

Follow-up outcomes of mucosal defect closures after endoscopic resection using a helix tacking system and endoclips.

Background and AimsThe X-Tack endoscopic HeliX tacking system (Apollo Endosurgery, Austin, Tex, USA) has recently been approved by the Food and Drug Administration and is slowly gaining popularity for the closure of large tissue defects. Despite its increasing use, outcome data of using the X-Tack system for mucosal defect closure after endoscopic resection (ER) are limited. Here, we report the follow-up outcomes of a series of cases that underwent ER and mucosal closure aided by the HeliX tacking system.MethodsWe identified a total of 5 cases in which the X-Tack system and endoclips were used for mucosal defect closure after ER. The cases involved ER of large and/or flat polyps in the duodenum and colon. The patients were followed up at 4, 6, and 9 months after ER.ResultsIn all cases, X-Tacks with endoclips achieved complete closure of the large mucosal defects. None of the patients experienced any adverse events, such as abdominal pain or bleeding. At follow-up, the X-Tacks either fell off or were seen grouped or situated as a single piece (tack) in the mucosa where initially placed. None of the endoclips were found during the follow-up endoscopic examinations.ConclusionsThe X-Tack system together with endoclips facilitated complete closure of large mucosal defects, especially for lesions located in difficult locations. At follow-up, several retained X-Tacks were found either in groups or as a single piece. The X-Tacks seen in groups will likely fall off with repetitive pulling forces with food or feces. However, the single tacks that were secured in the wall may stay indefinitely. The novel HeliX tacking system seems to be a promising aid for the effective closure of large mucosal defects; however, further studies are needed to assess the long-term outcome of this novel system.

Visualization of Absorbed Lipid in the Normal Duodenal Epithelium Using Magnifying Endoscopy with Narrow-Band Imaging.

Subepithelial microvascular pattern cannot be visualized on the surface of adenoma and carcinoma by magnifying endoscopy due to a white opaque substance (WOS), which consists of minute lipid droplets accumulated in the neoplastic epithelium. We aimed to investigate whether the WOS is visualized in the duodenum after exogenous fat loading (FL) administration in an open-label, randomized, controlled study. The patients scheduled to undergo endoscopic therapy for gastric epithelial neoplasms were enrolled in the study. They were randomly assigned to the FL or non-FL group. An initial (before FL administration) and follow-up (after two to three weeks) endoscopic examinations were conducted to observe the duodenal mucosa using magnifying narrow-band imaging. Each patient in the FL group consumed 250ml of Ensure H® four hours before the follow-up examination. Two experienced endoscopists determined the grade of the WOS. FL test results were judged positive for patients who showed a higher grade at the follow-up examination than at the initial examination. The rate of positive test results was compared between the two groups. Twenty patients (10 in the FL and 10 in the non-FL groups) were included. FL test results were positive for all 10 patients in the FL group, while they were negative for all 10 patients in the non-FL group (P < 0.001 by Fisher's exact test). Lipids loaded onto normal duodenal epithelium were absorbed, and the absorbed lipid droplets appeared as WOS on magnifying narrow-band imaging.

Salvage thoracoscopic esophagectomy after carbon-ion radiotherapy in a patient with esophageal squamous cell carcinoma: a case report

BackgroundCarbon-ion radiotherapy (CIRT) for esophageal cancer has been receiving significant attention given its high local control rates and minimal damage to normal tissues. However, the efficacy and safety of salvage surgery after CIRT for esophageal cancer remain unclear. We report the case of a patient who underwent salvage thoracoscopic surgery after CIRT.Case presentationA 51-year-old woman underwent upper gastrointestinal endoscopy and a type 0-IIa + 0-IIc esophageal squamous cell carcinoma located 27–29 cm from the patient’s incisors, classified as clinical stage I (T1bN0M0), was detected. She received CIRT (50.4 Gy [relative biological effectiveness, RBE]/12 fr) for localized esophageal cancer and achieved complete remission after 4 months. Six years after CIRT, follow-up endoscopic examination demonstrated a type 0-IIa + 0-IIc tumor in the previously treated area. In addition, a type 0-IIa lesion located 20–22 cm from the incisors was found. We diagnosed localized ESCC, classified as clinical stage I (T1bN0M0). Salvage thoracoscopic surgery was performed in the prone position with five access ports. Although the esophagus tightly adhered to the thoracic descending aorta and left main bronchus with severe fibrosis, the esophagus could be separated from the surrounding organs with careful forceps manipulation. The operation time and blood loss were 8 h 45 min and 253 mL, respectively. The patient was discharged from our hospital 17 days after the salvage surgery without any complications. Pathological findings revealed two squamous cell carcinomas. Both tumors were localized in the lamina propria mucosa, and lymph node metastasis was not detected. The tumors were diagnosed as pathological stage IA (pT1aN0M0) according to the TNM criteria. Moreover, pathological examinations showed severe fibrosis of the previously irradiated tissues compared to the normal esophagus located outside of the irradiation field. Following the surgery, the patient had no recurrence for 1 year and 6 months.ConclusionsThoracoscopic radical esophagectomy can be performed as salvage surgery. Careful and discreet surgery is integral to perform salvage surgery after CIRT since CIRT may cause severe adhesions and fibrosis in the irradiated field.

Human gastric cancer risk screening: From rat pepsinogen studies to the ABC method.

We examined the development of gastric cancer risk screening, from rat pepsinogen studies in an experimental rat gastric carcinogenesis model induced with N-methyl-N′-nitro-N-nitrosoguanidine (MNNG) and human pepsinogen studies in the 1970s and 1980s to the recent “ABC method” for human gastric cancer risk screening. First, decreased expression or absence of a major pepsinogen isozyme, PG1, was observed in the rat gastric mucosa from the early stages of gastric carcinogenesis to adenocarcinomas following treatment with MNNG. In the 1980s, decreases in PGI in the human gastric mucosa and serum were identified as markers of atrophic gastritis. In the 1990s, other researchers revealed that chronic infection with Helicobacter pylori (Hp) causes atrophic gastritis and later gastric cancer. In the 2000s, a gastric cancer risk screening method combining assays to detect serum anti-Hp IgG antibody and serum PGI and PGII levels, the “ABC method”, was established. Eradication of Hp and endoscopic follow-up examination after the ABC method are recommended to prevent gastric cancer.

Combination of the endoscopic septonasal flap technique and bioabsorbable steroid-eluting stents for repair of congenital choanal atresia in neonates and infants: a retrospective study

BackgroundMultiple surgical approaches have been proposed to repair the congenital choanal atresia. However, there remains no general consensus about the optimal surgical technique. This study aimed to describe and evaluate outcomes of the endoscopic septonasal flap technique combined with bioabsorbable steroid-eluting stents for repair of congenital choanal atresia in neonates and infants.MethodsClinical data of 37 neonates and infants with congenital choanal atresia who received nasal endoscopic surgery with the flap technique between January 2018 and July 2020 were analyzed retrospectively. All patients underwent the ultra‑low‑dose paranasal sinus computed tomography imaging preoperatively to confirm diagnosis and plan the surgery. In these patients, the mirrored L-shaped flap technique was performed for bilateral atresia and the cross-over L-shaped flap technique was performed for unilateral atresia. A total of 22 patients had silicone stents postoperatively and 15 patients had bioabsorbable steroid-eluting stents postoperatively. Silicone stents were removed at one month postoperatively under secondary general anesthesia, while no anesthesia was needed to remove the bioabsorbable steroid-eluting stents. Postoperative follow-up ranged from 10 months to 3 years.ResultsThe septonasal flap technique was performed in all patients. Compared with the silicone stents group, the average operative duration and the hospital length of stay in the bioabsorbable steroid-eluting stents group were decreased [(97.46 ± 15.37) min vs (83.49 ± 19.16) min t = 13.733, P < 0.001] [(12.8 ± 3.22) d vs (7.67 ± 3.91) d t = 15.082, P < 0.001], the average number of procedures was reduced [(2.04 ± 0.64) vs (1.00 ± 0.00), t = 82.689, P < 0.001], the differences were statistically significant. There were no reports of postoperative restenosis and complications in the bioabsorbable steroid-eluting stents group, and follow-up endoscopic examinations showed patency and stable nasal passages in all cases.ConclusionsThe endoscopic septonasal flap technique can effectively expose and expand the choanal bony structure for repair of congenital choanal atresia in neonates and infants. The combined use of this technique along with bioabsorbable steroid-eluting stents can help prevent the need for revision procedures and also against stent-related injuries.

Mo1685 INVESTIGATION OF PATHOLOGICAL RESECTED MARGIN UNCERTAIN CASES UNDERGOING ENDOSCOPIC PICEMEAL MUCOSAL RESECTION OF COLORECTAL POLYPS

Of the patients undergoing endoscopic mucosal resection (EMR), endoscopic piecemeal mucosal resection (EPMR) is often performed instead of en bloc resection. The problem with EPMR is that the complete resection rates are low, and the margins of resection are uncertain in pathological diagnosis. This study aimed to retrospectively evaluate the risk factors for the local recurrence in these EPMR cases. Our subjects included 76 patients (mean age: 68.8±11.1 years, males:48, females: 28, total 80 lesions) who had undergone EPMR between January 2013 and October 2019. These lesions were divided into sessile polyps ( 0-Is), 0-Isp, pedunculated polyps ( 0-Ip), and slightly elevate polyps (0-IIa) depending on their endoscopic shape, and the size, the location of the large intestine, pathological findings, and the local recurrence were examined retrospectively. For statistical analysis, multiple regression analysis and multiple comparison tests were performed, with a p-value of less than 0.05 considered indicating statistical significance. The breakdown of lesions consisted of type 0-Is:38, 0-Ip: 3, and 0- IIa: 39. The tumor size (mm) by type was average 0-Is: 12.8 ± 8.4, 0-Ip: 19.3 ± 11.0, and 0-IIa: 15.7 ± 6.4, respectively. A significant difference(P<0.001) was observed between 0-Is and 0-IIa. The tumors were located in the large intestine, cecum: 10 lesions (0-Is: 3, 0-Ip: 0, 0-IIa: 7), ascending colon: 14 lesions (0-Is: 6, 0-Ip: 0, 0-IIa: 8), transverse colon: 10 lesions (0-Is: 2, 0-Ip: 0, 0-IIa:8), descending colon: 4 lesions (0-Is: 2, 0-Ip: 0, 0-IIa: 2), sigmoid colon: 29 lesions (0-Is:23, 0-Ip: 1, 0I-IIa: 5), rectum: 13 lesions (0-Is: 2, 0-Ip: 2, 0-IIa: 9). The complete resection rates (%) that no residual tumor was found by both endoscopic and histologic examination were 0-Is: 15.8 (6/38), 0-Ip: 66.7 (2/3), 0-IIa: 20.5 (8/39). The follow-up endoscopic examinations were performed for 27 patients in whom the resected margins were uncertain in pathological diagnosis. The local recurrence developed in 29.6% (8/27) of patients and the breakdown of the recurrence rates(%) was 0-Is: 23.1 (3/13), 0-Ip: 100 (1/1), 0-IIa: 30.1 (4/13). The average diameter of the tumors was 28.1 ± 4.5 mm, and the histological examination of the resected tumor tissues revealed high-grade adenoma or adenocarcinoma in 75% ( 6/8) of the patients. Multiple regression analysis demonstrated a significant correlation between local recurrence and tumor sizes (r =0.0031; P<0.019). This study showed that the tumor size (>20mm) and high-grade lesions were risk factors for local recurrence among EPMR cases of resected margin uncertain in pathological diagnosis. Follow-up endoscopic examinations within 6 to 12 months are necessary for the detection of recurrence in these cases.

Incidence of metachronous gastric cancer after endoscopic submucosal dissection associated with eradication status of Helicobacter pylori.

This study compared the clinicopathological features and treatment outcomes of patients with primary early gastric cancers (EGCs) who had undergone Helicobacter pylori eradication and endoscopic submucosal dissection (ESD) with those of patients who were H. pylori-positive and had undergone ESD. Additionally, we investigated the incidence of metachronous cancer in these patients. We retrospectively analyzed 1849 EGCs in 1407 patients who underwent ESD whom 201 primary EGCs were detected after H. pylori eradication (eradication group) and 1648 primary EGCs were detected in patients infected with H. pylori (infection group). We evaluated the clinicopathological features and treatment outcomes of the first ESD. We next divided 938 patients whose follow-up periods were >1 year into three groups, an eradication group (n = 61), an infection group (n = 562), and an eradication after ESD group (n = 315). The groups' cumulative metachronous occurrence rates were determined. The eradication group's median tumor size was significantly smaller, and the tumors were significantly more likely to be flat/depressed than those in the infection group. The groups did not differ regarding the treatment outcomes. The cumulative incidence of metachronous cancer was significantly higher in the eradication group than in the eradication after ESD group (P = 0.0454) and in the infection group than in the eradication after ESD group (P = 0.0233). The treatment outcomes for EGC in the eradication group were favorable. The higher incidence of metachronous cancer in the eradication group suggests that careful endoscopic follow-up examinations are required.

The Long-Term Clinical and Endoscopic Outcomes of Cronkhite-Canada Syndrome.

INTRODUCTION:The prognosis of Cronkhite–Canada syndrome (CCS) is considered poor. Despite the recent therapeutic improvements, the survival outcomes and prognostic factors have been less studied. This study aimed to investigate the long-term clinical and endoscopic outcomes of CCS.METHODS:Thirty-one patients diagnosed since 1999 and followed up for over 6 months were included. Data regarding survival outcomes, clinical symptoms, endoscopic findings, and treatment were collected and analyzed. R (version 3.6.1) was used to perform the survival analyses.RESULTS:The median (interquartile range) follow-up time was 42.5 (19.5–85.8) months. The 5-year overall survival (OS) was 87.4%. The maximum gastric polyp size over 2 cm was associated with worse OS (Hazard ratio [HR]: 18, 95% confidence interval [CI]: 1.6–210, P = 0.021). The 3-year relapse-free survival (RFS) after corticosteroid treatment was 66.8%. Age older than 60 years (HR: 7.0, 95% CI: 1.5–33.0, P = 0.015) and maximum gastric polyp size over 2 cm (HR: 6.0, 95% CI: 1.6–23.0, P = 0.009) were associated with worse RFS. Twenty-three patients received follow-up endoscopic examinations, with a median (interquartile range) follow-up time of 29.0 (14.0–53.5) months. Eight (34.8%) and 12 (52.2%) patients achieved complete remission under gastroscopy and colonoscopy, respectively. Colonic lesions showed a tendency of earlier responses compared with gastric lesions (25.0 [11.3–39.8] months vs 31.0 [21.0–39.8] months).DISCUSSION:Patients with CCS usually responded well to glucocorticoids with a fairly good 5-year survival rate. Large gastric polyp was associated with worse OS and RFS, whereas age older than 60 years was another predictor for worse RFS. Diffuse gastrointestinal lesions partly or completely resolved after treatment, and colonic lesions showed a better response than gastric lesions.

Preoperative CT Colonography in Partially Obstructed Colon Cancer, and its Benefit in Surgical Management

Background and aims Stenotic colorectal carcinoma impending obstruction (SCRCIO) is a frequently encountered situation complicating 10% to 19% of colorectal cancers. This group of patients cannot undergo complete colonoscopic assessment. The aim of this study is to examine the accuracy of computed tomographic colonography (CTC) as preoperative assessment of the colon of patients with SCRCIO and to measure the effect on the surgical decision. Materials and methods This was a prospective study, from September 2009 through December 2012, on a cohort of symptomatic adult patients with SCRCIO. Patients underwent CTC evaluation after failed conventional colonoscopy (CC), followed by a follow-up endoscopic examination 3–6 months after surgical treatment. Results Twenty-nine patients with an average age of 55 were included in this study; the majority of stenotic masses were located in the sigmoid colon. Preoperative CTC matched the colonoscopy location of the stenotic masses (17 patients). CTC sensitivity per stenotic lesion detection was 100% and 92.5% for the location. Sensitivity was 100% for synchronous lesions, and CTC changed surgical plan in 17% of the patients. Conclusion CTC presented high sensitivity, specificity and accuracy for the identification of colonic lesions of any size. Preoperative CTC may possibly become the diagnostic procedure of choice for SCRCIO patients. It enables surgeons to evaluate the entire colon, minimizing the possibility of surgical re-intervention if there is a finding of synchronous neoplastic lesions at postoperative follow-up endoscopy.

2118 A Challenging Case of Recurrent Rectal Adenoma Despite Multiple Endoscopic Mucosal Resections (EMRs) and Trans-Anal Endoscopic Microsurgeries (TEMS)

INTRODUCTION: Detection and complete removal of colorectal adenomas is essential in reducing the incidence and mortality of cancer. Advanced rectal adenomas can be removed by a number of techniques including Endoscopic Mucosal Resection (EMR), Endoscopic Submucosal Dissection (ESD) and Trans-anal Endoscopic Microsurgery (TEMS). Despite complete resection, local recurrence remains a challenge in some patients. We report a rare case of a recurrent rectal adenoma despite multiple EMRs and TEMS procedures over a 5-year period. CASE DESCRIPTION/METHODS: A 63-year female was referred for EMR of a 2 cm rectal adenoma found on screening colonoscopy 5 years ago (Figure 1). Colonoscopy with en-bloc EMR was done without difficulty. On 6-month follow-up a recurrent adenoma was seen at EMR site. En-bloc EMR was again performed followed by argon plasma coagulation (APC) ablation of edges. Follow-up flexible sigmoidoscopy 6-months later again showed a recurrent adenoma. Patient was referred for TEMS; full-thickness resection was performed with negative margins on pathology specimen. Surveillance colonoscopy 6 months after TEMS revealed recurrent adenoma at the TEMS site. TEMS was repeated. Follow-up endoscopic examination and biopsy 2 months and 1 year after the second TEMS revealed no evidence of lesion recurrence (Figure 2). However her most recent colonoscopy, 3 years after the second TEMS, showed a recurrent 6 mm sessile adenoma at same site (Figure 3). After multidisciplinary consultation, she is scheduled to undergo a third TEMS procedure. DISCUSSION: The reported incidence of recurrent rectal adenoma is 4-11%. Factors affecting local recurrence include size of index polyp and completeness of resection. Despite complete resection, some patients will develop repeated recurrence. Ramkumar et al. reported 669 patients who underwent TEMS for treatment of rectal lesions; 15 pts required 3 or more TEMS procedures. Repeat TEMS was shown to be safe with similar postoperative complications and similar rates of margin clearance (81% vs 88%, P = 0.09) compared to primary TEMS 1 . In our patient, a rectal adenoma recurred despite 2 en-bloc EMRs and 2 TEMS. This demonstrates the need for close surveillance and the importance of a multi-disciplinary treatment approach in these patients.

2707 Gastric Mucosa-Associated Lymphoid Tissue Lymophoma Treated by Endoscopic Mucosal Resection

INTRODUCTION: Primary low-grade gastric Mucosa-associated lymphoid tissue (MALT) lymphoma is a distinctive type of B-cell lymphoma. Endoscopic appearances of low-grade gastric MALT lymphoma are quite varied and polypoid or subepithelial type (exophytic) is rare. Here, we reported the case of H. pylori negative gastric MALToma presenting as an exophytic subepithelial tumor, diagnosing and treating by endoscopic mucosal resection (EMR). CASE DESCRIPTION/METHODS: A 53-year-old man was referred to our hospital because of a large subepithelial tumor of the stomach, which was incidentally found on an endoscopy for a routine checkup in outside hospital. Initial outside endoscopic biopsy was a simple chronic gastritis. Physical examination and laboratory results were unremarkable. On endoscopic examination, a 2.0 cm sized round and hard exophytic subepithelial tumor was seen on the great curvature side of high body of the stomach. The tumor showed a well-demarcated smooth border without any erosion and ulceration. An abdominal pelvic CT demonstrated an enhancing subepithelial tumor without regional lymphadenopathy, such as gastrointestinal stromal tumor. EUS showed a hypoechoic and heterogeneous mass in the 2nd and 3rd layer with ill-defined internal margin. EMR was done for both the definite diagnosis and the treatment without complications because the tumor had a semipedunculated morphology. Results of a histopathologic examination of the resected tumor showed diffuse lymphocytic proliferation in the submucosa mimicking a subepithelial tumor with lymphoepithelial lesions. Dense lymphocytic infiltration composed of mainly B cells forming vague follicular colonization. Immunohistochemical stain of cytokeratin also showed presence of lymphoepithelial lesions. The Ki-67 was positive in 7%. Histologically, no H. pylori was observed in the luminal side. Finally, the patient was diagnosed as a H. pylori–negative extranodal marginal zone B-cell lymphoma (MALToma) (stage EI1). No additional treatment such as chemotherapy or radiation was performed. The follow-up endoscopic examination showed no recurrence until 2 years after EMR. DISCUSSION: We suggest that EMR may be an alternative treatment modality in the diagnosis and the treatment of gastric MALT lymphoma in cases of submucosal or polypoid morphology type, especially when H. pylori is negative. Further study in terms of feasibility, efficacy, and long-term safety of EMR as a curative treatment would be warranted.

Clinical Outcome of the Visible Coil During Endoscopy After Transcatheter Arterial Embolization for Gastrointestinal Bleeding.

This study was designed to evaluate the clinical outcome of the visible coil during endoscopy after transcatheter arterial embolization (TAE) for gastrointestinal bleeding. We retrospectively reviewed the medical records of 1415 patients who underwent TAE for gastrointestinal bleeding between 2001 and 2017. Among these 1415 patients, 70 underwent TAE using coils and consecutive follow-up endoscopy. Finally, 11 patients with an extravascular coil seen on follow-up endoscopic examination were included in this study. We evaluated the underlying cause of the gastrointestinal bleeding, the technical and clinical success rates, the type of extravascular coil after TAE, and the clinical outcomes of the extravascular coil seen on follow-up endoscopic examination. Of the 11 patients, the most common underlying cause of gastrointestinal bleeding was a duodenal ulcer (n = 7). On angiography, the bleeding artery was most commonly found in the gastroduodenal artery (n = 6). The technical success and clinical success rates of TAE were 100% and 90.9%, respectively. The type of extravascular coil found on endoscopic examination was classified by submucosal migration (n = 6) and protrusion (n = 5). On second-look endoscopic evaluation, 10 of 11 (90.9%) patients showed healing ulceration. On the final-look endoscopic evaluation, healing ulceration without further bleeding was seen in one (9.1%) patient and scar formation was seen in ten (90.9%) patients. Extravascular coil after TAE for gastrointestinal bleeding is rare, and the most common underlying cause is duodenal ulcer bleeding. The extravascular coils eventually show a healing process with adequate treatment of underlying bowel pathologies.

胃がんリスク層別化検査(ABC分類)受診3─4年後の内視鏡検査受診勧奨は有効か？

胃がんリスク層別化検査(ABC分類)受診3─4年後の内視鏡検査受診勧奨は有効か？

Nanofunctionalized Stent-Mediated Local Heat Treatment for the Suppression of Stent-Induced Tissue Hyperplasia.

Current therapeutic strategies are insufficient for suppressing stent-induced restenosis. Here, branched gold nanoparticles (BGNP)-coated self-expandable metallic stents (SEMSs) were developed for a local heat-induced suppression of stent-related tissue hyperplasia. Our polydopamine (PDA) coating on SEMS allowed BGNP crystal growth on the surface of SEMSs. The prepared BGNP-coated SEMS showed effective local heating under near-infrared laser irradiation. The effectiveness of BGNP-coated SEMSs for suppressing stent-related tissue hyperplasia was demonstrated in a rat esophageal model ( n = 52). BGNP-coated SEMS placement under fluoroscopic guidance was technically successful in all rats. The placed BGNP-coated SEMS in rat esophagus achieved three different local heat dose ranges (50, 65, and 80 °C) under fluoroscopic image-guided local irradiation. Follow-up endoscopic examination readily monitored the local heating and observed significantly decreased tissue hyperplasia at 4 weeks of local heat treatments (50 and 65 °C). Finally, Western blot, histology, immunohistochemistry (HSP70, αSMA, and TUNEL), and immunofluorescence (Ki67 and BrdU) analyses along with the statistical analysis confirmed that optimized BGNP-coated SEMS-mediated local heat treatments inducing the expression of anti-inflammatory HSP70 effectively suppresses tissue hyperplasia after stent placement in the esophagus. Our local heating with nanofunctionalized stents represents a promising new approach for suppressing stent-related tissue hyperplasia.

Endoscopic predictive factors associated with local recurrence after gastric endoscopic submucosal dissection

Objective: Endoscopic submucosal dissection (ESD) has been accepted as the treatment of choice for gastric epithelial neoplasia. Endoscopic characteristics of the primary lesion and post-ESD scars may be informative to predict the possibility of local recurrence.Methods: Between November 2008 and July 2015, a retrospective study was conducted in a single-tertiary referral hospital. Consecutive patients who underwent ESD for early gastric cancer (EGC) or high-grade dysplasia were analyzed to evaluate the incidence of local recurrence and associated endoscopic characteristics.Results: A total of 639 lesions were analyzed. The rates of en-bloc and complete resection were 98.1% and 95.5%, respectively. A total of 15 local recurrent lesions were found (2.3%). The endoscopic findings of primary lesions associated with local recurrence were a lesion size ≥20 mm (odds ratio, OR, 4.408; 95% confidence interval, CI, 1.369–14.186, p = .013) and incomplete endoscopic resection (OR 17.059, 95% CI 4.887–59.551, p < .001). During follow-up endoscopic examinations, atypical scar findings (non-flat morphology, erythematous color change and uneven surface pattern) were significant endoscopic findings to predict local recurrence. Local recurrence was absent for ESD scars with even-flat morphology without erythema.Conclusion: Lesions with larger size (≥ 20 mm) and incompletely resected lesions had higher risk of local recurrence. Endoscopic forceps biopsy is unnecessary for even-flat ESD scar without erythematous changes.