RESUMO
BACKGROUND: Large artificial gastric mucosal defects are always left unclosed for natural healing due to technique difficulties in closure. This study aims to evaluate the feasibility and safety of a new Twin-grasper Assisted Mucosal Inverted Closure (TAMIC) technique in closing large artificial gastric mucosal defects. METHODS: Endoscopic submucosal dissection (ESD) was performed in fifteen pigs to create large gastric mucosal defects. The mucosal defects were then either left unclosed or closed with metallic clips using TAMIC technique. Successful closure rate and the wound outcomes were assessed. RESULTS: Two mucosal defects with size of about 4.0 cm were left unclosed and healed two months after surgery. Thirteen large gastric mucosal defects were created by ESD with a medium size of 5.9 cm and were successfully closed with the TAMIC technique (100%), even in a mucosal defect with a width up to 8.5 cm. The mean closure time was 59.0 min. Wounds in eight stomachs remained completely closed 1 week after surgery (61.5%), while closure in the other five stomachs had partial wound dehiscence (38.5%). Four weeks later, all the closed defects healed well and 61.5% of the wounds still remained completely closed during healing. There was no delayed perforation or bleeding after surgery. In addition, there was less granulation in the submucosal layer of the closed wound sites than those under natural healing. CONCLUSIONS: The present study suggests that TAMIC is feasible and safe in closing large artificial gastric mucosal defects and could improve mucosal recovery compared to natural healing process.
Assuntos
Ressecção Endoscópica de Mucosa , Técnicas de Fechamento de Ferimentos , Suínos , Animais , Mucosa Gástrica/cirurgia , Complicações Pós-Operatórias , Instrumentos Cirúrgicos , Resultado do TratamentoRESUMO
OBJECTIVE: To develop an effective strategy for accurate diagnosis of focal liver lesions (FLLs) in patients with non-high risk for hepatocellular carcinoma (HCC). METHODS: From January 2012 to December 2015, consecutive patients with non-high risk for HCC who underwent contrast-enhanced ultrasound (CEUS) were included in this retrospective double-reader study. All patients were stratified into 2 different risks (intermediate, low-risk) groups according to criteria based on clinical characteristics, known as clinical risk stratification criteria. For the intermediate-risk group, the CEUS criteria for identifying benign lesions and HCCs were constructed based on selected CEUS features. The diagnostic performance of the clinical risk stratification criteria, and CEUS criteria for identifying benign lesions and HCCs was evaluated. RESULTS: This study included 348 FLLs in 348 patients. The sensitivity and specificity of the clinical risk stratification criteria for malignancy was 97.8 and 69.8%. Patients were classified as intermediate risk if they were male, or older than 40 years of age, or HBcAb positive, or having positive tumor markers. Otherwise, patients were classified as low risk. Among the 348 patients, 327 were in the intermediate-risk group and 21 were in the low-risk group. In the intermediate-risk group, the CEUS criteria for identifying benign lesions were any of the following features: 1) hyper/isoenhancement in the arterial phase without washout, 2) nonenhancement in all phases, 3) peripheral discontinuous globular enhancement in the arterial phase, 4) centrifugal enhancement or peripheral enhancement followed by no central enhancement, or 5) enhanced septa. The accuracy, sensitivity, and specificity of the CEUS criteria for identifying benign lesions were 94.5, 83.0, and 99.6%, respectively. Arterial phase hyperenhancement followed by mild and late washout (>60 seconds) was more common in HCC patients than in non-HCC patients (P < .001). Using arterial phase hyperenhancement followed by mild and late washout as the CEUS criteria for identifying HCCs, the sensitivity and specificity were 52.6 and 95.3%, but unfortunately, the positive predictive value was only 82.0%. For the low-risk group, no further analysis was performed due to the small sample size. CONCLUSIONS: Initial clinical risk stratification followed by assessment of certain CEUS features appears to be a promising strategy for the accurate diagnosis of FLLs in patients not at high risk for HCC.
Assuntos
Carcinoma Hepatocelular , Neoplasias Hepáticas , Humanos , Masculino , Feminino , Carcinoma Hepatocelular/diagnóstico por imagem , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/patologia , Estudos Retrospectivos , Meios de Contraste , Sensibilidade e Especificidade , Ultrassonografia , Imageamento por Ressonância MagnéticaRESUMO
OBJECTIVES: This study aimed to demonstrate the feasibility and safety of a novel twin-grasper assisted mucosal inverted closure (TAMIC) technique for large perforations after gastric endoscopic full-thickness resection (EFTR) in a porcine model. METHODS: Iatrogenic large perforations of the stomach were created and closed by an experienced endoscopist using the TAMIC technique in 12 pigs. Repeat gastroscopy was performed in 4 weeks after surgery to examine the wound sites and then the animals were killed. The primary outcomes were the successful TAMIC closure rate and the complete healing rate. Secondary end points included procedure time of TAMIC, complete inverted healing rate, delayed bleeding rate, and postsurgery perforation. Histologies of the wounds were analyzed by hematoxylin-eosin, Masson trichrome, and immunohistochemistry staining. RESULTS: The median size of the defects was 3.5 (range 2.5-4.5) cm. TAMIC was successfully performed in all the 12 pigs. Complete healing was achieved in 11 pigs 4 weeks after operation as one pig died postsurgery due to severe pneumonia. The median procedure time for TAMIC was 39 (range 23-81) min. The complete inverted healing rate was 45.5% (5/11). No delayed bleeding or postsurgery perforation was observed. Histologic analyses showed that both the epithelium and muscularis mucosae layers were appropriately connected under inverted healing. CONCLUSIONS: Twin-grasper assisted mucosal inverted closure is feasible and safe for closure of large perforations after gastric EFTR and could be a propagable and promising technique for clinical practice.
Assuntos
Ressecção Endoscópica de Mucosa , Neoplasias Gástricas , Animais , Suínos , Gastroscopia/métodos , Gastrectomia/métodos , Neoplasias Gástricas/cirurgia , Mucosa , Ressecção Endoscópica de Mucosa/efeitos adversos , Resultado do TratamentoRESUMO
In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this approach makes an innovative improvement in the treatment of G-GISTs that are less than 5 cm in size. Laparoscopy-endoscopy cooperative surgery (LECS) is used to combine endoscopic and laparoscopic surgeries, fully realizing their respective advantages and avoiding their drawbacks. The main steps are as follows. First, gastroscopy and laparoscopy are combined to confirm the location and boundary of the tumor. Tumor resection is carried out laparoscopically, guided by a gastroscope. The specimen is removed orally and the gastric wound closed laparoscopically. Then, gastroscopy and laparoscopy are combined to determine whether there is wound bleeding, if the suture is satisfactory, and if the gastric cavity is deformed. LECS has natural advantages in the treatment of G-GISTs that are less than 5 cm in size. The accurate estimation of tumor location and boundary greatly improves the complete resection rate of tumors. The risk of tumor rupture is substantially reduced, and the long-term prognosis of patients is significantly improved. The process allows for accurate resection of the tumor, maximum preservation of normal gastric tissue and organ function, and avoids postoperative gastric deformation. The patient's postoperative rehabilitation is greatly accelerated, and oral feeding can resume on the day of the operation. The specimen is taken out through the mouth to avoid the need for an extended abdominal incision. This greatly reduces the patient's postoperative pain and scarring. The method greatly shortens the postoperative hospital stay (i.e., discharge is possible on the day after the operation), increasing the turnover of hospital beds.