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1.
Surg Endosc ; 2020 May 19.
Artigo em Inglês | MEDLINE | ID: mdl-32430528

RESUMO

BACKGROUND: The surgery for esophageal cancer arising after prior gastrectomy is technically difficult with high morbidity and mortality. Endoscopic submucosal dissection (ESD) is a minimally invasive endoscopic treatment for superficial SCC with high curative resection rate. But few studies are concerned about ESD under these circumstances. The aim of this study was to elucidate the short- and long-term outcomes of ESD for superficial esophageal squamous cell cancer (SCC) in patients with prior gastrectomy. METHODS: From January 2009 to January 2019, 37 patients with prior gastrectomy who underwent ESD for superficial esophageal SCC were retrospectively enrolled at the Zhongshan Hospital, Fudan University in Shanghai, China. Rates of en bloc resection, complete resection, curative resection, incidence of postoperative bleeding, perforation and postoperative stricture were evaluated as short-term outcomes. Overall survival, and local recurrence-free survival were evaluated as long-term outcomes. RESULTS: The rate of en bloc resection, complete resection and curative resection were 94.6%, 86.5% and 78.4%, respectively. No perforation was observed. 1 (2.7%) patient experienced postoperative bleeding. During the median observation of 43 months, 3 (8.6%) patients experienced esophageal stricture, successfully managed by balloon dilation. 3(8.6%) patients had local recurrence after ESD with 5-year local recurrence-free survival rate of 91.4%. During the observation period, 4 patients died of other reasons. The 1, 3, 5-year overall survival rates were 97.1%, 97.1% and 91.4%. CONCLUSIONS: The short-term outcomes indicate ESD is technically difficult with lower resection completeness in patients after gastrectomy, while the long-term outcomes are rather favorable.

2.
Turk J Gastroenterol ; 31(1): 42-48, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32009613

RESUMO

BACKGROUND/AIMS: Studies evaluating submucosal tunneling endoscopic resection (STER) for the treatment of upper gastrointestinal submucosal tumors (SMTs) have recently increased. However, the efficacy and safety of STER for the treatment of large symptomatic SMTs in the esophagus have not been well investigated. The aim of the present study was to evaluate the efficacy and safety of STER for the treatment of large symptomatic SMTs in the esophagus. METHODS: A total of 24 patients with large symptomatic SMTs in the esophagus who underwent STER in our hospitals between January 2015 and May 2018 were included in the study. The tumors were confirmed to be of muscularis propria layer origin. Treatment outcomes, complications, and follow-up results were retrospectively analyzed. RESULTS: All 24 lesions were resected en bloc with STER. The mean maximum transverse diameter of the lesions was 4.7 (3.5-6.5) cm. The mean maximum longitudinal diameter of the lesions was 2.1 (1.5-3.0) cm. The mean duration from mucosal incision to complete mucosal closure was 65 (50-115) min. Postoperative pathological diagnosis confirmed 18 cases with leiomyomas, 4 cases with stromal tumors, and 2 cases with schwannomas. There were no major complications. There were no residual lesions or disease recurrence during follow-up. CONCLUSION: STER is safe and effective for the treatment of large symptomatic SMTs of muscularis propria layer origin in the esophagus.

3.
Surg Endosc ; 34(1): 159-169, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31139992

RESUMO

BACKGROUND: The endoscopic resection of gastrointestinal mesenchymal tumors (GIMTs) is widely accepted because of its minimal invasiveness. However, one major concern is the high rate of positive microscopic margins remaining following endoscopic resection, which was thought to be related to a higher risk of recurrence. This study aimed to determine whether positive margins affect the recurrence rate of gastric GIMTs and the factors associated with positive margins. METHODS: Patients with gastric GIMTs were recruited retrospectively from January 2008 to December 2013. Clinical and pathological features, endoscopic procedure information, and follow-up data were collected and analyzed. RESULTS: The study included 777 patients. All tumors were removed along with the pseudocapsule without macroscopic residual (ER0), and the median tumor size was 15.2 mm (range 3-100 mm). Pathological evaluation revealed 371(47.7%) GISTs. The rate of microscopic R1 resection rate was 47.0% (443/777). In a stepwise multivariate analysis, a significantly increased incidence of R1 resection was recorded for the GISTs (OR 11.13, 95% CI 3.00-41.37). In a subgroup analysis of GISTs, a univariate analysis revealed that EFTR achieved a higher rate of R0 resection (OR 0.56, 95% CI 0.31-1.00), but it was proven insignificant in a stepwise multivariate analysis. Local recurrence occurred in two patients (0.3%) during a mean follow-up time of 34.2 months. Differences in the recurrence rates between the R0 and R1 groups were statistically insignificant (P = 0.841). CONCLUSIONS: R1 resection for gastric GIMTs is not related to a higher recurrence rate than R0 resection, and ER0 resection is sufficient for gastric GIMTs.

4.
Gastrointest Endosc ; 91(1): 33-40.e1, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31421076

RESUMO

BACKGROUND AND AIMS: We aimed to establish a predictive model and develop a simple risk-scoring system (Zhongshan POEM Score) to help clinicians to characterize high-risk patients for clinical failure after peroral endoscopic myotomy (POEM). METHODS: A total of 1538 patients with achalasia treated with POEM with available follow-up data were included in this study and were randomly classified to the training cohort (n = 769) or internal validation cohort (n = 769). A risk-scoring system was developed using multivariate Cox regression analysis in the training cohort. The system was then internally validated by survival analysis in the validation cohort. RESULTS: During a median follow-up time of 42 months, 109 patients had clinical failure. In the training stage, 3 risk factors for clinical failure were weighted with point values: previous treatment (2 points), intraprocedural mucosal injury (2 points for type I and 6 points for type II), and clinical reflux (3 points). The patients were categorized into low-risk and high-risk groups. In the validation stage, Kaplan-Meier curves differed significantly between the 2 groups. Patients in the high-risk group had a significantly higher risk of clinical failure than those in the low-risk group (hazard ratio, 3.99; 95% confidence interval, 2.31-6.91; P < .001). Satisfactory discrimination and calibration were shown. CONCLUSIONS: This risk-scoring system demonstrated good performance in predicting clinical failure in patients who underwent POEM.

5.
Surg Endosc ; 33(11): 3864-3873, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31376013

RESUMO

BACKGROUND: Endoscopic full-thickness resection (EFTR) provides a significant advancement to the treatment of gastrointestinal submucosal tumors (SMTs). However, technological challenges, particularly in the gastric fundus, hinder its wider application. Here, we investigated the efficacy of a simple traction method that used dental floss and a hemoclip (DFC) to facilitate EFTR. METHODS: Between July 2014 and December 2016, we retrospectively reviewed data from all patients with SMTs in the gastric fundus originating from the muscularis propria layer that were treated by EFTR at Zhongshan Hospital of Fudan University. Baseline characteristics and clinical outcomes, including procedure time and complications rate, were compared between groups of patients receiving DFC-EFTR and conventional EFTR. RESULTS: A total of 192 patients were included in our analysis (64 in the DFC-EFTR group and 128 in the conventional EFTR group). Baseline characteristics for the two groups were similar. The mean time for DFC-EFTR and conventional EFTR was 44.2 ± 24.4 and 54.2 ± 33.2 min, respectively (P = 0.034). Although no serious adverse events presented in any of our cases, post-EFTR electrocoagulation syndrome (PEECS), as a minor complication, was less frequent in the DFC-EFTR group (3.1% vs. 12.5%, P = 0.036). Univariate and multivariate analysis identified that DFC, when used in EFTR, played a significant role in reducing procedure time and the rate of PEECS. The mean procedure time was significantly shorter in the DFC-EFTR group for lesions over 1.0 cm (P = 0.005), when the lesions were located in the greater curvature of the gastric fundus (P = 0.025) or when the lesions presented with intraluminal growth (P = 0.032). Moreover, when EFTR was carried out by experts, the mean procedure time was 20.4% shorter in the DFC-EFTR group (P = 0.038). CONCLUSIONS: This study indicated that DFC-EFTR for SMTs in the gastric fundus resulted in a shorter procedure time and reduced the risk of PEECS, a minor complication.

6.
Surg Endosc ; 2019 Aug 26.
Artigo em Inglês | MEDLINE | ID: mdl-31451922

RESUMO

BACKGROUND: Peroral endoscopic myotomy (POEM) is a safe and effective approach for achalasia. However, the safety, feasibility, perioperative and long-term efficacy in treating geriatric patients has not been well evaluated. METHODS: Data of 2367 patients diagnosed with achalasia and treated with POEM in the Endoscopy Center, Zhongshan Hospital, Fudan University from August 2010 to December 2017 were retrospectively reviewed. Last follow-up was in December 2018. Propensity score matching based on baseline characteristics was used to adjust for confounding. With a caliper of 0.01 in propensity scoring, 139 patients aged ≥ 65 years were matched at a 1:2 ratio with 275 patients aged < 65 years. Perioperative complications and long-term outcomes were compared between the two groups. RESULTS: After propensity score matching, the two groups had similar baseline clinical characteristics and distribution of propensity scores. The mean age was 70.22 years in geriatric patients and 42.02 in younger patients. Technical failure occurred in one geriatric and one non-geriatric patients (p = 0.485). The procedural time in geriatric patients was similar to younger patients [50 (interquartile range (IQR) 36-76) vs. 50 (IQR 36-70) min, p = 0.398]. There were also no significant differences in major perioperative adverse events (2.88% vs. 2.18%, p = 0.663) and hospitalization length (median 3 vs. 3 days, p = 0.488). During a median follow-up period of 41 months (IQR 26-60), mean decrease in Eckardt score and pressure of the LES were 6.63 and 11.9 mmHg in geriatric patients, which were similar to the change in non-geriatric patients (6.49 and 11.6 mmHg, p = 0.652 and 0.872, respectively). Clinical reflux occurred in 23.53% geriatric patients and 21.59% non-geriatric patients (p = 0.724). 5-year success rate of 92.94% was achieved in geriatric patients and 92.61% in younger patients (log-rank p = 0.737). CONCLUSIONS: POEM is a safe and reliable treatment in geriatric achalasia patients with confirmed short-term and long-term efficacy compared with those in non-geriatric patients.

7.
J Cancer ; 10(11): 2415-2424, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31258746

RESUMO

Esophageal cancer is one of the most aggressive and lethal gastrointestinal tract malignancies, with a poor overall five-year survival rate. Cordycepin, a major compound of Cordyceps sinensis, has been shown to have anticancer potential. This study focuses on the anticancer properties of cordycepin that target esophageal cancer and reveals molecular aspects underlying these effects. In our CCK-8 assays and colony formation assays, cordycepin significantly suppressed esophageal cancer cell proliferation. Moreover, cordycepin induced chromatin condensation in esophageal cancer cells and significantly increased the number of apoptotic cells through activation of caspase cascades, apoptotic signaling, and the regulation of Bcl-2 family members. Cell cycle assays showed that cordycepin altered cyclin-dependent kinase1 and cyclinB1 expression, which resulted in a G2/M phase blockade. Mechanistically, ERK pathway inactivation was involved in the anti-tumor functions of cordycepin. The same results were also observed in vivo. Taken together, these findings reveal that cordycepin induces pro-apoptosis and anti-proliferation mechanisms in cancer cells, and may represent a novel therapeutic agent.

8.
J Laparoendosc Adv Surg Tech A ; 29(7): 921-925, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31210576

RESUMO

Objective: Synchronous multiple primary early esophageal cancers (SMPEEC) are rare and aggressive. Early detection of esophageal cancer can improve survival rate. Endoscopic submucosal dissection (ESD) is a minimally invasive endoscopic treatment of early esophageal cancers. However, ESD for SMPEEC is little known. We aimed to clarify the clinical outcomes of simultaneous ESD treating SMPEEC. Methods: We retrospectively reviewed the medical data of 34 patients, who underwent ESD for SMPEEC at Endoscopy Center of Zhongshan Hospital, Fudan University, between May 2013 and December 2014. The data of lesion size, histopathology, en bloc resection, curative resection, complication, and tumor local recurrence were analyzed. Results: Among 34 patients, 67 lesions were removed simultaneously in 33 cases; 2 lesions were removed in 2 operations for 1 case. For the simultaneous resection, the en bloc rate was 97.01% (65/67) and the curative resection rate was 92.54% (62/67). Postoperative stricture occurred in two cases and delayed bleeding occurred in one case. There was one local recurrence, no metastasis or procedure-related death. Conclusions: Simultaneous ESD as a treatment for SMPEEC is technically feasible, benefited from reducing hospitalization time and medical expenses. For the cases with risk factors of complications, simultaneous ESD needs to be avoided.


Assuntos
Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas/cirurgia , Recidiva Local de Neoplasia/etiologia , Neoplasias Primárias Múltiplas/cirurgia , Hemorragia Pós-Operatória/etiologia , Idoso , Idoso de 80 Anos ou mais , Competência Clínica , Ressecção Endoscópica de Mucosa/efeitos adversos , Estenose Esofágica/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
9.
Neurogastroenterol Motil ; 31(5): e13565, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30868687

RESUMO

BACKGROUND: Achalasia is a motility disorder of unknown etiology. Previous studies supported the hypothesis that autoimmune-mediated inflammatory responses produce inhibitory neuronal degeneration. This study was designed to explore the role of mast cells in achalasia. METHODS: We collected information from 116 patients with achalasia who underwent peroral endoscopic myotomy between December 2016 and May 2017. Lower esophageal sphincter (LES) muscle biopsy was performed in all patients with achalasia, as well as 20 control subjects. The number of mast cells, interstitial cells of Cajal (ICCs), nNOS-positive cells, and S-100-positive cells in the LES were evaluated by immunohistochemistry. Pathological and clinical data were compared between groups. KEY RESULTS: Compared with controls, the LES of patients with achalasia had significantly fewer ICCs, nNOS-positive cells, and S-100-positive cells and a higher number of mast cells (all P < 0.001). Furthermore, the increased mast cell infiltration was significantly associated with decreased ICCs, nNOS-positive cells, and S-100-positive cells in patients with achalasia (all P < 0.05). Clinically, the number of strongly positive mast cells was highest in patients with type I achalasia and lowest in those with type III achalasia (P < 0.001). In addition, patients with a history of autoimmune disease or viral infection had greater mast cell infiltration in the LES muscle (P = 0.040). CONCLUSIONS & INFERENCES: In patients with achalasia, mast cell infiltration in the LES muscle is increased, in association with loss of ICCs and neuronal degeneration. Mast cells may thereby play a crucial role in the development of achalasia.


Assuntos
Acalasia Esofágica/patologia , Células Intersticiais de Cajal/patologia , Mastócitos/patologia , Degeneração Neural/patologia , Adolescente , Adulto , Idoso , Criança , Esfíncter Esofágico Inferior/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem
10.
World J Gastroenterol ; 25(7): 744-776, 2019 Feb 21.
Artigo em Inglês | MEDLINE | ID: mdl-30809078

RESUMO

With the digestive endoscopic tunnel technique (DETT), many diseases that previously would have been treated by surgery are now endoscopically curable by establishing a submucosal tunnel between the mucosa and muscularis propria (MP). Through the tunnel, endoscopic diagnosis or treatment is performed for lesions in the mucosa, in the MP, and even outside the gastrointestinal (GI) tract. At present, the tunnel technique application range covers the following: (1) Treatment of lesions originating from the mucosal layer, e.g., endoscopic submucosal tunnel dissection for oesophageal large or circular early-stage cancer or precancerosis; (2) treatment of lesions from the MP layer, per-oral endoscopic myotomy, submucosal tunnelling endoscopic resection, etc.; and (3) diagnosis and treatment of lesions outside the GI tract, such as resection of lymph nodes and benign tumour excision in the mediastinum or abdominal cavity. With the increasing number of DETTs performed worldwide, endoscopic tunnel therapeutics, which is based on DETT, has been gradually developed and optimized. However, there is not yet an expert consensus on DETT to regulate its indications, contraindications, surgical procedure, and postoperative treatment. The International DETT Alliance signed up this consensus to standardize the procedures of DETT. In this consensus, we describe the definition, mechanism, and significance of DETT, prevention of infection and concepts of DETT-associated complications, methods to establish a submucosal tunnel, and application of DETT for lesions in the mucosa, in the MP and outside the GI tract (indications and contraindications, procedures, pre- and postoperative treatments, effectiveness, complications and treatments, and a comparison between DETT and other operations).


Assuntos
Consenso , Doenças do Sistema Digestório/cirurgia , Ressecção Endoscópica de Mucosa/normas , Complicações Pós-Operatórias/prevenção & controle , Endoscópios Gastrointestinais , Ressecção Endoscópica de Mucosa/efeitos adversos , Ressecção Endoscópica de Mucosa/instrumentação , Ressecção Endoscópica de Mucosa/métodos , Humanos , Seleção de Pacientes , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/normas , Complicações Pós-Operatórias/etiologia , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/normas , Resultado do Tratamento
12.
Surg Endosc ; 33(8): 2553-2561, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30478693

RESUMO

BACKGROUND: Gastric small submucosal tumors (SMTs) are becoming increasingly common. However, the fundus of stomach is regarded as a difficult area for endoscopic resection (ER). In this study, we investigated the efficacy, safety, and long-term outcomes of ER for small SMTs of the gastric fundus in a large series of patients, research that was previously lacking. METHODS: 537 consecutive patients with SMTs no more than 20 mm in diameter, occurring in the gastric fundus and originating from the muscularis propria layer, which were treated with endoscopic submucosal excavation or endoscopic full-thickness resection (EFTR) were included in this retrospective study at Zhongshan Hospital of Fudan University from January 2013 to September 2016. Clinicopathological, endoscopic, and follow-up data were collected and analyzed. RESULTS: En bloc resection was achieved in 100% of patients, and complete resection was achieved for 530 (98.7%) lesions. Although the total rate of complications was 9.3%, few serious adverse events occurred in only three (0.6%) patients, including major pneumoperitoneum, major hydrothorax, and bleeding. Unlike lager tumor sizes and longer procedure times, endoscopist experience had a positive impact on decreasing the likelihood of complications. Based on statistical analysis, tumors with greater size near the cardia, which were treated by EFTR, were the significant contributors to longer operative times. A median follow-up of 32 months was available, and all patients were free from local recurrence or distant metastasis during the study period. CONCLUSIONS: Although the gastric fundus presents technical difficulties, ER is effective for the resection of small gastric SMTs with a high complete resection rate and rare serious adverse events.


Assuntos
Ressecção Endoscópica de Mucosa/métodos , Fundo Gástrico/cirurgia , Mucosa Gástrica/cirurgia , Tumores do Estroma Gastrointestinal/cirurgia , Leiomioma/cirurgia , Neurilemoma/cirurgia , Neoplasias Gástricas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Seguimentos , Fundo Gástrico/diagnóstico por imagem , Fundo Gástrico/patologia , Mucosa Gástrica/diagnóstico por imagem , Mucosa Gástrica/patologia , Tumores do Estroma Gastrointestinal/diagnóstico por imagem , Tumores do Estroma Gastrointestinal/patologia , Humanos , Leiomioma/diagnóstico por imagem , Leiomioma/patologia , Masculino , Pessoa de Meia-Idade , Neurilemoma/diagnóstico por imagem , Neurilemoma/patologia , Estudos Retrospectivos , Neoplasias Gástricas/diagnóstico por imagem , Neoplasias Gástricas/patologia , Resultado do Tratamento
13.
Gastrointest Endosc ; 89(4): 806-815.e1, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30452913

RESUMO

BACKGROUND AND AIMS: According to guidelines, endoscopic resection should only be performed for patients whose early gastric cancer invasion depth is within the mucosa or submucosa of the stomach regardless of lymph node involvement. The accurate prediction of invasion depth based on endoscopic images is crucial for screening patients for endoscopic resection. We constructed a convolutional neural network computer-aided detection (CNN-CAD) system based on endoscopic images to determine invasion depth and screen patients for endoscopic resection. METHODS: Endoscopic images of gastric cancer tumors were obtained from the Endoscopy Center of Zhongshan Hospital. An artificial intelligence-based CNN-CAD system was developed through transfer learning leveraging a state-of-the-art pretrained CNN architecture, ResNet50. A total of 790 images served as a development dataset and another 203 images as a test dataset. We used the CNN-CAD system to determine the invasion depth of gastric cancer and evaluated the system's classification accuracy by calculating its sensitivity, specificity, and area under the receiver operating characteristic curve. RESULTS: The area under the receiver operating characteristic curve for the CNN-CAD system was .94 (95% confidence interval [CI], .90-.97). At a threshold value of .5, sensitivity was 76.47%, and specificity 95.56%. Overall accuracy was 89.16%. Positive and negative predictive values were 89.66% and 88.97%, respectively. The CNN-CAD system achieved significantly higher accuracy (by 17.25%; 95% CI, 11.63-22.59) and specificity (by 32.21%; 95% CI, 26.78-37.44) than human endoscopists. CONCLUSIONS: We constructed a CNN-CAD system to determine the invasion depth of gastric cancer with high accuracy and specificity. This system distinguished early gastric cancer from deeper submucosal invasion and minimized overestimation of invasion depth, which could reduce unnecessary gastrectomy.


Assuntos
Carcinoma/patologia , Mucosa Gástrica/patologia , Gastroscopia/métodos , Redes Neurais de Computação , Neoplasias Gástricas/patologia , Inteligência Artificial , Carcinoma/diagnóstico , Carcinoma/cirurgia , Diagnóstico por Computador/métodos , Ressecção Endoscópica de Mucosa , Feminino , Gastrectomia , Mucosa Gástrica/cirurgia , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Invasividade Neoplásica , Curva ROC , Sensibilidade e Especificidade , Membrana Serosa/patologia , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/cirurgia
14.
Endoscopy ; 51(4): 307-316, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30261536

RESUMO

BACKGROUND: Peroral endoscopic myotomy (POEM) is a treatment option for patients with previous surgical or endoscopic treatment. We aimed to evaluate the influence of prior treatment on perioperative and follow-up outcomes in patients undergoing POEM. METHODS: From August 2010 to December 2014, a total of 1384 patients with achalasia underwent POEM at our center. We retrospectively reviewed 849 patients who completed follow-up. Patients with an Eckardt score ≥ 4 after POEM were considered to have a clinical failure. We compared variables between patients with and without prior treatment. We analyzed risk factors for perioperative major adverse events, and clinical reflux and failure during follow-up.  RESULTS: 245 patients (28.9 %) had undergone prior treatment, and 34 patients (4.0 %) experienced a major adverse event associated with the POEM procedure. During a median follow-up of 23 months (range 1 - 71), clinical reflux occurred in 203 patients (23.9 %) and clinical failure was recorded for 94 patients (11.1 %). Patients with prior treatment had a longer procedure duration (P = 0.001) and longer hospital stay after POEM (P = 0.001). Prior treatment was not an independent risk factor for major adverse events or clinical reflux (odds ratio [OR] 1.19, P = 0.65; OR 1.26, P = 0.19; logistic regression), but it did increase the rate of clinical failure during follow-up (hazard ratio 1.90, P = 0.002; Cox regression). CONCLUSIONS: POEM was performed safely with a low rate of major adverse events in patients with achalasia who had undergone prior surgical or endoscopic treatment. However, prior treatment increased the risk of clinical failure after POEM.


Assuntos
Endoscopia do Sistema Digestório , Acalasia Esofágica , Refluxo Gastroesofágico , Miotomia , Cirurgia Endoscópica por Orifício Natural , Complicações Pós-Operatórias/diagnóstico , Reoperação , China/epidemiologia , Endoscopia do Sistema Digestório/efeitos adversos , Endoscopia do Sistema Digestório/métodos , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/epidemiologia , Acalasia Esofágica/cirurgia , Feminino , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/etiologia , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Miotomia/efeitos adversos , Miotomia/métodos , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Cirurgia Endoscópica por Orifício Natural/métodos , Duração da Cirurgia , Avaliação de Processos e Resultados em Cuidados de Saúde , Reoperação/efeitos adversos , Reoperação/métodos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco
15.
Gastrointest Endosc ; 89(4): 769-778, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30218646

RESUMO

BACKGROUND AND AIMS: Mucosal injury (MI) is one of the most common perioperative adverse events of per-oral endoscopic myotomy (POEM). Severe undertreated MI may lead to contamination of the tunnel and even mediastinitis. This study explored the characteristics, predictors, and management approaches of intraoperative MI. METHODS: A retrospective review of the prospectively collected database at a large tertiary referral endoscopy unit was conducted for all patients undergoing POEM between August 2010 and March 2016. MI was graded according to the difficulty of repair (I, easy to repair; II, difficult to repair). The primary outcomes were the incidence and predictors of intraoperative MI. Secondary outcomes were MI details and the corresponding treatment. RESULTS: POEM was successfully performed in 1912 patients. A total of 338 patients experienced 387 MIs, for an overall frequency of 17.7% (338/1912). Type II MI was rare, with a frequency of 1.7% (39/1912). Major adverse events were more common in patients with MI than in those without MI (6.2% vs 2.5%, P < .001). On multivariable analysis, MI was independently associated with previous Heller myotomy (odds ratio [OR], 2.094; P = .026), previous POEM (OR, 2.441; P = .033), submucosal fibrosis (OR, 4.530; P < .001), mucosal edema (OR, 1.834; P = .001), and tunnel length ≥13 cm (OR, 2.699; P < .001). Previous POEM (OR, 5.005; P = .030) and submucosal fibrosis (OR, 12.074; P < .001) were significant predictors of type II MI. POEM experience >1 year was a protective factor for MI (OR, .614; P = .042) and type II MI (OR, .297; P = .042). CONCLUSIONS: MI during POEM is common, but type II injury is rare. Previous POEM and submucosal fibrosis were significant predictors of type II mucosal injury. POEM experience after the learning curve reduces the risk of MI.


Assuntos
Acalasia Esofágica/cirurgia , Mucosa Esofágica/lesões , Mucosa Gástrica/lesões , Complicações Intraoperatórias/epidemiologia , Piloromiotomia/efeitos adversos , Gastropatias/epidemiologia , Adulto , Cárdia/lesões , Edema/epidemiologia , Endoscopia do Sistema Digestório , Doenças do Esôfago/epidemiologia , Doenças do Esôfago/etiologia , Perfuração Esofágica/epidemiologia , Perfuração Esofágica/etiologia , Perfuração Esofágica/cirurgia , Feminino , Fibrose/epidemiologia , Fundo Gástrico/lesões , Miotomia de Heller/estatística & dados numéricos , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/cirurgia , Modelos Logísticos , Masculino , Mediastinite/epidemiologia , Mediastinite/etiologia , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Gastropatias/etiologia , Adulto Jovem
16.
Clin Gastroenterol Hepatol ; 17(1): 73-81.e3, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29704682

RESUMO

BACKGROUND & AIMS: Esophagectomy is the standard treatment for early-stage esophageal squamous cell carcinoma (EESCC), but patients who undergo this procedure have high morbidity and mortality. Endoscopic submucosal dissection (ESD) is a less-invasive procedure for treatment of EESCC, but is considered risky because this tumor frequently metastasizes to the lymph nodes. We aimed to directly compare outcomes of patients with EESCC treated with ESD vs esophagectomy. METHODS: We performed a retrospective cohort study of patients with T1a-m2/m3, or T1b EESCCs who underwent ESD (n = 322) or esophagectomy (n = 274) from October 1, 2011 through September 31, 2016 at Zhongshan Hospital in Shanghai, China. The primary outcome was all-cause mortality at the end of follow up (minimum of 6 months). Secondary outcomes included operation time, hospital stay, cost, perioperative mortalities/severe non-fatal adverse events, requirement for adjuvant therapies, and disease-specific mortality and cancer recurrence or metastasis at the end of the follow up period. RESULTS: Patients who underwent ESD were older (mean 63.5 years vs 62.3 years for patients receiving esophagectomy; P = .006) and a greater proportion was male (80.1% vs 70.4%; P = .006) and had a T1a tumor (74.5% vs 27%; P = .001). A lower proportion of patients who underwent ESD had perioperative mortality (0.3% vs 1.5% of patients receiving esophagectomy; P = .186) and non-fatal severe adverse events (15.2% vs 27.7%; P = .001)-specifically lower proportions of esophageal fistula (0.3% of patients receiving ESD vs 16.4% for patients receiving esophagectomy; P = .001) and pulmonary complications (0.3% vs 3.6%; P = .004). After a median follow-up time of 21 months (range, 6-73 months), there were no significant differences between treatments in all-cause mortality (7.4% for ESD vs 10.9%; P = .209) or rate of cancer recurrence or metastasis (9.1% for ESD vs 8.9%; P = .948). Disease-specific mortality was lower among patients who received ESD (3.4%) vs patients who patients who received esophagectomy (7.4%) (P = .049). In Cox regression analysis, depth of tumor invasion was the only factor associated with all-cause mortality (T1a-m3 or deeper vs T1a-m2: hazard ration, 3.54; P = .04). CONCLUSION: In a retrospective study of patients with T1am2/m3 or T1b EESCCs treated with ESD (n = 322) or esophagectomy (n = 274), we found lower proportions of patients receiving ESD to have perioperative adverse events or disease specific mortality after a median follow up time of 21 months. We found no difference in overall survival or cancer recurrence or metastasis in patients with T1a or T1b ESCCs treated with ESD vs esophagectomy.


Assuntos
Ressecção Endoscópica de Mucosa/métodos , Neoplasias Esofágicas/cirurgia , Carcinoma de Células Escamosas do Esôfago/cirurgia , Esofagectomia/métodos , Idoso , China , Feminino , Custos de Cuidados de Saúde , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento
17.
J Laparoendosc Adv Surg Tech A ; 28(10): 1261-1265, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29873625

RESUMO

BACKGROUND: Endoscopic full-thickness resection (EFTR) derived from endoscopic submucosal dissection has gradually been accepted and even promoted for the treatment of submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. However, there are some difficulties when EFTR is used to treat MP lesions in the gastric fundus. This study intends to explore whether EFTR can be made simpler, safer, and more effective with the traction assistance of dental floss. METHODS: The clinical data of patients (trial group) with lesions in the MP layer in the gastric fundus undergoing EFTR with traction assistance of dental floss at Zhongshan Hospital, in 2016, were reviewed retrospectively. The control group was matched with the trial group according to tumor size. The differences in tumor resection time, patient hospitalization time, and complication rate were evaluated. RESULTS: There was no significant difference in the average age of the two groups, each of which comprised 24 cases (58.7 ± 11.8 years versus 56.6 ± 7.9 years, t = 0.663, P = .511). However, there was a statistically significant difference in the operative time between the two groups (10.8 ± 2.8 minutes versus 19.0 ± 4.7 minutes, t = 7.298, P < .05). There was no statistically significant difference in the length of the postoperative hospital stay (3.2 ± 0.5 days versus 3.2 ± 0.5 days, t = 0.291, P = .772). In the trial group, there were 19 cases of gastrointestinal stromal tumors (group 1) and 5 cases of leiomyoma. The control group had similar results. Neither group experienced postoperative delayed bleeding, perforation, or other complications. CONCLUSIONS: When EFTR is used to treat SMTs originating from the MP in the gastric fundus, dental floss traction assistance can relieve the tumor boundary to simplify the surgical procedure and save the operation time.


Assuntos
Ressecção Endoscópica de Mucosa/métodos , Fundo Gástrico/patologia , Gastroscopia/métodos , Neoplasias Gástricas/cirurgia , Adulto , Idoso , Dispositivos para o Cuidado Bucal Domiciliar , Ressecção Endoscópica de Mucosa/efeitos adversos , Feminino , Seguimentos , Fundo Gástrico/cirurgia , Mucosa Gástrica/patologia , Mucosa Gástrica/cirurgia , Gastroscopia/efeitos adversos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Neoplasias Gástricas/patologia , Tração , Resultado do Tratamento
18.
Cancer Commun (Lond) ; 38(1): 3, 2018 03 21.
Artigo em Inglês | MEDLINE | ID: mdl-29764504

RESUMO

BACKGROUND: Colorectal carcinomas (CRCs) arise from premalignant precursors in an adenoma-carcinoma sequence, in which adenoma with high-grade dysplasia (HGD) and early-stage carcinoma are defined as advanced neoplasia. A limited number of studies have evaluated the long-term outcomes of endoscopic submucosal dissection (ESD) for advanced colorectal neoplasia. This study aimed to assess the efficacy and safety of ESD for advanced colorectal neoplasia as well as the long-term outcomes, including local recurrence and metastasis. METHODS: We analyzed data collected from 610 consecutive patients with 616 advanced colorectal neoplasia lesions treated with ESD between January 2007 and December 2013. Clinical, endoscopic, and histological data were collected over a median follow-up period of 58 months to determine tumor stage and type, resection status, complications, tumor recurrence, and distant metastasis. RESULTS: The overall rates of en bloc resection, histological complete resection, and major complications were 94.3%, 89.4%, and 2.3%, respectively. Hybrid ESD was an independent factor of piecemeal resection. Tumor location in the colon was associated with increased risk of ESD-related complications. During the follow-up period, all patients remained free of metastasis. However, local recurrence occurred in 4 patients (0.8%); piecemeal resection was a risk factor. CONCLUSIONS: ESD is effective and safe for resection of advanced colorectal neoplasia, with a high en bloc resection rate and favorable long-term outcomes. ESD is indicated for the treatment of HGD and early-stage CRC to obtain curative resection and reduce local recurrence rate.


Assuntos
Colo/cirurgia , Colonoscopia/métodos , Neoplasias Colorretais/cirurgia , Ressecção Endoscópica de Mucosa/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Colo/patologia , Colonoscopia/efeitos adversos , Neoplasias Colorretais/patologia , Dissecação/efeitos adversos , Dissecação/métodos , Ressecção Endoscópica de Mucosa/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Hemorragia Pós-Operatória/etiologia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
19.
J Laparoendosc Adv Surg Tech A ; 28(9): 1068-1073, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29620969

RESUMO

OBJECTIVE: With the improvement of endoscopic diagnosis, the discovery rate of the synchronous multiple primary early cancers in esophagus and stomach is gradually increased, while the traditional surgery bringing serious damages. Endoscopic submucosal dissection (ESD) has become the first treatment option of early cancer in the digestive tract partly. This study intends to explore the feasibility, safety, and effectiveness of ESD in the treatment of the synchronous multiple early gastric cancer or precancerous lesions in the esophagus and stomach. METHODS: From January 2008 to December 2016, data of 12 patients with early esophageal cancer and early gastric cancer treated by ESD in the Endoscopy Center of Zhongshan Hospital, Fudan University were reviewed. We analyzed the patient's history, the size of esophageal and gastric lesions, pathological results, the results of complete or curative resection, and so on. RESULTS: Among the 12 patients described in this study, all were diagnosed with synchronous multiple primary early cancers in the esophagus and stomach. Lesions were removed by ESD in 10 cases at the same time and were removed by stage in 2 cases. The complete resection rate was 100% (24/24), and the curative resection rate was 100% (24/24). Postoperative esophageal stricture occurred in 2 cases, which improved after dilation. Median follow-up time was 30 (8-115) months, when 9 patients survived and 3 patients died. However, the cause of death was not associated with treatment of this disease. CONCLUSION: ESD is a minimally invasive endoscopic surgery, which can be used as a method of treating synchronous multiple primary early cancers in the esophagus and stomach.


Assuntos
Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas/cirurgia , Neoplasias Primárias Múltiplas/cirurgia , Neoplasias Gástricas/cirurgia , Idoso , Dissecação/métodos , Ressecção Endoscópica de Mucosa/efeitos adversos , Neoplasias Esofágicas/patologia , Estenose Esofágica/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Primárias Múltiplas/patologia , Estudos Retrospectivos , Neoplasias Gástricas/patologia , Taxa de Sobrevida , Resultado do Tratamento , Carga Tumoral
20.
Gastrointest Endosc ; 88(1): 160-167, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29499127

RESUMO

BACKGROUND AND AIMS: The management of subepithelial tumors with a predominant extraluminal growth pattern or extra-GI tumors can be challenging and traditionally requires a surgical resection that is not only invasive but may carry a significant risk of morbidity and mortality. We aimed to assess the feasibility, safety, and efficacy of a novel endoscopic technique termed submucosal tunnel endoscopic resection for extraluminal tumors (STER-ET). METHODS: We prospectively enrolled patients who underwent STER-ET for GI subepithelial tumors with a predominant extraluminal growth pattern or extra-GI tumors located at the level of cardia or the proximal part of the lesser curvature of the stomach seen on cross-sectional imaging between January 2016 and March 2017. RESULTS: Eight patients underwent STER-ET. The mean (± standard deviation) tumor size was 2.8 ± 0.6 cm and 2.3 ± 0.8 cm in longest and shortest dimension, respectively. The average procedure time was 67 ± 4.4 minutes. The rates of curative en bloc resection and en bloc retrieval was 100% and 87.5%, respectively. On final histology, 6 tumors were GI stromal tumors, 1 was a schwannoma, and 1 was a foregut cyst. Five patients had capnoperitoneum during the procedure and required abdominal decompression. One patient had a small mucosotomy successfully treated with a hemostatic clip. There were no major adverse events or deaths. The median length of hospital stay was 3 days. There was no residual tumor on surveillance imaging after a mean follow-up period of 10.0 ± 2.1 months. CONCLUSIONS: STER-ET is a novel technique that appears to be safe and effective in achieving a curative resection for GI subepithelial tumors with a predominantly extraluminal growth pattern or extraluminal tumors in a selected group of patients. However, larger studies are required to validate our finding.


Assuntos
Cistos/cirurgia , Ressecção Endoscópica de Mucosa/métodos , Endoscopia do Sistema Digestório/métodos , Junção Esofagogástrica/cirurgia , Tumores do Estroma Gastrointestinal/cirurgia , Neurilemoma/cirurgia , Neoplasias Gástricas/cirurgia , Idoso , Cistos/diagnóstico por imagem , Cistos/patologia , Junção Esofagogástrica/diagnóstico por imagem , Junção Esofagogástrica/patologia , Feminino , Tumores do Estroma Gastrointestinal/diagnóstico por imagem , Tumores do Estroma Gastrointestinal/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Neurilemoma/diagnóstico por imagem , Neurilemoma/patologia , Estudos Prospectivos , Neoplasias Gástricas/diagnóstico por imagem , Neoplasias Gástricas/patologia , Tomografia Computadorizada por Raios X , Carga Tumoral
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