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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.
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.

3.
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.

4.
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.

5.
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.

6.
Gastrointest Endosc ; 90(5): 745-753.e2, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31302091

RESUMO

BACKGROUND AND AIMS: Few artificial intelligence-based technologies have been developed to improve the efficiency of screening for esophageal squamous cell carcinoma (ESCC). Here, we developed and validated a novel system of computer-aided detection (CAD) using a deep neural network (DNN) to localize and identify early ESCC under conventional endoscopic white-light imaging. METHODS: We collected 2428 (1332 abnormal, 1096 normal) esophagoscopic images from 746 patients to set up a novel DNN-CAD system in 2 centers and prepared a validation dataset containing 187 images from 52 patients. Sixteen endoscopists (senior, mid-level, and junior) were asked to review the images of the validation set. The diagnostic results, including accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were compared between the DNN-CAD system and endoscopists. RESULTS: The receiver operating characteristic curve for DNN-CAD showed that the area under the curve was >96%. For the validation dataset, DNN-CAD had a sensitivity, specificity, accuracy, PPV, and NPV of 97.8%, 85.4%, 91.4%, 86.4%, and 97.6%, respectively. The senior group achieved an average diagnostic accuracy of 88.8%, whereas the junior group had a lower value of 77.2%. After referring to the results of DNN-CAD, the average diagnostic ability of the endoscopists improved, especially in terms of sensitivity (74.2% vs 89.2%), accuracy (81.7% vs 91.1%), and NPV (79.3% vs 90.4%). CONCLUSIONS: The novel DNN-CAD system used for screening of early ESCC has high accuracy and sensitivity, and can help endoscopists to detect lesions previously ignored under white-light imaging.


Assuntos
Aprendizado Profundo , Endoscopia Gastrointestinal , Carcinoma de Células Escamosas do Esôfago/diagnóstico por imagem , Interpretação de Imagem Assistida por Computador/métodos , Reconhecimento Automatizado de Padrão , Adulto , Idoso , Área Sob a Curva , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Curva ROC , Reprodutibilidade dos Testes , Adulto Jovem
7.
Surg Endosc ; 33(11): 3605-3611, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31240477

RESUMO

BACKGROUND: Standard treatment for nonampullary duodenal tumors has not yet been established. In case of tumors originated from the muscularis propria (MP) layer and adherent to the serosa layer, the lesions can not be completely removed by ESD. However, with the development of the endoscopic suture technique, endoscopic full-thickness resection (EFTR) of duodenal subepithelial lesions has become possible. METHODS: We retrospectively analyzed 32 patients with nonampullary duodenal subepithelial lesions who underwent EFTR between February 2012 and January 2017. The suturing method, complications that occurred during and after the operations, perioperative management, tumor characteristics, and pathological findings were analyzed in all patients. RESULTS: The complete resection rate was 100%; all patients successfully received EFTR except for one patient who required conversion to open surgery. Severe abdominal pain was observed after the operation in one patient who then received laparoscopic exploration, and the possibility of delayed perforation was considered. Another patient showed a decline in blood oxygen saturation (SO2) and was transferred to the intensive care unit (ICU) for further management. Delayed bleeding and fistula were not observed. All patients achieved complete remission. CONCLUSION: EFTR is a safe, minimally invasive treatment modality that ensures complete eradication of the duodenal subepithelial lesions.


Assuntos
Neoplasias Duodenais/cirurgia , Recidiva Local de Neoplasia/cirurgia , Técnicas de Sutura , Adulto , Idoso , Idoso de 80 Anos ou mais , China , Neoplasias Duodenais/mortalidade , Neoplasias Duodenais/patologia , Endoscopia/métodos , Feminino , Tumores do Estroma Gastrointestinal/mortalidade , Tumores do Estroma Gastrointestinal/patologia , Tumores do Estroma Gastrointestinal/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Estudos Retrospectivos , Resultado do Tratamento
8.
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
9.
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
10.
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
11.
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
12.
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
13.
Appl Physiol Nutr Metab ; 44(1): 1-6, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29742356

RESUMO

Schisandrin B (Sch B), one of the main effective components of the dried fruit of Schisandra chinensis, protects neurons from oxidative stress in the central nervous system. Here we investigated the neuroprotective effect of Sch B against damage caused by acute oxidative stress and attempted to define the possible mechanisms. Using the elevated plus maze and open field test, we found that forced swimming, an acute stressor, significantly induced anxiety-like behavior that was alleviated by oral Sch B treatment. In addition, the Sch B treatment reduced toxicity, malondialdehyde levels, and production of reactive oxygen species, an important factor for neuron damage. Antioxidants under the control of the nuclear factor erythroid 2-related factor 2 (Nrf2) pathway, such as superoxide dismutase and glutathione, were significantly increased by Sch B treatment. Moreover, a higher percentage of intact cells in the amygdala of treated mice, revealed by Nissl staining, further verified the neuroprotective effect of Sch B. Several proteins, such as Nrf2 and its endogenous inhibitor Kelch-like ECH-associated protein 1 (Keap1), were abnormally expressed in mice subjected to forced swimming, but this abnormal expression was significantly reversed by Sch B treatment. Our results suggest that Sch B may be a potential therapeutic agent against anxiety associated with oxidative stress. The possible mechanism is neuroprotection through enhanced antioxidant activity.


Assuntos
Tonsila do Cerebelo/efeitos dos fármacos , Ansiolíticos/farmacologia , Antioxidantes/farmacologia , Ansiedade/tratamento farmacológico , Comportamento Animal/efeitos dos fármacos , Proteína 1 Associada a ECH Semelhante a Kelch/metabolismo , Lignanas/farmacologia , Fator 2 Relacionado a NF-E2/metabolismo , Fármacos Neuroprotetores/farmacologia , Estresse Oxidativo/efeitos dos fármacos , Compostos Policíclicos/farmacologia , Estresse Psicológico/tratamento farmacológico , Tonsila do Cerebelo/metabolismo , Tonsila do Cerebelo/fisiopatologia , Animais , Ansiedade/metabolismo , Ansiedade/fisiopatologia , Ansiedade/psicologia , Ciclo-Octanos/farmacologia , Modelos Animais de Doenças , Glutationa/metabolismo , Masculino , Malondialdeído/metabolismo , Camundongos Endogâmicos C57BL , Espécies Reativas de Oxigênio/metabolismo , Transdução de Sinais/efeitos dos fármacos , Estresse Psicológico/metabolismo , Estresse Psicológico/fisiopatologia , Estresse Psicológico/psicologia , Superóxido Dismutase/metabolismo
14.
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
15.
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
16.
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
17.
Endoscopy ; 50(9): 839-845, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29548040

RESUMO

BACKGROUND: According to the Japanese Esophageal Society (JES) guidelines, early esophageal squamous cell carcinoma (SCC) involving the muscularis mucosae (M3) or upper submucosal (SM1) layers are relative indications for endoscopic submucosal dissection (ESD). Additional esophagectomy or chemoradiotherapy is recommended for patients with relative indications after evaluation. However, elderly patients (≥ 60 years) with relative indications in China often refuse additional treatment because of the debilitating side effects. The aim of this study was to evaluate the long-term outcomes of elderly patients with relative indications who did not undergo additional treatment after ESD. METHODS: Data from elderly patients with relative indications who underwent ESD for early esophageal SCC between January 2008 and December 2013 were reviewed retrospectively. Stricture and recurrence, and 5-year progression-free survival (PFS) and overall survival rates were compared with patients with absolute indications for ESD. RESULTS: 158 elderly patients were included and analyzed (89 in the absolute indications group and 69 in the relative indications group). The baseline characteristics were balanced between the two groups. During 56 months (range 1 - 108) of follow-up, the postoperative stricture rates were similar in the absolute and relative indications groups (21.3 % vs. 31.9 %; P  = 0.13). The hazard ratio (HR) for PFS in the absolute vs. the relative indications groups was 1.025 (95 % confidence interval [CI] 0.36 - 2.95; P = 0.96). The 5-year PFS rates were 90.5 % (95 %CI 83.44 - 97.56) and 90.8 % (95 %CI 83.74 - 97.86) for the absolute and relative indications groups, respectively. The HR for overall survival in the absolute vs. the relative indications groups was 0.564 (95 %CI 0.13 - 2.52; P = 0.45). The 5-year overall survival rates were 96.6 % (95 %CI 92.88 - 100) and 95.6 % (95 %CI 90.70 - 100) for the absolute and relative indications groups, respectively. CONCLUSIONS: Based on this study, regular follow-up without additional treatment may be considered as another choice for elderly patients with early esophageal SCC and relative indications after ESD.


Assuntos
Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas , Carcinoma de Células Escamosas do Esôfago , Esofagoscopia , Efeitos Adversos de Longa Duração , Membrana Mucosa , Recidiva Local de Neoplasia , Complicações Pós-Operatórias , Idoso , China/epidemiologia , Ressecção Endoscópica de Mucosa/efeitos adversos , Ressecção Endoscópica de Mucosa/métodos , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/cirurgia , Carcinoma de Células Escamosas do Esôfago/mortalidade , Carcinoma de Células Escamosas do Esôfago/patologia , Carcinoma de Células Escamosas do Esôfago/cirurgia , Esofagoscopia/efeitos adversos , Esofagoscopia/métodos , Feminino , Humanos , Efeitos Adversos de Longa Duração/diagnóstico , Efeitos Adversos de Longa Duração/etiologia , Efeitos Adversos de Longa Duração/prevenção & controle , Masculino , Pessoa de Meia-Idade , Membrana Mucosa/diagnóstico por imagem , Membrana Mucosa/patologia , Membrana Mucosa/cirurgia , Recidiva Local de Neoplasia/diagnóstico , Recidiva Local de Neoplasia/prevenção & controle , Estadiamento de Neoplasias , Avaliação de Processos e Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Taxa de Sobrevida
18.
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
20.
Gastrointest Endosc ; 87(6): 1405-1412.e3, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29108981

RESUMO

BACKGROUND AND AIMS: Per-oral endoscopic myotomy (POEM) has received wide acceptance as a highly effective and safe treatment for esophageal achalasia. Short-term and small-scale studies are ample, but long-term large-scale studies are few. The aim of the study was to systematically analyze our long-term results of POEM, with particular emphasis on POEM failures and associated risk factors. METHODS: In this single-center study, consecutive patients treated with POEM between August 2010 and December 2012 were included. The Kaplan-Meier survival function was used to estimate clinical success rate at each year. The Cox proportional hazards model was used to analyze risk factors related to recurrence. RESULTS: A total of 564 patients were included. Major perioperative adverse events occurred in 36 patients (6.4%). After a median follow-up of 49 months (range, 3-68), the Eckardt score and lower esophageal sphincter (LES) pressure were significantly decreased (median Eckardt score, 8 to 2 [P < .05]; median LES pressure, 29.7 mm Hg to 11.9 mm Hg [P < .05]). Fifteen failures occurred within 3 months, 23 between 3 months and 3 years, and 10 after 3 years. The estimated clinical success rates at 1, 2, 3, 4, and 5 years were 94.2%, 92.2%, 91.1%, 88.6%, and 87.1%, respectively. Multivariate Cox regression revealed long disease duration (≥10 years) and history of prior interventions to be risk factors for recurrence. Clinical reflux occurred in 37.3% of patients (155/ 416). CONCLUSIONS: POEM is a highly safe and effective treatment for esophageal achalasia with favorable long-term outcomes.


Assuntos
Acalasia Esofágica/cirurgia , Esfíncter Esofágico Inferior/cirurgia , Complicações Pós-Operatórias/epidemiologia , Piloromiotomia , Adolescente , Adulto , Idoso , Criança , Estudos de Coortes , Endoscopia do Sistema Digestório , Feminino , Seguimentos , Refluxo Gastroesofágico/epidemiologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Manometria , Pessoa de Meia-Idade , Análise Multivariada , Miotomia , Cirurgia Endoscópica por Orifício Natural , Modelos de Riscos Proporcionais , Recidiva , Resultado do Tratamento , Adulto Jovem
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