Impact of endoscopic resection on the choice of surgical procedure in patients with additional laparoscopic gastrectomy.

BACKGROUND: Additional surgery is recommended for patients with noncurative resection after endoscopic submucosal dissection (ESD) for early gastric cancer. Additional resection requires the excision of an area larger than that of the resected mucosa in ESD, which is larger than the lesion, with convergence of the gastric mucosa due to scarring. Thus, the selection of the surgical procedure for lesion removal in specific areas can be affected by ESD. This study therefore aimed to evaluate the impact of ESD on the selection of additional gastrectomy in patients with early gastric cancer in the boundary area between the upper third and middle third of the stomach (UM boundary region). METHODS: Between January 2013 and June 2018, laparoscopic gastrectomy was performed in 89 patients with cT1N0M0 gastric cancer located only in the UM boundary region. The patients' backgrounds and surgical and pathological results were retrospectively investigated. The predictive factors for performing laparoscopic distal gastrectomy (LDG) were evaluated by multivariate analysis. RESULTS: Among 89 patients, 23 patients underwent ESD before surgery. LDG was significantly less often performed in the ESD-surgery group than in the surgery-only group (34.8% vs. 72.7%; p = 0.003). Preoperative ESD was an independent negative predictor of LDG (odds ratio = 0.266; p = 0.025). CONCLUSIONS: Preoperative ESD has an impact on the selection of the type of additional gastrectomy, including reducing the conduct of LDG for early gastric cancer in the UM boundary region.

Analysis of the factors involved in procedural failure: Endoscopic retrograde cholangiopancreatography using a short-type single-balloon enteroscope for patients with surgically altered gastrointestinal anatomy.

AIM: To analyze factors involved in procedural failure and to discuss responses to procedural failure by using the outcomes of endoscopic retrograde cholangiopancreatography (ERCP) carried out using a short-type single-balloon enteroscope (short SBE) in patients with surgically altered gastrointestinal anatomy. METHODS: The study sample included patients who underwent ERCP-related procedures using a short SBE between September 2011 and September 2018 at our hospital. Outcomes, including procedural success rate, were studied retrospectively to analyze the factors involved in procedural failure. RESULTS: Analysis included 191 procedures carried out in 121 patients. Procedural success rate was 85.9% with an adverse event rate of 8.4%. Causes of procedural failure included malignant biliary obstruction (odds ratio [OR] 2.89, 95% confidence interval [CI] 1.19-7.25, P = 0.02), first ERCP attempt (OR: 5.32, 95% CI: 1.30-36.30, P = 0.02), and Roux-en-Y reconstruction (OR: 0.08, 95% CI: 0.004-0.39, P < 0.001). With regard to the response to failure, in cases of malignant biliary obstruction, reattempted short SBE-assisted ERCP was difficult because of invasion of the small intestine or papilla. A large number of these cases required alternative treatment (10 of 15 cases, 66.7%) using percutaneous transhepatic biliary drainage (PTBD) or endoscopic ultrasound-guided biliary drainage (EUS-BD). CONCLUSION: Endoscopic retrograde cholangiopancreatography using a short SBE is safe and effective, with malignant biliary obstruction being a specific cause of failure. Technical proficiency with different modalities, such as PTBD and EUS-BD, is necessary to respond to failure in these cases.

Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: Review of the literature and recommendations from experts.

Prevention therapy is recommended for lesions >1/2 of the esophageal circumference. Locoregional steroid injection is recommended for lesions >1/2-3/4 of the esophageal circumference and oral steroids are recommended for lesions >1/2 of the subtotal circumference. For lesions of the entire circumference, oral steroid combined with injection steroid is considered. Endoscopic balloon dilatation (EBD) is the first choice of treatment for stricture after esophageal endoscopic submucosal dissection (ESD). Radical incision and cutting or self-expandable metallic stent can be considered for refractory stricture after EBD. In case of intraoperative perforation during esophageal ESD, endoscopic clip closure should be initially attempted. Surgery is considered for treatment of delayed perforation. Current standard practice for prevention of delayed bleeding after gastric ESD includes prophylactic coagulation of vessels on post-ESD ulcers and giving proton pump inhibitors. Chronic kidney disease stage 4 or 5, multiple antithrombotic drug use, anticoagulant use, and heparin bridging therapy are high-risk factors for delayed bleeding after gastric ESD. Intraoperative perforation during gastric ESD is initially managed by endoscopic clip closure. If endoscopic clip closure is difficult, other methods such as over-the-scope clip (OTSC), polyglycolic acid (PGA) sheet shielding etc. are attempted. Delayed perforation usually requires surgical intervention, but endoscopic closure by OTSC or PGA sheet may be considered. Resection of three-quarters of the circumference is a risk factor for stenosis after gastric ESD. Giving prophylactic local steroid injection and/or oral steroid is reported, but effectiveness has not been fully verified as has been done for esophageal stricture. The main management method for gastric stenosis is EBD but it may cause perforation.

Efficacy of an over-the-scope clip for preventing adverse events after duodenal endoscopic submucosal dissection: a prospective interventional study.

BACKGROUND: Duodenal endoscopic submucosal dissection (ESD) remains technically challenging, with a high risk of severe adverse events. Because exposure of the duodenal post-ESD mucosal defect to pancreatic juice and bile acid reportedly induces delayed perforation and bleeding, we examined whether defect closure using an over-the-scope clip (OTSC) system was useful for preventing postoperative adverse events. METHODS: From April 2016 to February 2017, a total of 50 consecutive patients with superficial non-ampullary duodenal epithelial tumors (SNADETs) larger than 10 mm, with no more than semi-circumferential spread, were prospectively enrolled in this study. All of the lesions were treated by experienced ESD operators and the post-ESD mucosal defect was closed using OTSCs. RESULTS: All of the SNADETs were completely removed by ESD, with an R0 resection rate of 88.0 %. The mean procedure and closure times were 67.3 ±â€Š58.8 minutes and 9.8 ±â€Š7.2 minutes, respectively. Although complete defect closure was achieved in 94.0 % of the patients (47/50), two patients required surgical conversion. Delayed perforation occurred in only one patient (2.1 %), who did not have successful closure of the defect, as misplacement of the OTSC exposed the muscle layer. Meanwhile, delayed bleeding occurred in three patients (6.3 %); however, the bleeding was easily controlled using endoscopic coagulation. The mean duration of postoperative hospitalization was 5.5 ±â€Š7.2 days. CONCLUSIONS: Prophylactic defect closure using OTSCs may be effective in reducing severe adverse events after duodenal ESD.

Endoscopic submucosal dissection for laterally spreading tumors involving the appendiceal orifice.

BACKGROUND: Since the endoscopic resection of laterally spreading tumors (LSTs) involving the appendiceal orifice remains technically difficult, such lesions are usually treated by surgical resection. However, with recent advances in endoscopic devices, endoscopic submucosal dissection (ESD) has become feasible and may be safely performed even for lesions involving the appendiceal orifice. Therefore, in order to assess the validity of endoscopic treatment for such lesions, we retrospectively evaluated the safety and efficacy of ESD. METHODS: A total of 30 patients with LSTs extending to within 10 mm of the appendiceal orifice (Group AO) and 122 patients with cecal LSTs located away from the appendiceal orifice (Group C) who were treated between December 2011 and September 2015 were retrospectively enrolled in the present study. The indications for ESD were determined by the preoperative endoscopic diagnosis made on the basis of Kudo's pit pattern classification. Based on these preoperative endoscopic diagnoses, 8 of the 30 enrolled patients underwent surgical resection as the initial treatment, because the tumor showed deep invasion beyond the orifice and/or a VN pit pattern was visible. The treatment outcomes (en bloc R0 resection rates, tumor size, procedure time, and complication rates) were compared between the two groups. RESULTS: The sensitivity and specificity for the cancer diagnosis were 81.8 and 94.7%, respectively. There was no significant difference in the en bloc R0 resection rate between Group AO and Group C (90.9 vs. 95.9%, P = 0.23). Furthermore, there were also no differences in the mean tumor size (30.0 ± 20.8 vs. 34.9 ± 14.5 mm, P = 0.17) or mean OR time (55.0 ± 39.2 vs. 58.9 ± 48.2 min P = 0.72) between the two groups. One case from Group AO (4.5%) was complicated by a perforation, which was successfully managed endoscopically. CONCLUSIONS: Although proficiency in endoscopic techniques is required, our results indicate that LSTs involving the appendiceal orifice can be successfully treated by ESD.

Development of a new classification for in vivo diagnosis of duodenal epithelial tumors with confocal laser endomicroscopy: A pilot study.

BACKGROUND AND AIM: Confocal laser endomicroscopy (CLE) has been established for in vivo diagnosis of various gastrointestinal diseases. However, validated criteria for confocal diagnosis of duodenal tumors do not exist. Therefore, the aim of the present pilot study was to develop a novel classification for in vivo optical diagnosis of duodenal tumors using CLE. METHODS: Consecutive patients with duodenal tumorous lesions were included. First, an initial classification system was developed which was then validated. Histopathology was used as a reference standard. RESULTS: A simple classification system for in vivo diagnosis of duodenal epithelial tumors using CLE was developed. Sensitivity, specificity, and accuracy were 90%, 100%, and 97%, respectively. Positive and negative predictive values were calculated as 100% and 96%. The kappa coefficient representing consistency was 1 between observers and within each observer. CONCLUSION: A new classification for in vivo diagnosis of duodenal epithelial tumors using confocal imaging has been developed. The new classification system allows adequate prediction of histology and could therefore be used to guide subsequent therapy of duodenal lesions.