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Kim Y, Ahn JY, Jung HY, Kang S, Song HJ, Choi KD, Kim DH, Lee JH, Na HK, Park YS. Endoscopic resection of gastric gastrointestinal stromal tumor using clip-and-cut endoscopic full-thickness resection: a single-center, retrospective cohort in Korea. Clin Endosc 2024; 57:350-363. [PMID: 38356170 PMCID: PMC11133991 DOI: 10.5946/ce.2023.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 11/16/2023] [Accepted: 11/19/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND/AIMS To overcome the technical limitations of classic endoscopic resection for gastric gastrointestinal stromal tumors (GISTs), various methods have been developed. In this study, we examined the role and feasibility of clip-and-cut procedures (clip-and-cut endoscopic full-thickness resection [cc-EFTR]) for gastric GISTs. METHODS Medical records of 83 patients diagnosed with GISTs after endoscopic resection between 2005 and 2021 were retrospectively reviewed. Moreover, clinical characteristics and outcomes were analyzed. RESULTS Endoscopic submucosal dissection (ESD) and cc-EFTR were performed in 51 and 32 patients, respectively. The GISTs were detected in the upper third of the stomach for ESD (52.9%) and cc-EFTR (90.6%). Within the cc-EFTR group, a majority of GISTs were located in the deep muscularis propria or serosal layer, accounting for 96.9%, as opposed to those in the ESD group (45.1%). The R0 resection rates were 51.0% and 84.4% in the ESD and cc-EFTR groups, respectively. Seven (8.4%) patients required surgical treatment (six patients underwent ESD and one underwent cc-EFTR,) due to residual tumor (n=5) and post-procedure adverse events (n=2). Patients undergoing R0 or R1 resection did not experience recurrence during a median 14-month follow-up period, except for one patient in the ESD group. CONCLUSIONS cc-EFTR displayed a high R0 resection rate; therefore, it is a safe and effective therapeutic option for small gastric GISTs.
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Affiliation(s)
- Yuri Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seokin Kang
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Soo Park
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Deng XM, Zhu TY, Wang GJ, Gao BL, Wang JT, Li RX, Zhang YF, Ding HX. Lymph node metastasis pattern and significance of left gastric artery lymph node dissection in esophagectomy for esophageal cancers. World J Surg Oncol 2021; 19:296. [PMID: 34635107 PMCID: PMC8504036 DOI: 10.1186/s12957-021-02405-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/19/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose To investigate the lymph node metastasis pattern and significance of dissection of the left gastric artery lymph nodes in radical en bloc esophagectomy for esophageal squamous carcinomas based on the lymphatic drainage pathway revealed by carbon nanoparticle labeling. Materials and methods Patients who underwent en bloc esophagectomy endoscopically were retrospectively enrolled. Carbon nanoparticles were injected in the submucosa of upper thoracic esophagus to label the relevant draining lymph nodes. The clinical data, lymph nodes dissected, surgical technique, and complications were analyzed. Results En bloc esophagectomy was successful in all 179 patients. Metastases to the left gastric artery lymph nodes were positive in 42 patients (23.5%) but negative in 137 (76.5%). The left gastric lymph nodes were labeled, whereas no celiac lymph nodes were labeled by carbon nanoparticles. A total of 4652 lymph nodes were resected, with 26 lymph nodes per patient. Seventy-three patients had lymph node metastasis (73/179). Seventeen patients had metastasis to the recurrent laryngeal nerve lymph nodes (9.5%). The metastasis rate of the lower thoracic esophageal cancer to the left gastric artery lymph nodes was 37.0%, significantly greater than that at the middle (15.4%) or upper (6.7%) thoracic segment. The lymph node metastasis rate was significantly (P < 0.05) increased with the length of the cancerous lesion, infiltration depth, and poor differentiation. Univariate analysis revealed that the metastasis rate to the left gastric artery lymph nodes was significantly (P < 0.05) associated with paraesophageal lymph node metastasis, para-cardial lymph metastasis, and TNM classification. Multivariate analysis indicated that cancer location (odds ratio 8.32, 95% confidence interval 2.12–32.24) was significantly (P < 0.05) associated with metastasis to the left gastric artery lymph nodes, with the cancer at the middle and lower thoracic segments significantly more than in the upper thoracic segment. Conclusion Certain patterns exist in lymph node metastasis of esophageal cancer, and in radical esophagectomy of esophageal cancers, dissection of the left gastric artery lymph nodes is necessary to prevent possible residual or metastasis of esophageal squamous carcinomas based on the lymphatic drainage pathway of esophageal carcinomas demonstrated by carbon nanoparticle labeling.
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Affiliation(s)
- Xiu-Mei Deng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Tian-Yu Zhu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Guo-Jun Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China.
| | - Bu-Lang Gao
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Jing-Tao Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Rui-Xin Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Yun-Fei Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
| | - Heng-Xuan Ding
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe Road, Zhengzhou, 450052, China
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3
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Bai X, Zheng J, Zhang B, Luo Y. Application of Computed Tomography Images Based on Peripheral Nerve Analysis in the Treatment of Gastric Scrotal Tumors. World Neurosurg 2020; 149:352-361. [PMID: 33075572 DOI: 10.1016/j.wneu.2020.10.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/10/2020] [Accepted: 10/10/2020] [Indexed: 02/07/2023]
Abstract
Gastric stromal tumor is a potentially malignant mesenchymal tumor that is difficult to diagnose before surgery. Computed tomography is the most commonly used tool for diagnosing gastrointestinal stromal tumor. This study combined peripheral nerve analysis and computed tomography for diagnosis and prognosis of gastrointestinal stromal tumor. This study shows that computed tomography can accurately show the location, shape, and size of gastric scrotal tumors and has important clinical value in identifying benign and malignant tumors as well as early clinical judgment and treatment and prognosis.
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Affiliation(s)
- Xiaoru Bai
- Department of Medical Imaging, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, China
| | - Jian Zheng
- Department of Medical Oncology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, China
| | - Bin Zhang
- Department of Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yahong Luo
- Department of Medical Imaging, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, China.
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4
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Bartell N, Bittner K, Kaul V, Kothari TH, Kothari S. Clinical efficacy of the over-the-scope clip device: A systematic review. World J Gastroenterol 2020; 26:3495-3516. [PMID: 32655272 PMCID: PMC7327783 DOI: 10.3748/wjg.v26.i24.3495] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/19/2020] [Accepted: 05/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The over-the-scope clip (OTSC) system has been increasingly utilized as a non-surgical option to endoscopically manage refractory gastrointestinal (GI) hemorrhage, perforations/luminal defects and fistulas. Limited data exist evaluating the efficacy and safety of OTSC. AIM To determine the clinical success and adverse event (AE) rates of OTSC across all GI indications. METHODS A PubMed search was conducted for eligible articles describing the application of the OTSC system for any indication in the GI tract. Any article or case series reporting data for less than 5 total patients was excluded. The primary outcome was the rate of clinical success. Secondary outcomes included: Technical success rate, OTSC-related AE rate and requirement for surgical intervention despite-OTSC placement. Pooled rates (per-indication and overall) were calculated as the number of patients with the event of interest divided by the total number of patients. RESULTS A total of 85 articles met our inclusion criteria (n = 3025 patients). OTSC was successfully deployed in 94.4% of patients (n = 2856/3025). The overall rate of clinical success (all indications) was 78.4% (n = 2371/3025). Per-indication clinical success rates were as follows: (1) 86.0% (1120/1303) for GI hemorrhage; (2) 85.3% (399/468) for perforation; (3) 55.8% (347/622) for fistulae; (4) 72.6% (284/391) for anastomotic leaks; (5) 92.8% (205/221) for defect closure following endoscopic resection (e.g., following endoscopic mucosal resection or endoscopic submucosal dissection); and (6) 80.0% (16/20) for stent fixation. AE's related to the deployment of OTSC were only reported in 64 of 85 studies (n = 1942 patients), with an overall AE rate of 2.1% (n = 40/1942). Salvage surgical intervention was required in 4.7% of patients (n = 143/3025). CONCLUSION This systematic review demonstrates that the OTSC system is a safe and effective endoscopic therapy to manage GI hemorrhage, perforations, anastomotic leaks, defects created by endoscopic resections and for stent fixation. Clinical success in fistula management appears limited. Further studies, including randomized controlled trials comparing OTSC with conventional and/or surgical therapies, are needed to determine which indication(s) are the most effective for its use.
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Affiliation(s)
- Nicholas Bartell
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Krystle Bittner
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Truptesh H Kothari
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Shivangi Kothari
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
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Tang SJ, Naga YM, Wu R, Zhang S. Over-the-scope clip-assisted endoscopic full thickness resection: a video-based case series. Surg Endosc 2020; 34:2780-2788. [PMID: 32189117 DOI: 10.1007/s00464-020-07481-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 02/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND In the management of mucosal neoplasm and early cancer, therapeutic gastrointestinal endoscopy evolved from simply polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection (ESD), to endoscopic full thickness resection (EFTR). Full thickness clip closure followed by transmural resection mimics surgical principles. It is safe, effective, and technically less demanding compared to other techniques. Over-the-scope clip (OTSC)-assisted EFTR or OTSC-EFTR enables the endoscopists to manage difficult lesions. METHODS We video recorded and report our 1-year single center experience of 12 consecutive EFTR cases since the dedicated OTSC-EFTR device was approved in the USA. RESULTS We demonstrate that OTSC-EFTR can be very useful to manage residual neoplastic tissue that cannot be removed during conventional mucosal resection due to deeper invasion, submucosal fibrosis, scaring from prior intervention, and appendiceal involvement. Caution should be used for EFTR of the ileocecal valve lesions. CONCLUSION We propose that layered or stacked biopsy of the appendiceal stump after EFTR should be performed to rule out a positive residual base. Due to the limited size of the FTRD resection hood (13 mm internal diameter × 23 mm depth), for larger sessile adenomas in the colon, we propose a hybrid approach for complete removal: piecemeal EMR for tumor debulking followed by OTSC-EFTR to achieve R0 resection. We believe OTSC-EFTR offers safety and efficiency with very high success rate.
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Affiliation(s)
- Shou-Jiang Tang
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA.
| | - Yehia M Naga
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Ruonan Wu
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS, 39216, USA
| | - Shengyu Zhang
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
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Sachdev AH, Iqbal S, Ribeiro IB, de Moura DTH. Use of omental patch and endoscopic closure technique as an alternative to surgery after endoscopic full thickness resection of gastric intestinal stromal tumors: A series of cases. World J Clin Cases 2020; 8:120-125. [PMID: 31970177 PMCID: PMC6962076 DOI: 10.12998/wjcc.v8.i1.120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 11/26/2019] [Accepted: 12/13/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastrointestinal stromal tumors (GISTs) originate from interstitial cells of Cajal. GISTs can occur anywhere along the gastrointestinal tract. Large lesions have traditionally been removed surgically. However, with recent innovations in advanced endoscopy, GISTs located within the stomach are now removed endoscopically. We describe a new innovative endoscopic technique to close large and hard to access defects after endoscopic full-thickness resection of gastric GISTs. CASE SUMMARY We present a series of three patients who were diagnosed with a gastric GIST. All patients underwent full-thickness endoscopic resection. In all cases, for closure of the surgical bed, conventional endoscopic techniques including hemoclips, endoloop and suturing were unsuccessful. We performed a new technique in which we pulled omental fat into the gastric lumen and completely closed the defect using endoscopic devices. All patients performed well post-procedure and computed tomography was carried out one day after the procedures which showed no extravasation of contrast. CONCLUSION The omental plug technique may be used as an alternative to surgery in selected cases of gastric perforation.
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Affiliation(s)
- Amit H Sachdev
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | | | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
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7
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Aoyama J, Goto O, Kawakubo H, Mayanagi S, Fukuda K, Irino T, Nakamura R, Wada N, Takeuchi H, Yahagi N, Kitagawa Y. Clinical outcomes of non-exposed endoscopic wall-inversion surgery for gastric submucosal tumors: long-term follow-up and functional results. Gastric Cancer 2020; 23:154-159. [PMID: 31270624 DOI: 10.1007/s10120-019-00985-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 06/28/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS To avoid the risk of iatrogenic dissemination during procedures, we have developed a combined laparoscopic and endoscopic surgery with a nonexposure technique for resection of gastric tumors. The study aim was to evaluate the feasibility and safety of non-exposed endoscopic wall-inversion surgery (NEWS) for gastric submucosal tumors (SMTs). METHODS Between August 2013 and February 2018, NEWS was performed for 42 patients with gastric SMTs ≤ 3 cm in diameter at our institution. We retrospectively investigated the patients' backgrounds, operative and perioperative outcomes, tumor pathological characteristics, and follow-up data. RESULTS All tumors were resected with negative margins by NEWS. The median operation time was 198 min, and the median estimated blood loss was 5.0 mL. Adverse events occurred in one patient with pneumonia. All patients were alive without recurrence within the median follow-up period of 29.2 months. The average body weight loss rate was 0.3 ± 4.0%. No food residue was observed at endoscopic follow-up. CONCLUSIONS On the basis of slight body weight loss and the absence of food residue observed in the postoperative endoscopy, NEWS appeared to be safe and feasible for gastric SMTs and to preserve function of the remnant stomach.
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Affiliation(s)
- Junya Aoyama
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Osamu Goto
- Division of Research and Department for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan. .,Department of Gastroenterology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Shuhei Mayanagi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Tomoyuki Irino
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Norihito Wada
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Department of Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Shizuoka, Japan
| | - Naohisa Yahagi
- Division of Research and Department for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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8
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Gabr A. Sealing the hole: endoscopic management of acute gastrointestinal perforations. Frontline Gastroenterol 2020; 11:55-61. [PMID: 31885841 PMCID: PMC6914298 DOI: 10.1136/flgastro-2018-101136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/03/2019] [Accepted: 02/16/2019] [Indexed: 02/04/2023] Open
Abstract
Acute perforations are one of the recognised complications of both diagnostic and therapeutic gastrointestinal (GI) endoscopy. The incidence rate varies according to the type of procedure and the anatomical location within the GI tract. For decades, surgical treatment has been the standard of care, but endoscopic closure has become a more popular approach, due to feasibility and the reduction of the burden of surgery. Various devices are available now such as through-the-scope clips, over-the-scope clips, endoscopic suturing devices, stents, bands and omental patch. All have been tested in studies done on humans or animal models, with a reasonable overall technical and clinical success rate, proving efficiency and feasibility of endoscopic closure. The choice of which device to use depends on the site and the size of the perforation. It also depends on availability of thee device and the endoscopist's experience. A number of factors that could predict success of endoscopic closure or favour surgical treatment have been suggested in different studies. After successful endoscopic closure, patients are usually kept nil by mouth and receive antibiotics for a duration that varied between different studies.
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Affiliation(s)
- Ahmed Gabr
- Gastroenterology, Palestine Hospital, Cairo, Egypt
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9
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Liu B, Chen H, Zhang W, Zhang G. A novel technique for removing large gastric subepithelial tumors with ESD method in the subcardia region. Oncol Lett 2019; 18:5277-5282. [PMID: 31612037 PMCID: PMC6781672 DOI: 10.3892/ol.2019.10894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023] Open
Abstract
Previously, patients with tumors larger than 4 cm in sub-cardia region usually received open gastrectomy. Due to its anatomic features, the cardia is often considered as a contraindicated area for endoscopic resection. Herein, we report a novel technique of endoscopic submucosal dissection (ESD) which facilitates the removal of gastric subepithelial tumors (SMTs) larger than 4 cm in the subcardia and fundus region. This is a retrospective case series of patients with SMTs larger than 4 cm in the subcardia and fundus regions who received the novel procedure of ESD between October 2015 and October 2016. The novel procedure of ESD involved a median linear incision of the mucosa being made in the central area of the tumor, followed by the submucosal dissection. The residual defect was finally closed using titanium endoclips. The endoscopical outcomes, histopathological findings as well as other complications were assessed. Eight patients fulfilled the entry criteria. The mean lesion size was 45.6±7.5 mm (range: 40.0-65.0 mm), and the mean operating time was 83±13 min (range: 60-100 min). The en bloc resection rate was 100%. Although perforations occurred in 5 out of 8 patients, they were successfully closed with endoclips. The median length of inpatient hospital stay was 6 days (range: 5-8 days). No patients needed further gastrectomy. The median follow-up was 36 months and none of the patients developed local recurrence or distant metastasis. The advanced procedure of ESD is feasible and safe for tumors more than 4 cm in the subcardia region. It could be applied as a novel technique for treating patient without surgical interventions.
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Affiliation(s)
- Bingtuan Liu
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China.,The First Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China.,Department of Gastroenterology, Jiangsu Jiangyin People's Hospital, Wuxi, Jiangsu 214400, P.R. China
| | - Han Chen
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Weifeng Zhang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China.,The First Clinical Medical College of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Guoxin Zhang
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
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10
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Duan TY, Tan YY, Wang XH, Lv L, Liu DL. A comparison of submucosal tunneling endoscopic resection and endoscopic full-thickness resection for gastric fundus submucosal tumors. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:160-165. [PMID: 29284271 DOI: 10.17235/reed.2017.4699/2016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM Both submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR) are effective methods for gastric fundus submucosal tumors (SMTs). However, there is little data that compares the two methods. The aim of this study was to compare the safety and efficacy of STER and EFTR for the treatment of SMTs in the gastric fundus. METHODS Clinical data was retrospectively collected from patients with gastric fundus SMTs who underwent STER or EFTR at our hospital from April 2011 to May 2016. Epidemiological data (gender, age), tumor size, procedure-related parameters, complications, postoperative hospital stay, cost and follow-up data were compared. RESULTS A total of 43 patients were enrolled: 15 underwent STER and the remaining 28 cases underwent EFTR. There were no significant differences between the two groups with regard to gender, age, tumor size, en bloc resection rate, operation time, pathohistological results and cost (p > 0.05). However, patients who underwent EFTR had a longer suture time, required a larger number of clips for closure and a prolonged postoperative hospital stay (p < 0.05). No recurrence was noted in either the STER or the EFTR group during a mean follow-up of 12.1 and 22.8 months, respectively. CONCLUSIONS The treatment efficacy of STER and EFTR for the treatment of gastric fundus SMTs was comparable. However, STER has some advantages over EFTR in terms of suture time, the number of clips required for closure and postoperative hospital stay.
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Affiliation(s)
- Tian-Ying Duan
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University
| | - Yu-Yong Tan
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University
| | - Xue-Hong Wang
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University
| | - Liang Lv
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University
| | - De-Liang Liu
- Gastroenterology, the Second Xiangya Hospital, China
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11
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Wada AM, Hashiba K, Otoch JP, Brasil H, Marson FP, Cassab J, Abdalla R, Artifon ELA. FULL-THICKNESS ENDOSCOPIC GASTRIC RESECTION USING A STAPLER AND GASTROSTOMY: A FEASIBILITY STUDY. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2018; 31:e1386. [PMID: 30133678 PMCID: PMC6097028 DOI: 10.1590/0102-672020180001e1386] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 06/28/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is currently the most frequently performed bariatric procedure in Turkey. The goal of weight reduction surgery is not only to decrease excess weight, but also to improve obesity related comorbidities and quality of life (QoL). AIM To evaluate the impact of LSG on patient quality of life, weight loss, and comorbidities associated with morbid obesity according to the updated BAROS criteria. METHODS Eleven hundred thirty-eight adult patients were undergone to LSG by our bariatric surgery team between January 2013 and January 2016. A questionnaire (The Bariatric Analysis and Reporting Outcome System - BAROS) was published on social media. The data on postoperative complications were collected from hospital database. RESULTS Number of respondants was 562 (49.4%). Six of 1138 patients(0.5%) had leakage. All patients who had leakage were respondants. The overall complication rate was 7.7%. After a mean period of 7.4±5.3 months(1-30), mean excess weight loss was 71.3±27.1% (10.2-155.4). The respondants reported 772 comorbidities. Of these, 162 (30%) were improved, and 420 (54.4%) were resolved. The mean scores for QoL were significantly increased after LSG (range, p<0.05 to <0.001). Of the 562 patients, 26 (4.6%) were classified as failures; 86 (15.3%) fair; 196 (34.9%) good; 144 (25.6%) very good, and 110 (19.6%) excellent results according to the updated BAROS scoring system. CONCLUSION LSG is a highly effective bariatric procedure in the manner of weight control, improvement in comorbidities and increasing of QoL in short- and mid-term.
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Affiliation(s)
| | - Kiyoshi Hashiba
- Sírio Libanês Institute for Teaching and Research, São Paulo, SP, Brazil
| | | | - Horus Brasil
- Sírio Libanês Institute for Teaching and Research, São Paulo, SP, Brazil
| | - Fernando P Marson
- Sírio Libanês Institute for Teaching and Research, São Paulo, SP, Brazil
| | - Jorge Cassab
- Sírio Libanês Institute for Teaching and Research, São Paulo, SP, Brazil
| | - Ricardo Abdalla
- Sírio Libanês Institute for Teaching and Research, São Paulo, SP, Brazil
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Tang X, Ren Y, Huang S, Gao Q, Zhou J, Wei Z, Jiang B, Gong W. Endoscopic Submucosal Tunnel Dissection for Upper Gastrointestinal Submucosal Tumors Originating from the Muscularis Propria Layer: A Single-Center Study. Gut Liver 2018; 11:620-627. [PMID: 28335098 PMCID: PMC5593323 DOI: 10.5009/gnl15424] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 10/12/2016] [Accepted: 10/18/2016] [Indexed: 02/05/2023] Open
Abstract
Background/Aims In recent years, endoscopic submucosal tunnel dissection (ESTD) has gained popularity worldwide. The aim of this study was to evaluate the safety and efficacy of ESTD in treating upper gastrointestinal submucosal tumors (SMTs) in a large-volume endoscopic center. Methods Patients with SMTs were enrolled in this study between January 2012 and January 2015. Demographic data, clinical data, and treatment outcome were collected and analyzed. Results Seventy SMTs originating from the muscularis propria (MP) layer were identified in 69 patients. All patients successfully underwent the ESTD procedure. The mean procedure time was 49.0±29.5 minutes, and the mean tumor size was 18.7±7.2 mm. Among all lesions, the majority (70.0%) were located in the esophagus, 12.9% in the cardia, and 17.1% in the stomach. Complete resection was achieved in 67 lesions (95.7%). Perforation occurred in three patients (4.3%), who were treated by endoclips. Pneumothorax occurred in two patients (2.9%) and was successfully managed by thoracic drainage. During a median follow-up of 18.1 months, patients were free of local recurrence or distant metastasis. Conclusions Our results demonstrated the feasibility and safety of ESTD in treating upper gastrointestinal SMTs originating from the MP layer. Large-scale comparative studies with other treatment methods should be conducted in the future.
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Affiliation(s)
- Xiaowei Tang
- Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, China
| | - Yutang Ren
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Silin Huang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiaoping Gao
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jieqiong Zhou
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China.,Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhengjie Wei
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Bo Jiang
- Departmemt of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China
| | - Wei Gong
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Kim CG. Endoscopic Full-Thickness Resection Combined with Laparoscopic Surgery. Clin Endosc 2018; 51:33-36. [PMID: 29331107 PMCID: PMC5806927 DOI: 10.5946/ce.2017.153] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/29/2017] [Accepted: 11/30/2017] [Indexed: 12/26/2022] Open
Abstract
Endoscopic full-thickness resection combined with laparoscopic surgery was recently developed. These procedures could be categorized as "Cut first and then suture" and "Suture first and then cut". "Cut first and then suture" includes laparoscopic and endoscopic cooperative surgery (LECS) and laparoscopy-assisted endoscopic full-thickness resection (LAEFR). Recent studies have demonstrated the safety and efficacy of LECS and LAEFR. However, these techniques are limited by the related exposure of the tumor and gastric mucosa to the peritoneal cavity and manipulation of these organs, which could lead to viable cancer cell seeding and the spillage of gastric juice into the peritoneal cavity. In the "Suture first and then cut" technique, the serosal side of the stomach is sutured to invert the stomach and subsequently endoscopic resection is performed. In this article, details of these techniques, including their advantages and limitations, are described.
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Affiliation(s)
- Chan Gyoo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
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14
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Schlag C, Menzel C, Götzberger M, Nennstiel S, Klare P, Wagenpfeil S, Schmid RM, Weirich G, von Delius S. Endoscopic ultrasound-guided tissue sampling of small subepithelial tumors of the upper gastrointestinal tract with a 22-gauge core biopsy needle. Endosc Int Open 2017; 5:E165-E171. [PMID: 28299351 PMCID: PMC5348295 DOI: 10.1055/s-0042-119948] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and study aims The optimal approach to small subepithelial tumors (SETs) of the upper gastrointestinal tract remains inconclusive. The aim of this study was to evaluate endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for less invasive tissue sampling of small SETs of the upper gastrointestinal tract. Patients and methods In this prospective observational study patients with small ( ≤ 3 cm) SETs of the upper gastrointestinal tract were eligible and underwent EUS-FNB with a 22-gauge core biopsy needle. The main outcome measure was the diagnostic yield. The number of obtained core biopsies was also assessed. Results Twenty patients were included. The mean SET size was 16 mm (range 10 - 27 mm). EUS-FNB was technically feasible in all cases and no complications were observed. The diagnostic yield was 75 %. Core biopsy specimens were obtained in only 25 % of cases. Conclusion EUS-FNB with a 22-gauge core biopsy needle of small SETs can achieve a definite diagnosis in the majority of cases. However, because core samples cannot regularly be obtained, EUS-FNB seems not to be convincingly superior to standard EUS-FNA in this setting.
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Affiliation(s)
- Christoph Schlag
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany,Corresponding author PD Dr. med. Christoph Schlag II. Medizinische Klinik und PoliklinikKlinikum rechts der Isar der Technischen Universität MünchenIsmaninger Straße 2281675 MünchenGermany089-4140-4871
| | - Christoph Menzel
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Manuela Götzberger
- Gastroenterologie, Klinikum Freising, Akademisches Lehrkrankenhaus der Technischen Universität München, Freising, Germany
| | - Simon Nennstiel
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Peter Klare
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stefan Wagenpfeil
- Institut für Medizinische Biometrie, Epidemiologie und Medizinische Informatik, Universität des Saarlandes, Campus Homburg, Homburg, Germany
| | - Roland M. Schmid
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Gregor Weirich
- Institut für Allgemeine Pathologie und Pathologische Anatomie, Technische Universität München, Munich, Germany
| | - Stefan von Delius
- II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Comparison between submucosal tunneling endoscopic resection and endoscopic full-thickness resection for gastric stromal tumors originating from the muscularis propria layer. Surg Endosc 2016; 31:3376-3382. [PMID: 27864722 DOI: 10.1007/s00464-016-5350-7] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 11/09/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Both submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR) are effective method for treating gastric gastrointestinal stromal tumors (GISTs); however, little is known about the comparison between STER and EFTR. The aim of the study was to compare the safety and efficacy of STER and EFTR for treating gastric GIST. METHODS We retrospectively collected the clinical data about patients with gastric GISTs who received STER or EFTR at our hospital from April 2011 to June 2016. Epidemiological data (gender, age), tumor size, procedure-related parameters, complications, length of stay, cost and follow-up data were compared between STER and EFTR. RESULTS A total of 52 patients were enrolled, and 20 of them received STER, while the other 32 cases received EFTR. There was no significant difference between the two groups in terms of gender, age, concomitant diseases, tumor size, en bloc resection rate, operation time, complications, pathohistological grade of GIST, hospital stay and cost (P > 0.05). However, patients who received EFTR had a longer suture time and needed more clips to close the gastric-wall defect (STER vs EFTR, 291.5 ± 68.7 vs 380.6 ± 96.9s and 6.0 ± 1.2 vs 7.6 ± 1.6, P < 0.05). No recurrence was noted in the STER and EFTR groups during a mean follow-up of 10.9 and 23.8 months, respectively. CONCLUSIONS The treatment efficacy between STER and EFTR for treating gastric GISTs was comparable, and a large-scale, randomized study is necessary for a more confirmed conclusion.
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Jain D, Mahmood E, Desai A, Singhal S. Endoscopic full thickness resection for gastric tumors originating from muscularis propria. World J Gastrointest Endosc 2016; 8:489-495. [PMID: 27499831 PMCID: PMC4959942 DOI: 10.4253/wjge.v8.i14.489] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/28/2016] [Accepted: 06/02/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To do systematic review of current literature for endoscopic full thickness resection (EFTR) technique for gastric tumors originating from muscularis propria.
METHODS: An extensive English literature search was done till December 2015; using PubMed and Google scholar to identify the peer reviewed original and review articles using keywords-EFTR, gastric tumor, muscularis propria. Human only studies were included. The references of pertinent studies were manually searched to identify additional relevant studies. The indications, procedural details, success rates, clinical outcomes, complications and limitations were considered. For the purpose of review, data from individual studies was combined to calculate mean. No other statistical test was applied.
RESULTS: A total of 9 original articles were identified. Four articles were from same institute and the time frames of these studies were overlapping. To avoid duplication of data, only the study with patients over the longest time interval was included and other three were excluded. In total six studies were included in the final review. In our systematic review, the mean success rate for EFTR of gastric tumors originating from muscularis propria was 96.8%. The mean procedure time varied from a minimum of 37 min to a maximum of 105 min. There was no reported mortality from the technique itself. The most common histological diagnosis was gastrointestinal stromal tumors and leiomyoma. Gastric wall defect closure by either metallic clips or over the scope clip (OTSC) had similar outcomes although experience with OTSC was limited to smaller lesions (< 3 cm).
CONCLUSION: EFTR is a minimally invasive technique to resect gastric submucosal tumors originating from muscularis propria with a high success rate and low complication rate.
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Shi D, Li R, Chen W, Zhang D, Zhang L, Guo R, Yao P, Wu X. Application of novel endoloops to close the defects resulted from endoscopic full-thickness resection with single-channel gastroscope: a multicenter study. Surg Endosc 2016; 31:837-842. [PMID: 27351654 DOI: 10.1007/s00464-016-5041-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 06/11/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The key step of the endoscopic full-thickness resection (EFTR) procedure is the successful closure of any gastric wall defect which ultimately avoids surgical intervention. This report presents a new method of closing large gastric defects left after EFTR, using metallic clips and novel endoloops by means of single-channel endoscope. METHODS We retrospectively analyzed 68 patients who were treated for gastric fundus gastrointestinal stromal tumors originating from the muscularis propria layer at four institutes between April 2014 and February 2015 and consequently underwent EFTR. The large gastric post-EFTR defects were completely closed with metallic clips and novel endoloops using single-channel endoscope, and all the patients were discharged with subsequent endoscopic and clinical follow-up. Patient characteristics, tumor size, en bloc resection rate, closure operation time, and postoperative adverse events were evaluated. RESULTS EFTR was successfully performed on 68 patients [41 male (60 %), 27 female (40 %); median age 61 years, range 38-73], and the en bloc resection rate was 100 %. Complete closure of all the gastric post-EFTR defects was achieved (success rate 100 %). The mean closure operation time was 13 min (range 9-21 min). The mean maximum size of the lesions was 2.6 cm (range 2.0-3.5 cm). One Mallory-Weiss syndrome and one delayed bleeding were resolved with nonsurgical treatment. The wounds were healed in all cases 1 month after the procedure. CONCLUSIONS The use of metallic clips and novel endoloops with single-channel endoscope is a relatively safe, easy, and feasible method for repairing large gastric post-EFTR defects.
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Affiliation(s)
- Dongtao Shi
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, China
| | - Rui Li
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, China.
| | - Weichang Chen
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, China
| | - Deqing Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, 188 Shizi Street, Suzhou, China
| | - Lei Zhang
- Department of Gastroenterology, The People's Hospital of Donghai County, Lianyungang, China
| | - Rui Guo
- Department of Gastroenterology, The People's Hospital of Donghai County, Lianyungang, China
| | - Ping Yao
- Department of Gastroenterology, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
| | - Xudong Wu
- Department of Gastroenterology, The First People's Hospital of Yancheng City, Yancheng, China
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Kim SY, Kim KO. Management of gastric subepithelial tumors: The role of endoscopy. World J Gastrointest Endosc 2016; 8:418-424. [PMID: 27298713 PMCID: PMC4896903 DOI: 10.4253/wjge.v8.i11.418] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 04/28/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023] Open
Abstract
With the wide use of esophagogastroduodenoscopy, the incidence of gastric subepithelial tumor (SET) diagnosis has increased. While the management of large or symptomatic gastric SETs is obvious, treatment of small (≤ 3 cm) asymptomatic gastric SETs remains inconclusive. Moreover, the presence of gastrointestinal stromal tumors with malignant potential is of concern, and endoscopic treatment of gastric SETs remains a subject of debate. Recently, numerous studies have demonstrated the feasibility of endoscopic treatment of gastric SETs, and have proposed various endoscopic procedures including endoscopic submucosal dissection, endoscopic muscularis dissection, endoscopic enucleation, endoscopic submucosal tunnel dissection, endoscopic full-thickness resection, and a hybrid approach (the combination of endoscopy and laparoscopy). In this review article, we discuss current endoscopic treatments for gastric SETs as well as the advantages and limitations of this type of therapy. Finally, we predict the availability of newly developed endoscopic treatments for gastric SETs.
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Eleftheriadis N, Inoue H, Ikeda H, Onimaru M, Maselli R, Santi G. Submucosal tunnel endoscopy: Peroral endoscopic myotomy and peroral endoscopic tumor resection. World J Gastrointest Endosc 2016; 8:86-103. [PMID: 26839649 PMCID: PMC4724034 DOI: 10.4253/wjge.v8.i2.86] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 10/19/2015] [Accepted: 11/24/2015] [Indexed: 02/05/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) is an innovative, minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy (LHM), not only for all types of esophageal achalasia [classical (I), vigorous (II), spastic (III), Chicago Classification], but also for advanced sigmoid type achalasia (S1 and S2), failed LHM, or other esophageal motility disorders (diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction (EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection (POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors (submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.
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Yang F, Wang S, Sun S, Liu X, Ge N, Wang G, Guo J, Liu W, Feng L, Ma W. Factors associated with endoscopic full-thickness resection of gastric submucosal tumors. Surg Endosc 2015; 29:3588-3593. [PMID: 25894443 PMCID: PMC4648854 DOI: 10.1007/s00464-015-4113-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/13/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To identify factors that impact the procedure and treatment outcomes for endoscopic full-thickness resection (EFTR) of gastric submucosal tumors (SMTs). METHODS Medical records were collected for all patients with gastric SMTs who underwent EFTR procedures in Shengjing Hospital between June 2012 and April 2014. The data from each patient were reviewed, including gender, age, maximum tumor size on endoscopic ultrasound (EUS), tumor location in stomach, length of EFTR procedure, pneumoperitoneum during EFTR, cost to close defects, length of hospital stay after the procedure, and procedure-related complications. RESULTS Endoscopic full-thickness resection of gastric SMTs was successfully performed in all 41 patients. Maximum size on EUS [parameter estimate (PE) = 4.443, 95% confidence interval (CI) 2.191-6.695; p = 0.000] and tumor location in the greater curvature (PE = 44.441, 95% CI 5.539-83.343; p = 0.026) were significantly associated with the length of the procedure. A pneumoperitoneum was more likely to occur during EFTR in tumors with a larger EUS size [odds ratio (OR) = 1.415, 95% CI 1.034-1.936; p = 0.03], and less likely to occur during EFTR for tumors located in the posterior wall (OR = 0.003, 95% CI 0-0.351; p = 0.017). The use of the over-the-scope clip (OTSC) system was significantly associated with shorter hospital stays (PE = -1.006, 95% CI -1.998 to -0.014; p = 0.047) and a higher cost of closing defects (PE = 854.742, 95% CI 358.377-1351.107; p = 0.001). CONCLUSIONS Endoscopic full-thickness resection is an effective and safe method for removing gastric SMTs. Tumor size on EUS and location of the tumor were associated with the duration of EFTR and the occurrence of a pneumoperitoneum during the procedure. The use of an OTSC system was significantly associated with shorter hospital stays and a higher cost of closing defects.
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Affiliation(s)
- Fei Yang
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning, China.
| | - Sheng Wang
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Siyu Sun
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning, China.
| | - Xiang Liu
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Nan Ge
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Guoxin Wang
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Jintao Guo
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Wen Liu
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Linlin Feng
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning, China
| | - Wenzhuang Ma
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning, China
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Lee DJK, Tan KY. Endoscopic surgery - exploring the modalities. World J Gastrointest Surg 2015; 7:326-334. [PMID: 26649156 PMCID: PMC4663387 DOI: 10.4240/wjgs.v7.i11.326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 09/14/2015] [Accepted: 10/01/2015] [Indexed: 02/07/2023] Open
Abstract
The adoption of endoscopic surgery continues to expand in clinical situations with the recent natural orifice transluminal endoscopic surgery technique enabling abdominal organ resection to be performed without necessitating any skin incision. In recent years, the development of numerous devices and platforms have allowed for such procedures to be carried out in a safer and more efficient manner, and in some ways to better simulate triangulation and surgical tasks (e.g., suturing and dissection). Furthermore, new novel techniques such as submucosal tunneling, endoscopic full-thickness resection and hybrid endo-laparoscopic approaches have further widened its use in more advanced diseases. Nevertheless, many of these new innovations are still at their pre-clinical stage. This review focuses on the various innovations in endoscopic surgery, with emphasis on devices and techniques that are currently in human use.
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Guo J, Liu Z, Sun S, Liu X, Wang S, Ge N, Wang G, Qi Y. Endoscopic full-thickness resection with defect closure using an over-the-scope clip for gastric subepithelial tumors originating from the muscularis propria. Surg Endosc 2015; 29:3356-3362. [PMID: 25701060 PMCID: PMC4607707 DOI: 10.1007/s00464-015-4076-2] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 01/12/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic full-thickness resection (EFTR) is a mini-invasive technique for gastric subepithelial tumors originating from the muscularis propria, which enables a full-thickness resection of tumors and can provide a complete basis for pathological diagnosis. Gastric fistula closure after EFTR is a challenge for endoscopists. In this study, we introduced EFTR with fistula closure using the over-the-scope clip (OTSC) system for gastric subepithelial tumors originating from the muscularis propria. OBJECTIVES To evaluate the feasibility and safety of fistula closure with OTSC by a retrospective analysis on the cases of EFTR with defect closure using OTSC for gastric subepithelial tumors originating from the muscularis propria in our hospital. METHODS The patients were selected who underwent EFTR for gastric subepithelial tumors originating from the muscularis propria (tumor diameter ≤2 cm) in our hospital from October 2013 to March 2014. After a full-thickness resection of tumors, the bilateral gastric mucous membranes of defect were clamped using twin graspers and then drawn into the transparent cap of OTSC, and the OTSC was released to close the defect after full suctioning. The success rate of defect closure with OTSC was observed, and the endoscopic follow-up was performed at 1 week, 1 and 6 months after operation to check OTSC closure. RESULTS Totally 23 patients were included into the study. The full-thickness resection rate of gastric tumors in the muscularis propria was 100 % (23/23), the success rate of defect closure was 100 %, and the average time of defect closure was 4.9 min (range 2-12 min). All patients experienced no postoperative complications such as bleeding and perforation. The postoperative follow-up time was 1-6 months (mean 3 months), and no OTSC detachment was found. CONCLUSIONS OTSC can be used to perform EFTR with defect closure for gastric tumors in the muscularis propria (tumor diameter ≤2 cm). It is simple, convenient, safe and effective.
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Affiliation(s)
- Jintao Guo
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning Province, China.
| | - Zhijun Liu
- Ultrasound Department, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning Province, China.
| | - Siyu Sun
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning Province, China.
| | - Xiang Liu
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning Province, China.
| | - Sheng Wang
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning Province, China.
| | - Nan Ge
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning Province, China.
| | - Guoxin Wang
- Endoscopic Center, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning Province, China.
| | - Yafei Qi
- Pathological Department, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Shenyang, 110004, Liaoning Province, China.
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Schmidt A, Meier B, Caca K. Endoscopic full-thickness resection: Current status. World J Gastroenterol 2015; 21:9273-9285. [PMID: 26309354 PMCID: PMC4541380 DOI: 10.3748/wjg.v21.i31.9273] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 05/16/2015] [Accepted: 07/03/2015] [Indexed: 02/06/2023] Open
Abstract
Conventional endoscopic resection techniques such as endoscopic mucosal resection or endoscopic submucosal dissection are powerful tools for treatment of gastrointestinal neoplasms. However, those techniques are restricted to superficial layers of the gastrointestinal wall. Endoscopic full-thickness resection (EFTR) is an evolving technique, which is just about to enter clinical routine. It is not only a powerful tool for diagnostic tissue acquisition but also has the potential to spare surgical therapy in selected patients. This review will give an overview about current EFTR techniques and devices.
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Kong SH, Diana M, Liu YY, Lee HJ, Legner A, Soares R, Swanström L, Dallemagne B, Yang HK, Marescaux J. Novel method for hybrid endo-laparoscopic full-thickness gastric resection using laparoscopic transgastric suture passer device. Surg Endosc 2015; 30:1683-91. [PMID: 26150225 DOI: 10.1007/s00464-015-4375-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 06/19/2015] [Accepted: 06/22/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Current surgical methods for partial gastric full-thickness resections (FTRs) are limited by long operative times and risk of gastric content spillage, especially for lesions located at the posterior wall. We propose a simplified hybrid approach to FTR with reduced risk of spillage. METHODS Resection margins were marked by endoscopic electrocautery to simulate a gastric lesion in the upper third of the posterior wall in eight pigs. A custom-made laparoscopic "suture passer" was made of a sharpened bendable dissecting forceps. Full-thickness sutures were alternatively passed from the serosa side with the suture passer through the gastric wall and grabbed endoluminally using an endoscopic grasper and vice versa. These transgastric sutures formed either a purse string (PS; n = 4) or a continuous horizontal mattress (HM; n = 4). Sutures were then fastened from the laparoscopic side, resulting in external outpouching of the lesion. The pouch was transected using 45-mm linear staplers. Operative time, resection margins, and number of staplers were evaluated. RESULTS The combined approach allowed one to precisely place the sutures around the pseudo lesions, despite the inflated stomach, and it included all target markings. PS and HM methods were similar regarding time for transgastric suture (780 s ± 219.1 s vs. 765 s ± 179.2 s, p = .885), resection margins (1.3 ± 1.0 cm vs. 0.8 ± 0.6 cm, p = .248), and number of staplers (3.8 ± 1.0 vs 3.3 ± 0.5, p = .405). Stapling time (600 s ± 189.7 s vs. 330 s ± 24.5 s, p = .028) was significantly shorter in the HM technique. CONCLUSION FTR with laparo-endoscopic transgastric suture application was feasible in the animal model. This technique allows one to achieve accurate resection margins with minimal risk of spillage.
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Affiliation(s)
- Seong-Ho Kong
- Image-Guided Minimally Invasive Surgical Institute, IHU-Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.,Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Michele Diana
- Image-Guided Minimally Invasive Surgical Institute, IHU-Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France. .,Research Institute Against Cancer of the Digestive System (IRCAD), Strasbourg, France.
| | - Yu-Yin Liu
- Research Institute Against Cancer of the Digestive System (IRCAD), Strasbourg, France.,Department of General Surgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Hyun-Jik Lee
- Image-Guided Minimally Invasive Surgical Institute, IHU-Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France
| | - Andras Legner
- Image-Guided Minimally Invasive Surgical Institute, IHU-Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France
| | - Renato Soares
- Image-Guided Minimally Invasive Surgical Institute, IHU-Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France
| | - Lee Swanström
- Image-Guided Minimally Invasive Surgical Institute, IHU-Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France
| | - Bernard Dallemagne
- Research Institute Against Cancer of the Digestive System (IRCAD), Strasbourg, France
| | - Han-Kwang Yang
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Jacques Marescaux
- Image-Guided Minimally Invasive Surgical Institute, IHU-Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France.,Research Institute Against Cancer of the Digestive System (IRCAD), Strasbourg, France
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25
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Goenka MK, Goenka U. Endotherapy of leaks and fistula. World J Gastrointest Endosc 2015; 7:702-13. [PMID: 26140097 PMCID: PMC4482829 DOI: 10.4253/wjge.v7.i7.702] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 03/05/2015] [Accepted: 04/01/2015] [Indexed: 02/05/2023] Open
Abstract
Perforations, leaks and fistula involving gastrointestinal (GI) tract are increasing encountered in clinical practice. There is a changing paradigm for their management with surgical approach being replaced by conservative approach including endoscopic therapy. Clips (through the scope and over the scope) and covered stent are front runners for endotherapy for GI leaks and fistula. Over the scope clips introduced recently, can treat larger defects compared to through the scope clips. Covered stents are suited for larger defects and those associated with luminal narrowing. However cervical esophagus, gastro-esophageal junction, stomach and right colonic lesions may be better for clip therapy rather than stenting. Recent developments in this field include use of endovac therapy which consists of a sponge with suction device, biodegradable stent, use of fibrin glue and some endo-suturing device. Conservative therapy with no surgical or endoscopic intervention, may be suitable for a small subset of patients. An algorithm based on location, size of defect, associated stricture, infection and available expertise needs to be developed to reduce the mortality and morbidity of this difficult clinical problem.
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Goto O, Takeuchi H, Kawakubo H, Sasaki M, Matsuda T, Matsuda S, Kigasawa Y, Kadota Y, Fujimoto A, Ochiai Y, Horii J, Uraoka T, Kitagawa Y, Yahagi N. First case of non-exposed endoscopic wall-inversion surgery with sentinel node basin dissection for early gastric cancer. Gastric Cancer 2015; 18:434-9. [PMID: 25087058 DOI: 10.1007/s10120-014-0406-7] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 07/14/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Non-exposed endoscopic wall-inversion surgery (NEWS) is a novel technique of endoscopic full-thickness resection without transluminal access mainly designed to treat gastric cancer. Here, we report a successful case of NEWS with sentinel node basin dissection (SNBD) for early gastric cancer (EGC) with the risk of lymph node metastasis. PATIENT AND METHODS A 55-year-old female patient with a 2-cm, diffuse-type intramucosal EGC with ulceration was referred to our hospital for a less invasive gastrectomy based on sentinel node navigation surgery. After obtaining informed consent, NEWS with SNBD was applied. After placing mucosal markings, indocyanine green solution was injected endoscopically into the submucosa around the lesion to examine sentinel nodes (SNs). The SN basin (the area of the left gastric artery), including three stained SNs(#3), was dissected, and an intraoperative pathological diagnosis confirmed that no metastasis had occurred. Subsequently, NEWS was performed for the primary lesion. Serosal markings were placed laparoscopically, submucosal injection was added endoscopically, and circumferential sero-muscular incision and suturing were performed laparoscopically, with the lesion inverted toward the inside of the stomach. Finally, the circumferential mucosal incision was performed, and the lesion was retrieved perorally. RESULTS The operation was finished in 270 min without complications. The patient was uneventfully discharged 10 days after the procedure. The final pathological diagnosis was coincident with the pre- and intraoperative assessment. CONCLUSIONS We demonstrated the feasibility and safety of NEWS with SNBD with a favorable result. This surgical concept is expected to become a promising, minimally invasive, function-preserving surgery to cure cases of EGC that are possibly node-positive.
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Affiliation(s)
- Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo, Japan
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Farnik H, Driller M, Kratt T, Schmidt C, Fähndrich M, Filmann N, Königsrainer A, Stallmach A, Heike M, Bechstein WO, Zeuzem S, Albert JG. Indication for 'Over the scope' (OTS)-clip vs. covered self-expanding metal stent (cSEMS) is unequal in upper gastrointestinal leakage: results from a retrospective head-to-head comparison. PLoS One 2015; 10:e0117483. [PMID: 25629619 PMCID: PMC4309679 DOI: 10.1371/journal.pone.0117483] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 12/23/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intestinal perforation or leakage increases morbidity and mortality of surgical and endoscopic interventions. We identified criteria for use of full-covered, extractable self-expanding metal stents (cSEMS) vs. 'Over the scope'-clips (OTSC) for leak closure. METHODS Patients who underwent endoscopic treatment for postoperative leakage, endoscopic perforation, or spontaneous rupture of the upper gastrointestinal tract between 2006 and 2013 were identified at four tertiary endoscopic centers. Technical success, outcome (e.g. duration of hospitalization, in-hospital mortality), and complications were assessed and analyzed with respect to etiology, size and location of leakage. RESULTS Of 106 patients (male: 75 (71%), female: 31 (29%); age (mean ± SD): 62.5 ± 1.3 years, 72 (69%) were treated by cSEMS and 34 (31%) by OTSC. For cSEMS vs. OTSC, mean treatment duration was 41.1 vs. 25 days, p<0.001, leakage size 10 (1-50) vs. 5 (1-30) mm (median (range)), and complications were observed in 68% vs. 8.8%, p<0.001, respectively. Clinical success for primary interventional treatment was observed in 29/72 (40%) vs. 24/34 (70%, p = 0.006), and clinical success at the end of follow-up was 46/72 (64%) vs. 29/34 (85%) for patients treated by cSEMS vs. OTSC; p = 0.04. CONCLUSION OTSC is preferred in small-sized lesions and in perforation caused by endoscopic interventions, cSEMS in patients with concomitant local infection or abscess. cSEMS is associated with a higher frequency of complications. Therefore, OTSC might be preferred if technically feasible. Indication criteria for cSEMS vs. OTSC vary and might impede design of randomized studies.
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Affiliation(s)
- Harald Farnik
- Medizinische Klinik 1, Johann Wolfgang Goethe-Universität, Frankfurt, Germany
| | - Marlene Driller
- Medizinische Klinik 1, Johann Wolfgang Goethe-Universität, Frankfurt, Germany
| | - Thomas Kratt
- Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Carsten Schmidt
- Klinik für Innere Medizin IV, Klinikum der Universität Jena, Jena, Germany
| | - Martin Fähndrich
- Medizinische Klinik Mitte Gastroenterologie, Städtisches Klinikum Dortmund, Dortmund, Germany
| | - Natalie Filmann
- Institut für Biostatistik und mathematische Modellierung, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Alfred Königsrainer
- Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Andreas Stallmach
- Klinik für Innere Medizin IV, Klinikum der Universität Jena, Jena, Germany
| | - Michael Heike
- Medizinische Klinik Mitte Gastroenterologie, Städtisches Klinikum Dortmund, Dortmund, Germany
| | - Wolf O. Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Johann Wolfgang Goethe-Universität, Frankfurt, Germany
| | - Stefan Zeuzem
- Medizinische Klinik 1, Johann Wolfgang Goethe-Universität, Frankfurt, Germany
| | - Jörg G. Albert
- Medizinische Klinik 1, Johann Wolfgang Goethe-Universität, Frankfurt, Germany
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Feussner H, Becker V, Bauer M, Kranzfelder M, Schirren R, Lüth T, Meining A, Wilhelm D. Developments in flexible endoscopic surgery: a review. Clin Exp Gastroenterol 2014; 8:31-42. [PMID: 25565878 PMCID: PMC4278730 DOI: 10.2147/ceg.s46584] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Flexible endoscopy is increasingly developing into a therapeutic instead of a purely diagnostic discipline. Improved visualization makes early lesions easily detectable and allows us to decide ad hoc on the required treatment. Deep enteroscopy allows the exploration of even the small bowel - for long a "white spot" for gastrointestinal endoscopy - and to perform direct treatment. Endoscopic submucosal dissection is a considerable step forward in oncologically correct endoscopic treatment of (early) malignant lesions. Though still technically challenging, it is increasingly facilitated by new manipulation techniques and tools that are being steadily optimized. Closure of wall defects and hemostasis could be improved significantly. Even the anatomy beyond the gastrointestinal wall is being explored by the therapeutic use of endoluminal ultrasound. Endosonographic-guided surgery is not only a suitable fallback solution if conventional endoscopic retrograde cholangiopancreatography fails, but even makes necrosectomy procedures, abscess drainage, and neurolysis feasible for the endoscopist. Newly developed endoscopic approaches aim at formerly distinctive surgical domains like gastroesophageal reflux disease, appendicitis, and cholecystitis. Combined endoscopic/laparoscopic interventional techniques could become the harbingers of natural orifice transluminal endoscopic surgery, whereas pure natural orifice transluminal endoscopic surgery is currently still in its beginnings.
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Affiliation(s)
- Hubertus Feussner
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Valentin Becker
- 2nd Medical Department, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Margit Bauer
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Michael Kranzfelder
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Rebekka Schirren
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Tim Lüth
- Institute of Microtechnology and Medical Device Technology, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Alexander Meining
- 2nd Medical Department, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Dirk Wilhelm
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
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Schurr MO, Baur FE, Krautwald M, Fehlker M, Wehrmann M, Gottwald T, Prosst RL. Endoscopic full-thickness resection and clip defect closure in the colon with the new FTRD system: experimental study. Surg Endosc 2014; 29:2434-41. [PMID: 25318369 DOI: 10.1007/s00464-014-3923-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 09/22/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The benefit of endoscopic full-thickness resection is the improved diagnostic work-up with an integral wall specimen which allows a precise determination of the tumor or its precursor and its infiltration depth into the wall. MATERIALS AND METHODS A new endoscopic full-thickness resection device (FTRD), which is a combination of a modified over-the-scope-clip (OTSC) system with an electrocautery snare, has been tested in an experimental setting. In eleven pigs, divided into three groups, endoscopic full-thickness resection was performed in the colon at one or two sites, respectively. Seven days (n = 7) or 28 days (n = 4) after the intervention, the animals were euthanized following endoscopic examination of the resection and clip application sites. Furthermore, two different clips were tested during these animal trials in order to evaluate the most effective clip design. RESULTS The average diameter of the tissue resected with the FTRD was 3.1, 3.6, and 5.4 cm in the three groups. On follow-up endoscopy 7 days after the intervention, fibrin coating and stool residues were found at all clips, causing minor inflammatory reactions. However, the colon wall under the clip was non-inflamed. After 28 days, the serosa had primarily healed in all cases. There were also stool residues at all clips; however, no acute inflammatory reactions were seen anymore, due to complete healing. Histological assessment did not show any signs of dehiscence in the region of the scar, or ischemia in the clip area. In addition, no wound infections, such as abscess formation, were observed. CONCLUSIONS This study demonstrates the safety and efficacy of the clip-and-cut technique using the new FTRD system. With the device, a local full-thickness colon resection can be easily created, and the resulting wall defect is reliably sealed by the endoluminal application of a modified OTSC clip.
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30
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Huang LY, Cui J, Lin SJ, Zhang B, Wu CR. Endoscopic full-thickness resection for gastric submucosal tumors arising from the muscularis propria layer. World J Gastroenterol 2014; 20:13981-13986. [PMID: 25320536 PMCID: PMC4194582 DOI: 10.3748/wjg.v20.i38.13981] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 06/13/2014] [Accepted: 07/16/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy, safety and feasibility of endoscopic full-thickness resection (EFR) for the treatment of gastric submucosal tumors (SMTs) arising from the muscularis propria.
METHODS: A total of 35 gastric SMTs arising from the muscularis propria layer were resected by EFR between January 2010 and September 2013. EFR consists of five major steps: injecting normal saline into the submucosa; pre-cutting the mucosal and submucosal layers around the lesion; making a circumferential incision as deep as the muscularis propria around the lesion using endoscopic submucosal dissection and an incision into the serosal layer around the lesion with a Hook knife; a full-thickness resection of the tumor, including the serosal layer with a Hook or IT knife; and closing the gastric wall with metallic clips.
RESULTS: Of the 35 gastric SMTs, 14 were located at the fundus, and 21 at the corpus. EFR removed all of the SMTs successfully, and the complete resection rate was 100%. The mean operation time was 90 min (60-155 min), the mean hospitalization time was 6.0 d (4-10 d), and the mean tumor size was 2.8 cm (2.0-4.5 cm). Pathological examination confirmed the presence of gastric stromal tumors in 25 patients, leiomyomas in 7 and gastric autonomous nerve tumors in 2. No gastric bleeding, peritonitis or abdominal abscess occurred after EFR. Postoperative contrast roentgenography on the third day detected no contrast extravasation into the abdominal cavity. The mean follow-up period was 6 mo, with no lesion residue or recurrence noted.
CONCLUSION: EFR is efficacious, safe and minimally invasive for patients with gastric SMTs arising from the muscularis propria layer. This technique is able to resect deep gastric lesions while providing precise pathological information about the lesion. With the development of EFR, the indications of endoscopic resection might be extended.
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Mennigen R, Senninger N, Laukoetter MG. Novel treatment options for perforations of the upper gastrointestinal tract: Endoscopic vacuum therapy and over-the-scope clips. World J Gastroenterol 2014; 20:7767-7776. [PMID: 24976714 PMCID: PMC4069305 DOI: 10.3748/wjg.v20.i24.7767] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 02/23/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention. In the past years, covered self-expanding metal stents were the mainstay of endoscopic therapy. However, two new techniques are now available that enlarge the possibilities of defect closure: endoscopic vacuum therapy (EVT), and over-the-scope clip (OTSC). EVT is performed by mounting a polyurethane sponge on a gastric tube and placing it into the leakage. Continuous suction is applied via the tube resulting in effective drainage of the cavity and the induction of wound healing, comparable to the application of vacuum therapy in cutaneous wounds. The system is changed every 3-5 d. The overall success rate of EVT in the literature ranges from 84% to 100%, with a mean of 90%; only few complications have been reported. OTSCs are loaded on a transparent cap which is mounted on the tip of a standard endoscope. By bringing the edges of the perforation into the cap, by suction or by dedicated devices, such as anchor or twin grasper, the OTSC can be placed to close the perforation. For acute endoscopy associated perforations, the mean success rate is 90% (range: 70%-100%). For other types of perforations (postoperative, other chronic leaks and fistulas) success rates are somewhat lower (68%, and 59%, respectively). Only few complications have been reported. Although first reports are promising, further studies are needed to define the exact role of EVT and OTSC in treatment algorithms of upper gastrointestinal perforations.
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Zhang Y, Wang X, Xiong G, Qian Y, Wang H, Liu L, Miao L, Fan Z. Complete defect closure of gastric submucosal tumors with purse-string sutures. Surg Endosc 2014; 28:1844-51. [PMID: 24442680 DOI: 10.1007/s00464-013-3404-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 12/24/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Gastric submucosal tumors (SMTs) originating from the muscularis propria layer are treated endoscopically. Successful closure of the wall defect is a critical step. This study evaluated the safety and feasibility of the endoscopic purse-string suture (EPSS) method using an endoloop and several metallic clips after endoscopic full-thickness resection (EFTR) or perforation due to endoscopic submucosal dissection (ESD). METHODS From December 2009 to April 2013, 30 patients with SMTs originating from the muscularis propria layer who received EFTR or ESD were retrospectively analyzed. After successful tumor resection, an endoloop was anchored onto the circumferential margin of the gastric defect with several metallic clips and tightened gently. Patient characteristics, tumor size, en bloc resection, and postoperative complications were evaluated. RESULTS For all 30 patients, EPSS was successfully performed after EFTR or perforation due to ESD. The mean diameter of the resected specimen was 1.9 cm. No severe complications occurred during or after the procedure. The lesions were healed 1 month after the procedure, as confirmed endoscopically. CONCLUSION The EPSS method using an endoloop and clips is an effective and safe technique for closing the gastric defect after EFTR or perforation due to ESD.
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Affiliation(s)
- Yin Zhang
- Department of Digestive Endoscopy and Medical Center for Digestive Diseases, Second Affiliated Hospital of Nanjing Medical University, Nanjing, China,
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Kim CG. Natural orifice transluminal endoscopic surgery and upper gastrointestinal tract. J Gastric Cancer 2013; 13:199-206. [PMID: 24511415 PMCID: PMC3915181 DOI: 10.5230/jgc.2013.13.4.199] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 12/16/2013] [Accepted: 12/17/2013] [Indexed: 12/18/2022] Open
Abstract
Since the first transgastric natural orifice transluminal endoscopic surgery was described, various applications and modified procedures have been investigated. Transgastric natural orifice transluminal endoscopic surgery for periotoneoscopy, cholecystectomy, and appendectomy all seem viable in humans, but additional studies are required to demonstrate their benefits and roles in clinical practice. The submucosal tunneling method enhances the safety of peritoneal access and gastric closure and minimizes the risk of intraperitoneal leakage of gastric air and juice. Submucosal tunneling involves submucosal tumor resection and peroral endoscopic myotomy. Peroral endoscopic myotomy is a safe and effective treatment option for achalasia, and the most promising natural orifice transluminal endoscopic surgery procedure. Endoscopic full-thickness resection is a rapidly developing natural orifice transluminal endoscopic surgery procedure for the upper gastrointestinal tract and can be performed with a hybrid natural orifice transluminal endoscopic surgery technique (combining a laparoscopic approach) to overcome some limitations of pure natural orifice transluminal endoscopic surgery. Studies to identify the most appropriate role of endoscopic full-thickness resection are anticipated. In this article, I review the procedures of natural orifice transluminal endoscopic surgery associated with the upper gastrointestinal tract.
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Affiliation(s)
- Chan Gyoo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
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Choi HH, Kim JS, Cheung DY, Cho YS. Which endoscopic treatment is the best for small rectal carcinoid tumors? World J Gastrointest Endosc 2013; 5:487-494. [PMID: 24147192 PMCID: PMC3797901 DOI: 10.4253/wjge.v5.i10.487] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 08/07/2013] [Accepted: 08/28/2013] [Indexed: 02/05/2023] Open
Abstract
The incidence of rectal carcinoids is rising because of the widespread use of screening colonoscopy. Rectal carcinoids detected incidentally are usually in earlier stages at diagnosis. Rectal carcinoids estimated endoscopically as < 10 mm in diameter without atypical features and confined to the submucosal layer can be removed endoscopically. Here, we review the efficacy and safety of various endoscopic treatments for small rectal carcinoid tumors, including conventional polypectomy, endoscopic mucosal resection (EMR), cap-assisted EMR (or aspiration lumpectomy), endoscopic submucosal resection with ligating device, endoscopic submucosal dissection, and transanal endoscopic microsurgery. It is necessary to carefully choose an effective and safe primary resection method for complete histological resection.
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Li L, Wang F, Wu B, Wang Q, Wang C, Liu J. Endoscopic submucosal dissection of gastric fundus subepithelial tumors originating from the muscularis propria. Exp Ther Med 2013; 6:391-395. [PMID: 24137195 PMCID: PMC3786878 DOI: 10.3892/etm.2013.1181] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 06/14/2013] [Indexed: 12/18/2022] Open
Abstract
Endoscopic resection of gastric subepithelial tumors (SETs) carries a high risk of perforation, particularly for tumors located at the gastric fundus and originating from the muscularis propria. Based on our experience with endoscopic submucosal dissection (ESD) and a novel endoscopic device, namely the ‘Resolution clip’ for the endoscopic closure of iatrogenic upper gastrointestinal (upper GI) perforations, we evaluated the clinical feasibility and safety of ESD for gastric fundus subepithelial tumors originating from the muscularis propria. In this prospective study, 11 consecutive patients who presented with gastric SETs ≤3 cm in diameter were enrolled. Regardless of whether perforation occurred, the gastric wall defect was closed with clips. The patients were followed up after the surgery. Endoscopic resection was successfully performed in 10 patients; however, in one patient a pure endoscopic approach was impossible as the lesion was severely adhered to surrounding tissue, and a switch to laparoscopic wedge resection was necessary. The mean resected tumor size was 18.8×17.2 mm and the mean surgery time of the 10 patients with ESD was 81 min (range 45–130 min). Histological diagnosis was gastrointestinal stromal tumor (GIST) in eight lesions [very low risk according to the National Institutes of Health (NIH) risk classification] and leiomyoma in three lesions. Perforation occurred in 3/10 patients. Gastric closure with the Resolution clips was performed successfully in all cases. Early post-ESD bleeding (EPEB) occurred in one patient. Basic ferric sulfate solution was sprayed during the upper GI endoscopy examination and the bleeding stopped. No complications occurred and the follow-up was unremarkable. In this early study, ESD using the Resolution clip was demonstrated to be a feasible and minimally invasive treatment for gastric fundus subepithelial tumors originating from the muscularis propria.
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Affiliation(s)
- Lei Li
- Department of Gastroenterology, Shandong Provincial Hospital, Shandong University, Jinan, Shandong 250021; ; Department of Gastroenterology, Taian Central Hospital, Taian, Shandong 271000, P.R. China
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