Preoperative diagnosis of gastrointestinal stromal tumor by endoscopic ultrasound-guided fine needle aspiration

AIM： to evaluate the role of endoscopic ultrasonographyguided fine needle aspiration （EUS-FNA） in the preoperative diagnosis of gastrointestinal stromal tumor （GIST）.METHODS： From September 2002 to June 2006, Fiftythree consecutive EUS-FNAs of GI tract subepithelial hypoechoic tumors with continuity to proper muscle layer suspected as GIST by standard EUS were evaluated prospectively. The reference standards for the final diagnosis were surgery （n = 31）, or clinical follow-up （n = 22）. Additionally, immunophenotyping of specimens obtained by EUS-FNA and surgical resection specimens were compared.RESULTS： In 2 cases puncture was not performed because of anatomical problems. The collection rate of adequate specimens from the GI tract subepithelial hypoechoic tumor with continuity to proper muscle layer was 82% （42/51）. The diagnostic rate for the tumor less than 2 cm, 2 to 4 cm, and 4 cm or more were 71% （15/21）, 86% （18/21）, and 100% （9/9）,respectively. In 29 surgically resected cases, the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of EUS-FNA using immunohistochemical analysis of GIST were 100%（24/24）, 80% （4/5）, 96% （24/25）, 100% （4/4）, and 97% （28/29）, respectively. No major complications were encountered.CONCLUSION： EUS-FNA with immunohistochemical analysis is a safe and accurate method in the pretherapeutic diagnosis of GIST. It should be taken into consideration in decision making, especially in early diagnosis following minimal invasive surgery for GIST.

Prognostic factors associated with mortality in patients with gastric fundal variceal bleeding

AIM To determine the prognostic factors associated with mortality in patients with gastric fundal variceal (GFV) bleeding.METHODS In total, 42 patients were endoscopically diagnosed with GFV bleeding from January 2000 to March 2014. We retrospectively reviewed the patients' medical records and assessed their history, etiology of liver cirrhosis, disease conditions, treatment options for GFV bleeding, medications administered before and after onset of GFV bleeding, blood test results(hemoglobin, albumin, and bilirubin concentrations), and imaging results(including computed tomography and abdominal ultrasonography). We also assessed the prognostic factors associated with short-term mortality(up to 90 d) and long-term mortality in all patients.RESULTS Multivariate analysis showed that prophylactic administration of antibiotics was an independent prognostic factor associated with decreases in short-term mortality (OR = 0.08, 95%CI: 0.01-0.52) and longterm mortality (OR = 0.27, 95%CI: 0.08-0.91) in patients with GFV bleeding. In contrast, concurrent hepatocellular carcinoma (HCC) and regular use of proton pump inhibitors (PPI) were independent prognostic factors associated with increases in shortterm mortality(HCC: OR = 15.4, 95%CI: 2.08-114.75; PPI: OR = 12.76, 95%CI: 2.13-76.52) and long-term mortality (HCC: OR = 7.89, 95%CI: 1.98-31.58; PPI: OR = 10.91, 95%CI: 2.86-41.65) in patients with GFV bleeding. The long-term overall survival rate was significantly lower in patients who regularly used PPI than in those who did not use PPI(P = 0.0074).CONCLUSION Administration of antibiotics is associated with decreased short- and long-term mortality, while concurrent HCC and regular PPI administration are associated with increased short- and long-term mortality.

Endoscopic submucosal dissection for esophageal granular cell tumor using the clutch cutter

Endoscopic submucosal dissection (ESD) with a knife is a technically demanding procedure associated with a high complication rate.The shortcomings of this method are the deficiencies of fixing the knife to the target lesion,and of compressing it.These shortcomings can lead to major complications such as perforation and bleeding.To reduce the risk of complications related to ESD,we developed a new grasping type scissors forceps (Clutch Cutter,Fujifilm,Japan) which can grasp and incise the targeted tissue using an electrosurgical current.Esophagogastroduodenoscopy on a 59-year-old Japanese man revealed a 16mm esophageal submucosal nodule with central depression.Endoscopic ultrasonography demonstrated a hypoechoic solid tumor limited to the submucosa without lymph node involvement.The histologic diagnosis of the specimen obtained by biopsy was granular cell tumor.It was safely and accurately resected without unexpected incision by ESD using the CC.No delayed hemorrhage or perforation occurred.Histological examination confirmed that the granular cell tumor was completely excised with negative resection margin.We report herein a case of esophageal granular cell tumor successfully treated by an ESD technique using the CC.

Double-balloon endoscopy in the diagnosis and management of GI tract diseases:Methodology,indications,safety,and clinical impact

AIM： To prospectively evaluate the indications, methodology, safety, and clinical impact of double-balloon endoscopy. METHODS： A total of 60 patients with suspected or documented small- or large-bowel diseases were investigated by double balloon endoscopy. A total of 103 procedures were performed （42 from the oral route, 60 from the anal route, and 1 from the stoma route）. The main outcome measurements were the time of insertion and the entire examination, complications, diagnostic yields, and the ability to successfully perform treatment. RESULTS： Observation of the entire small intestine was possible in 10 （40%） of 25 patients with total enteroscopy. The median insertion time was 122 min （range, 74-199 min）. Observation of the entire colon was possible in 13 （93%） of 14 patients at＂cer failure of total colonoscopy using a conventional colonoscope. Small-intestine abnormalities were found in 20 （43%） of 46 patients with indications of suspected or documented small bowel diseases, obscure GI tract bleeding, or a history of ileus. Endoscopic procedures including tattooing （n = 33）, bite biopsy （n = 17）, radiographic examination （n = 7）, EUS （n = 5）, hemostasis （n = 1）, polypectomy （n = 5）, balloon dilatation （n = 1）, endoscopic mucosal resection （n = 1） and lithotripsy （n = 1） were all successfully performed. No relevant technical problems or severe complications were encountered. CONCLUSION： Double balloon endoscopy is a feasible technique that allows adequate small and large bowel examination and potentially various endoscopic procedures of small-intestinal lesions. It is safe, useful, and also provides a high clinical impact.

Immediate detection of endoscopic retrograde cholangiopancreatographyrelated periampullary perforation: Fluoroscopy or endoscopy?

AIM: To investigate the causes and intraoperative detection of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations to support immediate or early diagnosis.

Safety advantage of endocut mode over endoscopic sphincterotomy for choledocholithiasis

AIM： To evaluate whether an automatically controlled cut system （endocut mode） could reduce the complication rate of endoscopic sphincterotomy （EST） and serum hyperamylasemia after EST compared to the conventional blended cut mode. METHODS： From January 2001 to October 2003, 134 patients with choledocholithiasis were assigned to either endocut mode group or conventional blended cut mode group at the time of sphincterotomy. The two groups were retrospectively compared for the complications after EST and serum amylase level before and 24 h after the procedure. RESULTS： Of the 134 patients treated, 79 were assigned to conventional blended cut mode group and 55 to endocut mode group. There was no significant difference in age, sex, and serum amylase level before EST between the two groups. Complications were found in 5 patients of the endocut mode group （9%）： hyperamylasemia （5 times higher than normal） in 4 and moderate pancreatitis in 1. Complications were found in 13 patients of the conventional blended cut mode group （16%）： hyperamylasemia in 12 and moderate pancreatitis in 1. Serum amylase levels were elevated in both groups 24 h after EST （P〈0.02）. The average serum amylase level 24 h after EST in the conventional blended cut mode group was significantly higher than that in the endocut mode group （P〈 0.05）. CONCLUSION： Endocut mode offers a safety advantage over conventional blended cut mode for pancreatitis after EST by reducing hyperamylasemia.

Endoscopic submucosal dissection of a rectal carcinoid tumor using grasping type scissors forceps

Endoscopic submucosal dissection （ESD） with a knife is a technically demanding procedure a ssociated with ahigh complication rate. The shortcomings of this meth-od are the inability to fix the knife to the target lesion,and compression of the lesion. These can lead to major complications such as perforation and bleeding. To reduce the risk of complications related to ESD, we developed a new grasping type scissors forceps （GSF）,which can grasp and incise the targeted tissue using electrosurgical current. Colonoscopy on a 55-year-old woman revealed a 10-ram rectal submucosal nodule.The histological diagnosis of the specimen obtained by biopsy was carcinoid tumor. Endoscopic ultrasonog-raphy demonstrated a hypoechoic solid tumor limitedto the submucosa without lymph node involvement. Itwas safely and accurately resected without unexpectedincision by ESD using a GSF. No delayed hemorrhage or perforation occurred. Histological examination confirmed the carcinoid tumor was completely excisedwith negative resection margin.

Clinical outcomes of Clutch Cutter endoscopic submucosal dissection for older patients with early gastric cancer

AIM To evaluate the clinical outcome of endoscopic submucosal dissection using the Clutch Cutter(ESDCC) in older patients. METHODS We reviewed 232 consecutive patients with early gastric cancer who underwent ESDCC between June 2010 and February 2014 at Aso Iizuka Hospital. We divided patients into two groups according to age: Older patients(> 80 years, n = 64) and non-older patients(≤ 80 years, n = 168). We retrospectively compared the prevalence rates of pre-existing comorbidities, anticoagulant therapy, en bloc resection, mean duration of hospitalization, incidence of ESDCC-related complications, change in performance status(PS) before and after ESDCC, and financial cost of admission. RESULTS The older group comprised 64 patients with a mean age of 84.1 years, and the non-older group comprised 168 patients with a mean age of 69.5 years. Older patients had significantly more pre-existing comorbidities than did non-older patients, specifically heart disease(P < 0.05). The en bloc resection rate in non-older patients was significantly higher than that in older patients(100% vs 95.3%, P = 0.02). There were no significant differences between the older and non-older groups in the incidence of ESDCC-related complications(i.e., postoperative bleeding and perforation) and the post-ESDCC change in PS. There were also no significant differences between the older and non-older groups in the mean duration of hospitalization(11.4 and 10.7 d, respectively) and financial cost of admission(657040 JPY and 574890 JPY, respectively).CONCLUSION ESDCC has a good clinical outcome in older patients.

Endoscopic mucosal resection vs endoscopic submucosal dissection for superficial non-ampullary duodenal tumors

BACKGROUND The selection of endoscopic treatments for superficial non-ampullary duodenal epithelial tumors(SNADETs)is controversial.AIM To compare the efficacy and safety of endoscopic mucosal resection(EMR)and endoscopic submucosal dissection(ESD)for SNADETs.METHODS We retrospectively analyzed the data of patients with SNADETs from a database of endoscopic treatment for SNADETs,which included eight hospitals in Fukuoka,Japan,between April 2001 and October 2017.A total of 142 patients with SNADETs treated with EMR or ESD were analyzed.Propensity score matching was performed to adjust for the differences in the patient characteristics between the two groups.We analyzed the treatment outcomes,including the rates of en bloc/complete resection,procedure time,adverse event rate,hospital stay,and local or metastatic recurrence.RESULTS Twenty-eight pairs of patients were created.The characteristics of patients between the two groups were similar after matching.The EMR group had a significantly shorter procedure time and hospital stay than those of the ESD group[median procedure time(interquartile range):6(3-10.75)min vs 87.5(68.5-136.5)min,P<0.001,hospital stay:8(6-10.75)d vs 11(8.25-14.75)d,P=0.006].Other outcomes were not significantly different between the two groups(en bloc resection rate:82.1%vs 92.9%,P=0.42;complete resection rate:71.4%vs 89.3%,P=0.18;and adverse event rate:3.6%vs 17.9%,P=0.19,local recurrence rate:3.6%vs 0%,P=1;metastatic recurrence rate:0%in both).Only one patient in the ESD group underwent emergency surgery owing to intraoperative perforation.CONCLUSION EMR has significantly shorter procedure time and hospital stay than ESD,and provides acceptable curability and safety compared to ESD.Accordingly,EMR for SNADETs is associated with lower medical costs.

Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography

AIM: To investigate the clinical outcome of double balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (DB-ERCP) in patients with altered gastrointestinal anatomy. METHODS: Between September 2006 and April 2011, 47 procedures of DB-ERCP were performed in 28 patients with a Roux-en-Y total gastrectomy (n = 11), Billroth Ⅱ gastrectomy (n = 15), or Roux-en-Y anastomosis with hepaticojejunostomy (n = 2). DB-ERCP was performed using a short-type DBE combined with several technical innovations such as using an endoscope attachment, marking by submucosal tattooing,selectively applying contrast medium, and CO2 insufflations. RESULTS: The papilla of Vater or hepaticojejunostomy site was reached in its entirety with a 96% success rate (45/47 procedures). There were no significant differences in the success rate of reaching the blind end with a DBE among Roux-en-Y total gastrectomy (96%), Billroth Ⅱ reconstruction (94%), or pancreatoduodenectomy (100%), respectively (P = 0.91). The total successful rate of cannulation and contrast enhancement of the target bile duct in patients whom the blind end was reached with a DBE was 40/45 procedures (89%). Again, there were no significant differences in the success rate of cannulation and contrast enhancement of the target bile duct with a DBE among Roux-en-Y total gastrectomy (88 %), Billroth Ⅱ reconstruction (89%), or pancreatoduodenectomy (100%), respectively (P = 0.67). Treatment was achieved in all 40 procedures (100%) in patients whom the contrast enhancement of the bile duct was successful. Common endoscopic treatments were endoscopic biliary drainage (24 procedures) and extraction of stones (14 procedures). Biliary drainage was done by placement of plastic stents. Stones extraction was done by lithotomy with the mechanical lithotripter followed by extraction with a basket or by the balloon pull-through method. Endoscopic sphincterotomy was performed in 14 procedures with a needle precutting knife using a guidewire. The mean total duration of the procedure was 93.6 ± 6.8 min and the mean time required to reach the papilla was 30.5 ± 3.7 min. The mean time required to reach the papilla tended to be shorter in Billroth Ⅱ reconstruction (20.9 ± 5.8 min) than that in Roux-en-Y total gastrectomy (37.1 ± 4.9 min) but there was no significant difference (P = 0.09). A major complication occurred in one patient (3.5%); perforation of the long limb in a patient with Billroth Ⅱ anastomosis.CONCLUSION: Short-type DBE combined with several technical innovations enabled us to perform ERCP in most patients with altered gastrointestinal anatomy.

Advances in endoscopic therapy using grasping-type scissors forceps(with video)

Endoscopic submucosal dissection(ESD)is a globally accepted minimally invasive therapy for early-stage gastrointestinal tract tumors.Although numerous electrosurgical knives have been developed for ESD,technical difficulties and high complication rates(bleeding and perforation)have limited their use worldwide.The grasping-type scissors forceps[clutch cutter(CC)]is the first forceps-type resection device developed with reference to hemostatic forceps.The aim was to allow easy and safe ESD throughout the gastro-intestinal tract,as a biopsy technique,using one device.The CC can grasp the target tissue accurately and pull it away from the underlying muscle layer prior to energizing the tissue,for safe and effective incision and hemostasis during ESD.Reported clinical studies showed that ESD using the CC(ESD-CC)is a safe(perforation rate:0%-3.6%;delayed bleeding rate:0%-4.2%),technically efficient(en-bloc resection rate:88.9%-100%),and single-device method for dissecting early-stage gastrointestinal tract tumors.The ESD-CC technique is simple and easy to learn because it can be completed simply by repeating the grasp,pull,and coagulate and/or incise actions using an electrosurgical current.The reported self-completion rate by nonexperts was significantly better with the CC than with conventional knives(61.7%vs 24.5%,respectively;P<0.001).Furthermore,the CC is used for other endoscopic therapies,such as endoscopic polypectomy for large pedunculated polyps,endoscopic myotomy for Zenker’s diverticulum,endoscopic treatment of buried bumper syndrome,and endoscopic necrosectomy for wall-off pancreatic necrosis.The initial reports using CC for these therapies have shown favorable results.In this review,we describe the structural features of the CC,how to use the instrument,efficacies of ESD-CC,and other unique endoscopic therapies using the CC.

Endoscopic submucosal dissection of gastric adenomas using the clutch cutter

To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) using the clutch cutter (CC) (ESD-CC) for gastric adenoma (GA). METHODSFrom June 2007 to August 2015, 122 consecutive patients with histological diagnoses of GA from specimens resected by ESD-CC were enrolled in this prospective study. The CC was used for all ESD steps (marking, mucosal incision, submucosal dissection, and hemostatic treatment), and its therapeutic efficacy and safety were assessed. RESULTSBoth the en-bloc resection rate and the R0 resection rate were 100% (122/122). The mean surgical time was 77.4 min, but the time varied significantly according to tumor size and location. No patients suffered perforation. Post-ESD-CC bleeding occurred in six cases (4.9%) that were successfully resolved by endoscopic hemostatic treatment. CONCLUSIONESD-CC is a technically efficient, safe, and easy method for resecting GA.