Endoscopic resection for calcifying fibrous tumors of the gastrointestinal tract

BACKGROUND Calcifying fibrous tumors(CFTs)are rare mesenchymal lesions that can occur in various sites throughout the body,including the tubular gastrointestinal(GI)tract.AIM To analyze the clinical findings of 36 patients with GI tract CFTs to provide guidance for diagnosis and treatment.METHODS This retrospective study included 36 patients diagnosed with CFTs of the GI tract.We collected demographic and clinical information and conducted regular follow-ups to assess for local recurrence.RESULTS The stomach was the most commonly involved site,accounting for 72.2%of the 36 CFTs.Endoscopic mucosal resection(n=1,2.8%),endoscopic submucosal dissection(n=14,38.9%),endoscopic full-thickness resection(n=16,44.4%),and submucosal tunneling endoscopic resection(n=5,13.9%)were used to resect calcifying fibrous tumors.Overall,34(94.4%)CFTs underwent complete endoscopic resections with a mean procedure time of 39.8±29.8 min.The average maximum diameter of the tumors was 10.6±4.3 cm.No complications,such as bleeding or perforation,occurred during an average hospital stay of 2.9±1.2 d.In addition,two patients developed new growth of CFTs near the primary tumor sites,and none of the patients developed distant metastases during the follow-up period.CONCLUSION GI tract CFTs are rare and typically benign tumors that can be effectively managed with endoscopic procedures.

Magnifying narrow-band imaging endoscopy is superior in diagnosis of early gastric cancer

AIM:To evaluate the diagnostic effectiveness of white light endoscopy,magnifying endoscopy(ME),and magnifying narrow-band imaging endoscopy(ME-NBI) in detecting early gastric cancer(EGC).METHODS:From March 2010 to June 2012,a total of 3616 patients received screening for gastric cancer by magnifying endoscopy. There were 3675 focal gastric lesions detected using conventional high definition white light endoscopy(HD-WLE) in four different referentialhospitals that were recruited for further investigation using ME and ME-NBI. The images obtained from HD-WLE,ME,and ME-NBI were reviewed by four experienced endoscopists to evaluate their diagnostic effectiveness for EGC. The diagnosis of cancerous and non-cancerous lesions was conducted by evaluating the microvascular and microsurface patterns using the VS classification system. The final endoscopic diagnosis of each lesion was determined by consultation when a disagreement occurred. We used histopathological results as the gold standard for the diagnosis of EGC.RESULTS:Among the 3675 lesions found,1508 were validated by pathological findings as chronic gastritis,1279 as chronic gastritis with intestinal metaplasia,631 as low-grade neoplasia,and 257 as EGC. The sensitivity,specificity,positive predictive value,negative predictive value,and accuracy of HD-WLE for the diagnosis of EGC were 71.2%,99.1%,85.5%,97.9% and 97.1%,respectively. The results of ME for diagnosing EGC were 81.3%,98.8%,83.3%,98.6% and 97.6%,respectively. The results of ME-NBI for the diagnosis of EGC were 87.2%,98.6%,82.1%,99.0% and 97.8%,respectively. The diagnostic sensitivity and accuracy of paired ME and ME-NBI were significantly better than those of HD-WLE(P < 0.05).CONCLUSION:HD-WLE has a relatively high accuracy for diagnosing EGC and is an effective screening tool. Further investigations of ME and ME-NBI are required to achieve superior accuracy.

New progress in endoscopic treatment of esophageal diseases

The technique of endoscopic submucosal dissection(ESD),which was developed for en bloc resection of large lesions in the stomach,has been widely accepted for the treatment of the entire gastrointestinal tract.Many minimally invasive endoscopic therapies based on ESD have been developed recently.Endoscopic submucosal excavation,submucosal tunneling endoscopic resection and laparoscopic-endoscopic cooperative surgery have been used to remove submucosal tumors,especially tumors which originate from the muscularis propria of the digestive tract.Peroral endoscopic myotomy has recently been described as a scarless and less invasive surgical myotomy option for the treatment of achalasia.Patients benefit from minimally invasive endoscopic therapy.This article,in the highlight topic series,provides detailed information on the indications and treatments for esophageal diseases.

Self-expandable metallic stent placement plus laparoscopy for acute malignant colorectal obstruction

AIM:To investigate the clinical advantages of the stent-laparoscopy approach to treat colorectal cancer(CRC)patients with acute colorectal obstruction(ACO).METHODS:From April 2008 to April 2012,surgeryrelated parameters,complications,overall survival(OS),and disease-free survival(DFS)of 74 consecutive patients with left-sided CRC presented with ACO who underwent self-expandable metallic stent(SEMS)placement followed by one-stage open(n=58)or laparoscopic resection(n=16)were evaluated retrospectively.The stent-laparoscopy group was also compared with a control group of 96 CRC patients who underwent regular laparoscopy without ACO between January 2010 and December 2011 to explore whether SEMS placement influenced the laparoscopic procedure or reduced long-term survival by influencing CRC oncological characteristics.RESULTS:The characteristics of patients among these groups were comparable.The rate of conversion to open surgery was 12.5%in the stent-laparoscopy group.Bowel function recovery and postoperative hospital stay were significantly shorter(3.3±0.9 d vs 4.2±1.5 d and 6.7±1.1 d vs 9.5±6.7 d,P=0.016 and P=0.005),and surgical time was significantly longer(152.1±44.4 min vs 127.4±38.4 min,P=0.045)in the stent-laparoscopy group than in the stent-open group.Surgery-related complications and the rate of admission to the intensive care unit were lower in the stent-laparoscopy group.There were no significant differences in the interval between stenting and surgery,intraoperative blood loss,OS,and DFS between the two stent groups.Compared with those in the stentlaparoscopy group,all surgery-related parameters,complications,OS,and DFS in the control group were comparable.CONCLUSION:The stent-laparoscopy approach is a feasible,rapid,and minimally invasive option for patients with ACO caused by left-sided CRC and can achieve a favorable long-term prognosis.

Endoscopic submucosal dissection for foregut neuroendocrine tumors:An initial study

AIM:To evaluate the feasibility and efficacy of endoscopic submucosal dissection(ESD) for foregut neuroendocrine tumors(NETs).METHODS:From April 2008 to December 2010,patients with confirmed histological diagnosis of foregut NETs were included.None had regional lymph node enlargement or distant metastases to the liver or lung on preoperative computerized tomography scanning or endoscopic ultrasonography(EUS).ESD was attempted under general anesthesia.After making several marking dots around the lesion,a mixture solution was injected into the submucosa.The mucosa was incised outside the marking dots.Dissection of the submucosal layer beneath the tumor was performed under direct vision to achieve complete en bloc resection of the specimen.Tumor features,clinicopathological characteristics,complete resection rate,and complications were evaluated.Foregut NETs were graded as G1,G2,or G3 on the basis of proliferative activity by mitotic count or Ki-67 index.All patients underwent regular follow-up to evaluate for any local recurrence or distant metastasis.RESULTS:Those treated by ESD included 24 patients with 29 foregut NETs.The locations of the 29 lesions are as follows:esophagus(n = 1),cardia(n = 1),stomach(n = 23),and duodenal bulb(n = 4).All lesions were found incidentally during routine upper gastrointestinal endoscopy for other indications,and none had symptoms of carcinoid syndrome.Preoperative EUS showed that all tumors were confined to the submucosa.Among the 24 gastric lesions,16 lesions in 11 patients were type I gastric NETs arising in chronic atrophic gastritis with hypergastrinemia,while the other 8 solitary lesions were type Ⅲ because of absence of atrophic gastritis in these cases.All of the tumors were removed in an en bloc fashion.The average maximum diameter of the lesions was 9.4 mm(range:2-30 mm),and the procedure time was 20.3 min(range:10-45 min).According to the World Health Organization 2010 classification,histological evaluation determined that 26 lesions were NET-G1,2 gastric lesions were NET-G2,and 1 esophageal lesion was neuroendocrine carcinoma(NEC).Complete resection was achieved in 28 lesions(28/29,96.6%),and all of them were confined to the submucosa in histopathologic assessment with no lymphovascular invasion.The remaining patient with NEC underwent additional surgery because the resected specimens revealed angiolymphatic and muscularis invasion,as well as incomplete resection.Delayed bleeding occurred in 1 case 3 d after ESD,which was managed by endoscopic treatment.There were no procedure-related perforations.During a mean follow-up period of 24.4 mo(range:12-48 mo),local recurrence occurred in only 1 patient 7 mo after initial ESD.This patient successfully underwent repeat ESD.Metastasis to lymph nodes or distal organs was not observed in any patient.No patients died during the study period.CONCLUSION:ESD appears to be a safe,feasible,and effective procedure for providing accurate histopathological evaluations and curative treatment for eligible foregut NETs.

Comparative study on artificial intelligence systems for detecting early esophageal squamous cell carcinoma between narrow-band and white-light imaging

BACKGROUND Non-magnifying endoscopy with narrow-band imaging(NM-NBI)has been frequently used in routine screening of esophagus squamous cell carcinoma(ESCC).The performance of NBI for screening of early ESCC is,however,significantly affected by operator experience.Artificial intelligence may be a unique approach to compensate for the lack of operator experience.AIM To construct a computer-aided detection(CAD)system for application in NMNBI to identify early ESCC and to compare it with our previously reported CAD system with endoscopic white-light imaging(WLI).METHODS A total of 2167 abnormal NM-NBI images of early ESCC and 2568 normal images were collected from three institutions(Zhongshan Hospital of Fudan University,Xuhui Hospital,and Kiang Wu Hospital)as the training dataset,and 316 pairs of images,each pair including images obtained by WLI and NBI(same part),were collected for validation.Twenty endoscopists participated in this study to review the validation images with or without the assistance of the CAD systems.The diagnostic results of the two CAD systems and improvement in diagnostic efficacy of endoscopists were compared in terms of sensitivity,specificity,accuracy,positive predictive value,and negative predictive value.RESULTS The area under receiver operating characteristic curve for CAD-NBI was 0.9761.For the validation dataset,the sensitivity,specificity,accuracy,positive predictive value,and negative predictive value of CAD-NBI were 91.0%,96.7%,94.3%,95.3%,and 93.6%,respectively,while those of CAD-WLI were 98.5%,83.1%,89.5%,80.8%,and 98.7%,respectively.CAD-NBI showed superior accuracy and specificity than CAD-WLI(P=0.028 and P≤0.001,respectively),while CAD-WLI had higher sensitivity than CAD-NBI(P=0.006).By using both CAD-WLI and CAD-NBI,the endoscopists could improve their diagnostic efficacy to the highest level,with accuracy,sensitivity,and specificity of 94.9%,92.4%,and 96.7%,respectively.CONCLUSION The CAD-NBI system for screening early ESCC has higher accuracy and specificity than CAD-WLI.Endoscopists can achieve the best diagnostic efficacy using both CAD-WLI and CAD-NBI.

Management of iatrogenic colorectal perforation: From surgery to endoscopy

Iatrogenic colon perforation is one the most pernicious complications for patients undergoing endoscopic screening or therapy.It is a serious but rare complication of colonoscopy.However,with the expansion of the indications for endoscopic therapies for gastrointestinal diseases,the frequency of colorectal perforation has increased.The management of iatrogenic colorectal perforation is still a challenge for many endoscopists.The methods for treating this complication vary,including conservative treatment,surgical treatment,laparoscopy and endoscopy.In this review,we highlight the etiology,recognition and treatment of colorectal iatrogenic perforation.Specifically,we shed light on the endoscopic management of this rare complication.

Endoscopic biliary drainage for biliary obstruction

OBJECTIVE: To improve the successful rate of endoscopic biliary drainage. METHODS: Three hundred and fifty-two patients with biliary obstruction were given biliary drainage via duodenoscope from January 1998 to December 2002. 258 patients received endoscopic naso-biliary drainage (ENBD), 51 endoscopic retrograde biliary drainage (ERBD), and 43 endoscopic metal biliary endoprothesis (EMBE). RESULTS: Of the 352 patients with biliary obstruction, 337 succeeded in drainage by endoscopy and 15 failed. Ten ENBD failed patients were handled successfully by readjustment of the site of the naso-biliary tube. In 3 ERBD failed patients, 2 were given plastic stents with appropriate length and got a fluent drainage. Percutaneous transhepatic biliary drainage (PTBD) was performed in one patient after failure of endoscopic management. In 2 patients with failed EMBE, one stent could not exceed the site of tumor stricture and one was obstructed by tumor implantation only one month after EMBE. Placement of another metallic stent and a plastic stent through the previous prothesis for each patient ensured a successful drainage. CONCLUSIONS: The effect of endoscopic biliary drainage for biliary obstruction is definite. Drainage failure can be avoided or remedied as early as possible by taking some active measures.

Endoscopic resection of colorectal granular cell tumors

AIM: To determine the feasibility and effectiveness of endoscopic resection for the treatment of colorectal granular cell tumors(GCTs). METHODS: This was a retrospective study performed at a single institution. From January 2008 to April 2015, we examined a total of 11 lesions in 11 patients who were treated by an endoscopic procedure for colorectal GCTs in the Endoscopy Center, Zhongshan hospital of Fudan University, Shanghai, China. Either endoscopic mucosal resection or endoscopic submucosal dissection(ESD) was performed by three surgeons with expertise in endoscopic treatment. The pre- and postoperative condition and follow-up of these patients were evaluated by colonoscopy and endoscopic ultrasonography(EUS).RESULTS: Of these 11 lesions, 2 were located in the cecum, 3 were in the ileocecal junction, 5 were in the ascending colon, and 1 was in the rectum. The median maximum diameter of the tumors was 0.81 cm(range 0.4-1.2 cm). The en bloc rate was 100%, and the complete resection rate was 90.9%(10/11). postoperative pathology in one patient showed a tumor at the cauterization margin. however, during ESD, this lesion was removed en bloc, and no tumor tissue was seen in the wound. No perforations or delayed perforations were observed and emergency surgery was not required for complications. All patients were followed up to May 2015, and none had recurrence, metastasis, or complaints of discomfort.CONCLUSION: Endoscopic treatment performed by endoscopists with sufficient experience appears to be feasible and effective for colorectal GCTs.

Ligation-assisted endoscopic submucosal resection with circumferential mucosal incision for duodenal carcinoid tumor

Here we present the case of a 64-year-old female with a duodenal carcinoid tumor treated by ligation-assisted endoscopic submucosal resection(ESMR-L) with circumferential mucosal incision(CMI). Band ligation was effective in resecting the duodenal carcinoid tumor after CMI,with an uneventful post-procedural course. Histopathological examination showed clear tumor margins at deeper tissue levels. Thus,in the present case,ESMR-L with CMI was useful for the treatment of duodenal carcinoid tumor.

水悬浮下双尼龙绳套扎联合高频电切治疗结肠粗蒂息肉

目的探讨内镜水下双尼龙绳套扎联合高频电切治疗结肠粗蒂息肉的可行性。方法回顾性研究2017年1月-2018年6月复旦大学附属中山医院内镜水悬浮下双尼龙绳套扎联合高频电切治疗的43例结肠粗蒂息肉患者的临床资料。观察患者术后有无出血等并发症发生;随访观察患者有无迟发性出血发生。结果43例患者共成功切除43枚结肠粗蒂息肉,息肉最大直径1.0~3.5 cm,平均2.7 cm;息肉蒂部直径0.5~1.5 cm,平均1.1 cm;内镜下手术时间5~16 min,平均9.2 min。肠腔内灌注水量120~750 mL,平均330 mL。尼龙绳套扎次数1至2次,平均1.1次,尼龙绳一次套扎成功率95.4%(41/43)。息肉完整切除率100.0%,整块切除率100.0%,患者息肉切除治疗有效率为100.0%。43枚息肉经病理检查证实为腺瘤性息肉。无1例患者术中出血;随访期间无1例患者发生迟发性出血。结论内镜水悬浮下双尼龙绳套扎联合高频电切治疗结肠粗蒂息肉,是安全可行的。

Endoscopic resection of tumors in the lower digestive tract

As endoscopic technology has developed and matured,the endoscopic resection of gastrointestinal tract polyps has become a widely used treatment. Colorectal polyps are the most common type of polyp, which are best managed by early resection before the polyp undergoes malignant transformation. Methods for treating colorectal tumors are numerous, including argon plasma coagulation, endoscopic mucosal resection, endoscopic submucosal dissection, and laparoscopic-endoscopic cooperative surgery. In this review, we will highlight several currently used clinical endoscopic resection methods and how they are selected based on the characteristics of the targeted tumor. Specifically, we will focus on laparoscopic-endoscopic cooperative surgery.

Endoscopic sphincterotomy or papillary balloon dilatation for choledocholithiasis

Objective: To assess the safety and effect of endoscopicsphincterotomy (EST) and endoscopic papillary bal-loon dilatation (EPBD) for choledocholithiasis.Methods: 328 patients with choledocholithiasis weresubjected to EST or EPBD; they included 174 patientswith single stone, 112 patients with two stones and 42patients with three stones (one patient with 20 stones).Patients with stones less than 10 mm in diameter un-derwent EPBD and those with stones larger than 11mm in diameter underwent EST.Results: EST and EPBD succeeded in 323 patients(98.5%), and failed in 5. Stones in 98 patients wereexcluded spontaneously after endoscopic therapy. 207patients were subjected to basket or balloon stone ex-traction. Stones in 14 patients were discharged bybasket lithotripsy. Four patients were given wavelithotripsy. Stones in 22 of the 323 patients were ex-tracted thoroughly after 2-3 times attempts. Totalcomplications were noted in 2.5% of the patients.Hemorrhage from the gastrointestinal tract was seenin one patient, cholangitis in 4 patients, and pancre-atitis in 3 patients. In 92 patients receiving digestivetract barium X-ray examination, 86 developed nobarium reflux to the baliary tract, 2 pneumobilia, 4barium reflux to the biliary tract.Conclusion: EST and EPBD are relatively safe and effec-tive in treatment of choledocholithiasis, and have fewcomplications.

Long-term outcomes of endoscopic submucosal dissection for high-grade dysplasia and early-stage carcinoma in the colorectum

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