Clinical efficacy of Gamma Knife® combined with transarterial chemoembolization and immunotherapy in the treatment of primary liver cancer

BACKGROUND This study was designed to investigate the clinical efficacy and safety of Gamma Knife®combined with transarterial chemoembolization(TACE)and immunotherapy in the treatment of primary liver cancer.AIM To investigate the clinical efficacy and safety of Gamma Knife®combined with TACE and immune-targeted therapy in the treatment of primary liver cancer.METHODS Clinical data from 51 patients with primary liver cancer admitted to our hospital between May 2018 and October 2022 were retrospectively collected.All patients underwent Gamma Knife®treatment combined with TACE and immunotherapy.The clinical efficacy,changes in liver function,overall survival(OS),and progression-free survival(PFS)of patients with different treatment responses were evaluated,and adverse reactions were recorded.RESULTS The last follow-up for this study was conducted on October 31,2023.Clinical evaluation of the 51 patients with primary liver cancer revealed a partial response(PR)in 27 patients,accounting for 52.94%(27/51);stable disease(SD)in 16 patients,accounting for 31.37%(16/51);and progressive disease(PD)in 8 patients,accounting for 15.69%(8/51).The objective response rate was 52.94%,and the disease control rate was 84.31%.Alanine aminotransferase,aspartate aminotransferase,lactate dehydrogenase,and alpha-fetoprotein isoform levels decreased after treatment compared with pretreatment(all P=0.000).The median OS was 26 months[95%confidence interval(95%CI):19.946-32.054]in the PR group and 19 months(95%CI:14.156-23.125)in the SD+PD group,with a statistically significant difference(P=0.015).The median PFS was 20 months(95%CI:18.441-34.559)in the PR group and 12 months(95%CI:8.745-13.425)in the SD+PD group,with a statistically significant difference(P=0.002).Common adverse reactions during treatment included nausea and vomiting(39.22%),thrombocytopenia(27.45%),and leukopenia(25.49%),with no treatment-related deaths reported.CONCLUSION Gamma Knife®combined with TACE and immune-targeted therapy is safe and effective in the treatment of primary liver cancer and has a good effect on improving the clinical benefit rate and liver function of patients.

Emerging molecules,tools,technology,and future of surgical knife in gastroenterology

The 21^(st) century has started with several innovations in the medical sciences,with wide applications in health care management.This development has taken in the field of medicines(newer drugs/molecules),various tools and technology which has completely changed the patient management including abdominal surgery.Surgery for abdominal diseases has moved from maximally invasive to minimally invasive(laparoscopic and robotic)surgery.Some of the newer medicines have its impact on need for surgical intervention.This article focuses on the development of these emerging molecules,tools,and technology and their impact on present surgical form and its future effects on the surgical intervention in gastroenterological diseases.

Usefulness of a novel slim type Flush Knife-BT over conventional Flush Knife-BT in esophageal endoscopic submucosal dissection

To investigated the usefulness of a novel slim type ball-tipped FlushKnife (FlushKnife-BTS) over ball-tipped FlushKnife (FlushKnife-BT) in functional experiments and clinical practice.METHODSIn order to evaluate the functionality of FlushKnife-BTS, water aspiration speed, resistance to knife insertion through the scope, and waterjet flushing speed were compared between FlushKnife-BTS and BT. In clinical practice, esophageal endoscopic submucosal dissection (ESD) performed using FlushKnife-BTS or BT by an experienced endoscopist between October 2015 and January 2016 were retrospectively reviewed. The treatment speed and frequency of removing and reinserting the knife to aspirate fluid and air during ESD sessions were analyzed.RESULTSFunctional experiments revealed that water aspiration speed by the endoscope equipped with a 2.8-mm working channel with FlushKnife-BTS was 7.7-fold faster than that with conventional FlushKnife-BT. Resistance to knife insertion inside the scope with a 2.8-mm working channel was reduced by 40% with FlushKnife-BTS. The waterjet flushing speed was faster with the use of FlushKnife-BT. In clinical practice, a comparison of 6 and 7 ESD using FlushKnife-BT and BTS, respectively, revealed that the median treatment speed was 25.5 mm2/min (range 19.6-30.3) in the BT group and 44.2 mm2/min (range 15.5-55.4) in the BTS group (P = 0.0633). However, the median treatment speed was significantly faster with FlushKnife-BTS when the resection size was larger than 1000 m2 (n = 4, median 24.2 mm2/min, range 19.6-27.7 vs n = 4, median 47.4 mm2/min, range 44.2-55.4, P = 0.0209). The frequency of knife replacement was less in the BTS group (median 1.76 times in one hour, range 0-5.45) than in the BT group (7.02 times in one hour, range 4.23-15) (P = 0.0065).CONCLUSIONOur results indicate that FlushKnife-BTS enhances the performance of ESD, particularly for large lesions, by improving air and fluid aspiration and knife insertion during ESD and reducing the frequency of knife removal and reinsertion.

CyberKnife系统技术评估和临床应用评价

介绍了Cyber Knife系统作为最新型的立体定向放射治疗设备之一的独有优势,同时提出了临床上其仍然存有一定局限性且有待被重新认识。最后对Cyber Knife系统的技术特点及临床应用情况进行了评估和总结,指出不断拓展治疗空间、提升引导图像中组织解剖信息是Cyber Knife系统未来发展的方向。

金标伪影对CyberKnife射野剂量学影响的计算与测量

目的:分析植入的金标在CT扫描时产生的金属伪影对Cyber Knife射野的剂量学影响。方法:用CT模拟机对固体水进行扫描以获取金标不同深度位置的CT图像,在计划系统中,分别制作以电离室收集极为等中心的单射野照射计划,并将相应计划移植到指定金标伪影密度覆盖值的CT图像并执行计划进行测量。结果:金标的植入对等中心剂量的影响在0.5%左右,而伪影对剂量及相同深度离轴点处吸收剂量影响达3%,并随金标植入深度的增加而降低;给伪影指定密度覆盖值后,其对剂量的影响可降低至1%;金标伪影使得金标后方的百分深度剂量(percentage depth dose,PDD)有明显跌落区,伪影密度值的覆盖可以减少对PDD的影响;金标对偏心比(off-center ratio,OCR)的影响较小,但使OCR曲线相对稍加平坦。结论:通过伪影覆盖可有效降低金标伪影对剂量的影响。

CyberKnife等中心及非等中心立体定向治疗计划质量及效率评价

目的探讨并评价Cyber Knife(CK)系统利用等中心和非等中心两种计划模式立体定向治疗计划(SRT)的剂量学特性及差异。方法将18例肿瘤患者分为A、B两组:A为小体积组即肿瘤大小在3 cm以下;B为大体积组即肿瘤大小在3 cm以上。每组9例患者计划分别给予同一处方剂量条件40 Gy/5F。在相同的条件下,分别以等中心和非等中心两种布野方式立体定向治疗技术设计相应的计划,通过其靶区适形指数(CI)、非均匀指数(HI)、梯度指数(GI)和危及器官等剂量学参数,分析评估SRT计划优化质量及实施效率,从而实现评价两种治疗模式的剂量学差异。结果等中心组计划执行的平均治疗时间(P=0.002)及机器MUs(P<0.001)明显优于非等中心组;CI均值(A:P=0.027;B:P=0.007)和GI均值(A:P<0.001;B:P<0.001)分别小于非等中心组;HI均值则略高于非等中心组(A:P=0.029;B:P<0.001);A组平均剂量归一值(P=0.011)等中心组优于非等中心组,而B组(P=0.012)等中心组低于非等中心组。结论等中心治疗模式在治疗时间、MU数及GI上均优于非等中心,在CI和HI上略低于非等中心模式。小体积肿瘤可考虑等中心治疗模式,而大体积肿瘤则宜用非等中心治疗模式;但仍需更多的临床病例给予研究。

Endoscopic submucosal tunnel dissection of upper gastrointestinal submucosal tumors: A comparative study of hook knife vs hybrid knife

AIM to compare the efficacy and safety of a hook knife(HO) with a hybrid knife(HK) during endoscopic submucosal tunnel dissection(EStD) procedure.METHODS Between August 2012 and December 2015, the ESt D procedure was performed for 83 upper GI submucosal lesions, which originated from the muscularis propria layer identified by upper endoscopy and endoscopic ultrasonography. Of these, 34 lesions were treated by a HO, whereas 49 lesions were treated by a HK. Data regarding age, gender, presenting symptoms, tumor location and size, procedure time, complications, en bloc resection rate and others were analyzed and compared between the two groups.RESULTS there were no significant differences in the age, gender, presenting symptoms and tumor location between the two groups. EStD was successfully completed in all the patients, and no case was converted to laparoscopy. the mean procedure time was significantly shorter in the HK group than in the HO group(41.3 ± 20.3 min vs 57.2 ± 28.0 min, p = 0.004). the mean frequency of device exchange was 1.4 ± 0.6 in the HK group and significantly less than 3.3 ± 0.6 in the HO group(p < 0.001). the differences in tumor size and histopathological diagnoses were not significant between the two groups(p = 0.813, p = 0.363, respectively). Both groups had an equal en bloc resection rate and complete resection rate. Additionally, the complication rate was similar between the two groups(p = 0.901). During the follow-up, no recurrence occurred in either group.CONCLUSION We demonstrate for the first time that HO and HK do not differ in efficacy or safety, but HK reduces the frequency of device exchange and procedure time.

A novel device for endoscopic submucosal dissection,the Fork knife

AIM： To introduce and evaluate the efficacy and technical aspects of endoscopic submucosal dissection （ESD） using a novel device, the Fork knife. METHODS： From March 2004 to April 2008, ESD was performed on 265 gastric lesions using a Fork knife （Endo FS） （group A） and on 72 gastric lesions using a Flexknife （group B） at a single tertiary referral center. We retrospectively compared the endoscopic characteristics of the tumors, pathological findings, and sizes of the resected specimens. We also compared the en b/oc resection rate, complete resection rate, complications, and procedure time between the two groups. RESULTS： The mean size of the resected specimens was 4.27 ± 1.26 cm in group A and 4.29 ± 1.48 cm in group B. The en b/oc resection rate was 95.8% （254/265 lesions） in group A and 93.1% （67/72） in group B. Complete ESD without tumor cell invasion of the resected margin was obtained in 81.1% （215/265） of group A and in 73.6% （53/72） of group B. The perforation rate was 0.8% （2/265） in group A and 1.4% （1/72） in group B. The mean procedure time was 59.63 ± 56.12 min in group A and 76.65 ± 70.75 min in group B （P 〈 0.05）. CONCLUSION： The Fork knife （Endo FS） is useful for clinical practice and has the advantage of reducing the procedure time.

内镜下Dual-knife开窗术在困难胆管插管中的应用

目的探讨Dual-knife在内镜下逆行胰胆管造影术(endoscopic retrograde cholangiopan-creatography,ERCP)胆总管困难插管中应用的安全性和有效性。方法回顾性分析华中科技大学同济医学院附属协和医院2014年3月至2019年8月间2564例行ERCP病人的临床资料,共215例病人在术中被诊断为胆总管插管困难,应用Dual-knife行乳头开窗术(Dual-knife fistulosphincterotomy,DKF)。结果所有215例病人中,212例实现胆管插管,成功率为98.60%;平均时间为3.5 min(2~8 min)。与标准插管相比,并发症发生率无明显增加(P>0.05)。15例病人发生轻度切缘出血,经局部喷洒去甲肾上腺素、Dual-knife凝血、和谐夹夹闭后成功止血;3例病人因开窗后出现潜在穿孔,但未造成后腹膜腔感染,遂保守治疗好转。Dual-knife开窗术后,共有21例(9.8%)出现轻、中度胰腺炎,15例病人出现胆管炎(6.9%),均保守治疗成功;没有病人因穿孔行手术治疗,也没有与该手术相关的死亡。结论采用Dual-knife行乳头开窗术,可实现标准插管失败病人选择性胆管插管;其并不增加病人术后并发症和死亡率,是一种有效、简便、安全的方法。

基于CyberKnife脊柱追踪系统的胸椎转移瘤放疗摆位误差分析

目的:基于Xsight脊柱追踪系统对胸椎转移瘤治疗前摆位及治疗中体位稳定性进行定量分析,以期为临床应用提供参考。方法:选择10例行射波刀(Cyber Knife,CK)治疗的胸椎转移瘤患者,采用真空垫行体位固定,应用Xsight脊柱追踪系统进行追踪治疗,并在首次治疗后做等中心十字线标记用于后续治疗的摆位参考;治疗过程中每隔60 s采集一次正交图像,并参考数字重建图像(digital reconstructedly radiograph,DRR)行配准校正且记录其误差,分析治疗分次内体位稳定性以及治疗照射误差。结果:患者治疗前分次间左右(X)、头脚(Y)、垂直(Z)3个方向的线性摆位误差(系统误差±随机误差)分别为(1.66±3.48)、(0.12±5.88)、(0.08±3.54)mm,推算其常规外放边界分别为7.5、5.0、3.1 mm;分次内平移误差均小于0.9 mm,旋转误差均小于0.8°;CK治疗过程中X、Y、Z 3个方向的治疗照射误差分别为0.34、0.31、0.25 mm。结论:CK治疗中运用首分次等中心标记法实现了对常规治疗等中心摆位的误差分析,为胸椎转移瘤临床常规治疗提供了参考;同时,由于患者体位变化引起的照射误差较小,实现了对靶区照射的高度准确性。

Endoscopic submucosal dissection for early esophageal neoplasms using the stag beetle knife

AIM To determine short-and long-term outcomes of endoscopic submucosal dissection(ESD) using the stag beetle(SB) knife, a scissor-shaped device.METHODS Seventy consecutive patients with 96 early esophageal neoplasms, who underwent ESD using a SB knife at Kure Medical Center and Chugoku Cancer Center, Japan, between April 2010 and August 2016, were retrospectively evaluated. Clinicopathological characteristics of lesions and procedural adverse events were assessed. Therapeutic success was evaluated on the basis of en bloc, histologically complete, and curative or non-curative resection rates. Overall and tumor-specific survival, local or distant recurrence, and 3-and 5-year cumulative overall metachronous cancer rates were also assessed.RESULTS Eligible patients had dysplasia/intraepithelial neoplasia(22%) or early cancers(squamous cell carcinoma, 78%). The median procedural time was 60 min and on average, the lesions measured 24 mm in diameter, yielding 33-mm tissue defects. The en bloc resection rate was 100%, with 95% and 81% of dissections deemed histologically complete and curative, respectively. All procedures were completed without accidental incisions/perforations or delayed bleeding. During follow-up(mean, 35 ± 23 mo), no local recurrences or metastases were observed. The 3-and 5-year survival rates were 83% and 70%, respectively, with corresponding rates of 85% and 75% for curative resections and 74% and 49% for noncurative resections. The 3-and 5-year cumulative rates of metachronous cancer in the patients with curative resections were 14% and 26%, respectively.CONCLUSION ESD procedures using the SB knife are feasible, safe, and effective for treating early esophageal neoplasms, yielding favorable short-and long-term outcomes.

Treatment of gastric remnant cancer post distal gastrectomy by endoscopic submucosal dissection using an insulation-tipped diathermic knife

AIM: To evaluate the effectiveness of endoscopic submucosal dissection using an insulation-tipped diathermic knife (IT-ESD) for the treatment of patients with gastric remnant cancer. METHODS: Thirty-two patients with early gastric cancer in the remnant stomach, who underwent distal gastrectomy due to gastric carcinoma, were treated with endoscopic mucosal resection (EMR) or ESD at Sumitomo Besshi Hospital and Shikoku Cancer Center in the 10-year period from January 1998 to December 2007, including 17 patients treated with IT-ESD. Retrospectively, patient backgrounds, the one-piece resection rate, complete resection (CR) rate, operation time, bleeding rate, and perforation rate were compared between patients treated with conventional EMR and those treated with IT-ESD. RESULTS: The CR rate (40% in the EMR group vs 82% in the IT-ESD group) was significantly higher in the IT-ESD group than in the EMR group; however, the operation time was significantly longer for the IT- ESD group (57.6 ± 31.9 min vs 21.1 ± 12.2 min). No significant differences were found in the rate of underlying cardiopulmonary disease (IT-ESD group, 12% vs EMR group, 13%), one-piece resection rate (100% vs 73%), bleeding rate (18% vs 6.7%), and perforation rate (0% vs 0%) between the two groups. CONCLUSION: IT-ESD appears to be an effective treatment for gastric remnant cancer post distal gastrectomy because of its high CR rate. It is useful for histological confirmation of successful treatment. Thelong-term outcome needs to be evaluated in the future.

Treatment of over 20 mm gastric cancer by endoscopic submucosal dissection using an insulation-tipped diathermic knife

AIM： To evaluate the effectiveness of endoscopic submucosal dissection using an insulation-tipped diathermic knife （IT-ESD） for the treatment of patients with over 20 mm early gastric cancer （EGC）. METHODS： A total of 112 patients with over 10 mm EGC were treated with IT-ESD at Sumitomo Besshi Hospital and Shikoku Cancer Center in the 5 year period from January 2002 to December 2006, including 40 patients with over 20 mm EGC. We compared patient backgrounds, the one-piece resection rate, complete resection （CR） rate, operation time, bleeding rate, perforation rate between patients with over 20 mm EGC [over 20 mm group （21-40 ram）] and the remaining patients （under 20 mm group）. RESULTS： We found no significant difference in the rate of underlying cardiopulmonary disease （over 20 mm group vs under 20 mm group, 5.0% vs 5.6%）, one- piece resection rate （95% vs 96%）, CR rate （85% vs 89%）, operation time （72.3 rain vs 66.5 rain）, bleeding rate （50 vs 4.2%）, and perforation rate （0% vs 1.4%） between the 2 groups. Three patients in each group had submucosal invasion and two in each groups underwent additional surgery. CONCLUSION： There was no significant difference in the outcome resulting from IT-ESD between the 2 groups. Our study proves that IT-ESD is a feasible treatment for patients with over 20 mm mucosal gastric cancer although the long-term outcome should be evaluated in the future.

射波刀Cyberknife治疗无法手术切除原发性肝内胆管细胞癌疗效观察

目的观察立体定向放射治疗(SBRT)对无法手术切除原发性肝内胆管细胞癌(ICC)的疗效及不良反应。方法对28例原发性ICC患者行射波刀SBRT,给予总剂量为45 Gy(36~54 Gy),分割3~5次,处方剂量线范围为70%~92%。按照RECIST1.1标准进行实体瘤近期疗效评价,采用Kaplanmeier方法分析生存率及疾病控制率,Cox方法进行多因素分析评价影响预后的因素,美国放射肿瘤学协作组(RTOG 2.0)标准进行放射反应评级。结果 28例患者中,完全缓解(CR)3例(10.7%),部分缓解(PR)10例(35.7%),无变化(SD)12例(42.9%),进展(PD)3例(10.7%),疾病有效率(CR+PR)为46.4%,疾病控制率(CR+PR+SD)为89.3%。治疗后随访3~42月,中位随访时间为16月,1、2年生存率分别为57.1%、32.1%,28例患者的中位生存期15月(95%CI:7.22~22.78)。所有患者对治疗耐受良好,不良反应轻微,治疗不良反应主要局限于1~2级,未出现大于3级的不良反应。多因素分析显示肿瘤直径较大、淋巴结转移、临床分期较晚可能导致较差的预后(P<0.01)。结论对于无法手术切除的原发性ICC,射波刀SBRT疗效显著,安全性好,值得进一步临床推广。

Clinical outcomes following salvage Gamma Knife radiosurgery for recurrent glioblastoma

Glioblastoma multiforme(GBM) is the most common malignant primary brain tumor with a survival prognosis of 14-16 mo for the highest functioning patients. Despite aggressive, multimodal upfront therapies, the majority of GBMs will recur in approximately six months. Salvage therapy options for recurrent GBM(r GBM) are an area of intense research. This study compares recent survival and quality of life outcomes following Gamma Knife radiosurgery(GKRS) salvage therapy. Following a Pub Med search for studies usingGKRS as salvage therapy for malignant gliomas, nine articles from 2005 to July 2013 were identified which evaluated rG BM treatment. In this review, we compare overall survival following diagnosis, overall survival following salvage treatment, progression-free survival, time to recurrence, local tumor control, and adverse radiation effects. This report discusses results for rG BM patient populations alone, not for mixed populations with other tumor histology grades. All nine studies reported median overall survival rates(from diagnosis, range:16.7-33.2 mo; from salvage, range:9-17.9 mo). Three studies identified median progression-free survival(range:4.6-14.9 mo). Two showed median time to recurrence of GBM. Two discussed local tumor control. Six studies reported adverse radiation effects(range:0%-46% of patients). The greatest survival advantages were seen in patients who received GKRS salvage along with other treatments, like resection or bevacizumab, suggesting that appropriately tailored multimodal therapy should be considered with each rG BM patient. However, there needs to be a randomized clinical trial to test GKRS for rG BM before the possibility of selection bias can be dismissed.

Natural orifice transluminal endoscopic wedge hepatic resection with a water-jet hybrid knife in a non-survival porcine model

AIM: To explore the feasibility of a water-jet hybrid knife to facilitate wedge hepatic resection using a natural orifice transluminal endoscopic surgery (NOTES) approach in a non-survival porcine model. METHODS: The Erbe Jet2 water-jet system allows a needleless, tissue-selective hydro-dissection with a pre-selected pressure. Using this system, wedge hepatic resection was performed through three natural routes (trans-anal, trans-vaginal and trans-umbilical) in three female pigs weighing 35 kg under general anesthesia. Entry into the peritoneal cavity was via a 15-mm incision using a hook knife. The targeted liver segment was marked by an APC probe, followed by wedge hepatic resection performed using a water-jet hybrid knife with the aid of a 4-mm transparent distance soft cap mounted onto the tip of the endoscope for holding up the desired plane. The exposed vascular and ductal structures were clipped with Endoclips. Hemostasis was applied to the bleeding cut edges of the liver parenchyma by electrocautery. After the procedure, the incision site was left open, and the animal was euthanized followed by necropsy. RESULTS: Using the Erbe Jet2 water-jet system, trans-anal and trans-vaginal wedge hepatic resection was successfully performed in two pigs without laparoscopic assistance. Trans-umbilical attempt failed due to an unstable operating platform. The incision for peritoneal entry took 1 min, and about 2 h was spent on excision of the liver tissue. The intra-operative blood loss ranged from 100 to 250 mL. Microscopically, the hydro-dissections were relatively precise and gentle, preserving most vessels. CONCLUSION: The Erbe Jet2 water-jet system can safely accomplish non-anatomic wedge hepatic resection in NOTES, which deserves further studies to shorten the dissection time.

Application of needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography

BACKGROUND: Getting directly into the common bile duct (CBD) is the most important step for successful therapeutic biliary endoscopy. In 5%-10% of cases, the CBD remains inaccessible, necessitating pre-cut papillotomy or fistulotomy with a needle-knife. The aim of this study was to assess the value of early application of the needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Patients with failed biliary cannulation after 10 minutes or guide wire entering the pancreatic tube 3 times were randomly divided into group of needle-knife cut and group of persistent cannulation by standard techniques. The cannulation times, success rates and complication rates were compared between the two groups. RESULTS: A total of 948 therapeutic biliary ERCP procedures were performed between October 2004 and February 2006. Of 91 patients with difficult biliary cannulation, 43 patients underwent needle-knife cut: the cannulation success rate was 90.7%, the mean cannulation time was 5.6 minutes, and the complication rate was 9.3%. The other 48 patients underwent persistent cannulation by standard techniques: the cannulation success rate was 75%, the mean cannulation time was 10.2 minutes, and the complication rate was 14.6%. Significant differences were observed in cannulation success rate and cannulation time but in complication rate between the two groups.CONCLUSION: The early application of the needle-knife in difficult biliary cannulation is time-saving, safe and effective, with no increase in complication rate.

Diagnostic and Therapeutic Cold Knife Conization for Cervical Intraepithelial Neoplasia

OBJECTIVE of using cold （CIN）. METHODS To evaluate the diagnostic and therapeutic efficacy knife conization for cervical intraepithelial neoplasia We retrospectively analyzed 186 cases with CIN diagnosed and treated in our hospital; compared the histologic diagnoses from cervical conization and from colposcopic multiple punch biopsies, and then evaluated their postoperative histologic findings and clinical outcomes. RESULTS Of the 186 cases, there was a correlation in histologic findings between cervical conization and colposcopic multiple punch biopsies in 138 cases （74.2%）, and there was no correlation in the other 48 cases （25.8%）. Incomplete excision was performed in 8 cases （4.3%）, but the failure rate was only 1.1%; the cure rate was 98.9%. Five cases with early invasive cancer were found. Eleven patients underwent subsequent hysterectomy. The main complications associated with conization were hemorrhage and cervical stenosis. Bleeding occurred in 8 （4.3%） of the patients, and cervical stenosis occurred in 3 （1.6%）. CONCLUSION Cervical intraepithelial neoplasia was diagnosed more accurately using conization than by colposcopic multiple punch biopsies. Conization can also play an important role in the treatment for CIN. If properly performed, the procedure has a low risk of complications. It can provide an accurate histologic representation of the disease process, and be curative in most cases.

Novel endoscopic management of buried bumper syndrome in percutaneous endoscopic gastrostomy: The Olympus Hook Knife

Buried bumper syndrome(BBS) is an uncommon but serious complication of percutaneous endoscopic gastrostomy. It involves the internal fixation device, or "bumper", migrating into the gastric wall and subsequent mucosal overgrowth. We described a case series of four patients with BBS treated with a novel endoscopic technique using a Hook Knife between June 2016 and February 2017. The Hook Knife is a rotating L-shaped cutting wire designed for hooking tissue and pulling it away from the gastric wall towards the lumen. The technique was successful in all four cases with no complications. Each patient was discharged on the day of treatment. The Hook Knife is a manoeuvrable, safe and effective device for endoscopic removal of buried bumpers and could avoid surgery in a high risk group of patients. To our knowledge this technique has not been described previously. We suggest that this technique should be added to the treatment algorithms for managing BBS.

Stereotactic body radiotherapy using Cyber Knife for locally advanced unresectable and metastatic pancreatic cancer

AIM: To evaluate the efficacy and toxicity of stereotactic body radiotherapy using Cyber Knife for locally advanced unresectable and metastatic pancreatic cancer.METHODS: From June 2010 to May 2014,25 patients with locally advanced unresectable and metastatic pancreatic cancer underwent stereotactic body radiotherapy.Nine patients presented with unresectable locally advanced disease and 16 had metastatic disease.Primary end-points of this study were overall survival,relief of abdominal pain,and toxicity.RESULTS: Fourteen patients were treated with a total dose of 30-36 Gy in three fractions and the remainder with 40-48 Gy in four fractions.Median follow-up was 11 mo(range: 2-25 mo).The median survival duration calculated from the time of stereotactic body radiotherapy for the entire group,the locally advanced group,and the metastatic group was 9.0 mo,13.5 mo,and 8.5 mo,respectively.Overall survival was 37% and 18% at one and two years,respectively.Abdominal pain relief was achieved within 2 wk of completing radiotherapy in the patients who received successful palliation(13 of 20 patients had significant pain).Five patients(20%) had grade 1 nausea,and one(4%) had grade 2 nausea.No acute grade 3+ toxicity was seen.CONCLUSION: Stereotactic body radiotherapy using the Cyber Knife system is a promising,noninvasive,palliative treatment with acceptable toxicity for locally advanced unresectable and metastatic pancreatic cancer.