A Case Report of One-Point Gastric Cancer

Carcinoma of the stomach is the most common malignant tumor in China. Due to advanced endoscopic techniques and equipment, the detection of early gastric carcinoma （EGC） has increased worldwide. Yet gastric one-point cancer is rarely detected.

Endoscopic submucosal tunnel dissection for largesuperficial esophageal squamous cell neoplasms

Endoscopic submucosal dissection(ESD)is a wellestablished treatment for superficial esophageal squamous cell neoplasms(SESCNs)with no risk of lymphatic metastasis.However,for large SESCNs,especially when exceeding two-thirds of the esophageal circumference,conventional ESD is time-consuming and has an increased risk of adverse events.Based on the submucosal tunnel conception,endoscopic submucosal tunnel dissection(ESTD)was first introduced by us to remove large SESCNs,with excellent results.Studies from different centers also reported favorable results.Compared with conventional ESD,ESTD has a more rapid dissection speed and R0 resection rate.Currently in China,ESTD for large SESCNs is an important part of the digestive endoscopic tunnel technique,as is peroral endoscopic myotomy for achalasia and submucosal tunnel endoscopic resection for submucosal tumors of the muscularis propria.However,not all patients with SESCNs are candidates for ESTD,and postoperative esophageal strictures should also be taken into consideration,especially for lesions with a circumference greater than three-quarters.In this article,we describe our experience,review the literature of ESTD,and provide detailed information on indications,standard procedures,outcomes,and complications of ESTD.

Gastric adenocarcinoma of fundic gland type:Endoscopicand clinicopathological features

Gastric adenocarcinoma of fundic gland type(GA-FG) with chief cell differentiation was recently proposed as an extremely rare type of gastric adenocarcinoma. Here, we report 4 cases of GA-FG with chief cell differentiation. Endoscopic features included a submucosal tumor shape or a flat shape, whitish discoloration and dilated vessels on the surface. The tumors were located in the upper or middle third of the stomach. All cases were preoperatively diagnosed as GA-FG by biopsy, and endoscopic submucosal dissection was performed. Resected specimens revealed well-differentiated adenocarcinomas resembling chief cells. Tumor cells were diffusely positive for pepsinogen-Ⅰ, but partially positive for H+/K+-ATPase in scattered locations around the tumor margin. Despite the presence of minimal invasion of the carcinoma into the submucosal layer, which was observed in two cases, neither lymphatic nor venous invasion was detected in any of the cases. Finally, all cases showed less aggressive clinical behavior with low grade malignancy.

Endoscopic resection of superficial gastrointestinal tumors

Therapeutic endoscopy plays a major role in the management of gastrointestinal (GI) neoplasia. Its indications can be generalized into four broad categories; to remove or obliterate neoplastic lesion, to palliate malignant obstruction, or to treat bleeding. Only endoscopic resection allows complete histological staging of the cancer, which is critical as it allows stratification and refinement for further treatment. Although other endoscopic techniques, such as ablation therapy, may also cure early GI cancer, they can not provide a definitive pathological specimen. Early stage lesions reveal low frequency of lymph node metastasis which allows for less invasive treatments and thereby improving the quality of life when compared to surgery. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are now accepted worldwide as treatment modalities for early cancers of the GI tract.

Endoscopic diagnosis and management of type I neuroendocrine tumors

Type I gastric neuroendocrine tumors(TI-GNETs) are related to chronic atrophic gastritis with hypergastrinemia and enterochromaffin-like cell hyperplasia. The incidence of TI-GNETs has significantly increased, with the great majority being TI-GNETs. TI-GNETs present as small(< 10 mm) and multiple lesions endoscopically and are generally limited to the mucosa or submucosa. Narrow band imaging and high resolution magnification endoscopy may be helpful for the endoscopic diagnosis of TI-GNETs. TI-GNETs are usually histologically classified by World Health Organization criteria as G1 tumors. Therefore, TI-GNETs tend to display nearly benign behavior with a low risk of progression or metastasis. Several treatment options are currently available for these tumors, including surgical resection, endoscopic resection, and endoscopic surveillance. However, debate persists about the best management technique for TIGNETs.

Safety and efficacy of carbon dioxide insufflation during gastric endoscopic submucosal dissection

AIM: To compare the safety and efficacy of carbon dioxide(CO2) and air insufflation during gastric endoscopic submucosal dissection(ESD).METHODS: This study involved 116 patients who underwent gastric ESD between January and December 2009.After eliminating 29 patients who fit the exclusion criteria,87 patients,without known pulmonary dysfunction,were randomized into the CO2 insufflation(n = 36) or air insufflation(n = 51) groups.Standard ESD was performed with a CO2 regulation unit(constant rate of 1.4 L/min) used for patients undergoing CO2 insufflation.Patients received diazepam for conscious sedation and pentazocine for analgesia.Transcutaneous CO2 tension(Ptc CO2) was recorded 15 min before,during,and after ESD with insufflation.Ptc CO2,the correlation between Ptc CO2 and procedure time,and ESD-related complications were compared between the two groups.Arterial blood gases were analyzed after ESD in the first 30 patients(12 with CO2 and 18 with air insufflation) to assess the correlation between arterial blood CO2 partial pressure(Pa CO2) and Ptc CO2.RESULTS: There were no differences in respiratoryfunctions,median sedative doses,or median procedure times between the groups.Similarly,there was no significant difference in post-ESD blood gas parameters,including Pa CO2,between the CO2 and air groups(44.6 mm Hg vs 45 mm Hg).Both groups demonstrated median p H values of 7.36,and none of the patients exhibited acidemia.No significant differences were observed between the CO2 and air groups with respect to baseline Ptc CO2(39 mm Hg vs 40 mm Hg),peak Ptc CO2 during ESD(52 mm Hg vs 51 mm Hg),or median Ptc CO2 after ESD(50 mm Hg vs 50 mm Hg).There was a strong correlation between Pa CO2 and Ptc CO2(r = 0.66; P < 0.001).The incidence of Mallory-Weiss tears was significantly lower with CO2 insufflation than with air insufflation(0% vs 15.6%,P = 0.013).CO2 insufflation did not cause any adverse events,such as CO2 narcosis or gas embolisms.CONCLUSION: CO2 insufflation during gastric ESD results in similar blood gas levels as air insufflation,and also reduces the incidence of Mallory-Weiss tears.

Submucosal tunnel endoscopy:Peroral endoscopicmyotomy and peroral endoscopic tumor resection

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.

Future directions of duodenal endoscopic submucosal dissection

Endoscopic therapies for lesions of the duodenum are technically more difficult than those for lesions of the other parts of the gastrointestinal tract due to the anatomical features of the duodenum, and the incidence rate of complications such as perforation and bleeding is also higher. These aforementioned trends were especially noticeable for the case of duodenal endoscopic submucosal dissection(ESD). The indication for ESD of duodenal tumors should be determined by assessment of the histopathology, macroscopic morphology, and diameter of the tumors. The three types of candidate lesions for endoscopic therapy are adenoma, carcinoma, and neuroendocrine tumors. For applying endoscopic therapies to duodenal lesions, accurate preoperative histopathological diagnosis is necessary. The most important technical issue in duodenal ESD is the submucosal dissection process. In duodenal ESD, a short needle-type knife is suitable for the mucosal incision and submucosal dissection processes, and the Small-caliber-tip Transparent hood is an important tool. After endoscopic therapies, the wound should be closed by clipping in order to prevent complications such as secondary hemorrhage and delayed perforation. At present, the criteria for selection between ESD and EMR vary among institutions. The indications for ESD should be carefully considered. Duodenal ESD should have limitations, such as the need for its being performed by experts with abundant experience in performing the procedure.

Delayed esophageal perforation occurring with endoscopic submucosal dissection:A report of two cases

We report two cases of delayed esophageal perforation occurring with endoscopic submucosal dissection. Our cases involved delayed perforation after 10 d in case 1 and after 6 d in case 2. Both cases were related to solid food. We performed subtotal esophagectomy with gastric tube reconstruction of the esophagus via the subcutaneous route anterior to the thoracic wall without conservative treatment because both cases involved chest pain and major leakage of food into the mediastinum. Postoperative complications were a local factor(including suture failure and esophageal stricture) in case 1, and we performed endoscopic balloon dilatation five times for esophageal stricture. There was no intrathoracic and mediastinal infection in either case. Surgical treatment for delayed esophageal perforation can be performed safely and surely if diagnosis and assessment are not delayed.

Circumstance of endoscopic and laparoscopic treatments for gastric cancer in Japan: A review of epidemiological studies using a national administrative database

Currently, endoscopic submucosal dissection(ESD) and laparoscopic gastrectomy(LG) have become widely accepted and increasingly play important roles in the treatment of gastric cancer. Data from an administrative database associated with the diagnosis procedure combination(DPC) system have revealed some circumstances of ESD and LG in Japan. Some studiesdemonstrated that medical costs or length of stay of patients receiving ESD for gastric cancer had become significantly reduced while length of hospitalization and costs were significantly increased in older patients. With respect to LG, some recent reports have shown that this has been a cost-beneficial treatment for patients compared with open gastrectomy while simultaneous LG and cholecystectomy is a safe procedure for patients with both gastric cancer and gallbladder stones. These epidemiological studies using the administrative database in the DPC system closely reflect clinical circumstances of endoscopic and surgical treatment for gastric cancer in Japan. However, DPC database does not contain detailed clinical data such as histological types and lesion size of gastric cancer. The link between the DPC database and another detailed clinical database may be vital for future research into endoscopic and laparoscopic treatments for gastric cancer.

Use of water jet instruments in gastrointestinal endoscopy

In recent years, water jet instruments have been used in the field of gastrointestinal endoscopy, mainly in two clinical situations: Investigation and treatment under endoscopic view. Injecting water jet into the gastrointestinal lumen is helpful for maintaining a clear endoscopic view, washing away blood or mucous in the lumen or on the surface of the tip of the endoscope. This contributes to reducing time and discomfort of examination. Water jet technology is an alternative method for dissecting soft tissue; this method does not harm the small vessels or cause mechanical or thermal damage. However, its use in clinical settings has been limited to the transmucosal injection of water into the submucosal layer that elevates the mucosa to prepare for endoscopic mucosal resection or endoscopic submucosal dissection, instead of tissue dissection, which may occur because of the continuous water jet. A preclinical study has been conducted using a pulsed water jet system as an alternative method for submucosal dissection by reducing intraoperative water consumption and maintenance of dissection capability. This review introduces recent studies pertaining to using a water jet in gastrointestinal endoscopy and discusses future prospects.

胃底腺型肿瘤内镜黏膜下剥离术治疗的临床效果评价及病理学特点分析

为研究胃底腺型肿瘤内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗的临床效果并分析其病理学特点,收集2018年8月-2022年6月于首都医科大附属北京朝阳医院消化内镜中心行ESD,并且术后病理提示为胃底腺型胃癌或胃泌酸腺腺瘤的7例患者临床病理资料,评估患者临床特征、手术并发症情况、术前及术后病理资料和随访相关数据。7例患者病变均位于胃底部,均完成ESD治疗,术中及术后均未出现出血、穿孔等并发症。术后病理提示肿瘤细胞均起源于黏膜深层,具有浸润性生长模式,大部分肿瘤表面覆盖有正常的小凹上皮,4例患者肿瘤细胞浸润至黏膜下层,其中1例患者黏膜下浸润深度>500μm(550μm)。免疫组化提示MUC-6均呈弥漫性阳性,提示肿瘤为主细胞来源,所有病例MUC-2、MUC-5AC、CDX-2、CD10、CgA表达均为阴性。患者平均随访时间为22个月,术后溃疡愈合良好,未见病变复发。说明胃底腺型肿瘤有相对独特的生物学特性,ESD是治疗胃底腺型肿瘤首选的治疗方式。另外胃底腺型肿瘤组织学特点明确,可依靠免疫组化指标与其他胃部肿瘤进行鉴别。

内镜黏膜下剥离术治疗胃黏膜病变术后复发相关因素分析

目的探讨内镜黏膜下剥离术（ESD）治疗胃黏膜高级别上皮内瘤变（HGIN）及早期胃癌（EGC）术后复发情况及其相关危险因素。方法总结2006年11月至2016年1月在解放军总医院内镜中心行ESD且术后病理诊断为HGIN及EGC的444例患者（451处病变）的临床和随访资料，统计分析术后复发的相关因素。结果ESD术后共随访410例患者，随访期间13例患者（13处病变）复发，复发率为3．2％，平均复发时间（17．6±9．6）个月（6—38个月）。通过单因素和多因素分析，病变直径〉4．0cm（P=0．012，OR=10．855，95％CI：1．673～70．442）是ESD术后复发的独立危险因素。结论随着病变范围增大，ESD术后复发率增加，对于病变较大的患者应加强术后监测。

经胃镜保留浆膜层切除上消化道固有肌层起源肿瘤技术初探

目的探讨经内镜浆膜下肿瘤剥离术（ESSD）治疗上消化道固有肌层起源的黏膜下肿瘤的安全性及有效性。方法收集2016年10月至2017年2月在南京鼓楼医院接受ESSD的6例固有肌层起源的黏膜下肿瘤患者资料，分析手术时间、手术成功率、术后病理、并发症等。结果纳入的6例患者均完整切除肿瘤，其中1例患者发生浆膜面穿孔。肿瘤平均大小（27．5±10．0）mm，手术平均耗时（49±18）min。术后病理均提示为低危险度间质瘤。6例患者均顺利出院，未发生严重并发症。结论ESSD作为一种新兴的内镜下治疗方法，对固有肌层起源肿瘤安全可靠。

早期结直肠癌内镜治疗方式的探讨

目的评价内镜治疗早期结直肠癌的安全性及有效性，并探讨不同类型病变内镜治疗方式的选择。方法对113例早期结直肠癌行内镜治疗病例进行回顾性分析，依内镜治疗方式分为高频电圈套切除、EMR及ESD组，分析比较各组之间标本大小、整块切除率、完全切除率、操作时间、并发症发生率及复发率等。结果有蒂型病变11例应用高频电圈套切除术及EMR治疗，均为整块切除、完全切除，无严重并发症及复发。亚蒂型病变19例应用EMR及ESD治疗，EMR标本最大径显著小于ESD（P=0．026），整块切除率低于ESD[77．8％（14／18）比1／1，P=1．000]，完全切除率、复发率与ESD无明显差异（P〉0．05）。无蒂型病变83例，3种内镜治疗方式均有应用，ESD较EMR标本更大（P=0．000）、完全切除率更高[95．5％（42／44）比77．8％（28／36），P：0．041]、操作时间更长（P=0．000），严重并发症发生率[9．1％（4／44）比0]、整块切除率、复发率方面与EMR无明显差异（P〉0．05）。10例使用ESD联合圈套器（ESD-S）法，标本最大径介于EMR及标准ESD之间，均为整块切除、完全切除，操作时间明显低于标准ESD[（36．9~24．7）min比（120．4±152．3）min，P=0．004]。结论早期结直肠癌的内镜治疗安全有效，对于不同大体类型的病变可以选择不同的内镜治疗方式以尽可能达到整块切除、完全切除。ESD—S可作为从EMR向ESD过渡的方法选用。

内镜下黏膜剥离术治疗胃黏膜病变的远期疗效

目的分析内镜下黏膜剥离术(ESD)治疗胃黏膜高级别上皮内瘤变(HGIN)及早期胃癌(EGC)的远期疗效及影响囚素。方法回顾性研究解放军总医院消化内镜中心2006年11月至2010年8月共治疗的80例胃黏膜HGIN及EGC患者的资料,分析ESD治疗HGIN及EGC的疗效及其病变形态、浸润深度、病理类型对切除效果的影响。评价指标:完整切除率、组织学治愈率、生存率、并发症、复发率。结果内镜下ESD完整切除75例,切除率93.8%,组织学治愈79例,治愈率98.8%,其中,HGIN、黏膜内癌、黏膜肌层癌、黏膜下癌ESD完整切除率分别是100%(31/31)、92.3%(24/26)、92.3%(12/13)、80.0%(8/10);组织学治愈率分别是100%、(31/31)、100%(26/26)、100%(13/13)、90.0%(9/10):HGIN、黏膜内癌、黏膜肌层癌及黏膜下癌不同病理分型间完整切除率无差别,P>0.05;HGIN、黏膜内癌、黏膜肌层癌及黏膜下癌不同病理分型间组织学治愈率有差别,P<0.05。术中明显出血发生率为0;穿孔发生率0,术后迟发出血发生率2.5%,52例ESD患者术后随访,复发残留率1.9%(1/52),生存率100%(52/52)。结论 ESD组织学治愈率、复发率与病变病理类型、浸润深度有关。内镜下ESD治疗胃黏膜HGIN和EGC并发症少、生存率高。

内镜黏膜下剥离术治疗早期食管癌及癌前病变的临床评价

目的初步探讨内镜黏膜下剥离术（ESD）治疗早期食管癌及癌前病变的应用价值及安全性。方法2009年2月至2012年7月在南京医科大学第一附属医院接受ESD治疗的176例早期食管癌及癌前病变的病例，对其手术及治疗情况、近远期并发症、术后随访疗效等多个指标进行回顾比较。结果176例患者中，低级别上皮内瘤变56例，病灶长度1～10cm，平均4．3em，ESD平均手术时间62min。高级别上皮内瘤变80例，病灶长度1～10cm，平均5．0em，ESD平均手术时间72min。早期食管癌病例40例，病灶长度1-11em，平均5．7cm，ESD平均手术时间86min。术后出现胸骨后疼痛80例（45．5％），出血2例（1．1％），穿孔3例（1．7％），食管狭窄15例（8．5％），腹痛17例（9．6％），发热15例（8．5％），均未发生其他并发症。125例病例进行了随访，中位随访时间14个月（1～39个月）。病灶术后病理示，低级别上皮内瘤变的56例患者中，54例一次性完整切除病灶，3．6％（2／56）边缘有残留；高级别上皮内瘤变的80例患者中，76例一次性完整切除病灶，5．0％（4／80）切缘有残留；食管早期癌的40例患者中，37例为一次性完整切除，7．5％（3／40）切缘见残留。所有病理基底均未见残留，且术后病理提示所有患者病变范围均未突破黏膜下层。病灶局灶复发3例（1．7％）。101例进行了术后2个月的胃镜复查，创面愈合率100％（101／101）。79例完成了术后6个月的胃镜复查，其中2例局灶复发，1例发现贲门病变，创面愈合率100％（79／79）。52例完成了术后12个月的胃镜复查，1例局灶复发，创面愈合率100％（52／52）。结论ESD能够一次性完整切除病灶，有利于病理诊断，并且病灶复发率低、并发症少、创伤小，是诊断及治疗早期食管癌及癌前病变的安全有效的方法。