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ABSTRACT Background: Esophageal endoscopic submucosal dissection (EESD) is a complex and time-consuming procedure at which training are mainly available in Japan. There is a paucity of data concerning the learning curve to master EESD by Western endoscopists. Objective: This study aimed to assess the learning curve effect on patient's clinical outcome for EESD. Methods: This is a retrospective observational study. Enrolling patients that underwent EESD from 2009 to 2021. The analysis was divided into two periods; T1: case 1 to 49 and T2: case 50 to 98. The following features were analyzed for each group: patients and tumors characteristics, en-bloc, complete and curative resection rates, procedure duration and adverse events rate. Results: Ninety-eight EESD procedures were performed. Mean procedure time was 111.8 min and 103.6 min for T1 and T2, respectively (P=0.004). En bloc resection rate was 93.8% and 97.9% for T1 and T2, respectively (P=0.307). Complete resection rate was 79.5% and 85.7% for T1 and T2, respectively (P=0.424). Curative resection rate was 65.3% and 71.4% for T1 and T2, respectively (P=0.258). Four patients had complications; three during T1 period and one during T2 period. Overall mortality rate: 0%. Conclusion: The esophageal endoscopic submucosal dissection could be performed effectively and safely by an adequately trained Western endoscopist.
RESUMO Contexto: A dissecção endoscópica da submucosa do esôfago (DSEE) é um procedimento complexo, cujo treinamento está disponível principalmente no Japão. Há uma escassez de dados sobre a curva de aprendizado para se capacitar na realização da DSEE por endoscopistas ocidentais. Objetivo: Este estudo teve como objetivo avaliar o efeito da curva de aprendizado no resultado clínico dos pacientes submetidos a DSEE. Métodos: Trata-se de um estudo observacional retrospectivo. Foram incluídos pacientes submetidos a DSEE no período de 2009 a 2021. A análise foi dividida em dois períodos; T1: caso 1 a 49 e T2: caso 50 a 98. Os seguintes parâmetros foram analisados para cada grupo: características clínicas dos pacientes e dos tumores de esôfago, taxas de ressecção em bloco, completa e curativa, duração do procedimento e taxa de eventos adversos. Resultados: Noventa e oito procedimentos de DSEE foram realizados. O tempo médio do procedimento foi de 111,8 min e 103,6 min nos períodos T1 e T2, respectivamente (P=0,004). A taxa de ressecção em bloco foi de 93,8% e 97,9% nos períodos T1 e T2, respectivamente (P=0,307). A taxa de ressecção completa foi de 79,5% e 85,7% nos períodos T1 e T2, respectivamente (P=0,424). A taxa de ressecção curativa foi de 65,3% e 71,4% para T1 e T2, respectivamente (P=0,258). Quatro pacientes tiveram complicações; três durante o período T1 e um durante o período T2. Taxa de mortalidade geral: 0%. Conclusão: A DSEE pode ser realizada de forma eficaz e segura por um endoscopista ocidental adequadamente treinado.
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Endoscopic submucosal dissection (ESD) is the common method for treatment of early gastric cancer. Compared with endoscopic mucosal resection (EMR), ESD can completely remove large lesions while ensuring negative margins as much as possible, which enables a more accurate pathological staging of tissue and reduces the risk of postoperative cancer recurrence. On the other hand, ESD generally results in larger ulcerations than EMR, which increases the likelihood of complications such as bleeding and perforation. Delayed bleeding is one of the main complications after gastric ESD. Delayed bleeding after ESD can cause hemorrhagic shock and even death, so we should take effective management strategies to prevent the occurrence of delayed bleeding after gastric ESD, such as the use of acid suppressive drugs, enough intraoperative hemostasis, lesion closure, and the use of lesion covering materials.
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Objective:To explore the quality of life (QOL) and the related influencing factors of patients with early esophageal cancer after endoscopic submucosal dissection (ESD).Methods:A questionnaire survey was conducted in 167 early esophageal cancer patients who underwent ESD in Shanxi Province Cancer Hospital from January 2022 to July 2022. European Organization for Research and Treatment of Cancer Quality of Life Assessment Core Scale (EORTC QLQ-C30) and the Esophageal Cancer Supplementary Scale (EORTC QLQ-OES18) were used to compare QOL of patients with different clinical characteristics before surgery, 1 month after surgery and 6 months after surgery, And multiple logistic regression analysis was used to analyze the influencing factors of patients' QOL at 6 months after surgery.Results:EORTC QLQ-C30 showed that the scores of the patients' physical function, role function, and social function at 1 month and 6 months after surgery were lower than those before surgery, and the differences were statistically significant (all P < 0.05). The scores of dyspnea, constipation, nausea and vomiting, fatigue, and economic status in the symptom area were higher than those before surgery, and the differences were statistically significant (all P < 0.05). According to EORTC QLQ-OES18, the scores of difficulty in swallowing oral fluid, obstruction, poor eating initiative, dry mouth, and cough at 1 month and 6 months after surgery were higher than those before surgery, and the differences were statistically significant (all P < 0.05). The score of dysphagia at 1 month after surgery was higher than that before surgery, while the score at 6 months after surgery was lower than that before surgery, and the differences were statistically significant (all P < 0.05). The score of dyspepsia at 1 month and 6 months after surgery was lower than that before surgery, and the difference was statistically significant (all P < 0.05). Multivariate analysis showed that the lesion perimeter >1/2 perimeter (lesion perimeter >1/2 perimeter vs. lesion perimeter ≤ 1/2 perimeter: OR = 2.072, 95% CI 1.536-2.796, P < 0.05) and postoperative esophageal stricture dilatation (undergoing esophageal stricture dilatation or not: OR = 2.193, 95% CI 1.429-2.789, P < 0.05) were independent risk factors affecting the QOL of patients at 6 months after surgery. Conclusions:The QOL of early esophageal cancer patients after ESD is decreased compared with that before surgery, and the main manifestations include physical function, role function, social function, and symptom. The area of lesion and undergoing esophageal stricture dilatation or not are factors affecting the QOL of patients after surgery.
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Objective:To investigate the characteristics, process, and prognosis of esophageal stricture after circumferential endoscopic submucosal dissection (ESD), and to preliminarily analyze the prevention and treatment effects of simple dilation, stent placement, mucosal transplantation, and glucocorticoid (hereinafter referred to as hormone) application in esophageal stricture.Methods:From August 2017 to March 2022, at the First Affiliated Hospital of Zhengzhou University, the clinical and follow-up data of 55 patients who underwent circumferential ESD for early esophageal cancer and precancerous lesions were retrospectively analyzed. According to the prevention and treatment methods for esophageal stricture, the patients were divided into two groups: simple dilation group (23 cases) and combined dilation group (32 cases). The combined dilation group was divided into mucosal transplantation subgroup (9 cases), stent placement subgroup (14 cases), hormone application subgroup (7 cases), and bleomycin subgroup (2 cases, excluded from comparative analysis due to limited cases). Overall prognosis of patients was observed. Treatment efficacy, prognosis, and adverse events were compared among the simple dilation group, mucosal transplantation subgroup, stent placement subgroup, and hormone application subgroup. Independent samples t-test, chi-square test, and Fisher′s exact test were used for statistical analysis. Results:Among the 55 patients, the follow-up time was (894.1±417.7) days. Refractory esophageal stricture (total dilation times ≥ 5) occurred in 33 patients (60.0%). Fifty-two patients (94.5%) achieved clinical remission of the stricture. The total number of dilations was 5.8±4.0, and the average dysphagia-free period was (52.3±37.1) days. The dysphagia-free period of mucosal transplantation subgroup was longer than that of the simple dilation group, stent placement subgroup, and hormone application subgroup ((114.5±50.0) days vs. (40.9±20.0), (39.7±10.0), and (40.9±25.5) days, respectively), and the differences were statistically significant ( t=4.82, 3.77 and 3.14, P<0.001, =0.011, =0.009). There were no statistically significant differences between the simple dilation group and the mucosal transplantation subgroup, stent placement subgroup, and hormone application subgroup in the total number of dilations (6.8±4.8 vs. 3.0±2.5, 5.8±2.2, and 5.7±5.0), stricture remission rate (95.7%, 22/23 vs. 8/9, 13/14, and 7/7), and incidence of adverse events (17.4%, 4/23 vs. 5/9, 5/14, and 2/7; all P>0.05). Conclusions:Esophageal stricture formed after circumferential ESD shows the characteristics of recurrence and intractability. The over all number of dilations is high, and the average dysphagia-free period is short. Most patients can achieve clinical remission of the stricture after multiple times of endoscopic dilation treatment. However mucosal transplantation, stent placement, and hormone application cannot well intervene the natural process of esophageal stricture.
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Objective:To investigate the consistency between the iodine-unstained area and the pathological size of endoscopic submucosal dissection (ESD) specimens of superficial esophageal cancer.Methods:A retrospective study was performed on data of 32 patients with superficial esophageal cancer who accepted ESD from May 2019 to April 2020 in the First Affiliated Hospital, Zhejiang University School of Medicine. The maximum transverse diameter and maximum longitudinal diameter of the iodine-unstained area were compared with the tumor pathological area. A size difference no more than 0.5 cm was considered as conformity, any difference between 0.5 and 1.0 cm was considered as non-conformity, and any difference no less than 1.0 cm was considered as serious non-conformity. At the same time, pink sign after spraying Lugo solution and the consistency of pink sign area with the iodine free area were observed.Results:A total of 32 patients with 33 lesions were enrolled in this study, including 23 males and 9 females and the age of the patients was 59.5±7.3 years. There were 19 (57.6%) lesions whose size of iodine-unstained area was consistent with the tumor pathological area. These 19 lesions were all positive for the pink sign, and the pink sign area overlapped with the iodine-unstained area. In addition, 4 (12.1%) iodine-unstained areas of the lesions did not match the size of the pathological area, and 10 (30.3%) iodine-unstained areas of the lesions were seriously inconsistent with the size of the pathological area. These 14 (42.4%) lesions were all positive for pink sign, and the pink sign area was significantly smaller than the iodine-unstained area. Among the 14 discordant lesions, 2 lesions underwent ESD according to the iodine-unstained area, which resulted in excessive resection and postoperative stenosis.Conclusion:Determining the extent of superficial esophageal cancer by iodine-unstained areas before ESD may lead to excessive resection of the lesions, which is related to the fact that the iodine-unstained areas of the lesions are sometimes significantly larger than the pink sign areas. Therefore, in order to achieve precise treatment, endoscopists can choose the iodine-unstained area with positive pink sign as the first choice for resection.
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Objective:To analyze the clinicopathological features of de novo early colorectal cancer and to evaluate the efficacy of endoscopic treatment.Methods:Patients with de novo early colorectal cancer who underwent endoscopic resection in Beijing Friendship Hospital, Capital Medical University from June 2020 to May 2022 were enrolled. The baseline data, endoscopic manifestations, treatment methods, postoperative pathological results and prognosis of the patients were collected retrospectively.Results:A total of 33 patients with de novo early colorectal cancer were enrolled with the age of 62.67 ± 8.62 years, and the male to female ratio was 7.25∶1. The long diameter of lesions was 0.96 ± 0.36 cm. The lesion morphology was mainly superficial phenotype (type 0-Ⅱ), accounting for 72.7% (24/33). Endoscopic submucosal dissection (ESD) was performed in 29 cases and endoscopic mucosal resection (EMR) was performed in 4 cases. Postoperative pathology showed that 11 cases (33.3%) were well differentiated tubular adenocarcinoma, of which the superficial submucosal layer was invaded in 2 cases. Twenty cases (60.6%) were moderately differentiated tubular adenocarcinoma, of which the superficial submucosa layer was invaded in 5 cases and the deep submucosa layer in 15 cases. Two cases (6.1%) were moderately-poorly differentiated tubular adenocarcinoma, where the deep submucosa layer was invaded in both. There was significant correlation between the depth of invasion and the degree of differentiation ( P<0.001), and moderately and moderately-poorly differentiated lesions were more likely to invade the deep submucosa layer. The en bloc resection rate was 100.0% (33/33), the complete resection rate was 97.0% (32/33), and the curative resection rate was 42.4% (14/33). Among the 19 patients who did not achieve curative resection, 13 patients received supplementary surgical treatment. No tumor residue or lymph node metastasis was found in the postoperative pathology. All patients were followed up for 3-25 months, and no signs of local recurrence or metastasis were found. Conclusion:Most de novo early colorectal cancers are superficial phenotype under endoscopy. The pathology is mainly moderately differentiated tubular adenocarcinoma. Endoscopic resection of de novo early colorectal cancer shows encouraging short-term efficacy.
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Objective:To compare the histopathological features and treatment efficacy of different methods for metachronous early gastric cancer (MEGC) in the remnant stomach.Methods:A total of 66 patients [38 endoscopic submucosal dissection (ESD) and 28 gastrectomy] with MEGC in the remnant stomach from January 2014 to December 2020 in Drum Tower Hospital were divided into the ESD group and the gastrectomy group. The baseline characteristics, histopathological features, treatment efficacy, and cost differences of the two groups were analyzed.Results:The MEGC in the remnant stomach mostly occurred in elderly male patients, with the mean age of 69.7±8.5 years. The mean interval of the occurrence of MEGC in the remnant stomach was 6 years. As for the tumor location, the gastric body (31.6%) was the main location in the ESD group and gastric cardia (53.6%) in the gastrectomy group with significant difference ( χ2=11.07, P=0.026). The mean operation time, hospital stay, postoperative fasting time, and total treatment cost were 80.0 min, 6.0 d, 1.5 d, ￥19 436 in the ESD group and 215.0 min, 19.0 d, 6.5 d, and ￥68 665 in the gastrectomy group, respectively, with significant differences between the two groups ( P<0.05). The overall survival rate during follow-up was 76.3% in the ESD group and 71.4% in the gastrectomy group with no significant difference between the two groups ( χ2=0.736, P=0.778). In terms of postoperative complications, the incidences of bleeding and infection were 7.9% and 5.3% in the ESD group, and those of obstruction and infection were both 14.3% in the gastrectomy group. There was significant difference in the incidences of postoperative obstruction between the two groups ( P<0.05). Conclusion:ESD is safe and effective for MEGC in the remnant stomach and is better than gastrectomy in terms of the treatment cost and operation time, but the long-term efficacy still needs to be validated by large-scale prospective studies.
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To investigate the effect of long-term indwelling gastric tube on the prevention and treatment of esophageal stenosis after endoscopic submucosal dissection (ESD) for esophageal circumferential superficial cancer, data of patients with esophageal circumferential superficial cancer who underwent ESD in the First Affiliated Hospital of Nanjing Medical University from January 2018 to December 2021 were retrospectively analyzed. There were 15 patients with gastric tube placement (GTP) after ESD (the GTP group ), and 23 patients without GTP (the non-GTP group). The general information, lesion location, pathological stage, postoperative complications, degree of esophageal stenosis (water intake), pain conditions, number of hospitalizations and medical expenses were compared between the two groups. The results showed that there was no significant difference in age, gender, lesion location or postoperative pathological stage between the two groups ( P>0.05). Compared with the non-GTP group, the rate of water intake in the GTP group was significantly higher (11/15 VS 6/23, P<0.05), the frequency of pain was less in the GTP group (7.3±3.1 times VS 10.7±3.6 times, t=3.00, P<0.05), and the number of hospitalizations and the medical expenses after ESD to before and after stent placement were significantly lower in the GTP group than those in the non-GTP group ( P<0.05). There were no significant differences in the incidence of delayed bleeding and perforation, or time of the first stenosis after ESD between the two groups ( P>0.05). The results of the study initially showed that long-term indwelling gastric tube after ESD can reduce the degree of esophageal stenosis with good safety for esophageal circumferential superficial lesions.
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To evaluate the clinical effects and pathological characteristics of gastric tumors of fundic gland type treated with endoscopic submucosal dissection (ESD), data of 7 patients who treated by ESD and whose postoperative pathology indicated gastric adenocarcinoma of fundic gland type or gastric oxyntic gland adenoma in Endoscopic Center of Beijing Chao-Yang Hospital of Capital Medical University from August 2018 to June 2022 were collected. The clinical characteristics, surgical complications, preoperative and postoperative pathological data and follow-up data were evaluated. The lesions of the 7 patients were all located at gastric fundus, and were treated by ESD successfully. No bleeding, perforation or other complications occurred during and after the operation. Postoperative pathology showed that tumor cells originated from deep mucosa with an invasive growth pattern. Most of tumor surfaces were covered with normal concave epithelium. Tumors infiltrated into submucosa in 4 patients, and submucosa infiltration depth was more than 500 μm (550 μm) in 1 patient. Immunohistochemistry showed that MUC-6 was diffusely positive, indicating that the tumor originated from the main cell source. The expressions of MUC-2, MUC-5AC, CDX-2, CD10, and CgA were negative in all cases. With the mean follow-up time of 21 months, the ulcer healed well after the operation, with no recurrence. Gastric tumors of fundic gland type have relatively unique biological characteristics, and ESD is the preferred treatment. In addition, the histological characteristics can be used to differentiate from other gastric tumors by immunohistochemistry.
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Objective:To develop a novel, flexible, dual-arm, master-slave digestive endoscopic minimally invasive surgical robot system named dual-arm robotic endoscopic assistant for minimally invasive surgery (DREAMS) and to evaluate its feasibility for endoscopic submucosal dissection (ESD) by using ex vivo porcine stomachs.Methods:A novel endoscopic robot (DREAMS) system was developed which was composed of a flexible two-channel endoscope, two flexible robotic manipulators, a master controller, a robotic arm, and a control system. A total of 10 artificial round-like lesions with diameters ranging from 15 to 25 mm were created (5 in gastric antrum and 5 in gastric body) by using fresh peeled stomach of healthy pigs as the model. Submucosal dissection was performed with the assistance of the DREAMS system by two operators. The main outcome was submucosal dissection speed, and the secondary outcomes included muscular injury rate, perforation rate, and grasping efficiency of the robot.Results:All 10 lesions were successfully dissected en bloc by using the DREAMS system. The diameter of the artificial lesions was 22.34±2.39 mm, dissection time was 15.00±8.90 min, submucosal dissection speed was 141.79±79.12 mm 2/min, and the number of tractions required by each ESD was 4.2 times. Muscular injury occurred in 4/10 cases of ESD. No perforation occurred. Conclusion:The initial animal experiment shows the DREAMS system is safe and effective.
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Objective:To investigate the risk factors for intraoperative hemorrhage during endoscopic submucosal dissection (ESD) for colorectal lesions.Methods:Data of 386 patients with colorectal lesions, who underwent ESD at The Third People's Hospital of Datong and its cooperative hospital, Nanjing Drum Tower Hospital, from December 2019 to August 2021 were retrospectively analyzed. The patients were divided into the hemorrhage group ( n=85) and the non-hemorrhage group ( n=301) according to intraoperative hemorrhage. The correlationship of patients'basic information, lesion-related factors and hemorrhage during colorectal ESD was analyzed. Univariate and multivariate logistic regression were used to identify the risk factors for intraoperative hemorrhage during ESD. The risk predictive model of intraoperative hemorrhage during ESD was established according to the screened risk factors, and receiver operator characteristic (ROC) curve was used to evaluate the predictive model. Results:Univariate logistic regression showed that a history of diabetes ( OR=2.340, P<0.05), a history of coronary atherosclerotic heart diseases ( OR=3.100, P<0.05), the lesion located in the rectum ( OR=3.272, P<0.05), longer lesion ( OR=1.093, P<0.05), wider lesion ( OR=1.057, P<0.05), larger lesion ( OR=1.126, P<0.05), depressed lesion ( OR=6.128, P<0.05), the laterally spreading lesion ( OR=2.651, P<0.05), the lesion infiltrated into the SM-S layer ( OR=0.088, P<0.05), the lesion infiltrated into the SM-D layer ( OR=0.174, P<0.05), the diameter of hemorrhage vessels 0.5~<1.0 times of the diameter of incision knife ( OR=246.854, P<0.05), the postoperative pathology as early cancer ( OR=7.000, P<0.05) were risk factors for intraoperative hemorrhage during ESD. Considering the quantitative relationship between the length, the width and the area of lesions, multi-factor models were constructed using the length and area of lesions respectively. Forward stepwise regression was used to screen variables and determine the final model, and the results showed that a history of coronary atherosclerotic heart diseases, the depressed lesion, the longer lesion, the larger lesion, the diameter of hemorrhage vessels 0.5~<1.0 times of the diameter of the incision knife were independent risk factors for intraoperative hemorrhage during ESD. The two modeling results of the lesion length and the lesion area were very similar. Therefore, lesion length was recommended to describe lesions in clinical practice. Conclusion:A history of coronary atherosclerotic heart disease, the depressed lesion, the longer lesion, the larger lesion, the diameter of vessels 0.5~<1.0 times of that of the incision knife are independent risk factors for intraoperative hemorrhage during ESD.
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Objective:To evaluate the effects of hemoclips on preventing delayed bleeding for early gastric cancer (EGC) after endoscopic submucosal dissection (ESD).Methods:Clinical data of 459 patients who underwent ESD for EGC in Beijing Friendship Hospital from June 2013 to August 2020 were collected retrospectively. Patients were divided into group A (hemoclip group, n=162) and group B (non-hemoclip group, n=297) according to whether preventive hemostatic clip treatment was performed after resection. Delayed bleeding within 2 weeks after ESD was observed. Univariate analysis and subgroup analysis were conducted for the delayed bleeding incidence and clinicopathological features. Results:Delayed bleeding incidences of group A and group B were 3.1% (5/162) and 8.1% (24/297) with significant difference between the two groups ( χ2=4.418, P=0.036). Subgroup analysis showed that there were significant differences in the delayed bleeding incidence between the two groups when the diameter of the tumor >20 mm [3.5% (2/57) VS 15.3% (13/85), χ2=5.016, P=0.025], the tumor located in the lower part of the stomach [1.0% (1/97) VS 10.4% (20/192), χ2=8.425, P=0.004], and the depth of tumor invasion was M/SM1 [3.2% (5/157) VS 8.1% (23/285), χ2=4.072, P=0.044]. There were no significant differences in the delayed bleeding incidence between group A and group B when the diameter of the tumor ≤20 mm, the tumor located in the upper/medial part of the stomach and the depth of tumor invasion was SM2 ( P>0.05). Conclusion:Hemoclips can prevent delayed bleeding after ESD for EGC, which is mainly observed in a tumor of diameter >20 mm, located in the lower part of the stomach and M/SM1 tumor invasion. It has little effect on the prevention when the tumor diameter ≤20 mm and located in the upper/medial part of the stomach.
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Objective:To evaluate the clinical efficacy of C-type endoscopic submucosal dissection (C-ESD) for rectal neuroendocrine tumors (NEN).Methods:The retrospective analysis was performed on data of 55 patients who underwent ESD for rectal NEN at the Department of Endoscopy in Quanzhou First Hospital from January 2018 to July 2021. Patients were divided into the C-ESD group ( n=28) and the conventional ESD group ( n=27). The dissection time, the dissection speed, the number of submucosal injections, the enbloc resection rate, the curative resection rate and the rate of postoperative complications of the two groups were compared. Results:There were no statistically significant differences in basic information between the two groups ( P>0.05). The dissection time was 13.8±4.2 min in the C-ESD group and 19.9±3.9 min in the conventional ESD group with statistically significant difference ( t=5.649, P<0.001). The dissection speed in the C-ESD group was 0.08±0.04 cm 2/min, which was faster than 0.06±0.04 cm 2/min in the conventional ESD group ( t=2.218, P=0.031). The number of submucosal injections in the C-ESD group was less than that in the conventional ESD group [2 (1, 2) VS 3 (2, 3), Z=-8.701, P<0.001]. The lesions were enbloc resected in both groups. The curative resection rate in the C-ESD group was 100.0% (28/28) and 88.9% (24/27) in the conventional ESD group with statistically significant difference ( P=0.011). There were 7 cases of postoperative complications in the conventional ESD group, including 1 delayed bleeding, 5 delayed perforation and 1 muscularis propria injury, while no postoperative complications occurred in the C-ESD group ( P=0.004). Conclusion:C-ESD is a safe and effective treatment strategy for colorectal NEN, which can shorten the dissection time, improve the dissection speed, reduce the number of submucosal injections, improve the curative resection rate, and reduce complications.
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OBJECTIVE@#To evaluate the pathological characteristics of endoscopic submucosal dissection (ESD) specimens for early gastric cancer and precancerous lesions, accumulating experience for clinical management and pathological analysis.@*METHODS@#A total of 411 cases of early gastric cancer or precancerous lesions underwent ESD. According to the Japanese guidelines for ESD treatment of early gastric cancer and classification of gastric carcinoma, the clinicopathological data, pathologic evaluation, concordance rate of pathological diagnosis between preoperative endoscopic forceps biopsies and their ESD specimens (in 400 cases), as well as the risk factors of non-curative resection of early gastric cancer, were analyzed retrospectively.@*RESULTS@#23.4% (96/411) of the 411 cases were adenoma/low-grade dysplasia and 76.6% (315/411) were early gastric cancer. The latter included 28.0% (115/411) non-invasive carcinoma/high-grade dysplasia and 48.7% (200/411) invasive carcinoma. The concordance rate of pathological diagnosis between endoscopic forceps biopsies and ESD specimens was 66.0% (264/400), correlating with pathological diagnosis and lesion location (P < 0.01). The rate of upgraded diagnosis and downgraded diagnosis after ESD was 29.8% (119/400) and 4.2% (17/400), respectively. Among the 315 cases of early gastric cancer, there were 277 cases (87.9%) of differentiated type and 38 cases (12.1%) of undifferentiated type. In the study, 262 cases (83.2%) met with absolute indication, while 53 cases (16.8%) met relative indication. En bloc and curative resection rates were 98.1% and 82.9%, respectively. Risk factors for non-curative resection included a long diameter >20 mm (OR=3.631, 95%CI: 1.170-11.270, P=0.026), tumor infiltration into submucosa (OR=69.761, 95%CI: 21.033-231.376, P < 0.001)and undifferentiated tumor histology (OR=16.950, 95%CI: 4.585-62.664, P < 0.001).@*CONCLUSION@#Several subjective and objective factors, such as the limitations of biopsy samples, the characteristics and distribution of the lesions, different pathological understanding, and the endoscopic sampling and observation, can lead to the differences between the preoperative and postoperative pathological diagnosis of ESD. In particular, the pathological upgrade of postoperative diagnosis was more significant and should receive more attention by endoscopists and pathologists. The curative resection rate of early gastric cancer in ESD was high. Non-curative resection was related to the long diameter, the depth of tumor invasion and histological classification. ESD can also be performed in undifferentiated early gastric cancer if meeting the indication criteria. The comprehensive and standardized pathological analysis of ESD specimens is clinically important to evaluate the curative effect of ESD operation and patient outcomes.
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Humans , Stomach Neoplasms/pathology , Endoscopic Mucosal Resection , Retrospective Studies , Endoscopy , Precancerous ConditionsABSTRACT
OBJECTIVE@#To investigate the clinicopathological features of Helicobacter pylori (Hp)-negative early gastric cancer.@*METHODS@#The clinicopathological data of 30 cases of Hp-negative early gastric cancer were collected retrospectively at Pingdingshan Medical District, 989 Hospital of PLA Joint Logistics Support Force, and Beijing Chaoyang Hospital, Capital Medical University, from 2009 to 2021, and the histomorphological characteristics and immunophenotype were observed, and combined with the literature to explore.@*RESULTS@#The median age of 30 patients was 58.5 years (range: 21-80 years), including 13 males and 17 females. The upper part of the stomach was 13 cases, the middle part of the sto-mach was 9 cases, and the lower part of the stomach was 8 cases. The median diameter of the tumor was 11 mm (range: 1-30 mm). According to the Paris classification, 9 cases were 0-Ⅱa, 7 cases were 0-Ⅱb, and 14 cases were 0-Ⅱc. Endoscopic examination showed that 18 cases of lesions were red, 12 cases of lesions were faded or white, and microvascular structures and microsurface structures were abnormal. In all the cases, collecting venules were regularly arranged in the gastric body and corner mucosa. There were 18 cases of well differentiated adenocarcinoma in the mucosa. The tumor presented glandular tubular-like and papillary structure, with dense glands and disordered arrangement; the cells were cuboidal or columnar, with increased nuclear chromatin and loss of nuclear polarity, and most of them expressed gastric mucin. Signet-ring cell carcinoma was found in 7 cases, all the cancer tissues were composed of signet-ring cells, and the cancer cells were mainly distributed in the middle layer to the surface layer of mucosa. Gastric oxyntic gland adenoma (gastric adenocarcinoma of the fundic gland type confined to mucosa) in 2 cases, gastric adenocarcinoma of the fundic gland type in 2 cases, and gastric adenocarcinoma of fundic gland mucosa type in 1 case. The tumor tissue was composed of branching tubular glands, except 1 case of mucosal surface epithelium was partially neoplastic, the other 4 cases of mucosal surface epi-thelium were all non-neoplastic; the cells were arranged in a single layer, and the nucleus was close to the basal side, and the nucleus was only slightly atypical. Pepsinogen I and H+/K+ ATPase were positive in 5 cases of gastric fundus gland type tumors, and 1 case of foveolar-type tumor cells at the surface and depth of mucosa showed MUC5AC positive. The gastric mucosa adjacent to cancer was generally normal in all cases, without atrophy, intestinal metaplasia and Hp.@*CONCLUSION@#Hp-negative early gastric cancer is a heterogeneous disease group with various histological types, and tubular adenocarcinoma and signet-ring cell carcinoma are common. Tubular adenocarcinoma mostly occurs in the elderly and the upper to middle part of the stomach, while signet-ring cell carcinoma mostly occurs in young and middle-aged people and the lower part of the stomach. Gastric neoplasm of the fundic gland type is relatively rare.
Subject(s)
Male , Aged , Middle Aged , Female , Humans , Young Adult , Adult , Aged, 80 and over , Stomach Neoplasms/pathology , Helicobacter pylori , Retrospective Studies , Helicobacter Infections/diagnosis , Adenocarcinoma/pathology , Carcinoma, Signet Ring Cell/pathologyABSTRACT
Objective:To compare the short- and long-term efficacy and safety of endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) in the treatment of rectal neuroendocrine tumor (NET) with maximum diameter ≤20 mm.Methods:From January 1, 2014 to June 30, 2022, the clinical data of 111 patients with rectal NET with maximum diameter ≤20 mm treated by ESD or TEM at Peking University People′s Hospital were retrospectively analyzed. According to the treatment of ESD or TEM, 111 patients with rectal NET were divided into ESD group (76 cases) and TEM group (35 cases). The clinicopathological characteristics (age, distance from anal margin, depth of invasion, etc.) were compared between patients with tumor maximum diameter<10 mm and 10 to 20 mm, and between ESD group patients and TEM group patients. The clinical efficacy and prognosis were also compared between ESD group and TEM group. The follow-up time was 41 months (16 months, 76 months). The propensity score matching (PSM) method was used to balance the differences of clinical characteristics between ESD and TEM groups. Independent sample t test, Wilcoxon rank-sum and chi-square test were used for statistical analysis. The risk factors of lymph node or distant metastasis were analyzed by univariate and multivariate binary logistic regression. Results:The maximum tumor diameter of 111 patients with rectal NET was (6.6±0.3) mm (ranged from 2 to 20 mm). The maximum tumor diameter of 85 cases (76.6%) was <10 mm and that of 26 cases (23.4%) was between 10 mm and 20 mm. There were statistically significant differences in age, distance from the anal margin and incidence of submucosal infiltration between patients with tumor maximum diameter<10 mm and patients with tumor maximum diameter 10 to 20 mm ((49.8±11.6 ) years old vs. (56.8±13.8) years old; 5.0 cm (4.0 cm, 8.0 cm) vs. 8.0 cm (5.0 cm, 8.0 cm); 69.4%, 59/85 vs. 96.2%, 25/26; t=2.58, Z=-2.23, χ2=6.35, P=0.011, 0.026 and 0.012). The en block resection rate of rectal NET treated with ESD or TEM was 100.0%(111/111), the complete resection rate was 93.7% (104/111), and the postoperative bleeding rate was 2.7% (3/111). There were no postoperative perforation or other major complications. During the follow-up period, there was no local recurrence. The metachronous recurrent rate was 0.9% (1/111), 3.6% (4/111) patients had lymph node or distant metastasis, and there was no death. Compared with patients with tumor maximum diameter<10 mm, more patients with tumor maximum diameter of 10 to 20 mm selected TEM (57.7%, 15/26 vs. 23.5%, 20/85), and the difference was statistically significant ( χ2=10.76, P=0.001). Before PSM, a total of 7 patients in the ESD group had positive vertical margins, and during the follow-up of 21 months (15 months, 48 months), 2 patients had lymph node or distant metastasis and received surgery. The proportion of patients with tumor maximum diameter of 10 to 20 mm and submucosal invasion in TEM group were both higher than those in ESD group (42.9%, 15/35 vs. 14.5%, 11/76; 88.6%, 31/35 vs. 69.7%, 53/76), and the differences were statistically significant( χ2=10.76 and 3.65, P=0.001 and 0.032). After PSM, there were no statistically significant differences in the complete resection rate, postoperative bleeding rate, metachronous recurrence rate, lymph node or distant metastasis rate between ESD group and TEM group (89.3%, 25/28 vs.100.0%, 28/28; 3.6%, 1/28 vs. 0, 0/28; 3.6%, 1/28 vs. 0, 0/28; 0, 0/28 vs.3.6%, 1/28; all P>0.05). However, the operation time and hospital stay of the ESD group were both shorter than those of the TEM group (27.0 min (25.0 min, 30.0 min) vs. 39.0 min (32.0 min, 45.0 min); 5.0 d (4.0 d, 5.0 d) vs. 6.0 d (3.0 d, 9.0 d)), and the differences were statistically significant ( Z=-3.38 and -2.23, P=0.001 and 0.021). Conclusion:The efficacy of ESD and TEM in rectal NET with maximum diameter ≤ 20 mm is equal, however, ESD has the advantage of shorter procedure time and hospital stay.
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Objective:To investigate the efficacy and safety of modified endoscopic submucosal multi-tunnel dissection (ESMTD) for superficial circumferential esophageal cancer with an axial length of more than 8 cm.Methods:Data of 79 patients with superficial circumferential esophageal cancer with lesion length of more than 8 cm who were treated in the First Affiliated Hospital of Nanjing Medical University from January 2018 to December 2021 were retrospectively analyzed. Patients were divided into modified ESMTD group (32 cases) and surgery group (47 cases) according to the treatment. The en bloc resection rate, complete resection rate, operation time, hospitalization time, medical expenses, incidence of procedure-related complications of the two groups were compared.Results:The en bloc resection rate in the modified ESMTD group and the surgery group were both 100.0% ( χ2=0.000, P=1.000), and the complete resection rate were 96.9% (31/32) and 97.9% (46/47) ( χ2=0.000, P=1.000), respectively. The operation time in the modified ESMTD group was shorter than that in the surgery group (150.5±17.2 min VS 185.8±15.2 min, t=9.527, P<0.001). The incidence of delayed bleeding [3.1% (1/32) VS 10.6% (5/47), χ2=0.648, P=0.421] and delayed perforation [3.1% (1/32) VS 4.3% (2/47), χ2=0.000, P=1.000] in the two groups were not statistically different. Postoperative C-reactive protein (64.3±6.9 mg/L VS 89.2±7.4 mg/L, t=15.634, P<0.001) and neutrophil levels [(10.1±1.4)×10 9/L VS (13.1±1.2)×10 9/L, t=15.083, P<0.001] were lower in the modified ESMTD group than those in the surgery group. The hospital stay of the modified ESMTD group was shorter than that of the other group (9.2±1.2 d VS 11.5±1.2 d, t=8.363, P<0.001), and the medical expense was less than that of the surgery group (32±3 thousand yuan VS 59±6 thousand yuan, t=26.384, P<0.001). Conclusion:Compared with traditional surgery, modified ESMTD for the treatment of superficial circumferential esophageal cancer with an axial length >8 cm has definite curative effect, safety, short hospital stay, and low medical costs, and can preserve the integrity of the esophagus and improve the quality of life of patients. It has good clinical application value.
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Objective:To study the safety and efficacy of hiatal hernia-endoscopic submucosal dissection (HH-ESD) for the treatment of giant hiatal hernia (>3 cm in length) complicated with refractory gastroesophageal reflux disease (GERD).Methods:Patients with giant hiatal hernia complicated with refractory GERD who voluntarily received HH-ESD at the Digestive Endoscopy Center of the Affiliated People's Hospital of Inner Mongolia Medical University from April 2018 to March 2020 were included in the clinical study. The completion of HH-ESD and the occurrence of complications were observed, and the changes of indicators before and after the treatment were observed, including gastroesophageal reflux disease-health related quality of life (GERD-HRQL) score, gastroesophageal reflux disease questionnaire (GERD-Q) score, endoscopy results, 24 h esophageal pH monitoring results, esophageal high-resolution manometry results and proton pump inhibitor (PPI) usage.Results:Data of 10 patients were collected during the study, with a medical history of 2-10 years. All patients successfully underwent HH-ESD treatment. No adverse events such as perforation and massive bleeding occurred during the operation, and the hospital stay was 6-12 days. Dysphagia occurred in 3 cases after the operation, which was relieved spontaneously within 3 or 6 months. The preoperative GERD-HRQL scores ranged from 19 to 29, which were reduced to 0-14 and 0-8 at 3 and 12 months after the operation, respectively. The preoperative GERD-Q score was 9-17, and the scores at 3 and 12 months after the operation were all 6-9, which were significantly lower than those before. Gastroscopy showed that esophagitis was improved in all patients, hernia sac was reduced, and Hill grade was reduced compared with that before. The preoperative DeMeester score was 30.3-247.1, and the postoperative 12-month score was 0.2-29.9, which was significantly lower than that before. The long diameter of hiatal hernia was 3.0-6.0 cm before the operation and 0-5.0 cm at 12 months after, which was smaller than that before. At 12 months of the follow-up, 7 patients had stopped PPI, and the remaining 3 had changed to intermittent oral PPI.Conclusion:Preliminary results show that HH-ESD is safe and effective for the treatment of giant hiatal hernia complicated with refractory GERD.
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Objective:To evaluate the clinical outcomes of additional surgery after non-curative endoscopic submucosal dissection (ESD) for early gastric cancer.Methods:Sixty-nine patients with early gastric cancer who underwent ESD and were diagnosed as having non-curative resection by postoperative pathology at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 2014 to December 2020 were included in the retrospective observation. Patients were divided into the additional surgery group ( n=12) and the follow-up group ( n=57). The differences in clinical and pathological data of the two groups, the surgical outcomes of the additional surgery group, three-year recurrence-free survival and tumor-specific survival of the two groups, and the independent risk factors affecting three-year recurrence-free survival in the follow-up group were analyzed. Results:Compared with the follow-up group, the rates of submucosal infiltration [66.7% (8/12) VS 21.1% (12/57), χ 2=7.927, P=0.005], vascular invasion [33.3% (4/12) VS 1.8% (1/57), P=0.003] and nerve invasion [16.7% (2/12) VS 0.0% (0/57), P=0.028] in the additional surgery group were significantly higher. In the additional surgery group, the interval between the additional surgery and ESD was 18.5 d (7-55 d), the surgical time was 286.4±85.9 min, and the number of dissected lymph nodes was 25.6±7.4. Four patients (33.3%) had residual tumor. Postoperative complications occurred in 4 patients (33.3%) (all were discharged after conservative treatment), and there was no perioperative death. One patient developed liver metastases 17 months after the surgery, and died 22 months after surgery due to liver metastases. One patient died 22 months after surgery due to non-tumor causes. The three-year recurrence-free survival and three-year tumor-specific survival in additional surgery group were 91.7% (11/12) and 91.7% (11/12), respectively, and those in the follow-up group were 87.7% (50/57) and 100.0% (57/57), respectively. Multivariate Cox regression analysis showed that tumor size ≥2 cm was an independent risk factor for three-year recurrence-free survival in the follow-up group ( P=0.037, HR=15.595, 95% CI: 1.181-205.952). Conclusion:Additional surgery and close follow-up are safe and feasible therapeutic strategies for early gastric cancer patients who underwent non-curative ESD. Clinicians should make reasonable choice based on the pathological results, patients' physical condition and surgery intention. But for patients with primary tumor size ≥2 cm, additional surgery is recommended.
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From January 2016 to December 2020, 6 cases of polyps in the appendix cavity with a diameter of 0.3-1.3 cm were treated by endoscopy in the Department of Gastroenterology of Beijing Friendship Hospital, Capital Medical University. All 6 cases underwent endoscopic treatment successfully, including 3 cases of en bloc endoscopic mucosal resection (EMR), 1 case of piecemeal EMR, 1 case of endoscopic submucosal dissection (ESD), and 1 case of removed by cold forceps. No complications such as bleeding, perforation, infection or acute appendicitis occurred.The wound healed well with no recurrence after re-examination in 3 cases, and 3 others were not re-examined by colonoscopy yet. The results preliminarily confirmed that endoscopic treatment of intraluminal polyps in the appendix cavity is safe and effective.