Therapeutic effect analysis of colorectal polyps with diameter≥2.5cm treated by endoscopic submucosal dissection: A report of 567 cases / 中国实用外科杂志

OBJECTIVE: To evaluate the effectiveness of endoscopic submucosal dissection(ESD) in treating colorectal polyps with diameter≥2.5 cm. METHODS: The clinical data of 567 cases of colorectal polyps with diameter≥2.5 cmtreated by ESD at Endoscopy Center,Zhongshan Hospital,Fudan University between January 2007 and November 2016 were analyzed retrospectively. The data included clinical and pathological characteristics, complications and follow-up.RESULTS: Of all lesions, the median diameter was 3.0 cm(2.5 to 15.0). Among them, 448 lesions(79.0%)were high grade intraepithelial neoplasia, and the other 119 lesions(21.0%)were intra-adenoma adenocarcinoma, focal cancerization or adenocarcinoma. The complete resection rate during operation was 99.1%(562/567). The en bloc resection rate was 78.3%(444/567), and the curative resection rate was 90.8%(515/567). Additional surgeries or endoscopic treatment were performed in 31 cases after ESD treatment. Postoperative bleeding occurred in 3.7%(21/567) of all cases. Penetration and electrocoagulation syndrome after ESD occurred in 1.2%(7/567) and 5.3%(30/567) of casesrespectively. The median length of follow-up was 40(12-90) months, with a local recurrence rate of 1.1%(6/536). Intraoperative complications were related to lesions ≥5.0 cm(P<0.001) and non-en bloc resection(P=0.034).Electrocoagulation syndrome was related to lesions ≥5.0 cm(P=0.004). Postponed bleeding after ESD was related to hypertension (P=0.008). Local recurrence was related to lesions ≥5.0 cm (P=0.037). CONCLUSION: Treating colorectal polyps ≥2.5 cm with ESD is safeand feasible, resulting in high rate of curative resection and an extremely low local-recurrencerate. However, polyps≥5.0 cm showld be cautionly evaluated before ESD.

Narrow band imaging versus iodine staining for margin determination of early esophageal cancer during endoscopic submucosal dissection / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the clinical value of narrow band imaging (NBI) and iodine staining for margin determination of early esophageal cancer during endoscopic submucosal dissection (ESD).</p><p><b>METHODS</b>Clinical data of 87 patients with early esophageal cancers undergoing endoscopic submucosal dissection (ESD) were analyzed retrospectively. Patients were assigned to NBI group and iodine staining group according to the staining method before ESD operation. Clinicopathological features, esophageal spasm ratio, operation time, en bloc resection rate, complications, local recurrence, and distant metastases were compared between the two groups.</p><p><b>RESULTS</b>There were 37 patients in NBI group while 50 patients in iodine staining group. Location and size of the lesions between two groups were not significantly different. The ratio of moderate-severe esophageal spasm in NBI group was significantly lower as compared to iodine staining group [10.8%(4/37) vs. 32.0%(16/50), P<0.05]. The average operation time in NBI group was significantly shorter than that in iodine staining group [(42.2±19.5) min vs. (53.3±30.9) min, P<0.05). All the tumors were resected in an en bloc fashion and the R0 resection rate was 100%. Perforations in 2 patients and delayed bleeding in 1 patient were successfully treated by endoscopic methods. Esophageal strictures occurred in 3 patients of NBI group and 4 patients of iodine staining group, who were treated by endoscopic dilation and retrievable stents. During mean 13.2 months (range 4 to 20 months) follow-up periods, local recurrence occurred in 2 patients of NBI group and 2 patients of iodine staining group. These patients received ESD or other surgery.</p><p><b>CONCLUSION</b>Compared with iodine staining, using NBI for margin determination of early esophageal cancer during ESD is more convenient and fast because of distinctly lower degree of esophageal spasm.</p>

Endoscopic therapy: standardization for less complications / 中华胃肠外科杂志

In recent years, the endoscopic treatment, which is based on the endoscopic mucosal resection and endoscopic submucosal dissection, has developed rapidly. Complication of the endoscopic therapy has been increasingly emphasized. When paying attention to the endoscopic technique innovation, we should also concern the standardization of endoscopic therapy and the prevention and treatment of its complications. Continuous improvement in the safety, practicality and efficacy of endoscopic therapy may translate into benefits for the patients.

Submucosal tunneling endoscopic resection in the treatment of rectal submucosal tumors originating from muscularis propria / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the clinical value of submucosal tunneling endoscopic resection (STER) for rectal submucosal tumors (SMT) originating from muscularis propria.</p><p><b>METHODS</b>Clinicopathological data of 8 cases with rectal SMT originating from muscularis propria undergoing STER in our center from March 2011 to March 2013 were analyzed retrospectively.</p><p><b>RESULTS</b>En bloc STER was performed successfully in all the 8 cases. The tumors location was 5-15 cm from the edge of anus. The resected specimen size ranged from 1.0 to 3.5 cm (average 1.8 cm). The mean procedure time was 51 min (range, 40-70 min). One patient developed mucosa perforation and was repaired with metal clips. One patient developed subcutaneous emphysema in one leg, which was disappeared after two weeks. Postoperative pathological examination revealed schwannoma in 3 cases, leiomyoma in 2 cases, stromal tumor in 1 case, and proliferation of collagen fibers nodular degeneration in 2 cases. Postoperative follow-up ranged from 6 to 30 months and no residual lesion or recurrence was found.</p><p><b>CONCLUSION</b>STER is a safe and effective method for rectal SMT originating from muscularis propria in our initial experience.</p>

Prevention and treatment of complications during and after endoscopic mucosal band ligation for esophageal precancerous lesions and early cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the prevention and treatment of complications during and after endoscopic mucosal band ligation (EMBL) for precancerous lesions and early cancer in the esophagus.</p><p><b>METHODS</b>Clinical data of 47 patients with esophageal precancerous lesions and early cancer undergoing EMBL in our center from June 2011 to August 2013 were reviewed retrospectively. Complications and associated treatment during operation, after operation and during follow-up were analyzed.</p><p><b>RESULTS</b>Complications during operation included 7 cases of bleeding (14.9%) and 1 case of perforation (2.1%), who received hot biopsy forceps and argon plasma coagulation to stop bleeding successfully, and titanium clamp to suture wound surface. No cutaneous emphysema and pneumothorax occurred. Complications after operation included 1 case of delayed bleeding (2.1%) who received blood stopping under gastroscope, 2 cases of mediastinal and subcutaneous emphysema (4.3%), 6 cases of pleural effusion (12.8%), and 5 cases of minor inflammation or segmental atelectasis of pulmonary (10.6%), who all received successful conservative treatment. Seven cases of esophageal stricture occurred during follow-up, who were improved by balloon dilatation and metal-film stent placement. No deaths associated with EMBL occurred. All the complications were cured through conservative treatment. No additional surgery associated with the complications was needed. Post-operative pathology revealed 1 case was chronic inflammatory hyperplasia, 11 were low-grade intraepithelial tumor, 15 were high-grade intraepithelial tumor, 8 were carcinoma in situ, 12 were squamous cancer (8 with invasion into mucous muscular layer, 4 into submucous layer). Only 1 case of submucous cancer needed transthorax esophageal cancer radical operation because of dangerous margin. No relapse case was found during followed-up.</p><p><b>CONCLUSION</b>EMBL can treat the esophageal precancerous lesions and early esophageal cancer effectively and its complications can be managed with conservative therapy usually.</p>

Membrane-covered self-expanding stents in the treatment of high-positioned esophageal stenosis or fistula / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the efficacy and safety of membrane-covered self-expanding metal stent in the treatment of high-positioned esophageal diseases, including esophageal stenosis, esophagotracheal fistula and anastomotic stricture.</p><p><b>METHODS</b>Clinical data of 84 patients who underwent stenting in our center from May 2005 to July 2013 were retrospectively analyzed. Of 84 patients, 31 were diagnosed as esophageal malignant stenosis, 2 compression stenosis, 10 radiation stenosis, 4 recurrent malignant stenosis, 27 anastomotic stricture, 1 esophageal stenosis after endoscopic submucosal dissection (ESD), 7 esophageal-tracheal fistula, 1 esophageal-mediastinal fistula, and 1 remnant stomach fistula. Distance from stenosis or fistula to central incisor was 15-20 cm in 48 cases, and more than 20 cm in 36 cases. All the patients were treated by 16 mm membrane-covered self-expanding metal stents. Main clinical manifestations and complications were evaluated.</p><p><b>RESULTS</b>A total of 100 stents were placed in 84 patients,with a success rate of 100%. There were no complications such as perforation and bleeding during operation. Dysphagia and cough were improved quickly with a success rate of 100%. After the placement of stents, the incidence of complication was 6.0% (5/84), of which 2 cases were severe retrosternal pain, 1 was tracheal collapse, and 2 were stent displacement. Seventy-six patients (90.5%) received complete follow-up of 1 to 36 months (mean 15 months). Re-stenosis occurred in 4 cases, new esophageal-tracheal fistula in 2 cases. Among these 6 cases, 5 cases underwent successfully stent placement once again, and another one case received Savary bougie and Argon-ion coagulation with good efficacy.</p><p><b>CONCLUSION</b>Endoscopic membrane-covered self-expanding metal stent placement is effective and safe for the relieve of dysphagia symptoms and the sealing of esophagotracheal fistula.</p>

Analysis of the short-term efficacy and safety of endoscopic mucosal band ligation in the treatment of esophageal precancerous lesions and esophageal early cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the short-term efficacy and safety of endoscopic mucosal band ligation(EMBL) in the treatment of esophageal precancerous lesions and esophageal early cancer.</p><p><b>METHODS</b>Clinicopathological data of 21 cases with esophageal precancerous lesions and esophageal early cancer undergoing EMBL at the Endoscopic Center in Zhongshan Hospital of Fudan University from January 2012 to November 2012 were analyzed retrospectively. Short-term efficacy and complications after operation were summarized.</p><p><b>RESULTS</b>All the 21 cases underwent EMBL operation successfully. The mean operative time was(21.0±8.3) minutes. No subcutaneous emphysema, mediastinal emphysema, pneumothorax or delayed bleeding occurred. Esophageal stricture occurred in 2 cases and the symptoms were alleviated after balloon dilation. Pathological examination showed moderate dysplasia(n=1), moderate-severe dysplasia(n=2), severe dysplasia(n=10), carcinoma in situ(n=2) and early stage of squamous cell carcinoma(n=6). All the resection margins were negative except for 1 case of early stage squamous cell carcinoma, whose margin was only 1 mm and so underwent additional open surgery for esophageal cancer. No relapse of cancer was found during follow-up.</p><p><b>CONCLUSION</b>EMBL can cure esophageal precancerous lesions and esophageal early cancer effectively and is safe, minimally invasive and simple to perform.</p>

Complete closure of gastric wall defect after endoscopic full-thick resection with metal clips and endoloop snare / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To study the value of the metal clips and endoloop snare for gastric wall defect after endoscopic full-thick resection(EFR).</p><p><b>METHODS</b>All the patients who underwent complete closure of gastric wall defect after endoscopic full-thick resection with metal clips and endoloop snare in the Endoscopy Center of Zhongshan hospital from March 2011 to October 2011 were retrospectively studied. The feasibility, safety, and efficacy were evaluated.</p><p><b>RESULTS</b>Fourteen patients were included in this study. The median age was 49(32-63) years. Lesions located in the gastric body in 5 cases, the gastric fundus in 8 cases, and the gastric antrum and body junction in 1 case. The were diameter was 0.6-3.0 cm. Complete closure rate was 100% using this technique. The median repair time was 12(8-20) min. No patients were converted to surgery or laparoscopic surgery. Four patients complained of abdomen pain with elevated body temperature, and ultrasonography showed minor peritoneal fluid in 2 cases, which were drained. These four cases were asked to maintain semi-reclining position and were put on fasting, continuous gastrointestinal decompression, and received antibiotics. They were discharged after 1-3 days. All the patients were followed up with a median time of 3(1-8) months. Nylon and clips residual were removed endoscopically and the wound healing was satisfactory.</p><p><b>CONCLUSION</b>Metal clips and endoloop snare is safe and effective for the closure of gastric wall defect after EFR.</p>

Therapeutic value of endoscopic submucosal dissection for gastrointestinal stromal tumor in the esophagogastric junction / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the safety and efficacy of endoscopic submucosal dissection (ESD) for gastrointestinal stromal tumor(GIST) in the esophagogastric junction(EGJ).</p><p><b>METHODS</b>Twenty patients with pathologically confirmed GIST in the EGJ were screened from all the patients undergoing ESD between November 2007 and June 2011. The clinicopathological and postoperative follow up data were analyzed.</p><p><b>RESULTS</b>There were 11 males and 9 females with the age ranging from 29 to 67 years(mean, 54.1 years). The maximum diameter of the lesions ranged from 8 to 20 mm(mean,14.8 mm). Fifteen patients underwent endoscopic submucosal excavation, 4 patients underwent endoscopic full-thickness resection, and 1 patient underwent submucosal tunneling endoscopic resection. The operative time ranged from 15 to 90 min(mean, 47.8 minutes). The estimated blood loss was 5 to 200 ml. The en bloc resection rate was 100%. Perforations occurred in 4 patients, pneumoperitoneum in 3 patients, cardia mucosal tear in 1 patient. All the complications were successfully managed with endoscopic intervention and conservative therapy. The post-operative follow up ranged from 3 to 36 months(mean, 13.2 months). No local recurrence or distant metastasis occurred.</p><p><b>CONCLUSION</b>ESD is a safe and effective procedure for GIST in the EGJ.</p>

Feasibility of endoscopic resection for gastric gastrointestinal stromal tumor / 中华胃肠外科杂志

In recent years, with the development of digestive endoscopy, endoscopic submucosal dissection(ESD) and its derived techniques including endoscopic submucosal excavation(ESE), submucosal tunnelling endoscopic resection(STER) and laparoscopic endoscopic combined surgery(LECS), can cure most of the gastric gastrointestinal stromal tumor(GIST). This article reviews the indication, method and evaluation of endoscopic resection for gastric GIST.

A pilot study of closure of gastric full-thickness defect with metallic clips in a rabbit model / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the feasibility, efficacy, and safety of metallic clips for closure of full-thickness defects in the stomach wall.</p><p><b>METHODS</b>Forty-eight rabbits were randomly divided into 4 groups with 12 in each group using random digits table. A 2 cm×2 cm full-thickness defect was created in the gastric body. No closure was performed in the first group; in the second group, mucosa closure with metallic clips; the third group, closure of full-thickness gastric tissue with metallic clip; the fourth group closure with 3-0 silk suture. After operation the animals were sacrificed at the third day and the seventh day. Wound healing was evaluated. Bursting pressure was recorded. HE and Masson staining was performed to inspect wound inflammation and tissue fibrosis situation.</p><p><b>RESULTS</b>After operation all the animals in the first group died within 34 hours, while those in other groups survived. No intraperitoneal bleeding or infection were seen in the survived animals. General observation showed that the metallic closure group caused less intraperitoneal adhesions. Operative time was shorter in the second and third group compared to the fourth group [(45.8 ± 1.6) min and (42.5 ± 1.5) min vs. (48.0 ± 1.4) min, P<0.05]. The bursting pressure on the third day was lower [(36.9 ± 4.6) mm Hg and (39.8 ± 4.1) mm Hg vs. (50.5 ± 4.2) mm Hg, P<0.05]. There was no significant difference in bursting pressure on the 7th day among the three groups [(95.0 ± 7.9) mm Hg and (97.8 ± 6.8) mm Hg vs. (98.5 ± 7.0) mm Hg, P>0.05]. HE staining revealed that metal closure had a better healing and Masson staining reflected no significant difference in healing at the same time point.</p><p><b>CONCLUSIONS</b>Metal clips closure full-thickness defects in the stomach, regardless in full thickness or mucosa closure, is as safe and effective as suture closure.</p>

Endoscopic treatment of duodenal Brunner adenoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the value of endoscopic treatment for duodenal Brunner adenoma.</p><p><b>METHODS</b>Twenty-nine cases of duodenal Brunner adenoma were diagnosed by pathology between November 2006 and May 2010 in the Endoscopy Center of Zhongshan Hospital. The clinical data were retrospectively analyzed.</p><p><b>RESULTS</b>In 29 cases, there were 13 males and 16 females. The median age was 55(29-72) years. The mean adenoma diameter was (1.7 ± 0.1) cm, among which 17 adenomas ranged from 0.5 to 1.0 cm, 6 ranged from 1.0 to 2.0 cm, and 6 greater than 2.0 cm. Nine cases were treated by polypectomy, 12 by endoscopic mucosal resection (EMR), and 8 by endoscopic submucosal dissection(ESD). En-bloc resection rate was 100%. Intraoperative bleeding was seen in one case (200 ml), managed by nonsurgical method, including electrocoagulation, metal clips and nylon rope. Perforation occurred in 1 case during the procedure and was managed by metal clips. Delayed bleeding occurred in 1 case in the second day and was managed endoscopically. During a median follow-up of 13 (range, 2-39) months, the quality of life was satisfactory in this cohort, and no patients developed long-term complications. There was one recurrence within 1 year after the procedure and a second ESD was performed.</p><p><b>CONCLUSION</b>Endoscopic treatment is technically feasible and may be considered as the procedure of choice for duodenal Brunner adenoma.</p>

Study on relationship of the K-ras mutation with the occurrence of colorectal liver metastasis and survival outcomes / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To analyze the relationship of K-ras mutation with the development of liver metastasis in colorectal cancer patients and the survival outcomes.</p><p><b>METHODS</b>From 2003 to 2008, 300 patients who underwent colorectal cancer surgery in the Department of General Surgery of Zhongshan Hospital, Fudan University were assigned to different groups, according to the diagnosis and follow-up results. The mutation of exon 2 of K-ras was detected in primary paraffin-embedded lesions by PCR and Pyrosequencing. The association of gene mutation with the development of liver metastasis and its prognosis was studied.</p><p><b>RESULTS</b>Among 300 cases, the mutations of exon 2 were present in 120 cases(40%). The G13D mutation was more common in metachronous metastasis group than that in synchronous group(17.0% vs. 8.0%, P=0.041). Multivariable regression analysis showed that G13D mutation was an independent risk factor(HR=1.108, 95%CI:1.032-5.062, P=0.048) for metachronous metastasis. Patients with mutated K-ras had a poorer overall survival compared to those without mutated K-ras for patients without liver metastasis(median overall, 65 vs. 72 months, P=0.039), and for patients who received metastasis resection(median disease-free survival 18 vs. 24 months, P=0.048). Multivariable analysis showed that K-ras mutation was an independent risk factors of overall survival(HR=1.561, 95%CI:1.022-6.422, P=0.045) in patients without liver metastasis.</p><p><b>CONCLUSION</b>Detection of K-ras mutation may predict the development of liver metastasis and prognosis.</p>

Selection and evaluation of endoscopic resection for submucosal tumors of the esophagogastric junction originating from muscularis propria / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the clinical application and indication of endoscopic dissection technique for submucosal tumors (SMTs) of the esophagogastric junction (EGJ) originating from the muscularis propria.</p><p><b>METHODS</b>A total of 143 SMTs of the EGJ were treated by endoscopic resection in the Endoscopy Center of Zhongshan Hospital Affiliated to Fudan University between March 2007 and June 2011. The clinical and histopathologic feature, surgical approach, en bloc resection rate, complications, and postoperative follow up were evaluated.</p><p><b>RESULTS</b>There were 74 males and 69 females with a mean age of 49.1 years old. The en bloc resection rate was 94.4%(135/143). There were 126 patients who underwent endoscopic submucosal excavation in an en bloc fashion. Six patients underwent endoscopic full-thickness resection without laparoscopic assistance. Three patients underwent submucosal tunneling endoscopic resection. The other 8 SMTs were partially resected for histological evaluation and the residual tumors were further treated with nylon snare ligation. The mean lesion size was 17.6 mm. The mean procedure time was 45.1 minutes and the mean intraoperative bleeding was 50.0 ml. Perforations occurred in 6 patients and metal clips were used to close the defect. One patient with Mallory-Weiss syndrome was successfully treated with conservative treatment. Pathological examination showed that the lesions were leiomyoma (n=121), gastrointestinal stromal tumor (n=20), granulosa cell tumor (n=1), and intermuscular lipoma (n=1). No local recurrence and distant metastasis were noted during the follow-up (range, 3-48 months).</p><p><b>CONCLUSION</b>Endoscopic resection technique is safe and effective, and should be selected for each patient individually.</p>

Feasibility of endoscopic full-thickness resection in the treatment of colorectal submucosal tumors / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the feasibility and safety of endoscopic full-thickness resection(EFTR) in the treatment of colorectal submucosal tumor(SMT).</p><p><b>METHODS</b>From September 2009 to March 2012, 4 cases with colorectal SMT received EFTR at the Endoscopic Center in the Zhongshan Hospital of Fudan University. The operative time, complications, and follow-up data were analyzed.</p><p><b>RESULTS</b>There were 3 females and 1 male. The age ranged from 33 to 78 years. The tumor location included the upper rectum(n=2), the ascending colon(n=1), and the descending colon(n=1). The mean operative time was 48.0(24-80) min. The mean diameter was 1.45(0.8-2.0) cm. Postoperative pathological examination revealed schwannoma, pneumatosis cystoides intestinalis, endometriosis, and mild hyperplasia of smooth muscle in the muscularis mucosa. There was no bleeding or perforation intraoperatively and postoperatively. Two patients developed abdominal pain and fever, one of whom had regional peritonitis and was managed by fasting and intravenous antibiotics. No surgical intervention was required. Postoperative follow up ranged from 1 to 30 months and no residual cancer or recurrence was found.</p><p><b>CONCLUSION</b>EFTR is a safe and effective method for colorectal SMT.</p>

Value of endoscopic submucosal dissection for duodenal lesions in 78 patients / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To assess the clinical value of endoscopic submucosal dissection(ESD) for duodenal lesion.</p><p><b>METHODS</b>A total of 78 patients with duodenal lesion were treated with ESD from November 2006 to August 2010. The clinical data were retrospectively analyzed.</p><p><b>RESULTS</b>There were 46 male and 14 female patients. The mean age was(54±9) years. The lesion location included the duodenal bulb(n=39, 50%), the junction of bulb and descending part(n=19, 24.4%), and the descending part(n=20, 25.8%). The mean diameter of the lesions was(2.1±1.7) cm. Fifty-one(65.4%) lesions originated from the mucosa, including inflammatory/ hyperplastic polyps(n=22, 28.2%), villous/tubular adenoma(n=26, 33.3%), and hamartomas polyps(n=3, 3.8%). Twenty-five(32.1%) lesions originated from the submucosa, including Brunner's glands adenoma(n=15, 19.2%), ectopic pancreas(n=3, 3.8%), carcinoid tumor(n=3, 3.8%), lipoma(n=2, 2.6%), myxoinoma(n=1, 1.3%), and angio-lymphangioma(n=1, 1.3%). There were two lesions originated from the muscularis propria(n=2, 2.5%), and both were ectopic pancreas. All cases received ESD successfully. The mean operative time was(37±41) min and the mean blood loss was(23±15) ml. The perioperative complication rate was 35.9%(28/78), including intraoperative perforation(n=6), delayed perforation(n=3), intraoperative hemorrhage(n=10), delayed bleeding(n=7), and transient elevation of serum amylase(n=2). Postoperative pathological examination showed vascular invasion with tumor cells in one patient, who received extended resection later. The remaining 77 patients showed no recurrence during the followed up(rang, 3-23 months) using endoscopy.</p><p><b>CONCLUSION</b>ESD is an effective, safe, minimally invasive method for the management of duodenal lesions.</p>

Application and evaluation of submucosal tunneling endoscopic resection of gastric submucosal tumors originating from the muscularis propria layer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the clinical value of submucosal tunneling endoscopic resection(STER) for gastric submucosal tumor(SMT) originating from the muscularis propria (MP) layer.</p><p><b>METHODS</b>Clinicopathological data of 23 cases with gastric SMT originating from the MP layer treated with STER from September 2010 to December 2011 were analyzed retrospectively.</p><p><b>RESULTS</b>There were 13 males and 10 females. The age ranged from 28 to 73(mean, 52.4) years old. Of the 23 SMTs, 11 were located in the cardia adjacent to the gastric body, 4 in the cardia adjacent to the fundus, 5 in the lesser curvature of gastric body and 3 in the gastric antrum of greater curvature. All the SMTs originating from the MP layer, 14 were located in the superficial MP layer and 9 in the deep MP layer(including 5 gastric SMTs close to serosa). En bloc STER was performed successfully in all the patients. The mean lesion size was 2.1 cm(range 1.5-3.2 cm). The mean procedure time was 54.8 min(range 30-125 min). Pathological examination showed that the lesions were leiomyomas(n=10), stromal tumors(n=8), glomus tumor(n=2), Schwannoma(n=2), and calcifying fibrous tumor(n=1). Both lateral and vertical margins were negative in all the cases. Three patients developed pneumothorax and subcutaneous emphysema and 5 pneumoperitoneum. One patient developed effusion under the left half of the diaphragm and secondary infection. All of them recovered uneventfully after conservative treatments. No delayed bleeding or GI tract leakage was noticed. None of the 23 cases encountered submucosal hematoma or infection. No tumor residual or recurrence was found during the follow up(range, 3-18 months).</p><p><b>CONCLUSIONS</b>STER is a safe, effective for appropriate lesions in the MP layer of the stomach. En bloc resection and accurate histopathological evaluations can be achieved.</p>

Effects of peroral endoscopic myotomy on esophageal dynamics in patients with esophageal achalasia / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the effects of peroral endoscopic myotomy(POEM) on esophageal dynamics in patients with esophageal achalasia.</p><p><b>METHODS</b>From September 2011 to November 2011, 20 cases with esophageal achalasia received POEM at the Endoscopic Center in the Zhongshan Hospital of Fudan University. Pre-operation esophageal dynamics of all the patients were evaluated by high resolution manometry(HRM) system and 3 days after operation the test was repeated. Lower esophagus sphincter resting pressure(LESP), 4-second integrated relaxation pressure(4sIRP), lower esophagus sphincter relax rate(LESRR), lower esophagus sphincter length(LESL), and esophageal manometry were analyzed.</p><p><b>RESULTS</b>After POEM, LESP decreased from(29.1±17.0) mm Hg to(14.6±4.9) mm Hg, and decrease rate was 49.8%(P<0.01). However, the decreases in LESRR and LESL were not statistically significant(P>0.05). Esophageal peristaltic contraction was absent in all the 20 patients preoperatively. After POEM, changes in the esophageal contraction were seen in 7 patients, and peristalsis was noticed but was below normal level. There were no significant changes in peristalsis in the remaining 13 patients.</p><p><b>CONCLUSION</b>POEM can significantly reduce LESP and 4sIRP in patients with achalasia, but can not affect the contraction of the esophagus.</p>

Clinical value of different magnifying chromoendoscopy methods in screening gastric precancerous lesions and early cancers / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To prospectively evaluate the clinical value of different magnifying chromoendoscopy(MCE) methods in screening gastric precancerous lesions and early cancers.</p><p><b>METHODS</b>Between March 2010 and October 2011, among all the patients aged over 40 who received esophagogastroduodenoscopy at Zhongshan hospital, Fudan University, suspicious lesion was detected in 699 patients, who were randomly assigned to three groups: epinephrine dye(n=240), indigo carmine dye(n=246), and acetic acid-indigo carmine mixture dye(n=213). Diagnosis was made according to surface patterns and microvessels of the lesion. Pathological diagnosis was used as the gold standard. The concordance between endoscopic diagnosis and pathological diagnosis was evaluated through the agreement(Kappa) test. McNemar Paired chi-square test was used to compare the concordance of three MCE methods, regular white light, magnification alone, and NBI magnifier before and after MCE.</p><p><b>RESULTS</b>Pathological examination showed inflammatory lesions in 415 patients, intestinal metaplasia in 190, low grade intra-epithelial neoplasia in 17, and high grade intra-epithelial neoplasia or early cancer in 77. The percentage of patients with consistent endoscopic and pathological diagnosis was 77.1%(185/240) for epinephrine dye, 80.5%(198/246) for indigo carmine dye, and 81.2%(173/213) for acetic acid-indigo carmine mixture dye. Kappa values were 0.579, 0.502, and 0.667 respectively(all P<0.01). For the screening of high grade intra-epithelial neoplasia or early cancer, the diagnostic sensitivities were 84.0%, 83.3%, and 92.9%, respectively, and the specificities were 98.6%, 97.3%, and 98.4%. All the three chromoendoscopy methods improved the diagnostic accuracy for precancerous lesions compared with conventional gastroscopic observation with white light(all P<0.01). Indigo carmine and acid-indigo carmine mixture dye improved the diagnostic accuracy of magnification alone(both P<0.05). There was no significant difference in diagnostic accuracy between each MCE method and magnifying NBI observation(all P>0.05).</p><p><b>CONCLUSION</b>NBI magnification and all the three MCE methods may improve the diagnostic accuracy of early gastric cancer and precancerous lesions.</p>

Application of enhanced recovery program after surgery(ERAS) in patients undergoing radical resection for colorectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the enhanced recovery program after surgery (ERAS) with conventional perioperative management in patients undergoing radical resection for colorectal cancer.</p><p><b>METHODS</b>The ERAS protocol included a combination of evidence-based and consensus methodology. A total of 597 consecutive patients undergoing elective colorectal resection were randomized to either the ERAS(n=299) or the control group(n=298). Outcomes related to nutrition and metabolism index, stress index, and recovery index were measured and recorded.</p><p><b>RESULTS</b>Demographics and operative parameters were similar between the two groups(P>0.05). The nutritional status of patients in the ERAS group was improved after surgery compared with that of the control group. On postoperative day (POD) 1, the HOMA-IR in the ERAS group was significantly lower than that in the control group(P<0.01). The cortisol level in the control group was elevated on both POD 1(P<0.01) and POD 5(P<0.01) compared to the preoperative level. However, the cortisol level was not increased until POD 5(P<0.01) in the ERAS group. The levels of TNF-α, IL-1β, IL-6, and IFN-γ were reduced in the ERAS group, indicating less postoperative stress responses compared with the control group. In addition, ERAS group was associated with accelerated recovery of gastrointestinal function. The postoperative length of stay [(5.7±1.6) d vs. (6.6±2.4) d, P<0.01] and expense[(15 998±2655) RMB vs. (17 763±3059) RMB, P<0.01] were reduced in the ERAS group. Twenty-eight patients(9.4%) in the control group and 29(9.7%) in the ERAS group developed complications, while the difference was not statistically significant(P>0.05).</p><p><b>CONCLUSION</b>ERAS protocol alleviates surgical stress response and accelerates postoperative recovery without compromising patient safety.</p>