Endosonographic Characteristics of Subepithelial Lesions of the Upper Digestive Tract: Experience of a Referral Center in Colombia

Introduction: Subepithelial lesions (SELs), described as bulges or masses covered by healthy-looking mucosa, are usually found incidentally during endoscopic studies. They are typically asymptomatic and are estimated to be identified in 1% of esophagogastroduodenoscopies performed. Materials and methods: A descriptive study was conducted with retrospective data collection. We included all patients treated at the Unión de Cirujanos, a referral gastroenterology unit of the Coffee Region in Manizales, between January 2020 and January 2022, who underwent endoscopic ultrasonography to study subepithelial-looking lesions located in the esophagus, stomach, and duodenum. Results: 152 endoscopic ultrasounds were performed, finding 108 SELs; 66.6% of the patients were women, and the average age was 58. Most SELs were located in the stomach (78.7%), the antrum being the most frequent location. The average diameter of the gastric SELs was 14.6 mm, and 47% of the lesions depended on the fourth echolayer; the most frequent presumptive diagnoses were gastrointestinal stromal tumor (GIST; 65.8%) and lipoma (11.7%). Conclusions: SELs of the GI tract originate in the muscularis mucosae, submucosa, or muscularis propria. They are most frequently located in the stomach, and their characterization usually requires endoscopic ultrasonography and histopathology. Treatment of these lesions remains controversial due to their low frequency, histological variety, and low malignant potential.

Introducción: las lesiones subepiteliales (LSE), descritas como abultamientos o masas cubiertas por mucosa de aspecto sano, se encuentran usualmente de manera incidental durante estudios endoscópicos; suelen ser asintomáticas y se estima que se identifican en el 1% de las esofagogastroduodenoscopias realizadas. Métodos: se realizó un estudio descriptivo con recolección retrospectiva de la información. Se incluyeron todos los pacientes atendidos en Unión de Cirujanos, unidad de gastroenterología de referencia del Eje Cafetero ubicada en la ciudad de Manizales, entre enero de 2020 y enero de 2022, a quienes se les realizó ultrasonografía endoscópica como parte del estudio de lesiones de aspecto subepitelial localizadas en el esófago, estómago y duodeno. Resultados: se realizaron 152 endosonografías y se encontraron 108 lesiones subepiteliales, 66,6% de los pacientes eran mujeres y el promedio de edad fue 58 años. La mayoría de las LSE se localizaron en el estómago (78,7%) y, de estas, la localización más frecuente fue el antro; el diámetro promedio de las LSE gástricas fue de 14,6 mm y el 47% de las lesiones eran dependientes de la cuarta ecocapa; los diagnósticos presuntivos más frecuentes fueron el tumor del estroma gastrointestinal (GIST; 65,8%) y lipoma (11,7%). Conclusiones: las LSE del tracto gastrointestinal se originan en la muscular de la mucosa, submucosa o muscular propia, de manera más frecuente se localizan en el estómago y su caracterización suele requerir la realización de ultrasonografía endoscópica y estudio histopatológico. El tratamiento de estas lesiones sigue siendo controversial debido a su baja frecuencia, variedad histológica y bajo potencial maligno.

Application of soft tissue augmentation in labial contour aesthetics of anterior dental implants / 口腔疾病防治

@#After tooth extraction, labial contour collapses due to inevitable physiologic bone remodeling. To achieve optimal outcomes for pink esthetic treatment at anterior implant sites, bone or soft tissue augmentation has been advocated to maintain or reconstruct the labial tissue contour. When choosing soft tissue augmentation for esthetic restoration, it is necessary to strictly grasp the indications for surgery. Soft tissue augmentation to maintain or reconstruct the labial tissue contour could be considered in patients with healthy soft tissue and no bone defects or only mild horizontal bone defects. In immediate, early and late implant placement, the timing of soft tissue augmentation may vary. In immediate implantation, the labial bone plate is intact, so it is highly recommended to simultaneously manage soft tissue during implant placement. However, patients may have large bone defects with early or late implant placement. The risk of augmenting bone and soft tissue simultaneously is likely too high, and bone augmentation surgery is often performed at the first stage while soft tissue augmentation surgery is performed at the second stage. Therefore, soft tissue surgery is often carried out simultaneously with abutment connection. Currently, soft tissue augmentation is achieved mostly with adjacent autologous soft tissue grafts, such as free gingival grafts, subepithelial connective tissue grafts or pedicle palatal flaps, which are often accompanied by a second surgical area. The replacement of autogenous soft tissue grafting with new biological materials will become an inevitable trend. In this article, we analyze and summarize the indications, timing and different methods of soft tissue augmentation to maintain and reconstruct the labial contour.

Coverage Of Multiple Maxillary Gingival Recessions Using Coronally Advanced Flap With Subepithelial Connective Tissue Graft: A Case Report

Background:This case report describes treatment of multiple gingival recession with subgingival connective tissue graft and coronally advanced flap technique in treatment of maxillary teeth. Material And Methods:Connective tissue grafting wasdone in relation to upper right second premolar, first premolar, canine, right central incisor, left central incisor and left lateral incisor (#15,#14,#13,#11,#21,#22). A split thickness flap was elevated without disturbing periosteum in this region. The area between canine and second premolar was selected to harvest the graft. The graft was placed on the recipient bed and suturing was done. Result:Predictable root surface coverage could be obtained with use of coronally advanced flap and subepithelial connective tissue graft. Conclusion:Subepithelial connective tissue graft along with coronally advanced flap still stand as a gold standard treatment for gingival recession coverage.

Lésion d'Antopol-Goldman (Antopol-Goldman lesion): Spontaneous renal pelvic subepithelial hematoma

Lésion d'Antopol-Goldman (Antopol-Goldman lesion) is a rare condition characterized by renal pelvic subepithelial hematoma simulating a neoplastic process. A 71-year-old lady presented with macroscopic hematuria and hypoenhancing mass lesion at the upper pole of left kidney. The patient underwent a radical nephrectomy for suspected renal cell carcinoma. Macroscopically a 3.5cm circumscribed hemorrhagic mass lesion was noted flush with the upper pole pelvicalyceal system. Microscopic examination revealed a pelvic subepithelial (suburothelial) organizing hematoma. Extensive sampling did not reveal any neoplastic etiology. The adjacent renal parenchyma and renal vessels were unremarkable. Antopol-Goldman lesion is a diagnostic quagmire, often culminating in unnecessary nephrectomy. This is a rare entity, and clinical awareness as a differential of renal filling defect can preclude a nephrectomy, we hereby discuss its clinico-pathological and treatment implications.

Resultados refractivos y visuales en cirugía fotoablativa en pacientes miopes / Refractive and visual results in photoablative surgery in myope patients

Objetivo: Evaluar los resultados refractivos y visuales post cirugía refractiva corneal con láser de excímero (LASEK-MMC o PRK-MMC) en pacientes miopes con o sin astigmatismo asociado. Método: Se realizó un estudio preexperimental del tipo antes y después, en el que fueron incluidos 81 pacientes (162 ojos) tratados con LASEK-MMC (65 pacientes) o PRK-MMC (16 pacientes) seguidos por tres meses. Se les realizó un examen oftalmológico completo y se evaluaron las variables: edad, sexo, diagnóstico y tipo de miopía, así como agudeza visual, esfera, cilindro, equivalente esférico precirugía y poscirugía. Además, se analizó la función visual y los resultados de la refracción. Resultados: El valor de la mediana de edad fue de 24,0 años en los pacientes tratados con LASEK-MMC y en el grupo con PRK-MMC fue de 23,0 años. En ambos grupos existió un predominio del sexo femenino. La totalidad de los pacientes tratados presentaba un astigmatismo miópico compuesto con niveles de miopía leve. A los tres meses el 96,9 por ciento de los pacientes tratados con LASEK-MMC y el 93,8 por ciento de los tratados con PRK-MMC tenían una agudeza visual no corregida de 20/20 o más y todos tenían una visión de 20/40 o más. Conclusiones: La cirugía fotoablativa con láser tiene buenos resultados refractivos y visuales ya que la mayoría de los pacientes quedaron emétropes con una marcada mejoría de la agudeza visual sin corrección y de la refracción en el posoperatorio(AU)

Objective: To evaluate refractive and visual outcomes after excimer laser corneal refractive surgery (laser-assisted subepithelial keratectomy [LASEK] or photorefractive keratectomy [PRK], with intraoperative application of mitomycin-C [MMC]) in myopic patients with or without associated astigmatism. Methods: A preexperimental, before-and-after study was carried out with 81 patients (162 eyes) treated with LASEK-MMC (65 patients) or PRK-MMC (16 patients) and followed for three months. A complete ophthalmologic examination was done and the following variables age, sex, diagnosis and type of myopia were assessed, as well as pre-surgery and post-surgery visual acuity, sphere, cylinder and spherical equivalent. In addition, visual function and the refraction results were analyzed. Results: The median age was 24.0 years in the LASEK-MMC group and 23.0 years in the PRK-MMC group. In both groups there was a predominance of the female sex. All treated patients had compound myopic astigmatism with mild myopia. At three months, 96.9 percent of patients treated with LASEK-MMC and 93.8 percent of patients treated with PRK-MMC had uncorrected visual acuity of 20/20 or better, and all had vision of 20/40 or better. Conclusions: Laser photoablative surgery has good refractive and visual outcomes as most patients became emmetropic with marked improvement in uncorrected visual acuity and refraction postoperatively(AU)

Risk factors for complications of therapeutic endoscopy for upper gastrointestinal subepithelial lesions / 中南大学学报(医学版)

OBJECTIVES@#To study the risk factors for complications after endoscopic therapy for upper gastrointestinal subepithelial lesions (SELs).@*METHODS@#Retrospective analysis was performed on 184 patients in the Department of Gastroenterology in the Third Xiangya Hospital, Central South University after therapeutic endoscopy [endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFR), endoscopic submucosal excavation (ESE), and submucosal tunneling endoscopic resection (STER)] for the upper gastrointestinal SELs from 2014-09-01 to 2019-09-30. The clinic data were collected and risk factors for postoperative complications were analyzed.@*RESULTS@#Among the 184 patients, 22 patients were in the complication group (including 3 cases of delayed bleeding, 2 cases of delayed perforation, and 17 cases of electrocoagulation syndrome) and 162 patients were in the non-complication group. There was no significant difference between the complication group and the non-complication group in gender, age over 70 year, basic diseases, lesion location, lesion invasion layers, pathological results, endoscopic therapy, and preventive closure of wounds (all @*CONCLUSIONS@#For the patients with upper gastrointestinal SELs after endoscopic minimally invasive therapy with the lesion diameter over 40 mm and the operative time over 120 minutes, it needs to highly alert to the occurrence of postoperative complications.

Prevalencia, características endoscópicas y manejo de las lesiones subepiteliales del tracto gastrointestinal superior / Prevalence, endoscopic characteristics and management of subepitelial lesions of the upper gastrointestinal tract / Prevalência, características endoscópicas e manejo das lesões subepiteliais do trato gastrointestinal superior

Introducción: Las lesiones subepiteliales (LSE) son hallazgos incidentales en las endoscopias. Algunas tienen potencial maligno. Objetivos: Valorar la prevalencia, características endoscópicas y manejo diagnóstico/terapéutico de LSE en video-gastroscopias (VGC). Materiales y métodos: Se incluyeron todas las VGC del periodo enero 2011-junio 2018. Los casos con datos faltantes fueron excluidos. Donde se identificó una LSE se consignó: indicación, edad, sexo, tamaño, ubicación e histología, hallazgos de la ultrasonografía endoscópica (USE), punción-aspiración con aguja fina (PAAF) y resección quirúrgica. Resultados: Se evidenciaron 54 LSE en 7.983 pacientes (0,7 %). 72 % eran mujeres y la indicación más común fue dispepsia (26 %). La localización más frecuente fue en el estómago (74 %). El tamaño medio fue de 16 mm (5-50 mm) y la mitad fueron menores a 10 mm. Siete presentaban mucosa ulcerada, 4 se ubicaban en el cuerpo gástrico y 86 % eran referidos por hemorragia digestiva/anemia. En 26 casos de 54 (48 %) se realizaron biopsias estándar y en 6 de los 54 (11 %) biopsias sobre biopsias, con rendimiento diagnóstico nulo. En un 11 % de ellos se realizó USE, todas mayores de 10 mm: 2 páncreas ectópicos, una lesión compatible con leiomioma, 2 lesiones de la muscular propia (leiomioma/GIST) y 1 compresión extrínseca. No se realizó ninguna PAAF. Todas las LSE fueron manejadas de forma conservadora. Conclusiones: Este es el primer estudio nacional sobre prevalencia de LSE del tracto gastrointestinal superior y resultó comparable al de otras series. El rendimiento diagnóstico de la biopsia fue nulo. En la mayoría de los casos las lesiones se manejaron según las recomendaciones de las guías internacionales.

Introduction: Subepithelial lesions (SELs) are incidental findings in endoscopy procedures. Most are benign, but some have malignant potential. Objectives: To evaluate the prevalence, endoscopic characteristics and diagnostic / therapeutic management of SELs in upper GI endoscopy. Materials and methods: All upper GI endoscopy from January 2011 to June 2018 were included. Cases with missing data were excluded. Indication, age, sex, size, location and histology, findings of endoscopic ultrasound (EUS), fine needle aspiration (FNA) and surgical resection were recorded in patients with SELs. Results: There were 54 SELs in 7983 patients (0.7 %). 72 % were women, and the most frequent indication was dyspepsia (26 %). The most frequent location was stomach (74 %). The average size was 16 mm (5-50 mm), half were less than 10 mm. Seven had ulcerated mucosa, 4 were located in the gastric body and 86 % were referred for digestive hemorrhage/anemia. In 26 of 54 (48 %) standard biopsies and in 6 of 54 (11 %) bite-on-bite biopsy were performed, with no diagnostic yield. In 11 % of the cases EUS was performed, all of them larger than 10 mm: 2 ectopic pancreas, one lesion compatible with leiomyoma, 2 lesions of the muscularis propria (leiomyoma/GIST) and 1 extrinsic compression. No FNA was performed. All SELs were managed conservatively. Conclusions: This is the first national study of the prevalence of SELs in the upper gastrointestinal tract and was comparable to that of other series. Biopsy diagnostic yield was zero. In most cases, lesions were managed according to international guidelines.

Introdução: lesões subepiteliais (LSE) são achadas incidentais em endoscopias. A maioria são benignas, mas algumas têm potencial maligno. Objetivos: Avaliar a prevalência, características endoscópicas e manejo diagnóstico/terapêutico das LSE em vídeo-gastroscopias (VGC). Materiais e métodos: Foram incluídos todas VGC do período de janeiro de 2011 a junho de 2018. Foram excluídos os casos com dados ausentes. Quando uma LSE foi identificada, foram indagados: indicação, idade, sexo, tamanho, localização e histologia, achados da ultrassonografia endoscópica (USE), aspiração por agulha fina (PAAF) e ressecção cirúrgica. Resultados: 54 LSE foram evidenciadas em 7.983 pacientes (0,7 %). 72 % eram mulheres e a indicação mais freqüente foi dispepsia (26 %). A localização mais freqüente foi estômago (74 %). O tamanho médio era de 16 mm (5-50 mm), a metade era menor que 10 mm. Sete tinham mucosa ulcerada, quatro estavam localizadas no corpo gástrico e 86% foram referidos por sangramento/anemia gastrointestinal. Em 26 de 54 (48 %) foram realizadas biópsias padrão e em 6 de 54 (11 %) biópsias sobre biópsias, com um desempenho diagnóstico nulo. Em 11 %, foi realizado uma USE, todas maiores que 10 mm: 2 pâncreas ectópico , uma lesão compatível com leiomioma, 2 lesões musculares (leiomioma/GIST) e 1 compressão extrínseca. Não foi realizada nenhuma PAAF. Todas as LSE foram manejadas de forma conservadora. Conclusões: Este é o primeiro estudo nacional de prevalência de LSE no trato gastrointestinal superior e foi comparável ao de outras séries. O rendimento diagnóstico da biópsia foi nulo. Na maioria dos casos, as lesões foram tratadas de acordo com as recomendações das diretrizes internacionais.

Clinical observation on removing or reserving the epithelial flap in high myopia correction by LASEK / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:To compare the clinical effects of removing or reserving the epithelial flap in high myopia correction by laser subepithelial keratomileusis(LASEK). <p>METHODS: Retrospective analysis of 58 patients(115 eyes)with high myopia received LASEK were selected and divided into reserving the epithelial flap group(30 patients, 59 eyes)and removing epithelial flap group(28 patients, 56 eyes)according to the order of the alternating vists. The changes of corneal irritation, epithelial healing time,uncorrected visual acuity and the occurrence of haze after surgery were observed.<p>RESULTS:Postoperative 1d, 2d, 3d, respectively, the pain score of the two groups were 1.64±0.64, 1.57±0.57; 0.83±0.49, 0.84±0.56; 0.36±0.48, 0.34±0.47, respectively, the differences were not significant(<i>P</i>>0.05). Postoperative 1wk, 1mo, 3mo, respectively, the uncorrected visual acuity of two group was 0.15±0.06, 0.12±0.05; 0.032±0.004, 0.041±0.003; 0.018±0.004, 0.022±0.005, and the differences were not significant(<i>P</i>>0.05). After 1mo, 3mo of surgery, the differences of the haze less than grade one of the two group, respectively, and were not significant(<i>P</i>>0.05), the differences of the haze of grade two of the two groups, respectively, and the differences were significant(<i>P</i><0.05). The epithelial healing time of the two groups were 4.22±0.30d, 3.89±0.32d(<i>P</i><0.05). The number of epithelial delayed healing of two groups was 0 eye and 10 eyes(<i>P</i><0.05).<p>CONCLUSION:It was similar both the changes of corneal irritation and uncorrected visual acuity of two groups,the rate of level two haze was higher in removing epithelial flap group. The time of healing of epithelium was quick than reserving the epithelial flap group,but the rate of delayed healing and poor healing of epithelium was higher than reserving the epithelial flap group. Therefore, for high myopia, it is worthy of clinical application of reserving the epithelial flap by LASEK.

Páncreas ectópico, diagnóstico diferencial de lesión gástrica subepitelial: reporte de caso y enfrentamiento inicial / Ectopic pancreas, differential diagnosis of subepithelial gastric lesion: case report and initial confrontation

Subepithelial lesions are generally an incidental diagnosis with an prevalence of 0.4%. These tumors represent a great diagnostic challenge, mainly when ruling out potentially malignant lesions, such as gastrointestinal stromal tumor (GIST), lymphomas and carcinomas. Among the many differential diagnosis, the ectopic pancreas arises with an prevalence of 1-2% in general population. The first diagnostic approach is performed using upper digestive endoscopy, computed tomography and endosonography. This last one has a diagnostic performance of less than 50%, which increases to 90% when it is associated with a histopathological examination. There is no current consensus regarding the management and monitoring of these lesions. Based on the imaging and histological characteristics, the possibilities range from observation to endoscopic or surgical resection. In this context, we will present a clinical case of ectopic pancreas as an incidental finding, and afterwards the diagnostic and therapeutic breakdown of subepithelial lesions.

Las lesiones subepiteliales son pesquisadas generalmente de manera incidental, con una prevalencia de 0,4%. Estos tumores suponen un gran desafío diagnóstico, principalmente al momento de descartar lesiones potencialmente malignas, como el tumor estromal gastrointestinal (GIST), linfomas y carcinomas. Dentro de los posibles diagnósticos, surge el páncreas ectópico, con una prevalencia de hasta 1-2% en la población general. La primera aproximación diagnóstica se realiza mediante endoscopia digestiva alta, tomografía computarizada y la endosonografía, ésta última con un rendimiento diagnóstico menor del 50%, que aumenta hasta el 90% al asociar el examen histopatológico. No existe consenso actual respecto al manejo y seguimiento de estas lesiones, que según sus características imagenológicas e histológicas, va desde la observación hasta la resección endoscópica o quirúrgica. En este contexto, se presenta un caso clínico de páncreas ectópico como hallazgo incidental y el desglose diagnóstico y terapéutico de las lesiones subepiteliales.

LASEK-mitomicina C versus PRK-mitomicina C en pacientes con miopía o astigmatismo miópico compuesto / LASEK-mitomycin C versus PRK-mitomycin C in patients with myopia or compound myopic astigmatism

RESUMEN Objetivo: Evaluar los resultados relacionados con la efectividad y la seguridad en el tratamiento con queratectomía subepitelial asistida por láser con mitomicina C versus queratectomía fotorreactiva con mitomicina C en ojos con miopía o astigmatismo miópico compuesto. Métodos: Se realizó un estudio experimental, longitudinal y prospectivo en el Instituto Cubano de Oftalmología Ramón Pando Ferrer entre abril del año 2016 y abril de 2017. Se empleó un muestreo aleatorio simple por el cual se obtuvo la técnica quirúrgica a realizar. El primer ojo operado fue el derecho y a la semana se realizó la cirugía en el ojo izquierdo, en el cual se aplicó la otra técnica quirúrgica. Esto permitió realizar en cada paciente ambas técnicas quirúrgicas. La muestra quedó constituida por 146 ojos (73 pacientes) que cumplían con los criterios de selección. Resultados: El comportamiento preoperatorio entre los dos grupos fue muy similar. En ninguno de los casos existieron diferencias en las variables que se evaluaron (agudeza visual sin corrección, agudeza visual mejor corregida, esfera, cilindro y equivalente esférico). La diferencia entre los valores preoperatorios y los encontrados a los 6 meses del tratamiento quirúrgico en cada grupo fueron estadísticamente significativos (p= 0,000) para todas las variables analizadas, excepto para la agudeza visual mejor corregida en el grupo de ojos tratados con láser con mitomicina C (p= 0,083). El haze y el defecto de epitelización fueron los dos tipos de complicaciones observadas. Conclusiones: Se demostró que ambas técnicas quirúrgicas son efectivas y seguras(AU)

ABSTRACT Objective: Evaluate the effectiveness and safety of laser-assisted subepithelial keratectomy with mitomycin C vs. photoreactive keratectomy with mitomycin C in eyes with myopia or compound myopic astigmatism. Methods: An experimental prospective longitudinal study was conducted at Ramón Pando Ferrer Cuban Institute of Ophthalmology from April 2016 to April 2017. Simple random sampling was used to decide on the surgical technique to be applied. Surgery was first performed on the right eye using one of the techniques, and then one week later on the left eye with the other technique. That way each patient could undergo both surgical techniques. The sample was composed of 146 eyes (73 patients) meeting the inclusion criteria. Results: Preoperative behavior was very similar in the two groups. In neither case were differences found in the variables analyzed (uncorrected visual acuity, best corrected visual acuity, sphere, cylinder and spherical equivalent). The differences between preoperative values and those found six months after surgery in each group were statistically significant for all the variables analyzed (p= 0.000), except for best corrected visual acuity in the group of eyes treated with laser with mitomycin C (p= 0.083). Haze and epithelization defect were the two types of complications observed. Conclusions: It was demonstrated that both surgical techniques are effective and safe(AU)

Comparison of the safety and efficacy of topical Tacrolimus (0.03%) versus dexamethasone (0.05%) for subepithelial infiltrates after adenoviral conjunctivitis

Purpose: To compare the safety and efficacy of tacrolimus 0.03% ointment with dexamethasone 0.05% ointment for subepithelial infiltrates (SEIs) following adenoviral keratoconjunctivitis (AK). Methods: A randomized, double blind trial was done. Eligibility criteria was corrected distance visual acuity of 6/9 Snellen or worse for at least 4 weeks with corneal SEIs following AK. The grading of SEIs was done on a scale of 0 to 3; 0, no infiltrates, 1 mild infiltration, 2 moderate infiltration and 3, severe infiltration. Consecutive patients with SEIs following AK were randomized to receive either topical tacrolimus 0.03% or dexamethasone 0.05% ointment twice daily for 6 months. Treatment was successful if there was reduction of SEIs and improvement in vision. Results: A total of 45 patients each were assigned to the Tacro and Dexa groups, respectively. Baseline characteristics of patients did not differ significantly (P > 0.001). There was a significant change in symptoms, vision and SEIs in both the groups. However, the magnitude was greater in tacro group. Treatment was successful in 37 (92.5%) patients in Tacro and 34 (85%) patients in dexa group. In dexa group, after a period of 1.24 ± 0.24 months, 7 (15.6%) patients developed a significant rise in intraocular pressure (IOP). Three (7.5%) eyes in tacro and 6 (15%) eyes in dexa group had recurrence of SEIs after cessation of therapy. Conclusion: Tacrolimus 0.03% is an effective alternative to dexamethasone 0.05% with low recurrence rate, no significant rise in IOP but may cause burning and foreign body sensation in some patients.

Current Status of Endoscopic Ultrasonography in Gastrointestinal Subepithelial Tumors

Gastrointestinal subepithelial tumors (GSTs) are usually detected incidentally on endoscopic or radiologic examinations. In conventional endoscopy, a GST usually presents as a protuberant lesion with an intact mucosal surface. As the lesion is located beneath the mucosal layer of the gastrointestinal tract, conventional biopsy typically does not reveal the pathologic diagnosis. First, a GST should be differentiated from an extrinsic compression through the positional change of the patient during conventional endoscopic examination. In cases of GSTs originating from the gastrointestinal wall, endoscopic ultrasonography (EUS) can be beneficial for narrowing the differential diagnosis through delineation of echo findings and by determining the layer of origin. EUS findings can also help determine the management strategies for GSTs by making a differential diagnosis according to malignant potential.

Contrast Enhanced Endoscopic Ultrasound Imaging for Gastrointestinal Subepithelial Tumors

Subepithelial tumors are divided into benign subepithelial and potentially malignant gastrointestinal stromal tumors. It is difficult to distinguish between these tumor types. Contrast-enhanced harmonic endoscopic ultrasound is reportedly useful for diagnosing subepithelial tumors, can be safely and easily performed by understanding the principle and method, and can be used to distinguish between tumor types with high sensitivity on the basis of differences in contrast effect. The generated image shows a hyper-enhancement pattern in gastrointestinal stromal tumors (sensitivity, 78%–100%; specificity, 60%–100%; accuracy, 60%–100%) and hypo-enhancement pattern in benign subepithelial tumors. Contrast-enhanced harmonic endoscopic ultrasound can be used to estimate the malignancy potential of gastrointestinal stromal tumors by evaluating the uniformity of the contrast and the blood vessels inside the tumor, with abnormal intra-tumor blood vessels, heterogeneous enhancement, and non-enhancing spots suggesting malignancy. Contrast-enhanced harmonic endoscopic ultrasound has a higher sensitivity than other imaging modalities for the detection of vascularity within gastrointestinal stromal tumors. Additionally, it has been reported that treatment effects can be estimated by evaluating the blood flow in the gastrointestinal stromal tumor before and after treatment with tyrosine kinase inhibitors using contrast-enhanced ultrasound. However, there will be subjective-bias and the results depends on the performer’s skill.

Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy in Gastrointestinal Subepithelial Tumors

The incidence of asymptomatic and incidentally found upper gastrointestinal subepithelial tumors (SETs) is increasing with the implementation of national cancer screening and the development of high-resolution endoscopy in Korea. However, endoscopy alone cannot be used to determine whether SETs are benign or malignant. Endoscopic ultrasound (EUS) is used to further characterize these lesions through the examination of their layered structure, internal echogenicity, size, and relationship to the extramural structure. These provide additional information on whether the lesion is benign or malignant. Nevertheless, the sensitivity and specificity of EUS alone in predicting malignancy is unsatisfactory. Recent guidelines have recommended deciding the timing of EUS-fine needle aspiration and biopsy (EUS-FNA/B) for SETs based on tumor size, malignant features on endoscopy, and high-risk features on EUS. The diagnostic accuracy of EUS-FNA/B is reportedly influenced by factors including needle size, number of needle passes, use of suction, use of a stylet in the needle assembly, fanning technique, availability of an on-site cytopathologist, and experience of the endosonographer. Therefore, according to the characteristics of the SETs, various subsequent methods and techniques should be appropriately employed to improve the diagnostic yield of EUS-FNA/B.

Laparoscopic Treatment of Gastric Subepithelial Tumor: Finding Ways to Manage with Shorter Hospitalization Days

PURPOSE: The standard treatment for gastric subepithelial tumor (SET) is surgical resection, which is primarily performed via laparoscopy. The aims of this study were firstly to evaluate factors influencing morbidity and hospitalization after treatment of gastric SET, and secondly, to figure out the factors how to make shorter hospitalization with equal safety. METHODS: We retrospectively enrolled 229 consecutive patients who underwent laparoscopic gastric wedge resection (LGWR) for gastric SET between August 2003 and December 2015. Patients were divided into two groups: the 3 days or less hospitalization group (N=82, group A) and the greater than 3 days hospitalization group (N=147, group B). RESULTS: Median tumor size was 3.0 cm (range, 0.2~13.0 cm) and mean postoperative hospitalization was 4.27±2.15 days. There were 6 complications (2.6%), with no cases of mortality. In group A, tumors were smaller (3.0±1.1 cm vs. 3.6±1.9 cm, p<0.01) and more likely to be located on the greater curvature (28% vs. 15%, p<0.01) compared with group B. The tumor growth pattern (exophytic tumor: 72% in group A vs. 65% in group B, p=0.25) was not different between the two groups. Multivariate analysis showed that tumor size larger than 5 cm and posterior wall tumor location were risk factors for longer hospital stay. CONCLUSION: We could reduce the hospitalization of patients with gastric SET less than 5cm sized and located on other than the posterior wall within 3days. Those patients could be a candidate for day surgery.

Comparison of the Diagnostic Ability of Endoscopic Ultrasonography and Abdominopelvic Computed Tomography in the Diagnosis of Gastric Subepithelial Tumors

BACKGROUND/AIMS: Endoscopic ultrasonography (EUS) is the most efficient imaging modality for gastric subepithelial tumors (SETs). However, abdominopelvic computed tomography (APCT) has other advantages in evaluating the characteristics, local extension, or invasion of SETs to adjacent organs. This study aimed to compare the diagnostic ability of EUS and APCT based on surgical histopathology results.METHODS: We retrospectively reviewed data from 53 patients who underwent both EUS and APCT before laparoscopic wedge resection for gastric SETs from January 2010 to December 2017 at a single institution. On the basis of histopathology results, we assessed the diagnostic ability of the 2 tests.RESULTS: The overall accuracy of EUS and APCT was 64.2% and 50.9%, respectively. In particular, the accuracy of EUS vs. APCT for the diagnosis of gastrointestinal stromal tumors (GISTs), leiomyomas, and ectopic pancreas was 83.9% vs. 74.2%, 37.5% vs. 0.0%, and 57.1% vs. 14.3%, respectively. Most of the incorrect diagnoses with EUS involved hypoechoic lesions originating in the fourth echolayer, with the most common misdiagnosed lesions being GISTs mistaken for leiomyomas and vice versa.CONCLUSIONS: APCT showed a lower overall accuracy than EUS; however, APCT remains a useful modality for malignant/potentially malignant gastric SETs.

Early Phase of Achalasia Manifested as an Esophageal Subepithelial Tumor / 대한소화기학회지

The Chicago classification (CC) defines an esophagogastric junction outflow obstruction (EGJOO) as the presence of several instances of intact or weak peristalsis, elevated median integrated relaxation pressure above 15 mmHg, and a discrepancy from the criteria of achalasia. The revised CC addresses the potential etiology of EGJOO, including the early forms of achalasia, mechanical obstruction, esophageal wall stiffness, or manifestation of hiatal hernia. A 58-year-old woman visited the Presbyterian Medical Center with swallowing difficulty. The patient underwent a high resolution manometry (HRM) examination and was diagnosed with EGJOO. Chest CT was performed to exclude a mechanical obstruction as a cause, and CT revealed a subepithelial tumor (SET) at the upper part of the esophagogastric junction. Therefore, laparoscopic surgery was performed and eccentric muscular hypertrophy of the distal esophagus was observed. Longitudinal myotomy and Dor fundoplication were also performed. The histology findings of the surgical specimens were consistent with achalasia. This paper reports a case of early achalasia that was finally diagnosed by the histology findings, but was initially diagnosed as EGJOO using HRM and misdiagnosed as SET in the image study.

Primary Gastric Small Cell Carcinoma: A Case Identified as a Large Subepithelial Tumor from Invisible State in 6 Months

Primary gastric small cell carcinoma (GSCC) is one of the gastroenteropancreatic neuroendocrine tumors. It is a rare cancer with a very aggressive behavior and a poor prognosis because of the high rate of metastases. It is usually found in far advanced stage. We experienced a case of GSCC which had developed into a large subepithelial tumor (SET) from invisible state in a short period. A 65-year-old man consulted our hospital because of early gastric cancer. He underwent endoscopic submucosal dissection for the early gastric cancer at high body posterior wall. After 6 months, the follow-up endoscopy showed a large newly developed SET-like lesion with central ulceration at the gastric cardia. Endoscopic biopsy revealed GSCC. Total gastrectomy was performed. One out of the 26 perigastric lymph nodes had a metastasis. He received 6 cycles of adjuvant chemotherapy with etoposide and cisplatin. He is still in good health 12 months after operation.

Clinical Significance of Extraluminal Compressions according to the Site of the Duodenum

BACKGROUND/AIMS: Differentiating extraluminal compressions from true subepithelial tumors in the duodenum by endoscopy alone is difficult. Endoscopic ultrasonography (EUS) is one of the most useful diagnostic modalities for this purpose. Extraluminal compression in the duodenum is occasionally observed, but its clinical significance has not been reported. Therefore, the aim of this study was to evaluate the clinical significance of extraluminal compression in the duodenum according to lesion location. MATERIALS AND METHODS: We retrospectively evaluated 22 patients diagnosed as having extraluminal compression in the duodenum based on EUS findings between January 2006 and December 2017. Some patients underwent abdominal computed tomography for accurate diagnosis. RESULTS: The location of the extraluminal compression was the duodenal bulb in 10 cases, the superior duodenal angle in 10 cases, and the second portion of the duodenum in 2 cases. Of the 22 cases, 12 were caused by normal structures, including vessels, the right kidney, the gallbladder, and the pancreas, and 10 were caused by pathological lesions, including the hepatic cyst, remnant cystic duct and dilated common bile duct after cholecystectomy; gallstones, gallbladder polyps, remnant cystic duct cancer, and pseudomyxoma peritoneii. The anterior wall of the duodenum was the most frequent location of extraluminal compression. However, the lesions in the anterior wall of the duodenal bulb and superior duodenal angle showed a high frequency of pathologic lesions, including malignancy. CONCLUSIONS: If the extraluminal compression is found in the anterior wall of the duodenum, EUS is needed because of the high frequency of pathological lesions.