Meta-analysis of Predictive Clinicopathologic Factors for Lymph Node Metastasis in Patients with Early Colorectal Carcinoma

The objective of this study was to conduct a meta-analysis to determine risk factors that may facilitate patient selection for radical resections or additional resections after a polypectomy. Eligible articles were identified by searches of PUBMED, Cochrane Library and Korean Medical Database using the terms (early colorectal carcinoma [ECC], lymph node metastasis [LNM], colectomy, endoscopic resection). Thirteen cohort studies of 7,066 ECC patients who only underwent radical surgery have been analysed. There was a significant risk of LNM when they had submucosal invasion (> or = SM2 or > or = 1,000 microm) (odds Ratio [OR], 3.00; 95% confidence interval [CI], 1.36-6.62, P = 0.007). Moreover, it has been found that vascular invasion (OR, 2.70; 95% CI, 1.95-3.74; P or = SM2 or > or = 1,000 microm submucosal invasion, vascular invasion, lymphatic invasion, poorly differentiated carcinomas or tumor budding, it is deemed that a more extensive resection accompanied by a lymph node dissection is necessary. Even if the lesion is completely removed by an endoscopic resection, an additional surgical resection should be considered in patients with poorly or moderately differentiated carcinomas or lymphovascular invasion.

Endoscopic Resection of Hypopharyngeal Squamous Cell Carcinoma

Hypopharyngeal cancers are often diagnosed at an advanced stage and have a poor prognosis. Even when they are diagnosed at an operable stage, surgery often results in substantial morbidity and decreased patients' quality of life. Although the endoscopic diagnosis of early hypopharyngeal cancer is difficult, recent developments in advanced imaging endoscopy have enabled easier diagnosis of these lesions. Endoscopic resection of early hypopharyngeal cancer is a potential minimally invasive treatment that can preserve the function and quality of life of patients. Reports of this procedure are limited, however. We report a case of hypopharygeal cancer treated with endoscopic resection.

A Case of Early Gastric Adenocarcinoma Resembling Subepithelial Tumor

Gastric cancer resembling subepithelial tumor is rare. It comprises approximately 0.5% of all resected gastric cancer cases. The features of gastric carcinoma resembling subepithelial tumor are erosion, erythema and central umbilication. Because only a small amount of cancerous tissue is present at the mucosal layer, differential diagnosis between subepithelial tumor and gastric cancer resembling subepithelial tumor is difficult. EUS is recommended to identify the origin and echogenicity of the lesion, characteristic features, and accurate size. We report a case of early gastric cancer misdiagnosed as a subepithelial tumor on the basis of standard endoscopy and EUS findings in a 63-year-old woman. The patient received endoscopic resection and additional surgical operation was performed to achieve complete resection.

A Case of Early Gastric Adenocarcinoma Resembling Subepithelial Tumor

Gastric cancer resembling subepithelial tumor is rare. It comprises approximately 0.5% of all resected gastric cancer cases. The features of gastric carcinoma resembling subepithelial tumor are erosion, erythema and central umbilication. Because only a small amount of cancerous tissue is present at the mucosal layer, differential diagnosis between subepithelial tumor and gastric cancer resembling subepithelial tumor is difficult. EUS is recommended to identify the origin and echogenicity of the lesion, characteristic features, and accurate size. We report a case of early gastric cancer misdiagnosed as a subepithelial tumor on the basis of standard endoscopy and EUS findings in a 63-year-old woman. The patient received endoscopic resection and additional surgical operation was performed to achieve complete resection.

Rectal hyposensitivity and functional anorectal outlet obstruction are common entities in patients with functional constipation but are not significantly associated

BACKGROUND/AIMS: The causes of functional anorectal outlet obstruction (outlet obstruction) include functional defecation disorder (FDD), rectocele, and rectal intussusception (RI). It is unclear whether outlet obstruction is associated with rectal hyposensitivity (RH) in patients with functional constipation (FC). The aim of this study was to determine the association between RH and outlet obstruction in patients with FC. METHODS: This was a retrospective study using a prospectively collected constipation database, and the population comprised 107 patients with FC (100 females; median age, 49 years). We performed anorectal manometry, defecography, rectal barostat, and at least two tests (balloon expulsion test, electromyography, or colon transit time study). RH was defined as one or more sensory threshold pressures raised beyond the normal range on rectal barostat. We investigated the association between the presence of RH and an outlet obstruction such as large rectocele (> 2 cm in size), RI, or FDD. RESULTS: Forty patients (37.4%) had RH. No significant difference was observed in RH between patients with small and large rectoceles (22 [44.9%] vs. 18 [31%], respectively; p = 0.140). No significant difference was observed in RH between the non-RI and RI groups (36 [36.7%] vs. 4 [30.8%], respectively; p = 0.599). Furthermore, no significant difference in RH was observed between the non-FDD and FDD groups (19 [35.8%] vs. 21 [38.9%], respectively; p = 0.745). CONCLUSIONS: RH and outlet obstruction are common entities but appear not to be significantly associated.

A Case of Endoscopic Closure to Postoperative Leak after Laparoscopic Sleeve Gastrectomy in Patient with Morbid Obesity / 이화의대지

Laparoscopic sleeve gastrectomy can reduce morbidity and mortality in patients with morbid obesity, but it can cause complications such as a gastrointestinal leak. A 30-year-old morbidly obese female who had type 2 diabetes mellitus and hypertension with estimated body mass index of 40.2 kg/m2 was admitted. Laparoscopic sleeve gastrectomy was performed. On postoperative day 19, a leak was suspicious on physical examination and radiologic findings. Conservative management was performed, but the patient was hemodynamically unstable and imminently septic. After laparoscopic drainage procedure, esophagogastroduodenoscopy was performed and revealed the fistula opening at staple line just below gastroesophageal junction. Fibrin tissue adhesive was injected around the fistula and the esophageal covered stent was inserted to cover the leak. At 14th days after stent insertion, the barium study confirmed no more leak. In this case, we experienced that the esophageal stent insertion with fibrin tissue adhesive injection may reduce recovery time of the fistula developed after laparoscopic sleeve gastrectomy.

Gastric Schwannoma Diagnosed by Endoscopic Ultrasonography-Guided Trucut Biopsy

Schwannomas of the gastrointestinal (GI) tract are rare subepithelial tumors comprising approximately 3.3% to 12.8% of all mesenchymal tumors of the GI tract. On endoscopic ultrasound (EUS) they are seen as hypoechoic tumors arising most commonly from the 4th proper muscle layer. Although EUS helps to distinguish tumor characteristics, tissue sampling is required for differentiation with other more common tumors such as GI stromal tumors. Both EUS-guided fine needle aspiration and EUS-guided trucut biopsy (EUS-TCB) can be used for tissue sampling. However, only EUS-TCB allows core biopsy and a high yield of immunohistochemical staining. We report a case of a gastric schwannoma diagnosed by EUS-TCB.

Intra-Abdominal Tuberculous Lymphadenitis Diagnosed Using an Endoscopic Ultrasonography-Guided ProCore Needle Biopsy

Intra-abdominal tuberculous lymphadenitis can mimic a variety of other abdominal disorders such as pancreatic cancer, metastatic lymph nodes, or lymphoma, which can make a proper diagnosis difficult. A correct diagnosis of intra-abdominal tuberculous lymphadenitis can lead to appropriate management. Endoscopic ultrasonography (EUS)-guided needle biopsy may be the procedure of choice for tissue acquisition when onsite cytopathology examination is unavailable because it is essential to obtain sufficient material suitable for the examination using an ancillary method, such as flow cytometry, molecular diagnosis, cytogenetics, or microbiological culture. We report a case of intra-abdominal tuberculous lymphadenitis diagnosed using an EUS-guided, 22-gauge histology new needle biopsy without an onsite cytopathology examination.

Clinical Characteristics and Treatment Outcome of Colonic Diverticulitis in Young Patients / 대한소화기학회지

BACKGROUND/AIMS: The clinical course and the most appropriate management of colonic diverticulitis in young patients are currently unresolved. This retrospective study was designed to compare young patients (40 years) regarding clinical characteristics of acute colonic diverticulitis and to determine whether differences exist in treatment outcome. METHODS: Three-hundred sixty eight patients presenting with acute colonic diverticulitis from March 2001 through April 2011 at Ewha Womans University Mokdong Hospital were reviewed retrospectively. The differences in clinical characteristics, treatment modality and recurrence between each group were analyzed. RESULTS: Two-hundred and six patients were aged 40 years or younger and 162 patients were older than 40 years. The older group was diagnosed more frequently with severe diverticulitis. Surgical treatment was significantly more frequent in the older group than in the younger group (15.4% vs. 4.4%, p<0.001). No significant difference was found in treatment modality between the two groups in patients with recurrence. The difference in recurrence between groups was not statistically significant. In multivariate analysis, left colonic diverticulitis was significantly associated with severe diverticulitis (OR, 14.651; 95% CI, 4.829-44.457) and emergency surgery (OR, 13.745; 95% CI, 4.390-43.031). CONCLUSIONS: When patients with colonic diverticulitis are treated conservatively, young age is no longer an independent risk factor for subsequent poor outcome. Diverticulitis in young patients does not have a particularly aggressive or fulminant course. Therefore, we recommend that diverticulitis management should be based on the severity and location of the disease, and not on the age of the patient.

Successful Treatment of Early Gastric Cancer Adjacent to a Fundal Varix by Endoscopic Submucosal Dissection and Endoscopic Cyanoacrylate Therapy

Endoscopic submucosal dissection (ESD) was developed for the en bloc resection of large early gastrointestinal neoplasms. A disadvantage of ESD is its technical difficulty, which requires advanced skills and is associated with a higher rate of complications. Endoscopic variceal obturation (EVO) using cyanoacrylate has emerged as the initial treatment of choice for acute gastric variceal bleeding. This procedure achieves hemostasis in 90% of cases. A 52-year-old patient with Child A alcoholic liver cirrhosis presented with early gastric cancer in the cardia and type 1 isolated gastric varices in the fundus. The two lesions were so close together that treatment was not easy. The lesions were managed successfully with a combination of ESD and EVO using cyanoacrylate.

Submucosal Endoscopy, a New Era of Pure Natural Orifice Translumenal Endoscopic Surgery (NOTES)

Natural orifice translumenal endoscopic surgery (NOTES) involves the intentional perforation of the viscera with an endoscope to access the abdominal cavity and perform an intraabdominal operation. In a brief time period, NOTES has been shown to be feasible in laboratory animal and human studies. Easy access to the peritoneal cavity and complete gastric closure should be secured before NOTES can be recommended as an acceptable alternative in clinical practice. The concept of submucosal endoscopy has been introduced as a solution to overcome these two primary barriers to human NOTES application. Its offset entry/exit access method effectively prevents contamination and allows the rapid closure of the entry site with a simple mucosal apposition. In addition, it could be used as an endoscopic working space for various submucosal conditions. Herein, the detailed procedures, laboratory results and human application of the submucosal endoscopy will be reviewed.

Capsule Endoscopy for Suspected Small Bowel Bleeding in Patients with Portal Hypertension

BACKGROUND/AIMS: In Korea, limited data are available on small bowel bleeding in patients with portal hypertension. This study reports on the use of capsule endoscopy in cases of suspected small bowel bleeding in patients with portal hypertension. METHODS: Capsule endoscopy was used at our hospital to evaluate small bowel disease in 501 cases from July 2003 to June 2010. Of those cases, nine patients with portal hypertension due to liver cirrhosis with suspected small bowel bleeding were selected for the study. A retrospective analysis was performed using data from medical records. RESULTS: Six of the nine (66.7%) patients were males with an average age of 53.4 years. The average hemoglobin level was 8.1 g/dL. Abnormalities noted during capsule endoscopy included portal hypertensive enteropathy in all nine cases (100%), jejunal varices in four (44.4%), jejunal and ileal angiodysplasia in five (55.5%), multiple small bowel erosions in one (11.1%), granularity of the jejunal mucosa in one (11.1%), and small bowel erythema in three (33.3%). Active bleeding from jejunal varices was detected in two patients (22.2%). Despite having no obvious active bleeding during the capsule endoscopy, four patients (44.4%) were diagnosed with portal hypertensive enteropathy with obscure small bowel bleeding. CONCLUSIONS: Capsule endoscopy is a useful diagnostic tool for the evaluation of small bowel bleeding in patients with portal hypertensive enteropathy. Additional prospective and multicenter studies on the use of capsule endoscopy are needed to evaluate the incidence and clinical importance of portal hypertensive enteropathy.

Endoscopic Treatment of Submucosal Tumor from Upper Gastrointestinal Tract

There are still some limitations in diagnosis of submucosal tumors of gastrointestinal tract. Surgical resection, fine needle aspiration and follow up studies have been considered to be the options for their treatments. However, severeal endoscopic resection techniques for the submucosal tumors are recently introduced and they have some advantages over the previous treatment options. This article is a review for the endoscopic treatment of the submucosal tumors of gastrointestinal tract.

Helicobacter pylori Eradication Suppresses Metachronous Gastric Cancer and Cyclooxygenase-2 Expression after Endoscopic Resection of Early Gastric Cancer

BACKGROUND/AIMS: The impact of Helicobacter pylori (H. pylori) eradication after endoscopic resection (ER) of early gastric cancer (EGC) has not been fully evaluated. We tried to find out the effect of H. pylori eradication therapy on the development of metachronous gastric cancers and changes in Cyclooxygenase-2 (COX-2) expression following attempts to eradicate H. pylori after ER of EGC. MATERIALS AND METHODS: We eradicated H. pylori in the patients with EGC after ER. Biopsy samples were taken according to the follow-up schedules for surveillance after ER. RESULTS: Fifty five patients were enrolled and finished the follow up schedules. Of the 55, 28 were successfully treated H. pylori infection, and the other 27 were failed eradication of H. pylori. The mean follow-up period was 60.8 months. Five in the H. pylori ongoing infection group developed metachronous gastric cancer, whereas no new gastric cancers were found in the 28 eradication group (P=0.023). COX-2 expression in the eradication group was significantly decreased (1.4+/-0.2, n=28), compared to that in H. pylori ongoing infection group (3.0+/-0.4, n=27, P=0.0001) after the follow-up. CONCLUSIONS: The eradication of H. pylori seems to have a preventative effect on the development of metachronous adenocarcinomas and a suppressive effect on COX-2 expression in the patients after ER for EGC.

Frozen Section Biopsy to Evaluation of Obscure Lateral Resection Margins during Gastric Endoscopic Submucosal Dissection for Early Gastric Cancer

PURPOSE: To determine the diagnostic utility of a frozen section biopsy in patients undergoing endoscopic submucosal dissection (ESD) for early gastric neoplasms with obscure margins even with chromoendoscopy using acetic acid and indigo carmine (AI chromoendoscopy). MATERIALS AND METHODS: The lateral spread of early gastric neoplasms was unclear even following AI chromoendoscopy in 38 patients who underwent ESD between June 2007 and May 2011. Frozen section biopsies were obtained by agreement of the degree of lateral spread between two endoscopists. Thus, frozen section biopsies were obtained from 23 patients (FBx group) and not in the other 15 patients (AI group). RESULTS: No significant differences were observed for size, histology, invasive depth, and location of lesions between the AI and FBx groups. No false positive or false negative results were observed in the frozen section diagnoses. Adenocarcinoma was revealed in three patients and tubular adenoma in one, thereby changing the delineation of lesion extent and achieving free lateral margins. The rates of free lateral resection margins and curative resection were significantly higher in the FBx group than those in the AI group. CONCLUSIONS: Frozen section biopsy can help endoscopists perform more safe and accurate ESD in patients with early gastric neoplasm.

Recent Advances in Image-enhanced Endoscopy

The desire to better recognized such malignancies, which may be difficult to distinguish from inflammation or trauma, has accelerated the development of endoscopy with new optical technologies. Narrow-band imaging is a novel endoscopic technique that may enhance the accuracy of diagnosis using narrow-bandwidth filters in a red-green-blue sequential illumination system. Autofluorescence imaging is based on the detection of natural tissue fluorescence emitted by endogenous molecules. I-scan technology using a digital filter that modifies normal images through software functions, is the newly developed image-enhanced endoscopic technology from PENTAX. Flexible spectral imaging color enhancement enhances the visualization of mucosal structure and microcirculation by the selection of spectral transmittance with a dedicated wavelength. Confocal laser endomicroscopy images were collected with an argon beam with a scanning depth of 0 (epithelium) to 250 microm (lamina propria) and analyzed using the reflected light.

Comparison of the Cut Direction between Gross Finding, Streoscopic Finding, and Pathologic Mapping of Endoscopic Submucosal Dissection Specimen / 대한소화기학회지

BACKGROUND/AIMS: The correct pathologic review is very important after endoscopic submucosal dissection. The cut direction of specimen should be the right angle of the closest area between the lesion and the lateral margin for the correct pathologic review. The aim of this study was to evaluate the concordance of the gross finding and stereoscopic finding compared to the pathologic mapping in the setting of the cut direction. METHODS: Between December 2008 and May 2009, the objects were 48 specimens in 46 patients who were diagnosed with early gastric cancer and high grade adenoma after endoscopic submucosal dissection. The specimens were stained with hematoxylin and observed by the stereoscopy and analyzed by the image analysis system. The cut direction was divided by an angle of 45 degree based on the oral side of the specimen, and the cut directions of the gross finding, the stereoscopic finding, and the pathologic finding were compared. RESULTS: The concordance of the gross finding in the setting of the cut direction was 68% (33/48), and the kappa value was 0.626, and the concordance of the stereoscopic finding in the setting of the cut direction was 87% (33/48), and the kappa value was 0.874. The accuracy of the gross finding was significantly lower than that of the stereoscopic finding in the setting of the cut direction (p<0.05). CONCLUSIONS: The endoscopist needs the careful observation and close attention in the setting of the cut direction of the specimen by gross finding, and stereoscopic analysis may be a useful tool for decision of the cut direction.

Changes in Indications and Diagnostic Rates of Capsule Endoscopy in a Single Center / 대한소화기내시경학회지

BACKGROUND/AIMS: The aim of this study was to investigate changes with time in indications for capsule endoscopy examinations (CEs) and diagnostic rates. METHODS: We retrospectively reviewed medical records of 425 CEs (417 patients), which were done for several different indications between March 2003 and May 2009. Indications, bowel cleansing, complete CEs, and diagnostic rates were compared between the first half (2003~2005) and the second half (2006~2009) of the study period. RESULTS: Overt bleeding and occult bleeding, respectively, accounted for 31% and 5.8% in the first half; and 45.4% and 12.4% in the second half. The differences were significant (p<0.05). Other indications were significantly decreased in the second half compared to the first half (29.6% and 7.7% respectively). Bowel cleansing was considered "adequate" in 48% in the first half vs. 61.6% in the second half (p<0.05). No significant difference was found in complete CE rates. There was a significant difference in diagnostic rates between the first half and the second half (23.8% and 43.9%, respectively). CONCLUSIONS: Cumulative experience and knowledge with CEs has led to an increased number of CEs for obscure bleeding and a decreased number of CEs for other indications in which the role of CEs was unclear. Improved diagnostic rates of CEs were accompanied by these changes in CEs indications.

A Case of Asymptomatic Aspiration of a Capsule Endoscope with a Successful Resolution

Aspiration is a very rare complication of capsule endoscopy, but it is potentially life-threatening and should be considered an emergency requiring immediate intervention since it can evolve into major airway compromise and obstructive pneumonitis. We experienced a case of asymptomatic aspiration of a capsule in a 75-year-old man. The aspirated capsule was diagnosed on routine chest and abdomen X-rays to confirm its position after ingestion. The capsule was removed via bronchoscopy using a net, without sequelae, after inducing the patient to cough. To prevent this complication, a thorough history of swallowing disorders is needed before capsule ingestion, and patients with swallowing difficulties should have the capsule placed in the duodenum endoscopically. Moreover, on capsule aspiration, cough induction is the most effective method of capsule removal.

The Antro-pyloric Capsular Movement by Capsule Endoscopy

BACKGROUND/AIMS: Capsule endoscopy (CE) is used for various purposes. The aims of this study were to classify the types of antro-pyloric capsular movement in CE and to investigate the relationship between the types of capsular movement and clinical factors, including gastric emptying time (GET). METHODS: Out of 103 patients who received CE between January 2004 and July 2006, 82 patients (33 female, mean age of 50.6 years) were retrospectively analyzed for capsular movement; 21 patients were excluded because of the history of medications and previous surgeries. CE images were interpreted by a single investigator in relation to the GET and types of antro-pyloric capsular movement. RESULTS: Antro-pyloric capsular movement was classified into four patterns: type 1, large longitudinal to-and-fro movements in the antrum followed by passage through the pylorus without resistance; type 2, after large longitudinal to-and-fro movements, passage through the pylorus with resistance (> 1 minute); type 3, mixed pattern of type 1 and 4; type 4, weak movement. Median GET by CE were 14.1 minutes (range, 1.2-50.1), 21.7 minutes (6.2-154.9), 57.3 minutes (14.9-249.8), and 58.8 minutes (21.0-249.5) for type 1, 2, 3, and 4, respectively. GET in type 1 and 2 were significantly shorter than that in type 3 and 4 (p < 0.05). Ten diabetic patients presented with type 2 (n = 5), 3 (n = 3), and 4 (n = 2) patterns, but not with type 1. CONCLUSIONS: Our results suggest the analysis of capsule movement using CE to be a possible method of evaluating the antro-pyloric movement.