Kye Won Kwon

Wire-guided endoscopic snare papillectomy for tumors of the major duodenal papilla

BACKGROUND Endoscopic excision for adenoma of the major duodenal papilla was introduced as an alternative to surgery, but postprocedure pancreatitis is a serious drawback. This study assessed the feasibility and the safety of endoscopic papillectomy with a guidewire and pancreatic-duct stent insertion to prevent pancreatitis. METHODS Six patients were enrolled. The snare loop was passed over a guidewire that had been inserted into the pancreatic duct. Immediately after snare resection, a pancreatic stent was placed along the indwelling guidewire. RESULTS En bloc papillectomy and pancreatic stent insertion were performed successfully in all patients. Pancreatitis did not develop acutely in any patient. Complications included cholangitis (n = 1) and late-onset pancreatitis owing to the pancreatic stent (n = 1). Scant residual adenomatous tissue was present at resection margins in two patients and was treated endoscopically. CONCLUSIONS Wire-guided endoscopic snare papillectomy in selected patients is a useful technique that maintains pancreatic-duct access for stent placement. This appears to prevent pancreatitis and to improve the outcome for patients undergoing endoscopic resection of papillary tumors.

The Usefulness and Limitation of Endoscopic Mucosal Resection Using the Incision and Submucosa Dissection (EISD) Methods for Early Gastric Cancer and Gastric Flat Adenoma in Korea

The Usefulness and Limitation of Endoscopic Mucosal Resection Using the Incision and Submucosa Dissection (EISD) Methods for Early Gastric Cancer and Gastric Flat Adenoma in Korea Chang Beom Ryu, Sang Gyune Kim, Sung Won Jung, In Sup Jung, Kye Won Kwon, Su Jin Hong, So Young Jin, Joo Young Cho, Joon Sung Lee, Moon Sung Lee, Chan Sup Shim, Boo Sung Kim Background: Conventional EMR technique is technically simple and convenient but with this procedure the size of specimen obtained from en bloc resection is very limited. En bloc resection is beneficial for accurate histopathological assessment of resected specimen of endoscopic mucosal resection (EMR). EMR using Incision and dissection methods (EISD) made it possible to perform en bloc resections of larger early stage gastric neoplasm with a reduction in the recurrence rate. But, it takes long time to perform the procedure and high incidence of complication. Aims: The aim of this study was to evaluate the clinical usefullness and limitation of EISD. Subjects & Methods: Between February 2001 and April 2004 September, 271 lesions of early neoplastic lesions of the stomach (M:F Z 169:70, mean age: 60.99) were performed by EMR with conventional method (EMR, n Z 41) or EISD (n Z 230). En bloc and complete resection rates, the total procedure time, recurrence and complication were evaluated. Results: 1) The en bloc resection and complete resection rates with EMR were 93.3% (14/15), 86.6% (13/15) for lesions 10 mm or less in size and 88.5% (23/26), 61.5% (16/26) between 11 and 15 mm. EISD, 91.2% (52/57), 89.5% (51/57) between 11 and 15 mm, 96.4% (54/56), 83.9% (47/56) 16-20 mm, 87.1% (54/62), 91.9% (57/62) 21-30 mm, 89% (49/55), 81.9% (45/55) for lesions 31 mm or more in size. 2) The total procedure time of EMR and EISD was 19i 58iG i⁄4 5i 52iG and 103i 30iG i ⁄4 45i 46iG 3)Recurrence rate was 9.6% (4/41) in EMR, 3.5% (8/230) in EISD. 4) Minor bleeding including oozing with conventional EMR occurred in 2.4% (1/41) and EISD 5.7% (13/230). Perforation with EISD only occurred in 3.0% (7/230). Conclusion: EISD was effective modality to perform high en bloc resection and complete resection rate in larger gastric flat adenoma and early gastric cancer. To avoid the complications such as perforation, it takes a lots of technical experiences. Key word: Gastric Neoplasms, endoscopic mucosal resection, Incision and dissection method, Endoscopic mucosal resection.

Clinicopathologic Study of Gastric Submucosal Tumor: Endosonographic and Immunohistochemical Findings of Gastrointestinal Stromal Tumors (GISTs) in Stomach

Clinicopathologic Study of Gastric Submucosal Tumor: Endosonographic and Immunohistochemical Findings of Gastrointestinal Stromal Tumors (GISTs) in Stomach Bong Min Ko, Su Jin Hong, Kye Won Kwon, Chang Beom Ryu, Joo Young Cho, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim, Boo Sung Kim BACKGROUND/AIM: The gastrointestinal stromal tumors (GIST) constitute the largest catergory of primary non-epithelial neoplasm of the gastrointestinal tract and include most tumors previously designated as leiomyomas/leiomyosarcomas. Clinically and pathologically, GIST represents a spectrum of tumors that include benign and malignant variants. A small proportion of tumors apparently lacking mitotic activity do metastasis. This study was performed to evaluate the need of follow up and treatment of GISTs. METHOD: This study was performed on 38 patients who had gastric submucosal tumor on endoscopy and endosonography (EUS) and confirmed by histologic examinations using immunohistochemistry between January 2001 and October 2003 at our hospital. We evaluated the clinical features, EUS findings (size, layer, echogenicity, cystic change, lobuation, marginal halo, echogenic foci) and immunohistochemical stain (CD117, CD34, SMA, S-100, Ki-67). RESULT: 1) 14 of the 38 patients in gastric submucosal tumors were diagnosed GIST. 2) The age of the patients with GIST ranged from 37 to 86 years old, with an average age of 58.3 years. 3) In GIST, lobulation on EUS findings was correlated with risk of aggressive behavior in GISTs significantly (<0.05). 4) Ki-67 was correlated with risk of aggressive behavior in GISTs significantly (<0.05). 5) GISTs appeared as hypoechoic mass arising from 2nd, 3rd and 4th layer. CONCLUSION: EUS and histologic diagnosis including immunohistochemical stain approach should be performed to differentiate diagnosis when showed gastric SMT. Although GISTs has low malignant potential, regular follow up or resection is needed. *T1650 Endoscopic and Echoendoscopic Evaluation of Gastric Varices Eradication with Cianoacrilate Erika Macedo, Fernanda Thuler, Veruska Di Sena, Gustavo De Paulo, Frank Nakao, Jose Ardengh, Angelo P. Ferrari Jr. Introduction: bleeding from gastric varices rupture is more severe than from esophageal varices. Usual endoscopic techniques (sclerotherapy and banding) are not good choices for gastric varices eradication. Cianoacrilate endoscopic injection has been reported as the best choice for such patients. Aim: to asses the value of echoendoscopy in monitoring gastric varices eradication by cianoacrilate injection. Method: 17 patients with Sarin type GEV2 varices were submitted to endoscopic injection of a cianoacrilate and lipiodol solution (1 ml each). Patients younger than 18 years and/or with severe systemic disease were excluded from the study. All patients were submitted to EUS and endoscopy before and at 3, 6 and 12 months after index treatment. Doppler signal was used during EUS. After each 3-month interval the injection was repeated if there was endoscopic evidence of remaining or recurrent varices. Results: our study group consisted of 10 men and 7 women, mean age 50.6 years (range 22 76, median 51 years). Portal hypertension was secondary to cirrhosis due to schistosomiasis (4), chronic B or C viral hepatitis (3 and 8) and alcohol abuse (2). Endoscopic injection was successfully performed in the U turn position, with no immediate complications. Three patients are still waiting for the first 3-month re-evaluation and two patients died of hepatic insufficiency, unrelated to bleeding. Among the remaining 12 patients, 8 finished the study (1 year follow-up), 4 had their 3and 6month follow-up (2 in each group). In seven patients there was a need for additional injection sessions: a mean of 1.8 sessions/patient (range 1-3). Endoscopic follow up showed complete eradication of variceal novel in every patient. EUS follow up showed absence of variceal flow (negative Doppler signal) in every patient considered eradicated by conventional endoscopy. There were no complications. Conclusion: endoscopic injection of cianoacrilate plus lipiodol is a safe and effective method for gastric varices eradication. EUS evaluation allows detection of variceal flow andmay help in planning additional treatment as well as in monitoring the patient.