Li-Ping Ye

Intramuscular injection of metoclopramide decreases the gastric transit time and does not increase the complete examination rate of capsule endoscopy: a prospective randomized controlled trial.

BACKGROUND/AIMS Capsule endoscopy (CE) reaches the cecum in about 80% of cases. Decreasing the gastric transit time (GTT) may increase the complete examination rate (CER). METHODOLOGY Patients (n=177) were prospectively randomized into 2 groups: the control group (n=88) and the intramuscular injection with metoclopramide (IIM) group (n=89). The OMOM CE system, which has the function of real-time monitoring, was used. The patients were injected with metoclopramide 15 minutes before swallowing the CE in the IIM group. The CE would be sent into the duodenum by gastroscopy if the GTT reached 120 minutes in the two groups. RESULTS No significant difference was noted between the two groups. Of the 169 cases without gastroscopic help, the mean GTT was shorter in the IIM group (n=87) than the control group (n=82) (p=0.002). But the CER was similar. Of 135 cases without gastroscopic help but reached the cecum, the mean GTT was shorter in the IIM group (n=71) than the control group (n=64) (p=0.015). But the mean small bowel transit time (SBTT) was similar. CONCLUSIONS Intramuscular injection of metoclopramide decreases the gastric transit time, but it does not change the SBTT or CER of capsule endoscopy in our study.

Submucosal tunnelling endoscopic resection for the treatment of esophageal submucosal tumours originating from the muscularis propria layer: An analysis of 15 cases

BACKGROUND AND AIMS The aim of this prospective study was to evaluate the feasibility of submucosal tunnelling endoscopic resection of esophageal tumours originating from the muscularis propria layer. METHODS Fifteen patients with esophageal submucosal tumours originating from the muscularis propria layer underwent submucosal tunnelling endoscopic resection between August 2011 and February 2012. The key steps were: (1) creating a submucosal tunnel from 5 cm above the tumour between the submucosal and muscular layers with a hook knife or hybrid knife; (2) dissecting the tumour by the technique of endoscopic submucosal dissection; (3) closing the mucosal incision site with clips after the tumour was removed. RESULTS Submucosal tunnelling endoscopic resection was successfully performed in all cases. The en bloc resection rate was 100%. The average tumour diameter was 1.8 cm (range 1.0-3.0 cm). During the procedure, perforation occurred in 3 patients, who recovered after conservative treatment. No residual tumour or tumour recurrence was detected during the follow-up period (mean: 3.5 months, range: 1-9 months). Pathological diagnoses of these tumours were leiomyomas (12/15) and gastrointestinal stromal tumours (3/15). CONCLUSIONS Submucosal tunnelling endoscopic resection is a feasible method for the treatment of small esophageal submucosal tumours originating from the muscularis propria layer.

Safety and efficacy of endoscopic excavation for gastric subepithelial tumors originating from the muscularis propria layer: results from a large study in China.

Background and Aim: In this retrospective study, we investigated the safety and efficacy of endoscopic excavation of gastric subepithelial tumors (SETs) originating from the muscularis propria (MP) layer. Materials and Methods: Between November 2007 and June 2012, 212 patients with gastric SETs originating from the MP layer were treated via endoscopic excavation. The key procedures were: (1) injecting a mixture solution (100 mL saline+2 mL indigo carmine+1 mL epinephrine) into the submucosa around the tumor; (2) making a cross-incision of the mucosa and then excavating the tumor by the technique of endoscopic excavation. After the tumor was completely excavated from the MP layer, it was removed using a snare; (3) closing the artificial ulcer with clips. Results: The mean diameter of the 212 tumors was 16.5 mm. Complete resection by endoscopic excavation was achieved in 204 cases (96.2%). The rate of complete resection was significantly higher for tumors <2 cm (98.0%) than for tumors >2 cm (91.9%) (P=0.035). Perforation occurred in 32 cases (15.1%), and massive bleeding occurred in 9 cases (4.2%) during the procedure. The rate of perforation was significantly higher for the fundus and the body than for antrum (21.5%, 11.5%, 0%, respectively; P=0.036), and also differed significantly in relation to histologic diagnosis (23.7% for gastrointestinal stromal tumors vs. 7.8% for leiomyoma; P=0.001). Histologic diagnosis showed that the density of gastrointestinal stromal tumors located in the fundus and the body of the stomach was significantly higher than in the antrum (44.1%, 51.9%, 13.3%, respectively; P=0.036). Conclusions: Endoscopic excavation is a safe and efficient method for resecting small (>3.5 cm) gastric SETs originating from the MP layer.

Endoscopic treatments for small gastric subepithelial tumors originating from muscularis propria layer

Minimally invasive endoscopic resection has become an increasingly popular method for patients with small (less than 3.5 cm in diameter) gastric subepithelial tumors (SETs) originating from the muscularis propria (MP) layer. Currently, the main endoscopic therapies for patients with such tumors are endoscopic muscularis excavation, endoscopic full-thickness resection, and submucosal tunneling endoscopic resection. Although these endoscopic techniques can be used for complete resection of the tumor and provide an accurate pathological diagnosis, these techniques have been associated with several negative events, such as incomplete resection, perforation, and bleeding. This review provides detailed information on the technical details, likely treatment outcomes, and complications associated with each endoscopic method for treating/removing small gastric SETs that originate from the MP layer.

MELD scores and Child-Pugh classifications predict the outcomes of ERCP in cirrhotic patients with choledocholithiasis: a retrospective cohort study.

AbstractEndoscopic retrograde cholangiopancreatography (ERCP) is challenging in cirrhotic patients with choledocholithiasis. We evaluated the safety and efficacy of ERCP in cirrhotic patients with choledocholithiasis and accessed the model for end-stage liver disease (MELD) scores and Child–Pugh classifications for prediction of morbidity and mortality.From January 2000 to June 2014, 77 ERCP operations were performed in cirrhotic patients with choledocholithiasis. The data on operative complications were analyzed. MELD scores and Child–Pugh classifications were calculated and associated with operative outcomes and survival. Telephone follow-up was performed to determine survival situations.No death, perforation, or hemorrhage caused by gastroesophageal varices occurred as a result of the procedure. The rate of intraoperative hemorrhage was 13.0%, and the rate of postoperative morbidity was 27.3% including hemorrhage (18.2%), post-ERCP pancreatitis (6.1%), aggravated infection of the biliary tract (1.3%), hepatic encephalopathy (1.3%), and respiratory failure (1.3%). Four (5.2%) patients had both intraoperative and postoperative hemorrhage. Receiver operating characteristic analysis identified MELD scores higher than 11.5 as the best cutoff value for predicting complication incidence (95% confidence interval = 0.63–0.87). Twenty-one (44.7%) patients with a MELD score above 11.5 developed a complication, and 3 (10%) patients who had a lower MELD score developed a complication (P = 0.001). Both MELD score and Child–Pugh classification had prognostic value in patients without jaundice, although sex may result in different prognostic values based on the 2 scores. The rate of complications was not significantly different among patients with different Child–Pugh classifications. No significant difference was observed in patients with different MELD scores or Child–Pugh classifications in terms of median survival times.ERCP is an effective and safe procedure in cirrhotic patients with choledocholithiasis. MELD scores can predict the risk of operative complications, but Child–Pugh classification system scores do not predict the risk of complications.

Safety of Endoscopic Resection for Upper Gastrointestinal Subepithelial Tumors Originating from the Muscularis Propria Layer: An Analysis of 733 Tumors

Objectives:Although endoscopic resection is an accepted technique for upper gastrointestinal subepithelial tumors (SETs) originating from the muscularis propria (MP) layer, published data regarding its complications are highly variable and limited to small data series. This study aimed to analyze the safety of endoscopic resection in a large case series.Methods:A total of 726 consecutive patients with 733 upper gastrointestinal SETs originating from the MP layer underwent endoscopic resection from June 2005 to December 2014. The complete resection rate, perioperative perforation rate, and perioperative bleeding rate were the main outcome measurements.Results:The complete resection rate was 97.1%. Ninety-four patients had complications (12.9%), including 88 with perioperative perforations (12.1%), 13 with perioperative bleeding (1.8%), 5 with localized peritonitis (0.7%), and one with delayed bleeding (0.1%). Eleven patients required surgery; the others were treated endoscopically. Risk factors for incomplete resection were extensive connection of the tumor to the MP layer (P=0.007) and extraluminal growth (P=0.048). Risk factors for perioperative perforation were larger tumor size (≤2.0 cm vs. 2.1–3.0 cm vs. >3.0 cm, P=0.021), extraluminal growth (P=0.046), and extensive connection (P<0.001). A risk factor for perioperative bleeding was larger tumor size (P=0.045). No residual or recurrent lesions were detected during the follow-up period (median: 28 months).Conclusions:Endoscopic resection is an effective and reasonably safe therapeutic method for treating/removing upper gastrointestinal SETs originating from the MP layer when managed by an experienced endoscopic team.

Endoscopic submucosal enucleation of small gastric gastrointestinal stromal tumors with cross-shaped incision: report of sixty-nine cases.

BACKGROUND/AIMS Gastric gastrointestinal stromal tumors (gastric GISTs) are the most common gastric submucosal tumors with potential for malignant transformation. Our aim was to assess the efficacy and safety of ESE for gastric GISTs. METHODOLOGY Small gastric GISTs were dealt with ESE between May 2007 and October 2010. RESULTS A total of 69 patients (42 men, 27 women; mean age 47.28±10.10 years) were treated. The mean diameter of the specimens was 1.87±0.57cm (range 0.7-3.0cm). The rates of intra-operative bleeding, delayed bleeding, perforation and surgery related complications were 7.25% (5/69), 1.45% (1/69), 33.33% (23/69) and 5.80% (4/69), respectively. The rate of perforation was 43.2% (19/44) at the fundus of the stomach and 16% (4/25) at the body (p=0.02). The mean time of the procedure was 41.07±10.79 minutes. Nineteen patients with perforation were treated by titanium clips and the rest by laparoscopy. Immunohistochemistry revealed that the positive rates of CD117 and CD34 were 88.41% and 68.12%, respectively. The gastric GISTs were all at low risk. At a mean follow-up period of 17.97±10.75 months (range 1 to 40 months) all of the patients were disease free. CONCLUSIONS ESE with a cross-shaped incision is possibly a very good choice for small gastric GISTs.

Endoscopic treatment of a sigmoid perforation caused by an ingested fish bone

A 68-year-old man was admitted with severe abdominal pain since the previous day. His physical examination was unremarkable, except for mild lower abdominal tenderness without rebound tenderness. Laboratory tests showed he had an elevated white blood cell count (11800 cells/μL) and increased C-reactive protein (CRP) level (105mg/L). A computed tomography (CT) scan revealed a radiodense linear foreign body that was extending transmurally through the wall of the sigmoid colon (▶Fig. 1). Colonoscopy demonstrated a fish bone stuck in the sigmoid colon wall (▶Fig. 2). The fish bone was carefully removed using foreign body forceps, leaving an approximately 0.5 ×0.5-cm perforation in the sigmoid colon wall. The perforation was closed by an over-the-scope clip (OTSC; Ovesco Endoscopy Ag, Germany) (▶Video1). After this endoscopic procedure, the patient’s lower abdominal discomfort immediately disappeared. He was treated with antibiotics for 3 days and was discharged from hospital without any early complications. Ingestion of foreign bodies, such as poultry bones, fish bones, coins, and dentures, is a common occurrence among elderly patients, children, alcoholics, patients with psychiatric disorders, and fast eaters [1]. Most foreign bodies are able to pass through the gastrointestinal tract without consequence, while some may lead to perforation, fistula, hemorrhage, or obstruction of the gastrointestinal tract [2]. Perforation of the sigmoid colon caused by an ingested fish bone is rare. Surgical treatment is usually inevitable if foreign bodies cannot be extracted endoscopically [3]; however, a case where a fish bone-induced sigmoid colonic perforation was successfully treated by conservative management had previously been reported [4]. In our case, the fish bone that had stuck in the wall of the sigmoid colon was successful-

Huge Lymphangioma of the Esophagus Resected by Endoscopic Piecemeal Mucosal Resection

We present an unusual case of a 41-year-old male patient with a large lymphangioma of the esophagus. Endoscopy revealed that the structure measured 60 × 10 mm in the mucosa and the submucosa and had a heterogenous echo pattern. The esophageal mass was successfully resected by endoscopic piecemeal mucosal resection. However, most esophageal lymphangiomas that are larger than 2 cm in diameter reported in the literature can be removed only through open surgery. Thus far, we know of no reported cases of endoscopic resection as a treatment for this case.

455 Endoscopic Full-Thickness Resection With Defect Closure by Clips and an Endoloop for Gastric Subepithelial Tumors Arising From the Muscularis Propria

Background and aims This retrospective study evaluated the safety and efficacy of endoscopic full-thickness resection (eFTR) with defect closure using clips and an endoloop for the treatment of gastric subepithelial tumors (SETs) arising from the muscularis propria (MP).