Ningli Chai

Moving knife tip on the thoracic aorta: High-risk submucosal tunneling endoscopic resection procedure for a puzzling submucosal mass in the esophagus

A 43‐YEAR‐OLD MAN was found to have an esophageal submucosal mass at 26 cm from the incisors, and preoperative endoscopic ultrasonography suggested a leiomyoma in the muscularis propria (MP) layer. Submucosal tunneling endoscopic resection (STER), derived from peroral endoscopic myotomy, was carried out and an inverse T incision was made first. Subsequently, a submucosal tunnel was established extending to the distal esophagus and a mass, covered with MP tissue, was discovered (Fig. 1). The mass was moving up and down rhythmically, and was soft to the touch. As a result of the possibility of aortic compression or cyst, endoscopic color Doppler ultrasonography was conducted and uncovered a homogeneous hypoechoic lesion just against the thoracic aorta (Fig. 2). Thus, we speculated the lesion was a cyst, given the softness of the mass. Then, en bloc resection was attempted; however, the mass was found to have deep involvement with the MP layer. Therefore, en bloc resection was abandoned and injection needle was used to puncture the “hypothetical cyst”, considering the very close distance between the lesion and the thoracic aorta. However, no liquid could be drawn from the lesion; moreover, snare resection also did not work. Therefore, we had to further resect the lesion in the deep MP layer, just against the thoracic aorta. Finally, an unpredictable solid mass (2.0 9 1.0 cm), which turned out to be stromal tumor pathologically, was resected in one piece; and the incision was closed with metal clips (Video S1). In this case, the stromal tumor showed a puzzling feature of softness to touch because the thoracic aorta was just behind the lesion and had good elasticity. The biggest challenge of this procedure also lied in the risky adjacent relationship. We reported this case intending to preliminarily determine the feasibility of STER for submucosal tumor that has deep involvement in the MP and located just against the aorta. Moreover, a reference is provided when a similar diagnostic problem is encountered. Authors declare no conflicts of interest for this article.

Comparison of endoscopic ultrasound, computed tomography and magnetic resonance imaging in assessment of detailed structures of pancreatic cystic neoplasms

AIM To evaluate the advantages of endoscopic ultrasound (EUS) in the assessment of detailed structures of pancreatic cystic neoplasms (PCNs) compared to computed tomography (CT) and magnetic resonance imaging (MRI). METHODS All patients with indeterminate PCNs underwent CT, MRI, and EUS. The detailed information, including size, number, the presence of a papilla/nodule, the presence of a septum, and the morphology of the pancreatic duct of PCNs were compared among the three imaging modalities. The size of each PCN was determined using the largest diameter measured. A cyst consisting of several small cysts was referred to as a mother-daughter cyst. Disagreement among the three imaging modalities regarding the total number of mother cysts resulted in the assumption that the correct number was the one in which the majority of imaging modalities indicated. RESULTS A total of 52 females and 16 males were evaluated. The median size of the cysts was 42.5 mm by EUS, 42.0 mm by CT and 38.0 mm by MRI; there was no significant difference in size as assessed among the three imaging techniques. The diagnostic sensitivity and ability of EUS to classify PCNs were 98.5% (67/68) and 92.6% (63/68), respectively. These percentages were higher than those of CT (73.1%, P < 0.001; 17.1%, P < 0.001) and MRI (81.3%, P = 0.001; 20.3%, P < 0.001). EUS was also able to better assess the number of daughter cysts in mother cysts than CT (P = 0.003); however, there was no significant difference between EUS and MRI in assessing mother-daughter cysts (P = 0.254). The papilla/nodule detection rate by EUS was 35.3% (24/68), much higher than those by CT (5.8%, 3/52) and MRI (6.3%, 4/64). The detection rate of the septum by EUS was 60.3% (41/68), which was higher than those by CT (34.6%, 18/52) and by MRI (46.9%, 30/64); the difference between EUS and CT was significant (P = 0.02). The rate of visualizing the pancreatic duct using EUS was 100%, whereas using CT and MRI it was less than 10%. CONCLUSION EUS helps visualize the detailed structures of PCNs and has many advantages over CT and MRI. EUS is valuable in the diagnosis and assessment of PCNs.

Simultaneous performance of one-tunnel per-oral endoscopic myotomy, submucosal tunneling endoscopic resection, and diverticulotomy.

A 53-year-old woman with cardia achalasia was seen to have a beak sign and a large diverticulum as shown by a radiograph (Fig. 1A). The endoscopic morphology of her esophagus was identified as Ling classification type IIIr: bending and expansion (maximum diameter, 6.1 cm) with a diverticulum on the right wall of the esophagus (Fig. 1B). It was hard to pass the endoscope through the cardia before per-oral endoscopic myotomy (POEM) could be undertaken. Because of the high pressure of the cardia, esophageal high-resolution manometry pressure was unsuccessful. An inverted T-shaped incision and a triangle knife were chosen as usual for POEM. Given the type IIIr esophagus, a 5-cm short tunnel near the diverticulum was made on the side of the spine. A white oval lesion was discovered unexpectedly in the muscularis propria during establishment of the tunnel (Fig. 1C). Submucosal tunneling endoscopic resection was performed to excavate the lesion. Myotomy was performed from the lower edge of the diverticulum

Effect of polyglycolic acid sheet plus esophageal stent placement in preventing esophageal stricture after endoscopic submucosal dissection in patients with early-stage esophageal cancer: A randomized, controlled trial

AIM To assess the effect of polyglycolic acid (PGA) plus stent placement compared with stent placement alone in the prevention of post-endoscopic submucosal dissection (ESD) esophageal stricture in early-stage esophageal cancer (EC) patients. METHODS Seventy EC patients undergoing ESD were enrolled in this randomized, controlled study. Patients were allocated randomly at a 1:1 ratio into two groups as follows: (1) PGA plus stent group (PGA sheet-coated stent placement was performed); and (2) Stent group (only stent placement was performed). This study was registered on http://www.chictr.org.cn (No. chictr-inr-16008709). RESULTS The occurrence rate of esophageal stricture in the PGA plus stent group was 20.5% (n = 7), which was lower than that in the stent group (46.9%, n = 15) (P = 0.024). The mean value of esophageal stricture time was 59.6 ± 16.1 d and 70.7 ± 28.6 d in the PGA plus stent group and stent group (P = 0.174), respectively. Times of balloon dilatation in the PGA plus stent group were less than those in the stent group [4 (2-5) vs 6 (1-14), P = 0.007]. The length (P = 0.080) and diameter (P = 0.061) of esophageal strictures were numerically decreased in the PGA plus stent group, whereas no difference in location (P = 0.232) between the two groups was found. Multivariate logistic analysis suggested that PGA plus stent placement (P = 0.026) was an independent predictive factor for a lower risk of esophageal stricture, while location in the middle third (P = 0.034) and circumferential range = 1/1 (P = 0.028) could independently predict a higher risk of esophageal stricture in EC patients after ESD. CONCLUSION PGA plus stent placement is more effective in preventing post-ESD esophageal stricture compared with stent placement alone in EC patients with early-stage disease.

Autologous Skin-Grafting Surgery for the Prevention of Esophageal Stenosis After Complete Circular Endoscopic Submucosal Tunnel Dissection

Department of Gastroenterology, Chinese PLA General Hospital, Beijing, China. Correspondence: E.L. (email: linghuenqiang@vip.sina.com) or Y.H. (email: 13720086335@163.com) Fig. 1 A 58-year-old man underwent double-tunnel endoscopic submucosal tunnel dissection (ESTD) in our hospital, for a 5-cm circumferential superficial esophageal neoplasm about 25–30 cm from the incisors (Supplementary Video). To prevent postoperative esophageal stenosis, we performed autologous skin-grafting surgery (ASGS) to fill the artificial ulcer in the esophagus, as described below. First, a 12 × 8 cm skin graft was harvested from the right outer thigh of the patient; subsequently, the graft was sewn into an oversleeve-like skin with an absorbable suture (VICRYL Plus; 4-0; 1.5 Ph. Eur.) (a). Then, the oversleeve-like skin graft was sewn on a fully covered esophageal stent (FCES) (Cook Medical; 10 cm) (b). Finally, the FCES was placed at the location of the artificial ulcer in the esophagus (Supplementary Video). An R0 resection was achieved, and the specimen was pathologically confirmed to be squamous-cell carcinoma. Endoscopic follow-up at 1 week showed that the skin graft was growing well (c). The FCES was removed after 4 weeks with no sign of stenosis, and the overwhelming majority of the graft skin survived; moreover, in terms of the colour and lustre, there were no significant differences between normal esophageal mucosa and the graft skin (d). One week after the FCES was removed, the normal mucosa and graft skin matched more closely (e). The patient had still not experienced stenosis and dysphagia at 7 weeks follow-up (3 weeks after removal of the FCES) (f); the biopsy tissue taken from the location of the skin graft was confirmed to be squamous epithelium. To the best of our knowledge, this is the first reported application of ASGS to prevent post-ESTD esophageal stenosis. It was previously confirmed that the autologous graft skin could survive on the artificial ulcer in the esophagus. However, further follow-up of this case is required to determine the long-term efficacy of this technique to preventing postoperative esophageal stenosis. (Informed consent was obtained from the patient to publish these images.) Normal mucosa

Endoscopic submucosal tunnel dissection and endoscopic submucosal dissection for large superficial esophageal squamous cell neoplasm: efficacy and safety study to guide future practice

Background and study aimsESTD and ESD are currently the two primary treatment options for superficial esophageal squamous cell neoplasm (SESCN) in China. However, in larger cases, ESD proves to be technically challenging and time saving, whereas ESTD exhibits promising efficacy. This study aims to evaluate the efficacy and safety of these two techniques for large SESCN.Patients and methodsA total of 150 patients with solitary large SESCN that underwent either ESTD (n = 52) or ESD (n = 98) between August 2011 and June 2016 were included in this study. Both efficacy and safety clinical data were collected and analyzed.ResultsAll of the 150 patients were found to successfully undergo ESTD or ESD with 92.68 ± 67.96 (mean ± SD) min. The specimen area was measured to be 13.79 ± 7.44 (mean ± SD) cm2 and the dissection speed was 17.99 ± 10.40 (mean ± SD) mm2/min. En bloc resection and R0 resection were achieved in 91.33% (137/150) and 86.00% (129/150) of the cases, respectively. A total of 8.67% (13/150) were found to have intra-operative adverse events. Based on statistical analysis, ESTD was found to have a higher dissection speed and a similar adverse event rate compared with ESD. Moreover, a long operation time was found to be an independent risk factor for intra-operative adverse events.ConclusionsESTD and ESD both were found to be effective and safe treatment options for the treatment of large SESCN. ESTD appeared to improve operation efficacy, which was reflected in a higher dissection speed compared with ESD. We also demonstrate that long operation times should be avoided as much as possible in order to reduce intra-operative adverse events.

Endoscopic Submucosal Tunnel Dissection for Large Gastric Neoplastic Lesions: A Case-Matched Controlled Study

Aim To evaluate the efficacy and safety of endoscopic submucosal tunnel dissection (ESTD) for resection of large superficial gastric lesions (SGLs). Methods The clinicopathological records of patients performed with ESTD or endoscopic submucosal dissection (ESD) for SGLs between January 2012 and January 2014 were retrospectively reviewed. 7 cases undergoing ESTD were enrolled to form the ESTD group. The cases were individually matched at a 1 : 1 ratio to other patients performed with ESD according to lesion location, ulcer or scar findings, resected specimen area, operation time and operators, and the matched cases constituting the ESD group. The treatment outcomes were compared between the two groups. Results The mean specimen size was 46 mm. 10 lesions were located in the cardia and 4 lesions in the lesser curvature of the lower gastric body. En bloc resection was achieved for all lesions. The mean ESTD resection time was 69 minutes as against 87.7 minutes for the ESD (P = 0.01). The mean resection speed was faster for ESTD than for ESD (18.86 mm2/min versus 13.76 mm2/min, P = 0.03). There were no significant differences regarding the safety and curability during the endoscopic follow-up (mean 27 months). Conclusions ESTD is effective and safe for the removal of SGLs and appears to be an optimal option for patients with large SGLs at suitable sites.

A prospective study of endoscopic ultrasonography features, cyst fluid carcinoembryonic antigen, and fluid cytology for the differentiation of small pancreatic cystic neoplasms.

Background and Objectives: With improvements in imaging technologies, pancreatic cystic lesions (PCLs) have been increasingly identified in recent years. However, the imaging modalities used to differentiate the categories of pancreatic cysts remain limited, which may cause confusion when planning treatment. Due to progress in endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) technology, auxiliary diagnosis by the detection of cystic fluid has become a recent trend. Methods: From March 2015 to April 2016, 120 patients with PCLs were enrolled in this study. According to the results of EUS, cyst fluid carcinoembryonic antigen (CEA) analysis, and cystic fluid cytology, the patients were divided into two groups: a nonmucinous and a mucinous group. Of those, 61 patients who had undergone surgical resection were included in the analysis. The clinical features, biochemical and tumor markers of cyst fluid as well as the cytological test results of the patients were compared with histopathology results. Results: A cyst size of 4.0 cm was used as the boundary value; a cyst ≤4.0 cm was defined as a small PCL. 87 (72.5%) lesions were ≤4.0 cm, and 33 (27.5%) lesions were >4.0 cm. Regarding the analysis of CEA and carbohydrate antigens 19-9 (CA19-9), significant differences were found between the nonmucinous and mucinous groups (P < 0.05) according to nonparametric independent samples tests. The EUS, cystic fluid CEA, and cystic fluid cytology results were compared with the tissue pathology findings using McNemars test (P < 0.05) and showed a sensitivity of 90% and a specificity of 84%. Conclusion: A diagnostic combination of EUS, cyst fluid CEA, and cystic fluid cytology could be used to differentiate small pancreatic cystic neoplasms. Cystic fluid cytology analysis is helpful for planning treatment for pancreatic cystic tumors that pose a surgical risk.

Prepyloric submucosal tunneling endoscopic resection for a case of inflammatory mass (with video)

A 28-year-old woman was found a submucosal mass in the greater curvature of prepyloric area under EUS (Figure 1). Submucosal tunneling endoscopic resection (STER)1, 2 was performed, and the procedure began with the creation of an inverse T entry (transverse entry incision, 1.0 cm; longitudinal entry incision, 0.5 cm)3 ; Subsequently, a submucosal tunnel of 4 cm was established, and ended about 0.5 cm distal to the mass; Afterward, the mass was extracted by a snare following on the endoscopic resection. Finally, the reversed T entry was closed by eight clips (Video 1). The final pathological result was a inflammatory mass (Figure 2). This article is protected by copyright. All rights reserved.

Ling classification describes endoscopic progressive process of achalasia and successful peroral endoscopy myotomy prevents endoscopic progression of achalasia

AIM To verify the hypothesis that the Ling classification describes the endoscopic progressive process of achalasia and determine the ability of successful peroral endoscopic myotomy (POEM) to prevent endoscopic progression of achalasia. METHODS We retrospectively reviewed the endoscopic findings, symptom duration, and manometric data in patients with achalasia. A total of 359 patients (197 women, 162 men) with a mean age of 42.1 years (range, 12-75 years) were evaluated. Symptom duration ranged from 2 to 360 mo, with a median of 36 mo. Patients were classified with Ling type I (n = 119), IIa (n = 106), IIb (n = 60), IIc (n = 60), or III (n = 14), according to the Ling classification. Of the 359 patients, 349 underwent POEM, among whom 21 had an endoscopic follow-up for more than 2 years. Pre-treatment and post-treatment Ling classifications of these 21 patients were compared. RESULTS Symptom duration increased significantly with increasing Ling classification (from I to III) (P < 0.05), whereas lower esophageal sphincter pressure decreased with increasing Ling type (from I to III) (P < 0.05). There was no difference in sex ratio or onset age among the Ling types, although the age at time of diagnosis was higher in Ling types IIc and III than in Ling types I, IIa, and IIb. Of the 21 patients, 19 underwent high-resolution manometry both before and after treatment. The mean preoperative and postoperative lower esophageal sphincter pressure were 34.6 mmHg (range, 15.3-59.4 mmHg) and 15.0 mmHg (range, 2.1-21.6 mmHg), respectively, indicating a statistically significant decrease after POEM. All of the 21 patients were treated successfully by POEM (postoperative Eckardt score ≤ 3) and still had the same Ling type during a mean follow-up period of 37.8 mo (range, 24-51 mo). CONCLUSION The Ling classification represents the endoscopic progressive process of achalasia and may be able to serve as an endoscopic assessment criterion for achalasia. Successful POEM (Eckardt score ≤ 3) seems to have the ability to prevent endoscopic evolvement of achalasia. However, studies with larger populations are warranted to confirm our findings.