Tao Gan

Endoscopic submucosal multi-tunnel dissection for circumferential superficial esophageal neoplastic lesions (with videos)

BACKGROUND AND AIMS Endoscopic submucosal tunnel dissection (ESTD) has been used for dissection of large esophageal neoplastic lesions, but there are still some technical problems in treating circumferential superficial esophageal neoplastic lesions. This study aimed to assess the efficacy and safety of endoscopic submucosal multi-tunnel dissection (ESMTD) for circumferential superficial esophageal neoplastic lesions in selected patients followed up for 1 to 12 months. METHODS From July 2014 to February 2015, the first series of 7 consecutive patients with circumferential superficial esophageal neoplastic lesions underwent ESMTD at our endoscopic center. The macroscopic types were classified according to the Paris endoscopic classification of superficial neoplastic lesions. RESULTS The average length of lesions was 6.1 cm in 7 selected patients. The operative time ranged from 69 to 169 minutes (mean 121 minutes). En bloc dissection with negative basal margins was achieved in all lesions without serious intraoperative adverse events. Esophageal stricture was observed in all patients 1 to 3 months after the operation and was relieved after a retrievable metal stent was placed or esophageal water balloon dilatation was performed; however, one patient died of cerebral infarction 2 months after ESMTD. CONCLUSIONS ESMTD is feasible, safe, and effective for the treatment of circumferential superficial esophageal neoplastic lesions in select patients.

When and why a colonoscopist should discontinue colonoscopy by himself

AIM To investigate when and why a colonoscopist should discontinue incomplete colonoscopy by himself. METHODS In this cross-sectional study, 517 difficult colonoscope insertions (Grade C, Kudos difficulty classification) screened from 37800 colonoscopy insertions were collected from April 2004 to June 2014 by three 4(th)-level (Kudos classification) colonoscopists. The following common factors for the incomplete insertion were excluded: structural obstruction of the colon or rectum, insufficient colon cleansing, discontinuation due to patients discomfort or pain, severe colon disease with a perforation risk (e.g., severe ischemic colonopathy). All the excluded patients were re-scheduled if permission was obtained from the patients whose intubation had failed. If the repeat intubations were still a failure because of the difficult operative techniques, those patients were also included in this study. The patients age, sex, anesthesia and colonoscope type were recorded before colonoscopy. During the colonoscopic examination, the influencing factors of fixation, tortuosity, laxity and redundancy of the colon were assessed, and the insertion time (> 10 min or ≤ 10 min) were registered. The insertion time was analyzed by t-test, and other factors were analyzed by univariate and multivariate logistic regression. RESULTS Three hundred and twenty-two (62.3%) of the 517 insertions were complete in the colonoscope insertion into the ileocecum, but 195 (37.7%) failed in the insertion. Fixation, tortuosity, laxity or redundancy occurred during the colonoscopic examination. Multivariate logistic regression analysis revealed that fixation (OR = 0.06, 95%CI: 0.03-0.16, P < 0.001) and tortuosity (OR = 0.04, 95%CI: 0.02-0.08, P < 0.001) were significantly related to the insertion into the ileocecum in the left hemicolon; multivariate logistic regression analysis also revealed that fixation (OR = 0.16, 95%CI: 0.06-0.39, P < 0.001), tortuosity (OR 0.23, 95%CI: 0.13-0.43, P < 0.001), redundancy (OR = 0.12, 95%CI: 0.05-0.26, P < 0.001) and sex (OR = 0.35, 95%CI: 0.20-0.63, P < 0.001) were significantly related to the insertion into the ileocecum in the right hemicolon. Prolonged insertion time (> 10 min) was an unfavorable factor for the insertion into the ileocecum. CONCLUSION Colonoscopy should be discontinued if freedom of the colonoscope bodys insertion and rotation is completely lost, and the insertion time is prolonged over 30 min.

Efficacy and safety of endoscopic submucosal tunnel dissection for superficial esophageal squamous cell carcinoma and precancerous lesions

AIM To evaluate the clinical outcomes of patients who underwent endoscopic submucosal tunnel dissection (ESTD) for esophageal squamous cell carcinoma (ESCC) and precancerous lesions. METHODS ESTD was performed in 289 patients. The clinical outcomes of the patients and pathological features of the lesions were retrospectively reviewed. RESULTS A total of 311 lesions were included in the analysis. The en bloc rate, complete resection rate, and curative resection rate were 99.04%, 81.28%, and 78.46%, respectively. The ESTD procedure time was 102.4 ± 35.1 min, the mean hospitalization time was 10.3 ± 2.8 d, and the average expenditure was 3766.5 ± 846.5 dollars. The intraoperative bleeding rate was 6.43%, the postoperative bleeding rate was 1.61%, the perforation rate was 1.93%, and the postoperative infection rate was 9.65%. Esophageal stricture and positive margin were severe adverse events, with an incidence rate of 14.79% and 15.76%, respectively. No tumor recurrence occurred during the follow-up period. CONCLUSION ESTD for ESCC and precancerous lesions is feasible and relatively safe, but for large mucosal lesions, the rate of esophageal stricture and positive margin is high.

Polyethylene Glycol for Small Bowel Capsule Endoscopy

Capsule endoscopy has been the first-line examination for small bowel diseases, yet its diagnostic yield is restricted by unsatisfactory bowel preparation. To evaluate the clinical effectiveness of different dosages of polyethylene glycol in patients undergoing capsule endoscopy, we performed a comprehensive meta-analysis of all randomized controlled trials involving polyethylene glycol in preparation for capsule endoscopy. The methodological quality of the trials was evaluated using the Cochrane Risk of Bias assessment instrument. In this study, 12 RCTs involving 2072 patients were included in this review. Our review indicated that 4 L and 2 L polyethylene (PEG) before capsule endoscopy (CE) and 500 mL PEG after CE increase the small bowel image quality, whereas 1 L PEG did not improve the small bowel image quality. PEG accelerated the gastric emptying time. There was no significant difference between the PEG group and control group in small bowel transit time, completion rates, and diagnostic yield.

Endoscopic Submucosal Tunnel Dissection: A Feasible Solution for Large Superficial Rectal Neoplastic Lesions.

BACKGROUND: Although endoscopic submucosal tunnel dissection has been used for the resection of esophageal and stomach neoplastic lesions, there are still no reports about large superficial rectal neoplastic lesions. Compared with esophageal and stomach endoscopic submucosal dissection, the dissection of large superficial rectal neoplastic lesions is more difficult because of the flimsy bowel wall with abundant vasculature in the submucosal region, which results in poor endoscopic maneuverability and serious complications, such as bleeding and perforation. OBJECTIVE: The study aimed to assess the efficacy and safety of endoscopic submucosal tunnel dissection for large superficial rectal neoplastic lesions over 5 to 24 months in selected patients. DESIGN: This was a prospective, single-center evaluation. SETTINGS: The study was conducted at a digestive endoscopic center. PATIENTS: Patients with large superficial rectal neoplastic lesions were included. INTERVENTIONS: Endoscopic submucosal tunnel dissection was performed in all of the patients with large, superficial rectal neoplastic lesions. The submucosal tunnel was created via a submucosal incision from the anal incision to the oral incision. Next, tunnel wall resection was performed to completely remove the lesion. MAIN OUTCOME MEASURES: Dissection speed, complications, and recurrence rate were measured. RESULTS: A total of 19 patients, including 13 men and 6 women, with an average age of 60.1 ± 12.2 years (range, 34.0–75.0 y) underwent endoscopic submucosal tunnel dissection. The average size of lesions was 17.54 ± 13.47 cm2. The mean operative time was 84.84 ± 53.49 minutes, and the operating speed was 21.01 ± 9.00 mm2/min. En bloc resections with negative basal margins were achieved in all cases without serious intraoperative complications. No recurrence was observed in any patient within 5 to 24 months after the operations. LIMITATIONS: This was a single-center study. CONCLUSIONS: Endoscopic submucosal tunnel dissection is feasible, safe, and effective for the treatment of large, superficial rectal neoplastic lesions in selected patients. See Video Abstract at http://links.lww.com/DCR/A321.