Search

Background and study aims Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) has improved the success rate of en-bloc resection. We report here on a new technique using an external grasping forceps. Patients and methods A total of 25 patients with suitable EGCs over 10 mm in diameter located in the gastric body were enrolled. After submucosal injection followed by circumcision of the lesion with a needle-knife, an external grasping forceps was introduced with the help of a second grasping forceps and anchored at the distal margin of the lesion. With gentle oral traction applied with this forceps, the lesion was dissected endoscopically in retroversion from the aboral side. Results The mean lesion size was 15.0 mm (range 10 - 25 mm). Using the technique described, all lesions could be resected en bloc with free margins. The mean procedure time was 45 min (range 30 - 80 minutes). No significant bleeding requiring blood transfusion or perforation occurred. Conclusions This technical modification may simplify and shorten the gastric ESD procedure, except for lesions in distal locations, without compromising the efficacy.

Novel Procedure of Endoscopic Submucosal Dissection Using Double Graspers for Early Stage Gastric Cancer Hiroyuki Imaeda, Yasushi Iwao, Haruhiko Ogata, Hitoshi Ichikawa, Hidekazu Suzuki, Nagamu Inoue, Mikiji Mori, Naoki Hosoe, Tatsuhiro Masaoka, Manabu Nakashita, Koichi Aiura, Hiroshi Nagata, Koichiro Kumai, Toshifumi Hibi Background and Aim: Endoscopic submucosal dissection (ESD) for early stage gastric cancer (EGC) has improved the success rate for en bloc resection. It has been also reported that several techniques of traction of lesions are useful for ESD; however, these are complicated and invasive. The aim of this study is to assess the usefulness of ESD using double graspers for EGC. Subjects and Methods: Subjects were 23 lesions of EGC, which were histopathologically differentiated adenocarcinomas within the mucosa and without ulcers. Mean size of the lesions was 16.3 mm, range from 10-35 mm. Sixteen of 23 lesions were at the gastric body, 5 at the antrum and 2 at the angulus. A short hood was attached to the distal tip of an endoscope. After marking around lesions, 10% glycerin with indigocarmine and epinephrine was injected into the submucosa. After circumferential cutting around the lesions using a needle knife at a Endo-Cut mode, the endoscope was pulled out once. Next, a grasper (inside grasper) inserted through an accessory channel of the endoscope grasped the tip of the other grasper (outside grasper), which was outside the endoscope. Both graspers and endoscope were inserted into the stomach, and the anal side of the lesions was grasped by the outside grasper controlled by the endoscope and the inside grasper. Thereafter, the inside grasper was released and pulled out. Finally, with traction of the lesions towards the oral side by the outside grasper, the submucosal layer of lesions was dissected using the needle knife at a forced coagulation mode. Hemostasis for bleeding was carried out using the needle knife at a spray coagulation mode or clips. Results: (1) All lesions were able to be grasped with the outside grasper. (2) Traction of the lesion towards the oral side by the outside grasper was able to make the submucosal layer wider and more visible. Therefore, dissection could be more easily carried out under direct vision, with both safety and certainty. (3) Both the endoscope and the outside grasper was able to be moved easily and independently. (4) All lesions were able to be resected en block. (5) No bleeding requiring blood transfusion or a perforation occurred. Conclusion: ESD using double graspers is very useful for easily dissecting EGC with safety and certainty not only at the body but also the angulus and the antrum. M1339 New Diagnostic and Therapeutic Strategy: Combination of Capsule Endoscopy (CE) and Double-Balloon Endoscopy (DBE) Michiko Iwamoto, HIronori Yamamoto, Hiroto Kita, Keijiro Sunada, Yoshikazu Hayashi, Hiroyuki Sato, Kentaro Sugano, Katuro Shirakawa, Tetuya Nakamura, Akira Terano Background: Capsule endoscopy (CE) and double-balloon endoscopy (DBE) both offer visualization of the entire small intestine (SI). CE is considered an effective diagnostic procedure, while DBE is potentially a therapeutic as well as a diagnostic technique but DBE requires both oral and anal approaches to view entire SI. Aim: To determine if the combination of CE and DBE is a useful as a diagnostic and therapeutic strategy for SI diseases. Methods: Thirteen patients with melena and anemia who had no specific findings by previous esophagogastroduodenoscopy (EGD) and colonoscopy were examined by both CE and DBE. CE was performed prior to DBE in order to both compare the findings of both tests, and to determine if CE data about the location of lesions CE was helpful in to the endoscopist performing DBE. Results: Visualization of the entire small bowel was adequate in all subjects. CE and DBE both identified the same source of bleeding in 9 of 13 (69%) subjects, 1 bleeding polyp, 2 arteriovenous malformations (AVM), 2 submucosal tumors (SMT), 1 bleeding small intestinal ulcer, 1 segmental edematous lesion, 1 gastric ulcer, 1 gastric antral vascular ectasia (GAVE); in one additional patient no lesions were seen by either exam. In 3 cases, SMTwas suggested by CE but not found by DBE. Endoscopic treatment was performed in 6 patients (1 polypectomy, argon plasma coagulation in 3 patients, 2 for AVMs and 1 for GAVE, and clipping for 1 bleeding gastric ulcer.) Surgical resection was performed for 2 SMT. In 1 patient with bleeding small intestinal ulcer, capsule retention occurred near the ring like stricture DBE with Balloon dilatation of the stricture to 15 mm allowed the capsule to pass naturally within 2 days. DBE was helpful for this case. Conclusion: In this small series the combination of CE and DBE appeared to be complementary. The identification and localization of lesions by CE was useful to the endoscopist performing DBE and DBE with stricture dilatation allowed a retained capsule to pass.

Procedure of Endoscopic Hemostasis Using a Distal Attachment and Short Clips Against Upper Gastrointestinal Bleeding Naoki Hosoe, Hiroyuki Imaeda, Haruhiko Ogata, Hidekazu Suzuki, Tatsuhiro Masaoka, Manabu Nakashita, Tomoko Tsuda, Hiroyuki Kimura, Koichi Aiura, Yasushi Iwao, Hiroshi Nagata, Koichiro Kumai, Toshifumi Hibi, Hiromasa Ishii BACKGROUND and AIM: Endoscopic hemostasis using hemoclips is useful against upper gastrointestinal bleeding, however it is difficult to perform hemoclipping against tangent view-lesions. A hood which is attached to a distal tip of an endoscope makes hemoclipping more easier, however it is sometimes difficult to observe lesions because clot is put into the hood. The aim of this study is to assess endoscopic hemostasis using a distal attachment and short clips against upper gastrointestinal bleeding. SUBJECTS and METHODS: Subjects were 103 patients with 117 lesions of upper gastrointestinal bleeding. A distal attachment, which was a short hood (4 mm in length) was attached to the distal tip of an endoscope from start of endoscopic examination. If lesions of upper gastrointesitinal bleeding were detected, hemoclipping using short clips was performed against them. This procedure had been performed against 50 lesions, including 20 of gastric ulcer, 14 of duodenal ulcer, 12 of lesion resected endoscopically against early gastric cancer and gastric adenoma, 3 of Mallory-Weiss syndrome and 1 of stomal ulcer. Endoscopic hemostasis by this procedure was analyzed. RESULTS: It was easy to insert the endoscope with the distal attachment into the upper GI in all patients.Appropriate endoscopic view using the distal attachmentwas achieved without disturbance of clot in all lesions. For tangent view-lesions, this attachment made endoscopic observation and treatment more easier. In addition, the entire short clip was able to be stored into this attachment, and certainly clamped a protruded visible vessel even if the bottom of the lesion was hard. Forty-seven of 50 lesions (94.0%) had temporal hemostasis and forty-six lesions (90.0%) had permanent hemostasis. One patient with multiple gastric ulcers, advanced hepatocellular carcinoma and bleeding tendency associated with DIC had temporal hemostasis, however he died of rebleeding from the ulcers. Two patients with duodenal ulcer and one patient with gastric ulcer underwent interventional radiology because visible vessels were more than 3mm. One patient with duodenal Dieulafoy’’s lesion close to papilla of Vater underwent endoscopic hemoclipping using a lateral-viewing endoscope. CONCLUSION: Endoscopic hemostasis with a distal attachment and short clips is useful against upper gastrointestinal bleeding. *M1777 Sensitivity and Inter-Observer Variability for Capsule Endoscopy Image Analysis in a Cohort of Novice Readers Gary Chen, Simon Chan, Clifford Quan, Mary Kalpakian, Tam Tran, Pedram Enayati, Mary Lee Henderson, Gareth Dulai, Ian Arnott, Fumiaki Kitahara, Jeff Gornbein, Rome Jutabha Capsule endoscopy image analysis is a time consuming and tedious process. The process for selecting, training, and validating an individual’s (reader) ability to accurately detect abnormalities has not been well studied. Aim: To determine the sensitivity, specificity, and concordance rate of novice readers (4th year medical students withminimal endoscopic background) for detecting pre-specified capsule endoscopic findings. Hypotheses: 1) Medical students can reliably detect small bowel lesions deemed as definitive lesions for obscure bleeding with a high degree of sensitivity but low specificity, and 2) the concordance rates between the readers and gold standard will be high. Methods: Ten encoded test cases with definitive sites for bleeding were administered to the readers (n=9) in a pre-set order (bleeding: AVM-3, Meckel’s-1, ulcers/aphthous lesions-3, foreign body with ulceration-2). The gold standard findings were pre-defined by 2 expert capsule endoscopists (over 75 capsule cases each). Twelve gold standard targets were identified among the 10 test cases. The readers were given a 30 minute overview of the Rapid Reader (GIVEN Imaging) software and instructions for thumbnailing anatomic landmarks and any potential abnormality. A proprietary software program was developed to compile and analyze thumbnailed finding with respect to sensitivity and specificity as compared to a gold standard and overall concordance rates. Results: The average sensitivity among the 9 medical students was 67% with gradual improvement in sensitivity and specificity over time. All findings were detected by at least 2 to 9 of the students. An average of 19 false positive incidental finding’s per case were made by each student. The concordance (Kappa statistic) between readers was 22% for these 12 gold standard findings (intra-class correlation=0.22). Conclusions: A panel of medical students with minimal endoscopic experience can reliably detect high risk bleeding lesions on capsule endoscopy with moderate sensitivity, and can pre-screen recordings to thumbnail potential abnormalities. Due to low specificity, expert capsule endoscopists must review these thumbnails to determine the clinical relevance of each finding. Additional studies are ongoing to assess other reader cohorts (nurses, GI fellows, non-medical) abilities to detect various bleeding as well as nonbleeding abnormalities on capsule endoscopy.