Abstracts

S1465

Prospective Randomized Comparison of a New Re-Opening

Endoclip with a Standard Clipping SystemAndreas Adler, Ioannis S. Papanikolaou, Wilfried Veltzke-Schlieker,Maria Papas, Bertram Wiedenmann, Thomas RoeschBackground: Endoscopic clipping together with injection therapy constitutefirst-line methods for endoscopic treatment of bleeding ulcers. Moreover, fistula orleakage closure by means of endoclipping are important applications in everydayclinical practice. However, as it is difficult to simulate clinical conditions in order toperform a formal comparison, systematic data comparing clipping systems untilrecently are scarce and mostly from experimental studies. Methods: Consecutivepatients with various clipping indications were randomized to either the newre-opening single-use endoclip applicator (Resolutionclip, Boston ScientificMedizintechnik Ratingen) (R) or the standard clip applicators (S), either reusable(HX-610, Olympus Co. Hamburg) or single-use Quickclip (Olympus Co. Hamburg)and Triclip (Wilson-Cook, Monchengladbach). Results: 59 patients with ulcer, post-polypectomy or Dieulafoy bleedings were randomized to the R-group; primaryhemostasis was achieved here with application of a mean of 1.4 clips (range 1-5). 56cases of similar bleedings were randomized to the S-group with primary hemostasisachieved after an application of a mean of 3.1 (range 1-7) clips (p ! 0.05). 26patients with an indication of closure of fistulas, anastomosis insufficiencies,Mallory-Weiss lesions or perforations were randomized to the R-group; here, anapplication of 2.2 (mean) (range 1-6) clips was necessary compared to 21 patientswho were randomized to the standard systems (here, a mean of 4.6, range 2-12clips were needed) (p ! 0.05). Use of a smaller number of clips was possible due tothe system’s re-opening possibility which allowed corrections in clip placement ina fashion similar to that of biopsy forceps. Another reason was the system’s betterhandling which resulted in better piling of tissue parts in the lesions. As branches ofthe R-clips are longer (10 mm vs. 6-8mm) lesions anatomically harder to bind (e.g.postpyloric or postbulbar vessel stumps) can be easier treated. R-clips alsoremained in situ longer than S-clips (68% vs. 27% after 10 days, p ! 0.05). Furtherfeatures were also assessed (ease and rapidity of use); they were in favor of theR-system but were not systematically analysed as a quantitative assessment wassubjective and thus virtually impossible. Conclusions: R-clips are more effectivethan S-systems in primary endoscopic hemaostasis as well as in closure of fistulas,anastomosis insufficiencies, Mallory-Weiss lesions and perforations. Theirsuperiority is probably due to their design which allow placement corrections,combined with long clip branches which make less clip applications necessary.

S1466

Usefullness of Endoscopic Submucosal Dissection (ESD) in

Treatment of Colorectal NeoplasmJinwoong Cho, Young Jae Lee, Gummo Jung, Jiwoong Kim, YongKeun ChoBackground/Aim: Endoscopic mucosal resection (EMR) is now the treatment ofchoice for the adenoma or mucosal cancer in colon. But, carpet type growingtumor and remnant elevated lesion is difficult to be resected in en bloc bycoventional technique. So, we performed ESD in colorectal neoplasm. The aim ofstudy is to evaluate the usefullness and safety in relation to clinical and pathologicparameters, and complications. Methods: ESD of 63 colorectal neoplasms wasperformed from January 2004 to November 2007. Indication was restricted toadenoma or mucosal cancer, difficult to be resected by conventional EMR. Results:The mean size of lesions was 24 � 19 mm, and the size of the resected specimenwas 32 � 25 mm. Pathologic diagnoses were 16 adenocarcinoma, 28 LGD, 14 HGDand 5 others. En bloc resection were achieved in 57 (91%), and 6 lesions wereresected in piecemeal fashion. Sufficient lateral margin was achieved in 48 (76%)lesions. There were 6 episodes (9%) of bleeding, which were managedendoscopically. Perforation was occured in 8 (13%) cases, and 1 case was treated bysurgery. Conclusion: Piecemeal resection in colorectal neoplasm has beenassociated with high rate of recurrence. ESD let us to overcome the problem ofincomplete resection in large carpet or remnant colorectal lesion.

S1467

The Significance of Tissue Immunohistochemical Staining After

ESD of Early Gastric CancerHyun Gun Kim, Seong Hwan Kim, Joo Young Cho, Yu Seoung Seo,Tae Hee Lee, Jin-Oh Kim, Joon Seong Lee, So Young Jin,Chan Sup Shim, Boo Sung Kim, Seok R. ChoiBackgrounds/Aim: Gastric and intestinal phenotypic cell markers are expressed ingastric cancer irrespective of their histology. Factor VIII related antigen (Factor VIII)and vascular endothelial growth factor (VEGF), D2-40, Cytokeratin (CK) areassociated with lymphovascular invasion and micrometastasis. The aim of this studyis to evaluate the relationship between the markers of immunohistochemicalstaining (IHCS) and tumor depth and histology using the specimens after endoscopicsubmucosal dissection (ESD). Materials and Methods: We investigated 219 patients, whounderwent IHCS with EGC treated by ESD from May, 2005 to March, 2007. Phenotypicexpression was determined by examining the markers of MUC1, MUC2, MUC5AC,MUC6, and CD10. Tumors were classified into gastric, gastric and intestinal mixed,intestinal, unclassified phenotypes according to the immunopositivity of the above

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markers. The presence of Factor VIII related antigen, VEGF, D2-40, CK were alsodetermined all tumors. We compared the phenotypic cell marker according to histologyand the Factor VIII, VEGF, D2-40, CK according to histology, phenotype, and depth oftumor invasion. Results: 72 patients were presented with gastric phenotype (32.9%)whereas mixed (82/37.4%), intestinal (64/29.2%), and unclassified (1/0.5%), respectively.Gastric phenotype was significantly higher incidence in patients with poorlydifferentiated adenocarcinoma (P Z 0.001) and SM tumors (P ! 0.05). Factor VIII,D2-40, CK were higher positivity in poorly type adenocarcinoma according to histology(P ! 0.05). According to depth, Factor VIII, VEGF, D2-40, CK were higher positivity inSM cancers than M cancers (P ! 0.05). Among those phenotypes, Factor VIII, VEGF,D2-40 were higher positivity in gastric type (P ! 0.05). Conclusion: The markers ofIHCS associated with lymphovascular invasion and micrometastasis were related withtumor depth and histology. This study suggests IHCS is important to predict theprognosis of patients who underwent ESD, especially according to extended criteria forEGC and the patients who were positive immunohistochemical markers oflymphovascular invasion and micrometastasis after ESD shold be close followed-up.

S1468

Successful Endoscopic En Bloc Dissection of Gastric Masses

Using Rat-Toothed ForcepsArnab Biswas, Abraham MathewIntroduction: Endoscopic mucosal resection is a widely accepted diagnostic andtherapeutic method for the resection of mucosal and submucosal lesions. Althoughlarge SMLs may be resected by using piecemeal techniques, studies have shownhigh rates of recurrence compared with en bloc resection. Endoscopic submucosaldissection (ESD) is a newer technique utilizing a needle-knife to perform successfulen bloc resections after sodium hyaluronate or saline injection are used to raisea submucosal cushion. We elaborate on a new technique for en-bloc dissection ona variety of submucosal gastric masses using the rat-toothed forceps. Patients andMethods: Five patients between July 2006 and August 2007 (mean age 68.6) withgastric masses, deemed resectable after EUS exam was offered endoscopicresection. ESD was carried out using a single-channel video endoscope. Salineinjections of 5-10mL using a sclerotherapy needle were used to raise the lesion andsurrounding mucosa. Needle knife was used to incise three-quarters of thecircumference, about a centimeter away from the lesion base. Rat-toothed forcepswere used to enter the submucosal plane. Dissection of the submucosal lesion wasaccomplished by repeatedly opening and closing the forceps in both directionsfrom the incision. Once the mass was freed from the submucosal plane, a snare wasused to remove it in its entirety. Hemostasis for bleeding following dissection wascarried out with saline and epinephrine mixture injection. Further hemostasis andpartial closure of the dissection site was achieved by placement of endoscopic clips.Results: ESD was technically feasible in 5/5 patients (100%). The diameter of theresected lesions was 10-30mm (mean 21.mm). Complete en bloc resection of thelesion was possible in 4/5 patients, piecemeal resection was performed in 1/5patients. There was minor bleeding from the resection site in 3 cases. Three lesionswere gastrointestinal stromal tumors, one was carcinoid, and one was an invertedfundic gland polyp. Three lesions were in the cardia, one in the gastric body, andone in the antrum. No recurrence occurred following en-bloc-resection.Discussion: Endoscopic submucosal dissection using rat-toothed forceps isa promising technique in procedures requiring submucosal dissection like removalof submucosal lesions and tumors in the upper GI tract. This technique employsa readily available device and limits the usage of needle knife reducing the risk ofperforation. While it does involve a skilled endoscopist, it is easy to do. Our seriesdemonstrates successful en-bloc dissection of large submucosal masses byendoscopic means rather than by surgery.

S1469

Technical Feasibility and Clinical Impact of Circumferential

Endoscopic Submucosal Dissection (Circumferential ESD) for

Superficial Esophageal CancerHitomi Minami, Haruhiro Inoue, Shigeharu Hamatani, Shin-Ei KudoBackground: Endoscopic submucosal dissection (ESD) has become more widelyaccepted as less invasive and possibly curative treatment of early-stage esophagealcancer with remarkable advancement of endoscopy and other related devices.Circumferential dissection of esophagus has not generally accepted as a standardprocedure because of subsequent stricture. 216 cases were performed EMR/ESD inour institution, 6.9% of them had almost circumferential spreading of neoplasia butits invasion depth was still limited to superficial mucosal layer. Objective: Thepurpose of this study is to clarify the efficacy and drawbacks of circumferentialresection. Patients and Methods: This report describes about 8 cases of circulardissection which are aged 59 to 81 (mean 72.5 y.o.). All of them had almost or fullycircumferential disease. Lengths of resected area were 5 to 10cm long (mean 8 cm).One case was adenocarcinoma and the rest of them were squamous cell carcinoma.All the patients received ESD using Triangle Tip Knife (TT knife) or EMR-Captechnique. Our original Triangle Tip Knife was newly designed to be less traumaticand to decrease the risk of bleeding. All cases received preventive balloon dilationand were successfully prevented from stricture by frequent dilation. Dilation wasstarted in 2 or 3 days after ESD. Duration and frequency were 72 to 183 days (mean116 days) and 17 to 40 times (mean 23.6 times). Results: In all the cases,circumferential ESD was successfully performed. No major complication or related

lume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB143