Objective:To determine risk factors for postoperative esophageal refractory stenosis after endoscopic submucosal dissection (ESD) of large-scale early esophageal carcinomas and precancerous lesions.Methods:Two hundred and twelve early esophageal carcinomas or precancerous lesions in 186 patients who underwent ESD larger than 3/4 the total esophageal circumference in Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, between July 2013 and December 2017 were divided into two groups according to session number of endoscopic balloon dilatation (EBD), the refractory stenosis group ( n=69, ≥6 EBD sessions) and non-refractory stenosis group ( n=117, ≤5 EBD sessions). Student′s t-test or Mann-Whitney U test was used for univariate analysis and χ2 test and Fisher exact test were used for comparison of categorical variables. Logistic regression was used for multivariate analysis. Results:Compared with the non-refractory stenosis group, the refractory stenosis group had statistically significant differences in the longitudinal diameter of lesions, the longitudinal diameter of artificial ulcer, lesion location, the circumferential range of lesions and the composition of the muscular layer injury (all P<0.05). After eliminating the factor of the vertical diameter of artificial ulcer (because there was significant correlation between the vertical diameter of artificial ulcer and the longitudinal diameter of lesion in clinical practice), multivariate logistic regression analysis showed that the longitudinal diameter of lesion>5 cm (VS ≤5 cm: P=0.003, OR=3.531, 95% CI:1.547-8.060), the location of lesion in the upper thoracic segment (VS lower thoracic segment: P=0.001, OR=36.720, 95% CI:4.233-318.551), in the cervical segment (VS lower thoracic segment: P=0.003, OR=24.959, 95% CI:2.927-212.795), the whole circumferential lesion (VS ≥3/4 but not the whole circumference: P<0.001, OR=10.082, 95% CI:4.196-24.226) and the presence of muscular layer injury ( P<0.001, OR=7.128, 95% CI:2.748-18.486) were more likely to lead to esophageal refractory stenosis after ESD. Conclusion:The longitudinal lesion diameter of more than 5 cm, the circumferential extent of esophageal ESD, cervical or upper-thoracic esophageal lesions, and muscular layer damage are independent risk factors for postoperative esophageal refractory stenosis after ESD for large-scale esophageal cancer and precancerous lesions.

OBJECTIVETo explore the risk factors contributing to the progression-free survival rate of patients undergoing endoscopic non-curative resection.

METHODSClinicopathological data of patients with early colorectal carcinoma and intraepithelial neoplasia undergoing endoscopic resection in our department from January 2009 to January 2015 were collected. Associated factors affecting the progression-free survival rate of the early colorectal carcinoma after endoscopic non-curative resection were analyzed. Any of the following conditions was defined as endoscopic non-curative resection: (1) positive lateral or vertical cutting margin; (2) submucosa invasion depth ≥1 000 μm; (3) vascular or lymphatic invasion; (4) low differentiation, including signet ring cell carcinoma or mucinous adenocarcinoma; (5) high grade tumor budding.

RESULTSClinicopathological data of 840 cases were collected. According to China's Endoscopic Screening, Diagnosis and Treatment Guidelines for Early Colorectal Cancer, 56(56/840, 6.7%) cases were defined as the non-curative resection, the metastasis or recurrence rate was 14.3%(8/56), 3-year progression-free survival rate was 85.7%(48/56), and 3-year overall survival rate was 94.6%(53/56). Univariate prognostic analysis showed that 3-year progression-free survival rate in low and moderate-high differentiation adenocarcinoma was 25.0% and 90.4%(χ=6.711, P=0.010), in patients with submucosa invasion depth ≥2 000 μm and <2 000 μm was 75.0% and 93.8%(χ=6.745, P=0.009), and in patients with and without vascular or lymphatic invasion was 60.0% and 88.2%(χ=7.708, P=0.005), whose differences were all significant. Multivariate Cox regression analysis revealed that low differentiation adencarcinoma (P=0.015, HR=8.021, 95%CI: 1.499-42.921), invasion depth ≥2 000 μm (HR=6.823, 95%CI: 1.299-35.848) and vascular or lymphatic invasion (HR=18.143, 95%CI: 2.079-158.358) were independent risk factors for the progression-free survival rate of the early colorectal carcinoma after endoscopic non-curative resection.

CONCLUSIONPathology after endoscopic non-curative resection for early colorectal carcinoma indicates that low differentiation adenocarcinoma, submucosa invasion depth ≥2 000 μm and vascular or lymphatic invasion are independent risk factors of poor prognosis.

OBJECTIVETo investigate the security and efficacy of a new endoscopic closure method of large defects after endoscopic full-thickness resection (EFTR) double purse-string suture using two endoloops and metallic clips via single-channel endoscopy.

METHODSClinical data of 23 cases with submucosal tumors (SMT) who received endoscopic resection from June 2015 to July 2016 in our National Cancer Center were collected. For gastric and esophageal SMTs or the mucosa layer injured during submucosal tunneling endoscopic resection (STER), double purse-string suture was conducted after EFTR. The key steps of closure were as follows: the endoloop was installed onto the delivery system and inserted into the gastric cavity to the defect location with endoscopy and then opened; the clips were transported into the gastric cavity from the biopsy channel; the endoloop was fixed onto the full thickness of gastric wall along the edge of the defect by clips one by one between the interval of about 5 mm; the endoloop was tightened slowly till the entire circumference of the defect was sutured, thus, one purse-string suture was done; in accordance with the operation above, another endoloop was released, and the second endoloop was fixed at 5-10 mm to the outer edge of the original one, and tied the endoloop gently; this sequence was continued till there was no gap, thus, the double-purse string suture was finished. A total of 23 patients were enrolled in the study, including 18 with gastric tumor and 5 with esophageal tumor, 15 males and 8 females, with the average age of 56 (19 to 76) years.

RESULTSEighteen cases of gastric SMT were successfully treated by endoscopic EFTR and double purse-string suture. The esophageal mucosa layer of all the 5 cases of esophageal SMT, including tumors of 3 cases located in cervical esophagus at 15-20 cm from the fore-tooth, 1 esophageal leiomyoma case complicated with squamous cell carcinoma in situ, and 1 case of mucosal layer injury during submucosal tunneling endoscopic resection (STER), was successfully repaired by using double purse-string suture. The mean maximum diameter of tumor was 2.3 cm, and the average suture time was 22.8 min. Postoperative pathology showed that 13 cases were gastrointestinal stromal tumors (GIST), 7 cases were leiomyoma, 2 cases were neurilemmoma, and 1 case was leiomyoma complicated with early squamous cell carcinoma in situ. No severe complications occurred during or after the operation.

CONCLUSIONSThe double purse-string suture by using metallic clips and endoloops with single channel endoscope is a relatively safe, easy, and reliable technique for repairing large gastric defect after EFTR. For cervical esophageal SMT, or the SMT combined with superficial mucosal lesions, and for the mucosa layer injury during submucosal tunneling endoscopic resection(STER), double purse-string suture is helpful to perform the closure.

OBJECTIVETo evaluate the efficacy of radiofrequency ablation(RFA) combined with endoscopic resection(ER) for eradicating widespread early non-flat type esophageal squamous cell carcinoma (ESCC) and precancerous lesions.

METHODSRetrospective analysis was performed on the clinical data of 4 patients with early non-flat type ESCC and precancerous lesions in January 2010 at the Cancer Institute and Hospital, Chinese Academy of Medical Sciences. Proportion of patients with histological complete response (CR) 3 months, 12 months to 5 years after operation and adverse events were observed.

RESULTSThese 4 patients were all male, aged from 47 to 71 (mean age 62) years, including 2 of ESCC, 1 of HGIN, 1 of MGIN confirmed by pathology. USL length was 6-12 (mean 8.5) cm. Treatment area (TA) length was 8-14 (mean 10.5) cm. Three cases were 0-II a (mean length 2 cm), and 1 case 0-II c (mean length 4 cm). Lesions of 2 cases were complete cycle, and other 2 cases occupied 3/4 circumference. Four patients completed their operations successfully. Total operation time was 42-105 (mean 66.8) min, RFA time was 3-12 (mean 8.25) min, and ER time was 6-20 (10.25) min, without bleeding and perforation. The mean hospital stay was 3 days. Pathology examination showed that 2 cases were ESCC G2 (lesion length 12, 8 cm; non-flat type lesion length 3, 4 cm), 1 was HGIN (lesion length 12 cm; non-flat type lesion length 1 cm) and 1 was MGIN (lesion length 6 cm; non-flat type lesion length 2 cm). Three cases were CR 3 months, 1 to 5 years after operation. One case had HGIN at 3-month and MGIN at 1-year and 3-year during follow up, and was CR after treatment with HALO. Postoperative esophageal stenosis occurred in 4 cases. Among them, 2 cases were mild without treatment, and 2 were severe, who were relieved by endoscopic water sac dilation for 5-8 (mean 6.5) times.

CONCLUSIONRFA combined with ER is effective and safe in the treatment of patients with early non-flat esophageal squamous cell carcinoma and precancerous lesions.

Aged ; Carcinoma, Squamous Cell ; surgery ; Catheter Ablation ; Esophageal Neoplasms ; surgery ; Esophageal Stenosis ; Esophagoscopy ; Humans ; Male ; Middle Aged ; Operative Time ; Retrospective Studies ; Treatment Outcome

Objective: To evaluate the short-term outcomes and safety of submucosal tunneling endoscopic resection (STER) for submucosal tumors (SMT) originating from muscularis propria (MP) layer at esophagogastric junction. Methods: The clinical data of 31 patients with SMT originating from MP layer at esophagogastric junction underwent STER were collected and retrospectively analyzed. Results: The success rate of STER of the thirty-one patients was 100%. The mean tumor size was (2.5±1.3) cm and the average operative time was (95.9±56.7) min. Perforation occurred in 3 patients and was successfully clipped by endo-clips during operation. One patient developed delayed bleeding and the bleeding was stopped by endoscopic hemostasis. Twenty-nine leiomyomas and two stromal tumors (GIST) were finally pathologically diagnosed. No local recurrence and distant metastasis were noted during the mean 15.4 months follow-up of 20 cases. According to the lesion size, 31 patients who received STER were divided into two groups. The operation time of maximum diameter ≥3.5 cm group was (134.0±70.6) min, significantly longer than (80.3±42.6) min of maximum diameter <3.5 cm group (P=0.014). However, the en bloc removal rate, postoperative hospital stay and the complication incidence between the two groups had no obvious differences (P>0.05). Univariate analysis showed that the piecemeal removal group had longer tumor diameter, higher incidence of irregular tumor morphology, and longer operative time than the en bloc removal group (all P<0.05). Stepwise logistic regression analysis showed that irregular shape was a risk factor for failure of en bloc removal (OR=18.000, 95% CI: 1.885~171.88, P=0.012). Conclusion As a new method of minimally invasive treatment, STER technology appears to be a safe and effective option for patients with SMT originating from MP layer at esophagogastric junction.

Objective To compare the efficacy, safety, and the life quality of patients with early gastric cancer ( EGC) between endoscopic submucosal dissection ( ESD) and surgical treatment. Methods A total of 460 cases with EGC receiving endoscopic therapy or surgical treatment were collected from October 2009 to January 2015 in the Cancer Hospital, Chinese Academy of Medical Sciences. The clinical efficacy and life quality of ESD and surgical treatment for EGC patients were retrospectively analyzed. Results There were 434 cases collected in the study, including 208 cases ( 229 lesions) in the ESD group and 226 cases in the surgery group. For the short-term clinical outcomes of the ESD group, the hospitalization time ( 7. 85 ± 3. 18 d VS 16. 68±5. 89 d, P<0. 001), hospitalization cost (3782. 30±1898. 84 CNY VS 9685. 60± 3643. 97 CNY, P<0. 001 ) and complications [ 0 ( 0/208 ) VS 6. 2% ( 14/226 ) , P<0. 001 ] were statistically different compared with those of the surgery group. For the long-term clinical outcomes, there was no statistical significance on recurrence rate[0. 4%(1/229) VS 0. 9% (2/226), P=0. 622] between the two groups. The cumulative multiple hazard probability curve showed that the ESD group had a significantly higher risk of multiple primary lesions than the surgery group ( P=0. 004) after the same follow-up period. In order to exclude the influence of confounding factors, COX regression model was used to control the age and other factors, and multiple primary risks of the two groups were also statistically significant ( P=0. 013) . The health score of self-evaluation and life quality between the two groups were statistically significant ( P<0. 001) . Conclusion For the short-term clinical outcomes, the ESD group was better than the surgery group. For the long-term clinical outcomes, multiple primary risks were higher in the ESD group than those in the surgery group, but most of the multiple primary cases were successfully treated with a second ESD. The health score of self-evaluation and life quality were better in the ESD group than those in the surgery group.

Objective To investigate the safety and feasibility of laparoscopic wedge resection for gastric gastrointestinal stromal tumors ( GIST ) . Methods One hundred GIST patients treated in our department between 2010 and 2014 were retrospectively enrolled, and their clinicopathological data were reviewed. Fifty patients underwent laparoscopic wedge resection, and open surgery cases were 1 ∶ 1 matched by tumor diameter. The clinicopathological characteristics, perioperative related factors, postoperative nutritional status and short?term outcome were compared between the two groups. Results Among the clinicopathological characteristics, only the age was of statistical significance (61.58±10.43 vs. 56.40±9.82, P=0.012) . Over fifty percent of the tumors occurred in the gastric body. Although the short?term survival did not show statistical significance, the laparoscopic group showed predominant advantages in estimated blood loss [(48.60±48.89) ml vs. (137.60±140.69) ml, P<0.001], average hospital stay[ (12.14±4.32) d vs.(17.22±7.11) d, P<0.001], oral intake time[ (3.76±1.73)d vs. (6.28±3.73)d, P<0.01], decline of prealbumin [(0.07±0.04)g/L vs. (0.11±0.05)g/L, P<0.001)], decline of transferrin [(0.51±0.29)g/L vs. (0.64±0.30) g/L, P=0.034] and complication (2.0% vs. 14.0%, P=0.027). Conclusion Laparoscopic wedge resection is feasible and safe for GIST surgery, allows a rapid recovery and having a better nutritional status in patients, and is a less invasive approach for patients.

Objective:To analyze the long-term therapeutic effect of endoscopic submucosal dissection (ESD) on the treatment of early gastric cancer (EGC).Methods:We retrospectively reviewed EGC patients who underwent ESD at Cancer Hospital, Chinese Academy of Medical Sciences (CAMS), from January 2009 to December 2016. The incidence rates of local recurrence, synchronous cancer and heterogeneous cancer were analyzed. Kaplan-Meier method was used to analyze 5-years recurrence free survival (RFS) and 5-years disease special survival (DSS) of all patients.Results:A total of 255 EGC patients were enrolled in this study, included 175 differentiated early gastric cancer (D-EGC) patients and 80 undifferentiated early gastric cancer (UD-EGC) patients. Among them, 171 patients within the extended indication of ESD while 84 patients beyond the extended indication of ESD. Among the 225 patients, the incidence rates of local recurrence, synchronous cancer and heterogeneous cancer were 2.0%, 2.0% and 2.4%, respectively. The local recurrence rates of D-EGC group and UD-EGC group was 1.7% and 2.5%, respectively, without significant difference ( χ2=0.176, P=0.675). The incidence rates of synchronous and heterogenous cancer in the D-EGC group were 2.3% and 3.4%, higher than 1.2% and 0 of UD-EGC group, although there was no significant difference ( χ2=0.306, P=0.580 vs χ2=2.809, P=0.094). There were no significant differences in 5-years RFS (91.3% vs 95.9%, P=0.236) and 5-years DSS (100% vs 98.6%, P=0.156) between D-EGC group and UD-EGC group. Conclusions:The long-term outcome of ESD in the treatment of EGS is good. More attention should be paid to the occurrence of local recurrence and heterogeneous cancer in EGC patients undergo ESD. These patients still have a good long-tern outcome even undergoing ESD for more than once.

Objective:To analysis the clinical and follow-up data of the early colorectal carcinoma (ECC) after endoscopic resection, and explore the long-term outcome of patients who underwent the endoscopic resection.Methods:During June 2008 to June 2016, data of endoscopic resection for 550 cases of ECC were collected, including general information and follow-up data. The influence factors of disease-free survival rate of ECC after endoscopic resection were analyzed and the risk factors on long-term outcomes such as submucosa invasion depth, poorly differentiated adenocarcinoma, vascular invasion and positive vertical margin were investigated.Results:The mean follow-up time of 550 patients treated with endoscopy was (60.7±36.8) months. Among them, 433 cases were high-level intra-mucosal neoplasia, 117 cases were submucosa invasion carcinoma (the invasion depth <1 000 μm were 33 cases, ≥1 000 μm were 84 cases), 461 cases were curative resection, while 89 cases were non-curative resection. During the follow-up, 6 patients occurred recurrence or metastasis, including 2 patients with local recurrence (1 patient accompanied by lymph node metastasis) and 4 patients with lymph node metastasis (2 patients accompanied by distant metastasis). The overall 5-years disease-free survival rate was 98.8%, the 5-years disease-free survival rate was 100.0% for patients with curative resection and 93.3% for patients with non-curative resection. A total of 89 cases underwent non-curative resection were accompanied with invasion depth ≥1 000 μm, vascular invasion, poorly differentiated adenocarcinoma and positive vertical margin. Among them, 62 cases were accompanied with 1 risk factor, 23 cases with 2 risk factors and 4 cases with 3 risk factors. The risks of lymph nodes and distant metastasis raised with the increase of risk factors.Conclusions:The incidence of lymph node metastasis in ECC is extremely low. Endoscopic treatment can achieve a good long-term outcome. Close follow-up should be conducted after endoscopic treatment, and additional treatment should be selected reasonably for the early colorectal carcinoma after endoscopic non-curative resection to improve the therapeutic efficacy of endoscopic resection.

Objective:To explore the short and long-term outcomes of endoscopic piecemeal mucosal resection including endoscopic mucosal resection (EMR) and multiband mucosectomy (MBM) for superficial esophageal carcinoma and precancerous lesions, and analyze the risk factors for prognosis.Methods:From March 1 2001 to May 31 2017, 371 patients with 416 lesions who were diagnosed as superficial esophageal carcinoma or high-grade intraepithelial neoplasm and underwent EMR or MBM were retrospectively enrolled in this study. Long-term recurrence free survival (RFS) rate and the risk factors, including submucosal invasion, poorly differentiation, vascular invasion and positive vertical margin, for the long-term outcome were also analyzed.Results:The incidence of complication was 17.1% in the EMR group and 17.4% in the MBM group, without significant difference ( P=1.000). The median follow-up period was 70.6 months. The 5-years RFS was 93.9% and 10-years RFS was 87.8%, respectively. Local recurrence was found in 2 cases in each group and they were curatively treated by endoscopic submucosal dissection. Heterogeneous multiple primary esophageal cancer was diagnosed in 5 and 3 cases for the EMR and MBM group, of whom 5 cases were curatively treated with endoscopic resection. Other 3 cases were diagnosed with advanced esophageal cancer, of whom 2 patients died. Lymph node metastasis (LNM) was found in 5 cases in the EMR group and 4 cases in the MBM group, of whom 6 patients died. Distant metastasis was found in 5 cases in the EMR group and 3 cases in the MBM group, of whom 5 patients died. There were 83 patients combined with risk factors including submucosal invasion, poorly differentiation, vascular invasion and positive vertical margin, of whom 8 patients were diagnosed as LNM and 8 patients as distant metastasis. The 5-years RFS of patients with 1, 2, and 3 risk factors were 93.6%, 82.2%, and 25.0%, and the difference was statistically significant ( P<0.001). Conclusions:EMR and MBM are both safe and feasible procedures for superficial esophageal carcinoma and precancerous lesions. Additional treatments should be selected according to the variety of risk factors to acquire better long-term outcome and life quality.