Objective To assess the clinical efficacy and safety of endoscopic submucosal dissection(ESD) for submucosal tumor(SMT) of the gastrointestinal(GI) tract.Methods A total of 19 patients with SMT of the GI tract diagnosed by endoscopy(6 in the esophagus,6 the stomach,1 the duodenum,1 the sigmoid,and 5 the rectum),were examined using endoscopic ultrasonography(EUS).Among the cases,18 lesions were within the submucosa and 1 in the muscularis propria.The SMTs were managed by ESD with a needle knife.After injection of physiological saline solution into the submucosal layer to separate the lesion from the muscle layer,the mucosa surrounding the lesion was pre-cut,and the connective tissues of the submucosa beneath the lesion were dissected.Then,the lesion was resected completely.Results The resected lesions sized 0.5-3.0 cm in diameter(mean,1.6 cm).Among the 19 lesions,18 were successfully resected with ESD.The mean ESD procedure time was 45 min(ranged from 15 to 105 min).Two patients had massive hemorrhage during ESD,which could not be controlled under a gastroscope.One of them was treated with balloon compression,and the other was managed surgically.None of the patients had delayed bleeding after ESD.Perforation of the GI tract occurred in 2 cases(the duodenal ball in one,and the gastric fundus in another) during the procedure,and was closed with endoclips without surgical treatment.One patient with rectal carcinoid developed subcutaneous emphysema after the operation owning to deep tearing of the muscle layer,and recovered after several days' conservative treatment.Histological evaluation showed that the tunica of the tumors was intact,and both the lateral and basal margins of the specimens were free of tumor cells.Conclusions ESD is an efficacious and safe procedure for the treatment of SMT of the GI tract.It is possible to completely resect submucosal lesions and provide sufficient pathological information.For the SMT originated from the muscularis propria,ESD should be performed cautiously.

Objective To discuss the value of endoscopy in the diagnosis and treatment of Dieulafoy disease. Methods Twenty-one patients with upper gastrointestinal bleeding caused by Dieulafoy disease from June 1994 to June 2002 were analyzed retrospectively with regard to endoscopic features, therapeutic methods and outcomes. Results Of the 21 cases, diagnosis was confirmed in the first endoscopic examination in 15 cases (71.4%), and in two or more examinations in 6 cases. The bleeding was successfully stopped under endoscope in 17 cases: after the initial treatment in 14 cases (66.7%) and after the second treatment in 3 cases (14.3%), while the open surgery was required in 4 cases (19.0%). Conclusions Endoscopy is the alternative of the first choice in the diagnosis and treatment of Dieulafoy disease.

Objective To assess the value of endoscopic submucosal dissection(ESD)for the treatment of early tumors located at the esophagogastric junction.Methods The clinical data of 57 patients with early tumors located at the esophagogastric junction who received ESD at the Zhongshan Hospital from November 2006to March 2011 were retrospectively analyzed.The operation time,blood loss,resection of tumor and perioperative complications were observed.The pre-and postoperative pathological findings were analyzed.Results ESD was successfully completed on the 57 patients.The median operation time was 55 minutes(range,25-95 minutes),and the median volume of blood loss was 74 ml(range,20-300 ml).En-bloc and piecemeal resections were carried out on 39 and 18 patients,respectively.The operative complication rate was 25%(14/57),including 5 patients complicated with perforation and 9 with bleeding.The postoperative complication rate was 16%(9/57),including 6 patients complicated with delayed hemorrhage and 3 with stricture of the esophagogastric junction.Of the 39 patients who were diagnosed as with high-level intraepithelial neoplasia preoperatively.3 were confirmed as with intramucosal carcinoma;of the 18 patients who were diagnosed as with intramucosal carcinoma preoperatively,4 were confirmed ag with adenocarcinoma.All patients were followed up for 9-27 months,no recurrence or metastasis was found.Conclusion ESD is effective and safe for the treatment of early tumors located at the esopha gogastric junction.

Objective To evaluate the efficacy of self-expanding metallic stents(SEMS)for acute proximal colon obstruction due to colon carcinoma.Methods From September 2004 to June 2010, a total of 81 patients(47 males and 34 females, aged 18-94 yr, mean 66.2 ± 7.5 yr)with acute proximal colon obstruction(proximal to spleen flex)caused by colon carcinoma were treated by SEMS.The success rate of stent drainage, safety of the procedure and the surgical removal rate of the carcinoma were evaluated.Results The tumors were located in transverse colon in 18(22.2%)patients, in hepatic flexure in 42 (51.9%)and in ascending colon in 21(25.9%).The success rate of stenting was 100%(81/81), and endoscopic decompression using SEMS placement was technically successful in 78 of 81 patients(96.3%).92.3%(72/78)patients underwent radical surgery 8 ± 1 days after stenting, among whom 5 underwent simultaneous hepatic metastasis foci resection and 3 others received partial resection of duodenum.Incidence of postoperative complications was 4.2%(3/72), including one case of poor healing and 2 cases of cardiopulmonary complications, which were all cured with conservative treatments.No perioperative death occurred.Conclusion Management of acute proximal colon obstruction due to colon carcinoma by using SEMS placement is effective and safe, which can be considered as a bridge method before curative surgery.

Objective To analyze the etiology of pseudoachalasia.Methods Patients who were diagnosed as having pseudoachalasia in Endoscopy Center of The Affiliated Zhongshan Hospital of Fudan University from September 2010 to June 2015 were retrospectively analysed.Results A total of 12 patients were enrolled in this study,6 males and 6 females.The median age,median disease duration and median Eckcardt score was 54.5(24.0～71.0) years old,2.5(0.2～ 10.0) years and 4(3～9),respectively.Seven cases were caused by malignant tumors,2 had benign tumors,and 3 peptic stricture.Conclusion The most common cause of pseudoachalasia is malignant tumors.Accurate diagnosis relies on the comprehensive medical history and complete examinations.

ObjectiveTo assess the clinical application of endoscopic submucosal dissection(ESD) for early esophageal carcinomas and pre-malignant lesions. MethodsESD was performed for early esophageal carcinomas and intraepithelial neoplasms without submucosal infiltration. First, normal saline was injected into the submucosa to elevate the lesion from the muscle layer. Then, the surrounding mucosa of the lesion were cut, and the lesion was dissected along the connective tissue of the submucosa. ResultsOf 15 early esophageal carcinomas and intraepithelial neoplasms, ranging from 2.5 to 4.5 cm (mean size 3.2 cm) , 14 (93.3%) underwent ESD successfully . All 14 lesions were confirmed pathologically, and no basal or dissected margin was involved. The mean ESD procedure time (from fluid injection to complete dissection) was 75 min ( ranging from 45 to 150 min). Minor bleeding (mean volume 30 ml) occurred in all lesions, which was stopped by electric coagulation, argon plasma coagulation and clamps. No delayed bleeding occurred. The perforation rate of ESD was 0(0/15). Fourteen patients were followed up after ESD for 6 to 18 months (mean=11.5), and healed with no residue or recurrence. ConclusionESD is a novel endoscopic procedure to reseet early esophageal carcinomas and pre-malignant lesions, with which large lesions can be resected and pathological information can be provided.

ObjectiveTo investigate the managements of complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA).MethodsData of 119 EA patients who underwent POEM from October 2010 to July 2011 were collected.Complications during and after POEM and during follow-up were analyzed.Results Complications during operation included bleeding in 19 patients ( 16.0％ ),mucosa rupture in 9 (7.6％),mediastinal and subcutaneous emphysema in 27 (22.7％ ) and pneumothorax in 3 (2.5％ ).Complications occurred at the night of procedure included pain in 43 (36.1％ ) patients and pneumothorax in 7 ( 5.9％ ).Postoperative complications included asymptomatic pneumothorax in 23 patients (19.3％),delayed hemorrhage in 1(0.8％),pleural effusion in 58 (48.7％ ),minor pulmonary inflammation or segmental atelectasis in 59 (49.6％),emphysema of mediasti-na and subcutaneous tissue in 76 (63.9％ ),and gas under diaphragm or aeroperitoneum in 47 (39.5％ ).Complications during follow-up included one case of dysphagia caused by stricture of mucosa and one case of dehiscence at the tunnel entry with food retention.No POEM-correlated death occurred.All the complications were cured by conservative treatments.No additional surgery was needed.ConclusionMain complications as emphysema of mediastina and subcutaneous tissue,pneumothorax,aeroperitoneum and bleeding during and after POEM can be treated timely and effectively with conservative treatment.

Objective To evaluate the clinical value of endoscopic piecemeal mucosal resection (EPMR) and endoscopic submucosal dissection (ESD) for treatment of esophageal mucosal lesion with diameter larger than 15 mm.Methods The data of 261 patients with esophageal mucosal lesions ≥15 mm and undergoing ESD (n=198) or EPMR (n=63) in Endoscopy Center of Zhongshan Hospital from September 2009 to August 2011 were retrospectively analyzed.Therapeutic effect, complications, and local recurrence were compared between the two groups.Results The lesion size was significantly larger in the ESD group than that in the EPMR group (3.02±1.13 mm VS 2.66±0.95 mm, P<0.05).The rates of en bloc resection, complete resection, and curative resection were 100% (198/198), 96% (190/198), and 94% (187/198), respectively in the ESD group.Only samples with horizontal margin obtained the pathological assessment in the EPMR group, and 2 cases were positive.The incidence of short-term complications including massive bleeding and perforation was no statistically different (P>0.05) between the two groups.The rate of postoperative esophageal stricture was higher in the EPMR group than that of the ESD group [22.6% (14/62) VS 6.2% (12/194),P<0.05] except for 5 cases with further surgery treatment (4 cases in the ESD group and 1 case in the EPMR group).The local recurrence rate was also higher in the EPMR group than that of the ESD group [11.5% (7/61) VS 3.7% (7/190), P<0.05], except for 10 cases with positive margin.Conclusion The therapeutic effect of ESD is superior to that of EPMR for esophageal mucosal lesions with diameter larger than 15 mm due to lower rate of local recurrence and acceptable complications.

Objective To evaluate the efficacy and safety of endoscopic submucosal dissection for the treatment of colorectal large laterally spreading tumor. Methods ESD was applied to treat 150 cases of colorectal LST with diameter larger than 4 cm. The morphological features of LST, distribution, the clinicopathological data and the en-bloc resection rate, complete resection rate, complications were retrospectively evaluated. Results There were 87 patients with LST-granular lesions and 63 patients with LST-nongranular lesions. Colorectal LST mainly distributed in the rectum for 109 cases (72.7%), sigmoid colon for 13 cases (8.7%), descending colon for 5 cases (3.3%), transverse colon for 8 cases (5.3%), ascending colon for 13 cases (8.7%), cecum for 2 cases (1.3%). There were 23 patients with low-grade neoplasia, 104 patients with high-grade intraepithelial neoplasia, 7 with intramucosal carcinoma and 16 with submucosal carcinoma. The en-bloc resection rate and complete resection rate were 92.7% (139/150) and 89.3%(134/150). Adverse events were intra-operative bleeding in 12 patients (8.0%), postoperative bleeding in 2 patients (1.3%), perforation in 3 patients (2.0%), postoperative stenosis in 3 patients (2.0%). Conclusion Colorectal large LST-NG has higher potential for malignancy. ESD is a safe and effective method to provide en-bloc and complete resection of colorectal large LST.

Objective To investigate the necessity of adding epinephrine to submucosal injection during endoscopic submucosal dissection(ESD).Methods Patients with early cancer and precancerous lesions of digestive system were prospectively enrolled and underwent ESD when the lesion was 2 cm or more in diameter from December 2013 to January 2014.Patients were randomly divided into two groups,the experimental group(n =54)used saline and indigo carmine for submucosal injection,while the control group(n =47) used a mixed solution including saline,indigo carmine and epinephrine for submucosal injection.Several procedure-related indices and delayed complications were compared between groups.Results All the tumors in both groups were removed en bloc,and all resected lesions showed both lateral and deep tumor-free margins.The mean operation time was 39.4 ±22.0 min in the experimental group,and 41.5 ± 18.7 in the control group.There were no statistical differences between two groups in the en bloc resection rate,complete resection rate,and mean operation time (all P ＞ 0.05).There were no intraoperative or delayed perforations in either group.In the experimental group,mild intraoperative bleeding occurred in 39 cases and moderate in 15 cases.In the control group,mild intraoperative bleeding occurred in 34 cases,moderate in 12 cases,and severe in 1 case.Delayed bleeding occurred in 1 case 3 days after ESD in the experimental group,while none happened in the control group.There were no statistical differences between two groups in intraoperative bleeding or delayed bleeding(P ＞ 0.05).Conclusion The therapeutic effect and complication rate are comparable regardless of addition of epinephrine to submucosal injection during ESD.