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 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 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 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 analyze the risk factors for postoperative stricture after endoscopic submucosal dissection (ESD) for early stage esophageal cancer.Methods The data of 362 patients with early esophageal cancer treated by ESD from January 2007 to February 2012 were reviewed to investigate the risk factors of postoperative stricture.Results Esophageal stricture after ESD occurred in 42 patients (11.6％)with a mean time from ESD to stricture of (58.5 ± 12.3) days.The rates of mild,median and severe stricture were 16.7％ (7/42),38.1％ (16/42) and 45.2％ (19/42),respectively.Multivariate analysis revealed that lesion range ＞ 3/4 esophageal circumference (odds ration [OR]:44.2 ; 95％ confidence interval [CI]:4.4-443.6) and tumor invasion beyond m2 (OR:14.2; 95 ％ CI:2.7-74.2) were independent risk factors.Stricture level was related to lesion's circumferential extension (relational coefficient (φ) =0.47,P ＜ 0.05) and tumor invasion depth (relational coefficient (φ) =0.647,P ＜ 0.05).Conclusion Circumferential extension and invasion depth of early esophageal cancer were independent risk factors for post-ESD esophageal stricture and related with the degree of stricture.

ObjectiveTo evaluate the clinical efficacy and safety of nylon ligation combined with endoscopic high-frequency electric snare for the treatment of colorectal polyps.MethodsThe clinical data of 345 patients with colorectal polyps who received the treatment of nylon ligation combined with endoscopic high-frequency electric snare at the Zhongshan Hospital of Fudan University from January 2006 to January 2011 were retrospectively analyzed.Complications including bleeding and perforation were observed.Postoperative wound healing and local residual recurrence were assessed during follow-up.ResultsA total of 362 colorectal polyps were successfully removed.The mean diameter of the colorectal polyps was 2.7 cm (range,1.5-4.0 cm). Operative bleeding occurred in 1 patient,and perforation in 1 patient.The results of histological examination showed that 93.6％(339/362) colorectal polyps were adenoma,17 were hyperplastic polyps,5 were inflammatory polyps,and caneeration of colorectal polyps in 1 patient was detected.Endoscopic follow-up was completed in 334 patients at the first month after operation,and 9 patients with residual benign colorectal polyps received endoscopic resection.No residue or recurrence was found in the other patients.Endoscopic follow-up was completed in 308 patients at the second months after operation,and no residue or recurrence was found.The overall effective rate was 97.1％ (299/308).ConclusionEndoscopic nylon ligation combined with endoscopic high-frequency electric snare is effective and safe for the treatment of colorectal polyps.

Objective To evaluate the clinical efficacy and safety of metallic hemoclips in the treatment of gastric defects during endoscopic full-thickness resection. Methods Patients with submucosal tumors derived from the muscularis propria and adhesion of the gastric serosa diagnosed by EUS and CT were enrolled in the study.A total of 62 patients,22 males and 40 females,mean age 58.5 years,were recruited into the present study from June 2009 to December 2010,in which 37 patients were with tumors in gastric fundus,20 in gastric body and 5 in antrum.All patients were treated with endoscopic full-thickness resection.After the operation,metallic hemoclips were used to close the defects through endoscopic biopsy channel.The closure success rate with metallic hemoclips were assessed.The patients were followed up endoscopically for evaluation of efficacy and safety of the procedures.Results All patients underwent endoscopic full-thickness resection.Uncontrollable bleeding occurred in 1 patient,who subsequently underwent emergent laparoscopic surgery and was excluded from the study.Metallic hemoclips were applied to close defects in 57 patients,and metallic hemoclips combined with omentum obstruction in 4 patients.The overall success rate was 100％ in 61 patients.Endoscopic follow-up was completed in all patients in average of 4.4 months.The clinical wound healing rate was 100％.No complications such as fever,abdominal pain were found in 2months after the procedures.Conclusion Application of metallic hemoclips during endoscopic full-thickness resection for gastric defects is a safe and effective technique.

ObjectiveTo evaluate a second endoscopy for prevention of delayed bleeding after ESD.MethodsData of 67 patients with gastric epithelial neoplasms undergoing ESD from May to November 2011 were reviewed.The median age was 63 ( 31 ～ 84) years.All patients were followed up by endoscopy on the first and the third day after ESD.ResultsOf 67 lesions,5 were located at cardia,6 at gastric body,3 at fundus,35 at antrum,16 at gastric angle,and 2 at residual stomach.The mean maximum diameter of the lesions was 3.73±4 1.24 (2.0 ～ 7.0) cm.There were no intraoperative complications.Post-ESD delayed bleeding was detected by endoscopy in 6 (9.0％ ) patients,with 5 on the third day and 1 on the fourth day.Forrest grading showed 2 cases of Ⅰ b,and 4 of Ⅱ b.All 6 cases were cured by endoscopy.The incidence of postoperative bleeding was far more than that evaluated based on the patients' clinical manifestations only.But therapeutic effect and saffety were the same according to the follow-up results.ConclusionIncidence of post-ESD bleeding is high,but there are no symptoms or severe consequences,so a second endoscopy after gastric ESD may contribute little to the prevention of delayed bleeding.