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 evaluate the feasibility and clinical value of endoscopic decompression with metal stent and colorectal tube for acute malignant colorectal obstruction. Methods With the aid of fluoroscopy, 26 cases with acute malignant colorectal obstruction were treated. Their obstructive sites consisted of rectum(n=14), sigmoid colon(n=8), descending colon(n=2) and transverse colon(n=1). Results In 18 of 26 patients, metal stents were successfully inserted (18/20, 90%), in 6 cases colorectal tube were successfully inserted(6/6, 100%), the total technical success rate was 92. 3% (24/26). Thereafter, 1 patient has no effect, 23 patients showed relief of obstructive symptoms within 1-2 days, the clinical success rate was 88.5% (23/26). Permanent metal stent placements were performed in 13 cases for palliative treatment, 10 underwent subsequent elective surgical resection after 7 ~ 10 days, without complications, such as anastomotic leakage and intraperitoneal infection. One case was failed in recurrent rectal carcinoma after resection, one case with widespread metastatic sigmoid colon carcinoma occurred colon perforation and received immediate Hartmann operation. Recurrent obstruction was detected in one patient with distal stent migration within 6 weeks, and second stent were placed to solve the problems. Stent occlusion from stool impaction was found in one patient 1 month after stent insertion, and was solved by endoscpic interventions. Conclusion Endoscopic decompression with metal stent and colorectal tube can alleviate the acute malignant colorectal obstructive sympotoms with high success rate. It is a simple, safe, effective and well tolerated method, and can obviate colostomy, prominently reduce trauma and agony, and increase the living quality of patients.

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.

Objective To investigate the therapeutic effect and safety of endoscopic submucosal dissection (ESD) for upper gastrointestinal neuroendocrine neoplasms.Methods A total of 19 lesions diagnosed as neuroendocrine neoplasm were treated by ESD.Pathological diagnosis was performed.Adverse eventss were recorded.Patients were followed up for recurrence and metastasis.Results Lesions,0.4-1.5 cm (mean 0.9 cm) in diameter,were all resected at one ESD procedure.The operation time was 15-50 min (mean 20 min).No mass bleeding or perforation occurred.18 cases were histologically diagnosed as neuroendocrine tumors,with 16 as G1 and 2 as G2.One lesion was confirmed as G3 neuroendocrine carcinoma and the patient was referred for extensive surgery.All resected samples were free of residual tumor cell in the lateral and basal margins.Postoperative bleeding occurred in one case and was controlled endoscopically.No recurrence was detected during a mean follow-up of 28 months.Conclusion ESD,as a novel procedure for the treatment of the upper gastrointestinal neuroendocrine neoplasm,is safe and efficacious in clinic.

Objective To assess the effectiveness and safety of the technique of endoscopic submucosal dissection (ESD) in upper gastrointestinal lesions. Methods The patients with mucosal or submucosal lesions of upper gastrointestinal tract detected by gastroscopy were enrolled. Endoscopic ultrasonography and/ or biopsy were applied to confirm the size, location, and nature of the lesions. The procedure of ESD, involving the use of hook knife, insulation-tipped diathermic knife ( IT knife), and high-frequency electric coagulation, was as follows : first, identified the lesions by gastroscopy or mucosal staining and marked it with needle knife or argon plasma coagulation (APC) ; second, raised the submucosa through submucosal injection of indigo carmine and diluted epinephrine. Then, pre-cut the circumferential mucosa of the target lesion; finally, completely dissected along the submucosal layer. Acid-suppressing and mucosal protection agents were administered postoperatively. Follow-up endoscopy was taken at 1, 2, 6 months after ESD to evaluate the progression of the lesions. Results A total of 153 cases were enrolled from August 2006 to January 2008, of which 85 were mucosal lesions and 68 were submucosal ones. The mucosal lesions included 2 cases of ulcerating type, 48 of protruding type, and 35 of erosive type, with the diameter ranging from 0. 4 to 5. 0 cm (mean 2. 0 era). All the mucosal lesions were dissected through endoscopy, with the operation time ranging from 15 to 210 minutes (mean 55 minutes). One patient received emergency endoscopic hemostaais becauseof delayed hemorrhage, seven others were treated conservatively because of perforation. All the wound surfaces healed during the follow-up, including 4 cases of recurrence, of which 3 received second ESD, and 1 was referred to surgery. Among the submucosal lesions, 52 cases underwent endoscopic ultrasonography before ESD, and the others were diagnosed by postoperative histology. The diameter of the lesion ranged from 0. 4 to 4. 0 cm ( mean 1.2 cm). All the submucosal lesions were removed completely in 10 to 182 minutes(mean 41 min), except one patient was treated by endoscopic nylon ligation. Eleven patients were treated conservatively because of perforation, and one received surgery because of the uncontrolled bleeding. Conclusion As a minimally invasive method, ESD may present a novel and promising procedure in treating mucosal or submucosal lesions of upper gastrointestinal tract, with the advantage of achieving large en-bloc resections, low recurrence rate, and few complications.

Objective To determine the efficacy and safety of endoscopic submucosal dissection(ESD) for local residual and recurrent lesions in digestive tract after endoscopic mucosal resection (EMR).Methods From June 2006 to November 2007, 15 patients with local residual and recurrent lesions of digestive tract after EMR underwent ESD. The procedures of ESD were as follows: normal saline was injected into the sub-to elevate the lesions from the muscle layer, and the mucosa around the lesions were pre-cut, then the connective tissue of the submucosa beneath the lesions was dissected, and the scar beneath the lesion was re-sected along the plane of the submucosa with a Hook-knife. Results The mean diameter of 15 residual and re-current lesions after EMR were 2. 3 era(0.8 ～ 3. 5 cm), of which 6 lesions were located in stomach, 3 in colon and 6 in rectunm. All cases showed negative lifting sign due to scar formation. Fourteen lesions were completely re-sected and the overall resection rate was 93.3%(14/15). It was pathologically confirmed that 13 cases showed no tumor involvement in lateral and basal resection margins, and the complete resection rate was 86.7% (13/15).The mean operation time was 87 min(ranging from 60 to 155 min). Minor bleeding occurred during ESD in all ca-ses, but there was no postoperative bleeding. Two cases had free air in abdominal cavity due to deep dissection,but recovered with conservative treatment after ESD without surgical involvement. The perforation rate was 13.3%(2/15). The mean follow-up period was 13 months and no recurrence was recorded. Conclusion ESD proves to be a novel, safe and effective procedure for local residual and recurrent lesions after previous EMR, which makes it possible to resect the lesions completely and provide precise pathological information.

Objective To evaluate the clinical efficacy and safety of 4 types of endoscopic nylon ligation in the treatment of submucosal tumors in upper gastrointestinal tract. Methods Those with submucosal tumors located in esophagus, stomach or duodenum were enrolled in the study. All patients were treated with endoscopic nylon ligation, which included direct ligation, ligation with a transparent cap, ligation with dual-channel endoscope, and ligation in combination with endoscopic submucosal dissection (ESD).The patients were followed up endoscopically for evaluation of efficacy and safety of the procedures. Results A total of 128 patients were recruited into the present study from June 2006 to December 2008. The tumors were in esophagus in 28 patients, in stomach in 82 and in duodenum in 18. Direct ligation was applied in 3 patients, ligation with a transparent cap in 105, ligation with a dual-channel endoscope in 8, and ligation plus ESD in 12. Endoscopic follow-up was completed in 111 patients. Reduced lesion size was observed in 16 patients ( 14. 4% ), residue nylon in 16 ( 14. 4% ) and no lesion in 71 others (63.9%). The overall effective rate was 92.8%. No delayed perforation or bleeding occurred. Conclusion Endoscopic ligation with nylon thread in combination with other assistant approaches is effective and safe for the treatment of submucosal tumors in upper gastrointestinal tract.

Objective To evaluate the safety, indications and clinical efficacy of single balloon enteroscopy (SBE) for diagnosis of small bowel diseases. Methods Data of 30 patients (21 males and 9 females) with suspected small bowel diseases, who underwent SBE from June to September 2009, were retrospectively studied to analyze the access, procedure time and complications of SBE. Results A total of 35 SBE procedures were performed on 30 patients. Procedures were performed via oral, anal and the combined routes in 15, 10 and 5 cases, respectively, and definite diagnosis was made in26 cases (86. 7% ). The average access times via oral and anal routes were 49.7 min and 48. 6 min, respectively. Patietns showed normal vital signs during the procedures. No such procedure-related complications as cadiovascular events, severe abdominal pain, bleeding or perforation, were observed. Conclusion SBE is a safe and reliable diagnostic modality of high clinical value for small bowel diseases.

Objective To investigate the clinicopathological features of specific subtypes of laterally spreading tumor (LST) and assess the outcomes of endoscopic submucosal dissection (ESD) based upon differentiation status.Methods A total of 174 cases of colorectal LST,treated with ESD between January 2007 and April 2011,were divided into granular type (LST-G) and non-granular type ( LST-NG),and further divided into 4 subtypes,including homogeneous granular,nodular mixed,flat elevated and pseudo-depressed types.Clinicopathological data and ESD parameters were compared between the four subtypes.Results Nodular mixed tumors were larger than homogeneous tumors,needed longer operation time and were more frequently seen in malignant transformation,high grade intraepithelial neoplasm ( HGIN ) as well as submucosal invasive cancer.So were peeudo-depressed tumors compared with flat elevated ones ( P ＜0.01 ).There was no significant difference between LST-G and LST-NG in the parameters of ESD including en bloc resection rate,complete resection rate and complete cure resection rate.The complications tended to be more frequent in nodular mixed tumors (bleeding rate:4.6％; peroration rate:3.5％ ) and pseudo-depressed tumors ( bleeding rate:11.1％ ; perforation rate 11.1％ ),but there was no severe complication in either homogeneous tumors or fiat elevated tumors.One recurrent pseudo-depressed tumor was found 6 months after ESD treatment.Conclusion The degree of technical difficulty appears higher for nodular mixed and pseudo-depressed tumors than for homogeneous and flat elevated tumors,as is shown in procedure time and complication rate.ESD for these two subtypes should better be performed by experienced endoscopists.Accurate differentiation of the LST lesions is needed in basic and clinical research.