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Laparoscopic mesh for massive esophageal hiatal hernia

Fusheng ZOU ; Mingfang QIN ; Wang CAI ; Hongzhi ZHAO

Chinese Journal of Digestive Endoscopy.2010;27(12):636-638. doi:10.3760/cma.j.issn.1007-5232.2010.12.007

Objective To assess the clinical outcome of massive hiatal hernia repair by mesh via laparoscopic approach. Methods A total of 31 patients with massive hiatal hernia who underwent laparoscopic repair from March 2005 to January 2009 were enrolled in the study, among which mesh was used in 20 patients. The clinical outcomes of these patients were compared with other 11 patients without mesh repair procedures. Results Surgical repair, combined with Dor fundoplication, was successful in all 31 cases.Five patients in the mesh group developed post-operative recurrent symptoms, 2 ( 10% ) of whom were confirmed by imaging study. Six patients in non-mesh group had recurrent symptoms after operation and 4 (36. 4% ) were confirmed. Conclusion Laparoscopic repair of massive hiatal hernia is technially demanding with a high post-operative recurrent rate. Administration of intro-operative mesh can reduce the difficulty of the procedure and recurrence as well.

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Feasibility of application of anti-reflux metallic stent for malignant biliary obstruction

Tiantian WANG ; Bing HU ; Yamin PAN ; Zhimei SHI ; Shuzhi WANG ; Rui LU ; Hui HUANG ; Shuping WANG

Chinese Journal of Digestive Endoscopy.2010;27(12):632-635. doi:10.3760/cma.j.issn.1007-5232.2010.12.006

Objective To evaluate the safety and efficacy of a newly designed anti-reflux metallic stent (ARMS) for malignant extra-hepatic biliary obstruction. Methods A total of 23 patients with unresectable biliary malignancy in the middle or lower part of common bile duct underwent endoscopic retrograde cholangiopancreatography (ERCP) and ARMs placement. The success rate, early complications, stent patency and patients' survival were recorded. Results The ARMSs were successfully placed in all patients and no procedure-related complication was recorded. The average operation time was similar to that of self-expanding metallic stents (SEMs). In 22 patients completing the follow-up, the total serum bilirubin dropped to normal within one month in 20. ARMs dysfunction occurred in 6, including tumor in-growth in 1, overgrowth in 2, and stent dislodgement in 3. Other patients were free of biliary symptoms until death or at the end of follow-up. The average stent patency of ARMs was 14 months. Patency rates at 3, 6, and 12 months were 95%, 74% and 56%, respectively. The mean patient survival was 7. 9 months ( 1-14 months).Postoperative survival rates at 3,6 and 12 months were 91.0%, 81.3% and 17. 2%, respectively. Conclusion Endoscopic placement of novel ARMs in patients with extra-hepatic biliary tumors is feasible,safe and effective.

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Expression of CXC chemokine receptor 4 in Barrett esophagus, esophageal adenocarcinoma and esophageal squamous cell carcinoma and its clinical significance

Chao ZHANG ; Hui TANG ; Lin LI ; Xinmin YAN ; Qiang GUO

Chinese Journal of Digestive Endoscopy.2010;27(11):589-593. doi:10.3760/cma.j.issn.1007-5232.2010.11.009

Objective To investigate the expressions of CXCR4 in Barrett esophagus (BE), esophageal adenocarcinoma (EADC) and esophageal squamous cell carcinoma (ESCC), and its relationship with pathology, clinical staging and lymph node metastasis. Methods The expressions of CXCR4 in 56 cases of normal esophageal mucosa, 80 BE (including 22 BE with multifocal dysplasia), 25 EADC and 48 ESCC were examined with immunohistochemical method. Results CXCR4 was expressed in most samples of BE (80. 8% ), EADC (68. 0% ) and ESCC (78.4%) without significant difference ( P ＞ 0. 05 ), which was significantly higher than that in normal esophageal mucosa (39. 3%, P ＜0. 01 ). The level of CXCR4 expression in BE, EADC or ESCC were not related with gender, age, or location of the foci ( P ＞ 0. 05). There was no significant difference in CXCR4 expression between BE without dysplasia or BE with multifocal dysplasia ( P ＞ 0. 05 ). CXCR4 expression level in well-differentiated EADC was significantly higher than that of mild or poorly differentiated (P ＜ 0. 05 ). CXCR4 expression level was higher in EADC with lymph node metastasis than those without ( P ＜ 0. 05 ). CXCR4 level in ESCC with TNM staging grades Ⅲ -Ⅳ was higher than that of grades Ⅰ - Ⅱ, and this variable was also higher in cases with lymph node metastasis than those without (P ＜ 0. 05), so was the case of well and poorly differentiated ESCC (P ＜ 0. 01 ). Conclusion Increased expression level of CXCR4 may be a common feature of EADC and ESCC, which is irrelevant to pathological types. CXCR4 level rises at the stage of BE, which is associated with the degree of tumor differentiation, lymph node metastasis and TNM staging. CXCR4 expression is of guiding significance in the diagnosis of BE, EADC and ESCC, and is the potential drug target.

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Assessment of four types of endoscopic ligation in treatment of submucosal tumors in upper gastrointestinal tract

Lili MA ; Shiyao CHEN ; Pinghong ZHOU ; Meidong XU ; Yiqun ZHANG ; Yunshi ZHONG ; Weifeng CHEN ; Wenzheng QIN ; Jianwei HU ; Liqing YAO

Chinese Journal of Digestive Endoscopy.2010;27(11):581-584. doi:10.3760/cma.j.issn.1007-5232.2010.11.007

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.

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Risk factors of recurrent common bile duct stones after ERCP

Xiufen TANG ; Xu REN ; Chunlan ZHU ; Xiaohong XU

Chinese Journal of Digestive Endoscopy.2010;27(11):572-575. doi:10.3760/cma.j.issn.1007-5232.2010.11.005

Objective To investigate the risk factors of recurrent common bile duct (CBD) stones after treatment with endoscopic retrograde cholangiopancreatography (ERCP). Methods A total of 802 patients with CBD stone and with complete follow-up data were recruited to the study, among which 297 patients were accompanied with gallstone, 222 patients having undergone cholecystectomy before ERCP and 283 having no gallstones. The CBD stone recurrent frequency and the possible risk factors were calculated with uni- and multi-variate logistic regression analysis. Results The patients were followed up at a mean duration of 84. 8 months, and CBD stone re-occurred in 92 (11.5%). Both uni- and multivariate analysis showed gallstones, CBD larger than 1.5 cm, endoscopic mechanical lithotrity (EML) and angle of bile duct less than 120° were risk factors of recurrence. Multivariate analysis showed cholesterol stones, cholangeal stricture or sphincter of Oddis dysfunction (SOD) were all risk factors for reccurrence. Univariate analysis revealed that history of cholecystectomy or Billroth Ⅱ gastrectomy, stones larger than 1.5 cm and multiple stones were risk factors of recurrence. Conclusion For those with CBD stones undergoing ERCP, gallstone,common bile larger than 1. 5cm, EML and the angle of CBD less than 120° are major risk factors of recurrence. History of cholecystectomy and Billroth Ⅱ gastrectomy, SOD, large CBD stone ( ≥1.5 cm), cholesterol stone and multiple stones are also associating risk factors.

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Large-diameter balloon sphincteroplasty for removal of bile duct stones: a prospective and randomized study from two endoscopy centers

Yamin PAN ; Jiayan ZHANG ; Yubao ZHOU ; Tiantian WANG ; Runhuang LIU ; Bing HU

Chinese Journal of Digestive Endoscopy.2010;27(11):564-567. doi:10.3760/cma.j.issn.1007-5232.2010.11.003

Objective To investigate the efficiency and safety of endoscopic large balloon dilation following small sphincterotomy (ESBD) for treatment of common bile duct (CBD) stones, and to prospectively compare it with traditional sphincterotomy (ES). Methods Patients with single or multiple calculi in extra-hepatic bile ducts and with the diameter of CBD larger than 13 mm, were randomized into 2 groups to receive maximal sphincterotomy (ES group), or partial sphincterotomy plus sphincteroplasty with 15mm-balloon (ESBD group), respectively, followed by conventional stones removal and/or lithotripsy. The success rate of stone clearance, operation time and related complications were observed. Results A total of 86 patients were enrolled in 2 endoscopy centers, with 2 excluded because of papillary pre-cut in 1 and non-compliance with the protocol in the other, and were randomly divided into groups ES and ESBD, with 42 patients in each. The clinical characteristics, including average diameter of CBD, size and quantity of calculi, and incidences of peri-ampullary diverticulum, of patients in both groups were all similar. Stones clearance with single session in 2 groups were 88% and 93%, respectively (P =0. 531 ). The operation time were (25.76 ± 12. 74) min and (26. 38 ± 12. 86) min ( P = 0. 825 ). The rate of mechanical lithotripsy was 36% and 25%, respectively (P=0. 363). Complications occurred in 5 cases in ES group (3 mild, 2 medium), and 2 mild complications occurred in ESBD group (no statistical difference). No death happened in any group.Conclusion ESBD is an effective method for clearance of extra-hepatic bile duct stones with the similar safety, compared with traditional sphincterotomy. It could be an optimal alternative for those with large stones or difficult sphincterotomy.

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Endoscopic sphincterotomy plus balloon dilation for difficult bile duct stones

Ming JI ; Yongjun WANG ; Li YU ; Yinglin NIU ; Peng LI ; Fujing Lü ; Wei LI ; Shutian ZHANG

Chinese Journal of Digestive Endoscopy.2010;27(11):568-571. doi:10.3760/cma.j.issn.1007-5232.2010.11.004

Objectiye To evaluate the therapeutic efficacy and safety of (endoscopic sphincterotomy, EST) plus balloon dilation for difficult bile duct stones. Methods Patients with difficult common bile duct stones on endoscopic retrograde cholangiopancreatography (ERCP) from March 2008 to December 2009 were randomly divided into 2 groups to receive EST or EST plus balloon dilation ( EST + EPBD), respectively. The success rate of complete stone removal, number of endoscopic sessions, the rate of using mechanical lithotripsy and the complication rate related to the procedure were compared between the 2 groups. Results Compared with EST alone, EST plus balloon dilation resulted in similar outcomes in terms of overall successful stone removal rate (2/62 vs. 2/61 ) and early complication rate (4/62 vs. 6/61, P ＞0. 05). However,EST group needed more sessions ( EST 15/46 vs. EST + EPBD 5/57, P ＜0. 05) and use of mechanical lithotripsy to achieve complete removal of stones ( EST 12/61 vs. EST + EPBD 4/61, P ＜0. 05 ). Conclusion EST plus balloon dilation is as safe and effective as, but more convenient than EST, for endoscopic removal of common bile duct stones.

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Biliary passage dilator assisted percutaneous endoscopic gastostomy in natural orifice translumenal endoscopic surgery

Xiuli ZHANG ; Qurratulain HYDER ; Ping TANG ; Wen LI ; Gang SUN ; Jing YANG ; Rugang ZHANG ; Yunsheng YANG

Chinese Journal of Digestive Endoscopy.2010;27(10):532-534. doi:10.3760/cma.j.issn.1007-5232.2010.10.008

Objective To explore the feasibility and safety of the biliary passage dilator assisted percutaneous endoscopic gastostomy(PEG)in natural orifice translumenal endoscopic surgery(NOTES).Methods Eleven hybrid dogs were recruited to the study.One dog was used for pilot study of biliary passage dilator assisted PEG.The rest ten were divied into 2 groups randomly(5 per group), receiving conventional PEG and biliary passage dilator assisted PEG, respectively.The efficacy and safety of these 2 methods in NOTES were compared.Two weeks later, routine gastroscopy was performed to detect the healing of luminal incision and all animals were sacrificed to explore the possible complications in the abdominal cavity.Results With the assistance of the biliary passage dilator, successful transgastric access to the peritoneal cavity was achieved in the pilot study.Biliary passage dilator assisted PEG was completed in all the 5 dogs of the experimetal group, while tradional PEG succeded in only 4.The average transgastric puncture time in the biliary passage dilator assisted PEG(7.0 ± 1.7 min)was significantly shorter than that of conventional PEG (11.0 ± 3.2 min, P ＜ 0.05).Nine dogs survived for 2 weeks postoperatively without loss of weight or peritonitis.Endoscopy showed transgastric puncture healed well.Autopsy revealed no gross adhering zone,bleeding, injury of adjacent organs or abcasses.Conclusion Compared with the conventional PEG, the biliary passage dilator assisted PEG shows the advantages of reduced difficulty and shoter time of puncture without any apparent complications.There is a good prospect of its application in NOTES.

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Self-expanding metallic stents for acute obstruction of the proximal colorectal cancer

Yunshi ZHONG ; Liqin YAO ; Jianmin XU ; Meidong XU ; Pinghong ZHOU ; Weifeng CHEN ; Ping WANG

Chinese Journal of Digestive Endoscopy.2010;27(10):505-508. doi:10.3760/cma.j.issn.1007-5232.2010.10.001

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.

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Endoscopy and endoscopic ultrasonography for heterotopic pancreas in upper gastrointestinal tract

Tianming CHENG ; Wen GUO ; Cunlong CHEN ; Wei ZHU ; Side LIU ; Yang BAI ; Yahua CHEN ; Bing XIAO ; Yali ZHANG ; Fachao ZHI ; Bo JIANG

Chinese Journal of Digestive Endoscopy.2010;27(8):415-418. doi:10.3760/cma.j.issn.1007-5232.2010.08.007

Objective To study the characteristics of heterotopic pancreas (HP) in upper gastrointestinal tract (UGIT) under endoscopy and endoscopic sonography ( EUS), and its endoscopic managements. Methods Data of 67 patients with pathologically confirmed HP in our hospital from March 2004 to November 2009, including clinical and endoscopic manifestations and sequelae after endoscopic resection,were retrospectively studied. Results Heterotopic pancreas were most commonly found as a single lesion in gastric antrum (62/67, 92. 5% ) and in gastric angle and duodenum as well, which were characterized by protrusion, with intact mucous membrane and centrally umbilicated. Of the 67 patients, 59 underwent EUS before endoscopic resection. Findings were heterogeneous and mixed echogenic lesions with indistinct borders involving both the second and third layers of the gastrointestinal wall, sometimes even involving the first and fourth layers. Most lesions (n =60) were removed by endoscopic mucosal resection (EMR), with basal residues in 25 cases, in which fourth layer involvement was observed in 23 cases (92. 0% ). Delayed bleeding occurred in 1 case at 3rd day after the procedure, and no other complications were observed. Complete removal was achieved in 8 cases ( including one receiving EMR previously ) with endoscopic submucosal dissection (ESD) , and there was no such severe complications as perforation. Postoperative pathological examinations revealed that the consistent rate of preoperative diagnosis with EUS was 91.5% (54/59). Conclusion Endoscopy combined with EUS is critical in diagnosis of HP in UGIT. EMR, especially with cap assistance, is the best method for those without involvement of muscularis propria, while ESD or endoscopic surveillance is a better alternative for those with 4th layer involvement.

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