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Endoscopic antralplasty for severe gastric stasis after wide endoscopic submucosal dissection in the antrum.

Ohara Y, Toyonaga T, Tanabe A, Takihara H, Baba S, Inoue T, Ono W, Kawara F, Tanaka S, Azuma T - Clin J Gastroenterol (2016)

Bottom Line: Endoscopic submucosal dissection was performed and resulted in more than five-sixths circumferential antral mucosal resection.The problem was speculated to be not due to any potential stricture but to antrum deformation resulting from the traction force toward the healing ulcer.Afterwards, the endoscopic findings have now been unchanged during 7 years of follow-up.

View Article: PubMed Central - PubMed

Affiliation: Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan.

ABSTRACT
A 75-year-old female underwent esophagogastroduodenoscopy, revealing a widely spreading tumor occupying the anterior wall, lesser curvature, and posterior wall of the antrum and lower body. Endoscopic submucosal dissection was performed and resulted in more than five-sixths circumferential antral mucosal resection. One month later, she complained of nausea, vomiting, and abdominal distention. Endoscopy showed residual food in the stomach and deformation of the antrum with traction toward the contracted scar in the lesser curvature. The pyloric ring could not be seen from the antrum although the endoscope was able to pass easily beyond the area of deformation and the pyloric ring was intact. Despite repeated endoscopic balloon dilations, the patient's symptoms remained refractory. The problem was speculated to be not due to any potential stricture but to antrum deformation resulting from the traction force toward the healing ulcer. We hypothesized that an additional countertraction force opposite the previous ESD site might resolve the problem, and ESD of approximately 2.5 cm size was performed in the greater curvature of the antrum. Along with development of a scar, traction toward the greater curvature was added, and the pyloric ring could be observed on repeat esophagogastroduodenoscopy. The symptoms were also gradually ameliorated. Afterwards, the endoscopic findings have now been unchanged during 7 years of follow-up.

No MeSH data available.


Related in: MedlinePlus

a Widely spreading tumor in the antrum and lower body. b Indigo carmine staining of the tumor. c Artificial ulcer after ESD with a mucosal defect of more than five-sixths circumference in the antrum and lower body. d Resected specimen measuring 110 × 70 mm
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Fig1: a Widely spreading tumor in the antrum and lower body. b Indigo carmine staining of the tumor. c Artificial ulcer after ESD with a mucosal defect of more than five-sixths circumference in the antrum and lower body. d Resected specimen measuring 110 × 70 mm

Mentions: A 75-year-old female consulted a nearby clinic because of abdominal pain. She underwent esophagogastroduodenoscopy, which revealed a widely spreading tumor occupying the anterior wall, lesser curvature, and posterior wall of the antrum and lower body (Fig. 1a, b). The biopsy showed a large, well-differentiated adenocarcinoma with no sign of deep submucosal invasion. ESD was indicated, and the patient underwent ESD using the Flush knife-BT (DK2618JB; Fujifilm Medical Co., Ltd., Tokyo, Japan) [5], without any intraoperative adverse events. The procedure took 79 min. The mucosal defect in the antrum and the lower body spanned more than five-sixths of the antral circumference (Fig. 1c). Histopathological observation showed a well-differentiated adenocarcinoma, 88 mm in size, invading 200 μm deep into the submucosa (Fig. 1d). The resected margin was tumor-negative. Although the resection was non-curative according to the JGES criteria [6], the patient did not choose to undergo additional surgery and was closely observed. One month later, the patient complained of symptoms of gastric stasis, including nausea, vomiting, abdominal distention, and loss of appetite. Endoscopy showed deformation of the antrum with traction toward the contracted scar in the lesser curvature and residual food in the stomach (Fig. 2a–c). The pyloric ring could not be seen from the antrum; however, the endoscope was able to pass easily beyond the area of deformation, which suggested that there was no severe physical stricture. The pyloric ring was also confirmed to be intact. Despite repeated endoscopic balloon dilations (EBDs), the patient’s symptoms did not improve. Two months later, she suffered from a full thickness tear in the upper stomach after vomiting, which was cured conservatively by gastric decompression and fasting. However, gastroparesis continued. These episodes suggested that the problem was not due to physical antrum stricture but due to deformation of the antrum resulting from the traction force toward the lesser curvature generated by the healing ESD induced ulcer. We hypothesized that an additional counter-traction force might resolve the problem. With the aim of releasing the deformation, ESD of approximately 2.5 cm in size was performed in the great curvature of the antrum (Fig. 3). Along with development of a scar, traction toward the great curvature was added, and the pyloric ring could be observed from the antrum 1 month later (Fig. 4a). The symptoms also gradually ameliorated, and finally resolved. During subsequent 7 years of follow up, the endoscopic findings have not changed (Fig. 4b, c), and no tumor recurrence or gastric stasis symptom has been observed.Fig. 1


Endoscopic antralplasty for severe gastric stasis after wide endoscopic submucosal dissection in the antrum.

Ohara Y, Toyonaga T, Tanabe A, Takihara H, Baba S, Inoue T, Ono W, Kawara F, Tanaka S, Azuma T - Clin J Gastroenterol (2016)

a Widely spreading tumor in the antrum and lower body. b Indigo carmine staining of the tumor. c Artificial ulcer after ESD with a mucosal defect of more than five-sixths circumference in the antrum and lower body. d Resected specimen measuring 110 × 70 mm
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4829617&req=5

Fig1: a Widely spreading tumor in the antrum and lower body. b Indigo carmine staining of the tumor. c Artificial ulcer after ESD with a mucosal defect of more than five-sixths circumference in the antrum and lower body. d Resected specimen measuring 110 × 70 mm
Mentions: A 75-year-old female consulted a nearby clinic because of abdominal pain. She underwent esophagogastroduodenoscopy, which revealed a widely spreading tumor occupying the anterior wall, lesser curvature, and posterior wall of the antrum and lower body (Fig. 1a, b). The biopsy showed a large, well-differentiated adenocarcinoma with no sign of deep submucosal invasion. ESD was indicated, and the patient underwent ESD using the Flush knife-BT (DK2618JB; Fujifilm Medical Co., Ltd., Tokyo, Japan) [5], without any intraoperative adverse events. The procedure took 79 min. The mucosal defect in the antrum and the lower body spanned more than five-sixths of the antral circumference (Fig. 1c). Histopathological observation showed a well-differentiated adenocarcinoma, 88 mm in size, invading 200 μm deep into the submucosa (Fig. 1d). The resected margin was tumor-negative. Although the resection was non-curative according to the JGES criteria [6], the patient did not choose to undergo additional surgery and was closely observed. One month later, the patient complained of symptoms of gastric stasis, including nausea, vomiting, abdominal distention, and loss of appetite. Endoscopy showed deformation of the antrum with traction toward the contracted scar in the lesser curvature and residual food in the stomach (Fig. 2a–c). The pyloric ring could not be seen from the antrum; however, the endoscope was able to pass easily beyond the area of deformation, which suggested that there was no severe physical stricture. The pyloric ring was also confirmed to be intact. Despite repeated endoscopic balloon dilations (EBDs), the patient’s symptoms did not improve. Two months later, she suffered from a full thickness tear in the upper stomach after vomiting, which was cured conservatively by gastric decompression and fasting. However, gastroparesis continued. These episodes suggested that the problem was not due to physical antrum stricture but due to deformation of the antrum resulting from the traction force toward the lesser curvature generated by the healing ESD induced ulcer. We hypothesized that an additional counter-traction force might resolve the problem. With the aim of releasing the deformation, ESD of approximately 2.5 cm in size was performed in the great curvature of the antrum (Fig. 3). Along with development of a scar, traction toward the great curvature was added, and the pyloric ring could be observed from the antrum 1 month later (Fig. 4a). The symptoms also gradually ameliorated, and finally resolved. During subsequent 7 years of follow up, the endoscopic findings have not changed (Fig. 4b, c), and no tumor recurrence or gastric stasis symptom has been observed.Fig. 1

Bottom Line: Endoscopic submucosal dissection was performed and resulted in more than five-sixths circumferential antral mucosal resection.The problem was speculated to be not due to any potential stricture but to antrum deformation resulting from the traction force toward the healing ulcer.Afterwards, the endoscopic findings have now been unchanged during 7 years of follow-up.

View Article: PubMed Central - PubMed

Affiliation: Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, Kobe, Japan.

ABSTRACT
A 75-year-old female underwent esophagogastroduodenoscopy, revealing a widely spreading tumor occupying the anterior wall, lesser curvature, and posterior wall of the antrum and lower body. Endoscopic submucosal dissection was performed and resulted in more than five-sixths circumferential antral mucosal resection. One month later, she complained of nausea, vomiting, and abdominal distention. Endoscopy showed residual food in the stomach and deformation of the antrum with traction toward the contracted scar in the lesser curvature. The pyloric ring could not be seen from the antrum although the endoscope was able to pass easily beyond the area of deformation and the pyloric ring was intact. Despite repeated endoscopic balloon dilations, the patient's symptoms remained refractory. The problem was speculated to be not due to any potential stricture but to antrum deformation resulting from the traction force toward the healing ulcer. We hypothesized that an additional countertraction force opposite the previous ESD site might resolve the problem, and ESD of approximately 2.5 cm size was performed in the greater curvature of the antrum. Along with development of a scar, traction toward the greater curvature was added, and the pyloric ring could be observed on repeat esophagogastroduodenoscopy. The symptoms were also gradually ameliorated. Afterwards, the endoscopic findings have now been unchanged during 7 years of follow-up.

No MeSH data available.


Related in: MedlinePlus