Clinical Endoscopy

Editorial

Endoscopic resection penetrating the muscularis propria for gastric gastrointestinal stromal tumors: advances and challenges: Jin Woong Cho; Clin Endosc 2024;57(3):329-331. Published online May 10, 2024; DOI: https://doi.org/10.5946/ce.2024.036

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Original Articles

Prevalence and natural course of incidental gastric subepithelial tumors: Dae-Hyuk Heo, Min A Yang, Jae Sun Song, Won Dong Lee, Jin Woong Cho; Clin Endosc 2024;57(4):495-500. Published online March 29, 2024; DOI: https://doi.org/10.5946/ce.2023.124

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Background
/Aims: Gastric subepithelial tumors (SETs) are often encountered during the upper gastrointestinal endoscopic screening. We assessed the prevalence of gastric SETs and the risk factors for their progression.
Methods
We reviewed the electronic medical records of 30,754 patients who underwent upper gastrointestinal endoscopic screening at our medical center between January 2013 and December 2016.
Results
Among the 30,754 patients examined, 599 (1.94%) had gastric SETs. The prevalence increased with age and was 9.56% in patients aged ≥70 years. In total, 262 patients underwent serial endoscopy for more than 6 months. The median age was 68 years (interquartile range [IQR], 61–74), and the number of females was 167 (63.7%). During a median follow-up of 58 months (IQR, 38–75), 22 patients (8.4%) showed significant changes in tumor size. An irregular border (odds ratio, 4.623; 95% confidence interval, 1.093–19.558; p=0.037) was a significant risk factor for progression. Seven patients underwent surgical or endoscopic resections. The pathologies of gastric SETs included leiomyomas (n=3), gastrointestinal stromal tumors (n=2), and lipomas (n=2).
Conclusions
The prevalence of gastric SETs increases with age. Most gastric SETs do not progress during long-term endoscopic examinations, and the risk of an increase in size is low in asymptomatic small SETs without irregular borders.

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Artificial Intelligence-Based Diagnosis of Gastric Mesenchymal Tumors Using Digital Endosonography Image Analysis
Dong Chan Joo, Gwang Ha Kim, Moon Won Lee, Bong Eun Lee, Ji Woo Kim, Kwang Baek Kim
Journal of Clinical Medicine.2024; 13(13): 3725. CrossRef

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Underestimation of endoscopic size in large gastric epithelial neoplasms: Jae Sun Song, Byung Sun Kim, Min A Yang, Young Jae Lee, Gum Mo Jung, Ji Woong Kim, Jin Woong Cho; Clin Endosc 2022;55(6):760-766. Published online May 19, 2022; DOI: https://doi.org/10.5946/ce.2021.269

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Background
/Aims: Endoscopic submucosal dissection (ESD) is an effective method for resecting gastric adenomas and adenocarcinomas. A significant discrepancy was observed between endoscopic and pathological sizes in samples obtained from patients undergoing ESD. This study elucidates the factors affecting size discrepancy after formalin fixation.
Methods
The records of 64 patients with 69 lesions were analyzed, including 50 adenomas and 19 adenocarcinomas. Data on location, gross shape, histology, and size after fixation in formalin were collected.
Results
The mean size of the resected specimen appeared to decrease after formalin fixation (37.5 mm prefixation vs. 35.8 mm postfixation, p<0.05). The mean long axis diameter of the lesions was 20.3±7.9 mm prefixation and 13.4±7.9 mm postfixation. Size differences in lesions smaller than 20 mm were significantly greater than those in lesions larger than 20 mm (7.6±5.6 mm vs. 2.5±5.8 mm, p<0.01). In multivariate analysis, a tumor size of ≥20 mm was found to be an independent factor affecting size postformalin fixation (p<0.05).
Conclusions
The endoscopic size of lesions before ESD may be underestimated in tumors larger than 20 mm in size. Therefore, increased attention must be paid during ESD to avoid instances of incomplete resection.

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Transcecal endoscopic appendectomy for management of complex appendiceal polyps extending into the appendiceal orifice
Tara Keihanian, Mai A Khalaf, Fuad Zain Aloor, Dina Hani Zamil, Salmaan Jawaid, Mohamed O. Othman
Endoscopy International Open.2024; 12(08): E932. CrossRef

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Predictive Factors for Differentiating Gastrointestinal Stromal Tumors from Leiomyomas Based on Endoscopic Ultrasonography Findings in Patients with Gastric Subepithelial Tumors: A Multicenter Retrospective Study: Sun Moon Kim, Eun Young Kim, Jin Woong Cho, Seong Woo Jeon, Ji Hyun Kim, Tae Hyeon Kim, Jeong Seop Moon, Jin-Oh Kim, the Research Group for Endoscopic Ultrasound of the Korean Society of Gastrointestinal Endoscopy; Clin Endosc 2021;54(6):872-880. Published online November 18, 2021; DOI: https://doi.org/10.5946/ce.2021.251

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Background
/Aims: The utility of endoscopic ultrasonography (EUS) for differentiating gastrointestinal stromal tumors (GISTs) and leiomyomas of the stomach is not well known. We aimed to evaluate the ability of EUS for differentiating gastric GISTs and leiomyomas.
Methods
We retrospectively reviewed the medical records of patients with histopathologically proven GISTs (n=274) and leiomyomas (n=87). In two consensus meetings, the inter-observer variability in the EUS image analysis was reduced. Using logistic regression analyses, we selected predictive factors and constructed a predictive model and nomogram for differentiating GISTs from leiomyomas. A receiver operating characteristic (ROC) curve analysis was performed to measure the discrimination performance in the development and internal validation sets.
Results
Multivariate analysis identified heterogeneity (odds ratio [OR], 9.48), non-cardia (OR, 19.11), and older age (OR, 1.06) as independent predictors of GISTs. The areas under the ROC curve of the predictive model using age, sex, and four EUS factors (homogeneity, location, anechoic spaces, and dimpling or ulcer) were 0.916 (sensitivity, 0.908; specificity, 0.793) and 0.904 (sensitivity, 0.908; specificity, 0.782) in the development and internal validation sets, respectively.
Conclusions
The predictive model and nomogram using age, sex and homogeneity, tumor location, presence of anechoic spaces, and presence of dimpling or ulcer on EUS may facilitate differentiation between GISTs and leiomyomas.

Citations

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Results of the interim analysis of a prospective, multicenter, observational study of small subepithelial lesions in the stomach
Masaya Iwamuro, Toshiharu Mitsuhashi, Tomoki Inaba, Kazuhiro Matsueda, Teruya Nagahara, Yoji Takeuchi, Hisashi Doyama, Masakatsu Mizuno, Tomoyuki Yada, Yoshinari Kawai, Jun Nakamura, Minoru Matsubara, Hiroko Nebiki, Keiko Niimi, Tatsuya Toyokawa, Ryuta Ta
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Giovanna Impellizzeri, Giulio Donato, Claudio De Angelis, Nico Pagano
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Endoscopic Ultrasound Advanced Techniques for Diagnosis of Gastrointestinal Stromal Tumours
Socrate Pallio, Stefano Francesco Crinò, Marcello Maida, Emanuele Sinagra, Vincenzo Francesco Tripodi, Antonio Facciorusso, Andrew Ofosu, Maria Cristina Conti Bellocchi, Endrit Shahini, Giuseppinella Melita
Cancers.2023; 15(4): 1285. CrossRef
Endoscopic ultrasound artificial intelligence-assisted for prediction of gastrointestinal stromal tumors diagnosis: A systematic review and meta-analysis
Rômulo Sérgio Araújo Gomes, Guilherme Henrique Peixoto de Oliveira, Diogo Turiani Hourneaux de Moura, Ana Paula Samy Tanaka Kotinda, Carolina Ogawa Matsubayashi, Bruno Salomão Hirsch, Matheus Oliveira Veras, João Guilherme Ribeiro Jordão Sasso, Roberto Pa
World Journal of Gastrointestinal Endoscopy.2023; 15(8): 528. CrossRef
Prevalence, natural progression, and clinical practices of upper gastrointestinal subepithelial lesions in Korea: a multicenter study
Younghee Choe, Yu Kyung Cho, Gwang Ha Kim, Jun-Ho Choi, Eun Soo Kim, Ji Hyun Kim, Eun Kwang Choi, Tae Hyeon Kim, Seong-Hun Kim, Do Hoon Kim
Clinical Endoscopy.2023; 56(6): 744. CrossRef
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燊苏
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The Diagnosis of Small Gastrointestinal Subepithelial Lesions by Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy
Masanari Sekine, Takeharu Asano, Hirosato Mashima
Diagnostics.2022; 12(4): 810. CrossRef
Diagnostic accuracy of endoscopic ultrasound with artificial intelligence for gastrointestinal stromal tumors: A meta‐analysis
Xiao Hua Ye, Lin Lin Zhao, Lei Wang
Journal of Digestive Diseases.2022; 23(5-6): 253. CrossRef

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Case Report

An Intractable Caustic Esophageal Stricture Successfully Managed with Sequential Treatment Comprising Incision with an Insulated-Tip Knife, Balloon Dilation, and an Oral Steroid: Woong Ki Lee, Byung Sun Kim, Min A Yang, So Hee Yun, Young Jae Lee, Ji Woong Kim, Jin Woong Cho; Clin Endosc 2016;49(6):560-563. Published online August 12, 2016; DOI: https://doi.org/10.5946/ce.2016.048

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Bougie or balloon dilation is a good short-term treatment for caustic esophageal strictures, although recurrence after dilation occurs in approximately 30% of these cases. Therefore, long-term treatment options are required in some cases, and endoscopic incisional therapy has been used for patients with an anastomotic stricture in the gastrointestinal tract. A 58-year-old woman presented with severe swallowing difficulty because of a caustic esophageal stricture, which was caused by accidental exposure to anhydrous acetic acid at infancy. She had undergone several previous bougie and balloon dilations but the stricture did not improve. We performed sequential treatment comprising incision with an insulated-tip knife, balloon dilation, and an oral steroid, which resulted in the patient’s symptoms markedly improving. Thus, we report this case of an intractable caustic esophageal stricture, which was successfully treated using combined endoscopic sequential treatment.

Citations

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A new simple endoscopic incision therapy for refractory benign oesophageal anastomotic stricture
Jeongmin Choi, Soo In Choi
BMJ Case Reports.2021; 14(3): e239798. CrossRef
Endoscopic incision for treatment of benign gastrointestinal strictures
Chengbai Liang, Yuyong Tan, Jiaxi Lu, Meixian Le, Deliang Liu
Expert Review of Gastroenterology & Hepatology.2020; 14(6): 445. CrossRef

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Focused Review Series: Advances in the management of upper GI SET

Current Guidelines in the Management of Upper Gastrointestinal Subepithelial Tumors: Jin Woong Cho, the Korean ESD Study Group; Clin Endosc 2016;49(3):235-240. Published online February 22, 2016; DOI: https://doi.org/10.5946/ce.2015.096

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Subepithelial tumors are frequently found in asymptomatic patients in Japan and Korea where cancer screening tests routinely include endoscopy. Most lesions are asymptomatic and clinically insignificant. However, carcinoid tumors, lymphomas, glomus tumor and gastrointestinal stromal tumors (GISTs) are malignant or have the potential to become malignant. Inflammation due to parasitic infestation by Anisakis and poorly differentiated adenocarcinomas in the stomach rarely present as subepithelial lesions. In contrast to the frequency of gastric GIST in the gastrointestinal system, they are uncommon in the duodenum and very rare in the esophagus. The prognosis of patients with GISTs in the stomach is relatively good compared with GISTs in other organs. Along with the location of the tumor, its size and mitotic count are major factors that determine the malignant potential of GIST. Small (<2 cm) asymptomatic GISTs usually have benign clinical course. GIST is the most common subepithelial tumor to occur in the stomach. Although various methods are employed to diagnose GISTs, the risk of GIST metastasis cannot be accurately predicted before lesions are completely resected. Recently, new endoscopic diagnostic methods and treatment techniques have been developed that allow the diagnosis and resection of lesions located in the muscularis propria, without any complications. These endoscopic methods have different indications depending on regions where they are performed.

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The Role of Endosonography in the Staging of Gastrointestinal Cancers: Jin Woong Cho; Clin Endosc 2015;48(4):297-301. Published online July 24, 2015; DOI: https://doi.org/10.5946/ce.2015.48.4.297

Abstract PDF PubReader ePub

Endosonography (EUS) enables the acquisition of clear images of the gastrointestinal tract wall and the surrounding structures. EUS enables much greater accuracy for staging decisions compared to computed tomography. Surgery for esophageal cancer has a high rate of morbidity and mortality, and it is important to decide on an appropriate treatment method through pre-surgical evaluation. Minimal invasive surgery is widely used for the treatment of gastrointestinal cancer, and endoscopic submucosal dissection is a safe treatment method for early cancer of the gastrointestinal tract that does not result in lymph node metastasis. EUS is essential for pre-surgical evaluation for all esophageal cancers. The use of EUS can effectively reduce unnecessary surgeries and thereby allow for appropriate treatment planning for patients. A number of different diagnostic modalities are available, but EUS is still the mainstay for pre-surgical evaluation of esophageal cancer. The role of EUS for early stomach cancer treatment as a tool for determining the need for endoscopic resection and for pre-surgical assessment is increasing.

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Lymph Node Metastases in Esophageal Carcinoma: An Endoscopist's View: Jin Woong Cho, Suck Chei Choi, Jae Young Jang, Sung Kwan Shin, Kee Don Choi, Jun Haeng Lee, Sang Gyun Kim, Jae Kyu Sung, Seong Woo Jeon, Il Ju Choi, Gwang Ha Kim, Sam Ryong Jee, Wan Sik Lee, Hwoon-Yong Jung, Korean ESD Study Group; Clin Endosc 2014;47(6):523-529. Published online November 30, 2014; DOI: https://doi.org/10.5946/ce.2014.47.6.523

Abstract PDF PubReader ePub

One of the most important prognostic factors in esophageal carcinoma is lymph node metastasis, and in particular, the number of affected lymph nodes, which influences long-term outcomes. The esophageal lymphatic system is connected longitudinally and transversally; thus, the pattern of lymph node metastases is very complex. Early esophageal cancer frequently exhibits skipped metastasis, and minimal surgery using sentinel node navigation cannot be performed. In Korea, most esophageal cancer cases are squamous cell carcinoma (SCC), although the incidence of adenocarcinoma has started to increase recently. Most previous reports have failed to differentiate between SCC and adenocarcinoma, despite the fact that the Union for International Cancer Control (7th edition) and American Joint Committee on Cancer staging systems both consider these separately because they differ in cause, biology, lymph node metastasis, and outcome. Endoscopic tumor resection is an effective and safe treatment for lesions with no associated lymph node metastasis. Esophageal mucosal cancer confined to the lamina propria is an absolute indication for endoscopic resection, and a lesion that has invaded the muscularis mucosae can be cured by local resection if invasion to the lymphatic system has not occurred.

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Stricture Occurring after Endoscopic Submucosal Dissection for Esophageal and Gastric Tumors: Gwang Ha Kim, Sam Ryong Jee, Jae Young Jang, Sung Kwan Shin, Kee Don Choi, Jun Haeng Lee, Sang Gyun Kim, Jae Kyu Sung, Suck Chei Choi, Seong Woo Jeon, Byung Ik Jang, Kyu Chan Huh, Dong Kyung Chang, Sung-Ae Jung, Bora Keum, Jin Woong Cho, Il Ju Choi, Hwoon-Yong Jung, Korean ESD Study Group; Clin Endosc 2014;47(6):516-522. Published online November 30, 2014; DOI: https://doi.org/10.5946/ce.2014.47.6.516

Abstract PDF PubReader ePub

Endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric and esophageal cancer. Compared to endoscopic mucosal resection, ESD has the advantage of enabling en bloc removal of tumors regardless of their size. However, ESD can result in a large artificial ulcer, which may lead to a considerable deformity. Circumferential mucosal defects of more than three-fourths the esophageal circumference, long longitudinal mucosal defects (>30 mm), and lesions in the upper esophagus are significant risk factors for the development of post-ESD strictures of the esophagus. In the stomach, a circumferential mucosal defects more than three-fourths in extent and longitudinal mucosal defects >5 cm are risk factors of post-ESD stricture. If scheduled early, regular endoscopic balloon dilation is effective in controlling and preventing post-ESD stricture. Moreover, intralesional steroid injections or oral steroids can achieve remission of dysphagia or reduce the need for repeated endoscopic balloon dilation. However, further study is needed to improve the prevention of stricture formation.

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A novel twin-grasper assisted mucosal inverted closure technique for closing large artificial gastric mucosal defects
Qinbo Cai, Huanjie Chen, Haobin Hou, Wenqing Dong, Lele Zhang, Minxuan Shen, Shaoxiong Yi, Rongman Xie, Xun Hou, Wentong Lan, Yulong He, Dongjie Yang
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The efficacy and safety of snare traction-assisted endoscopic submucosal dissection for circumferential superficial esophageal cancer
Nan Dai, Saif Ullah, Jingwen Zhang, Xiaoyu Wan, Shanshan Zhu, Ping Liu, Changqing Guo, Xinguang Cao
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Endoscopic Treatment of Early-stage Large Gastric Cancer and Closure with Hand-suturing Technique
Fatih Aslan, Serhat Özer, Orhun Çığ Taşkın
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Risk factors of refractory post-endoscopic submucosal dissection esophageal strictures
Enrique Pérez-Cuadrado Robles, Tom G. Moreels , Hubert Piessevaux , Ralph Yeung, Tarik Aouattah , Pierre H. Deprez
Revista Española de Enfermedades Digestivas.2021;[Epub] CrossRef
Early Esophageal Cancer
Mike T. Wei, Shai Friedland
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Comparison of general anesthesia and conscious sedation in procedure-related complications during esophageal endoscopic submucosal dissection
Seung Hyun Kim, Yong Seon Choi, Sang Kil Lee, Hanseul Oh, Seung Ho Choi
Surgical Endoscopy.2020; 34(8): 3560. CrossRef
Cyclodextrin Polymer Preserves Sirolimus Activity and Local Persistence for Antifibrotic Delivery over the Time Course of Wound Healing
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Yang Won Min
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Endoscopic submucosal dissection under general anesthesia for superficial esophageal squamous cell carcinoma is associated with better clinical outcomes
Byeong Geun Song, Yang Won Min, Ra Ri Cha, Hyuk Lee, Byung-Hoon Min, Jun Haeng Lee, Poong-Lyul Rhee, Jae J. Kim
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Woong Ki Lee, Byung Sun Kim, Min A Yang, So Hee Yun, Young Jae Lee, Ji Woong Kim, Jin Woong Cho
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Case Reports

Intramural Gastric Abscess Caused by a Toothpick Presenting as a Subepithelial Tumor: Wang Guk Oh, Mun Chul Kim, Hyun Ju Yoon, Jae Woo Park, Min A Yang, Cheon Beom Lee, Ji Woong Kim, Jin Woong Cho; Clin Endosc 2014;47(3):254-257. Published online May 31, 2014; DOI: https://doi.org/10.5946/ce.2014.47.3.254

Abstract PDF PubReader ePub

In the present report, we describe an unusual case of an intramural gastric abscess caused by a foreign body, detected in the form of a subepithelial tumor. A 64-year-old woman was referred to our gastroenterology clinic for further evaluation of a gastric subepithelial tumor. The patient presented with a 1-month history of sustained dull epigastric pain. Esophagogastroduodenoscopy revealed an ill-demarcated, round, smooth, protruding lesion with a small central erosion on the great curvature of the proximal antrum. Endoscopic ultrasonography indicated the presence of an ovoid, heterogeneous, hypoechoic lesion with small echogenic foci located in the submucosa and muscularis propria layers. An abdominal computed tomography scan showed focal gastric wall thickening and regional lymph node enlargement. Endoscopic submucosal dissection was performed for definite diagnosis and management. Thus, we detected a toothpick and removed it using grasping forceps. The final diagnosis was an intramural gastric abscess caused by a toothpick.

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I. Otero Balda, M. Augusto, C. Lassaigne, M. P. Maurin
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Cronkhite-Canada Syndrome Associated with Serrated Adenoma and Malignant Polyp: A Case Report and a Literature Review of 13 Cronkhite-Canada Syndrome Cases in Korea: So Hee Yun, Jin Woong Cho, Ji Woong Kim, Joong Keun Kim, Moon Sik Park, Na Eun Lee, Jae Un Lee, Young Jae Lee; Clin Endosc 2013;46(3):301-305. Published online May 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.3.301

Abstract PDF PubReader ePub

Cronkhite-Canada syndrome (CCS) is a rare nonfamilial polyposis syndrome characterized by epithelial disturbances both in the gastrointestinal tract and in the epidermis. The pathologic finding of the polyp is usually a hamartomatous polyp of the juvenile type; however, the possibility of serrated adenoma associated malignant neoplasm was reported in some Japanese cases. Up till now in South Korea, 13 CCS cases have been reported, but there was no case accompanied by the colon cancer. We report the first case of CCS associated with malignant colon polyp and serrated adenoma in Korea. A 72-year-old male patient who complained of diarrhea and weight loss was presented with both hands and feet nail dystrophy, hyperpigmentation, and alopecia. Endoscopic examination showed numerous hamartomatous polyps from the stomach to the colon. The pathologic results confirmed colon cancer and serrated adenoma. Helicobacter pylori eradication and prednisolone was used. Thus, the authors report this case along with a literature review.

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Shirin Haghighi, Sima Noorali, Amir Houshang Mohammad Alizadeh
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Carlos A Rubio, Åsa Edvardsson, Jan Björk, Anne Tuomisto, Timo Väisänen, Markus Mäkinen
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Cronkhite-Canada Syndrome: an unusual finding of gastro-intestinal adenomatous polyps in a syndrome characterized by hamartomatous polyps
Christopher M. Flannery, John A. Lunn
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Yi Qun Yu, Peter James Whorwell, Lin Heng Wang, Jun Xiang Li, Qing Chang, Jie Meng
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Tomas Slavik, Elizabeth Anne Montgomery
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Dong-Uk Kang, Dong-Hoon Yang, Yunsik Choi, Ji-Beom Kim, Ho-Su Lee, Hyo Jeong Lee, Sang Hyoung Park, Kee Wook Jung, Kyung-Jo Kim, Byong Duk Ye, Jeong-Sik Byeon, Seung-Jae Myung, Suk-Kyun Yang, Jin-Ho Kim
Intestinal Research.2013; 11(4): 317. CrossRef

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Review

The Role of Endoscopic Ultrasonography in T Staging: Early Gastric Cancer and Esophageal Cancer: Jin Woong Cho; Clin Endosc 2013;46(3):239-242. Published online May 31, 2013; DOI: https://doi.org/10.5946/ce.2013.46.3.239

Abstract PDF PubReader ePub

While a number of diagnostic methods have been developed, endoscopic ultrasound (EUS) still takes the most important role in the preoperative evaluation of esophageal cancer. EUS can detect lesions of all esophageal cancer and can accurately perform T staging. In a recent meta-analysis of EUS in esophageal cancer, the sensitivity and specificity of EUS on esophageal cancer were 81.6% and 99.4% in T1, 81.4% and 96.3% in T2, 91.4% and 94.4% in T3, and 92.4% and 97.4% in T4, respectively. The use of EUS can reduce unnecessary surgeries and lead to apply proper treatments to patients. The advance of endoscopic submucosal dissection have necessitated the presurgical detection of early cancer lesions without lymph node metastasis. Understanding the practical meanings of images shown by EUS is important to decide patients for whom endoscopic treatments can be effective. In early gastric cancer, EUS can accurately predict mucosal and SM1 (invasion into the submucosal layer of less than 500 µm from muscularis mucosa) lesions, which are considered as good indications for endoscopic treatments.

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Ichiro Yamada, Naoyuki Miyasaka, Keigo Hikishima, Keiji Kato, Kazuyuki Kojima, Tatsuyuki Kawano, Eisaku Ito, Daisuke Kobayashi, Yoshinobu Eishi, Hideyuki Okano
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