The pocket-creation method facilitates endoscopic submucosal dissection of gastric neoplasms involving the pyloric ring

Background and study aims Endoscopic submucosal dissection (ESD) of superficial gastric lesions involving the pyloric ring is difficult. The pocket-creation method (PCM) with a small-caliber-tip transparent hood can overcome this difficulty by compressing the pyloric sphincter applying both traction and counter-traction. The aim of this study is to clarify the usefulness of the PCM for ESD of superficial gastric neoplasms involving the pyloric ring compared to the conventional method (CM). Patients and methods From October 2006 to August 2019, 66 gastric lesions requiring duodenal submucosal dissection beyond the pyloric ring in 66 patients were resected. The CM was mainly performed in the first period (CM group, n = 46) and the PCM in the second period (PCM group, n = 20). We retrospectively reviewed their medical records. Results Although no significant differences were observed in en bloc resection rates between the two groups, the PCM group had a significantly higher R0 resection rate than the CM group (P = 0.047). There were no holes in resected specimens in the PCM group while three specimens in the CM group had a hole. The dissection speed in the PCM group tended to be higher than in the CM group, although it did not reach statistical significance (P = 0.148). No significant differences were observed for the incidence of adverse events. Conclusions This is the first study reporting the advantages of the PCM over the CM for ESD of gastric lesions involving the pyloric ring. We believe that the PCM is an effective strategy to compress the pyloric sphincter and facilitates R0 resection.

Does Pyloric-ring Resection in Pancreaticoduodenectomy Prevent Delayed Gastric Emptying?

Objective: Delayed gastric emptying (DGE) is a common, post pancreaticoduodenectomy (PD) complication, which prolongs hospital stay, increases the cost of treatment and delays adjuvant therapy. Although, pylorospasm is one of the proposed mechanisms, the results of pyloric ring resection PD remain controversial. Hence, this study investigated whether pyloric ring resection PD decreased the incidence of DGE.Material and Methods: Between June, 2015 and July, 2018; 74 patients underwent a PD for periampullary lesions, of whom 25 patients received pylorus-preserving PD (PPPD) and 49 patients received pyloric-ring resection PD (PRPD). DGE was classified according to the International Study Group of Pancreatic Surgery.Results: The incidence of DGE in the PPPD group and PRPD group were 48.0% (12 of 25 patients) and 20.4% (10 of 49 patients), respectively (p-value=0.029). Factors associated with DGE were pyloric preserving [adjusted Odds ratio (OR)=8.26, 95% confidence interval (CI): 1.96-34.82, p-value=0.002], preoperative biliary drainage (adjusted OR=0.19, 95% Cl: 0.05-0.78, p-value=0.013) and postoperative intraabdominal collection (adjusted OR=37, 95% Cl: 5.68-241.24, p-value<0.001).Conclusion: PRPD demonstrated a significant decrease of DGE, and should be one of the standard surgical treatments for periampullary carcinoma.

Endoscopic findings of gastric lesions in patients with eosinophilic gastrointestinal disorders

Background and study aims Eosinophilic gastrointestinal disorders are classified into eosinophilic esophagitis, eosinophilic gastritis, eosinophilic gastroenteritis, and eosinophilic colitis according to the site of eosinophilic infiltration. Although well established in eosinophilic esophagitis, endoscopic findings in eosinophilic gastritis and eosinophilic gastroenteritis with regard to gastric lesions have not been clearly described. The aim of this study was to identify endoscopic findings of gastric lesions associated with eosinophilic gastrointestinal disorders. Patients and methods Out of 278 patients with eosinophilic gastrointestinal disorders, 18 had eosinophilic gastritis or eosinophilic gastroenteritis confirmed by biopsy; their endoscopic images were analyzed retrospectively. The association between endoscopic findings and number of eosinophils in the gastric mucosa was investigated. Results Erythema was most frequently observed (72 %), followed by ulcers (39 %), discoloration (33 %), erosions (28 %), nodularity (28 %), and polyps (28 %). There were several unique endoscopic findings such as submucosal tumor-like deep large ulcers in three patients, antral Penthorum-like appearances (small nodules radially lined toward the pyloric ring) in three patients, “muskmelon-like appearances” (discolored mucosa-composed mesh pattern) in three patients, multiple white granular elevations in two patients, cracks (appearance of furrows similar to those in eosinophilic esophagitis) in five patients, and antral rings in one patient. No significant association was observed between endoscopic findings and number of gastric eosinophils. Conclusions Several unique endoscopic findings of gastric lesions were observed in patients with eosinophilic gastritis or eosinophilic gastroenteritis. Submucosal tumor-like ulcers, antral Penthorum-like appearances, muskmelon-like appearances, and cracks might be associated with eosinophilic gastrointestinal disorders.