Endoscopic submucosal tunnel dissection for a giant adenoma of the cecum (case report)

Endoscopic removal of giant adenomas of the cecum is associated with high risk of perforation and conversion to laparoscopic procedure. Endoscopic submucosal dissection for cecal adenomas had technical limitations due to the adjacent ileocecal valve and appendix opening, perpendicular operating angle. Case presentation of the possibility of successful removal of a large laterally spreading cecal adenoma by the method of endoscopic submucosal tunnel dissection (ESTD) never been described before for this tumor site and size. Patient 54 years old, an LST-G adenoma (5 cm in diameter, according to Kudo – IIIL, according to Sano – II) was detected in the dome of the cecum during colonoscopy. ESTD. The postoperative period without any unfavorable events; the patient was discharged on the 5th day after surgery. The morphological conclusion: tubulo-villous adenoma with moderate epithelial dysplasia, R0. ESTD is suitable for cecal giant adenomas.

Gastric peroral myotomy (G-POEM) in patients with delayed emptying function of the stomach

Introduction. Disorders in the gastric evacuation function are met in patients with gastroesophageal reflux. In most cases, simultaneous laparoscopic pyloroplasty can solve the problem. As an alternative to surgical pyloroplasty to treat gastroparesis, a new technique has been proposed – peroral submucosal pyloromyotomy or gastric peroral endoscopic myotomy (G-POEM). Recently, this endoscopic surgery has been implemented in adults and in newborns with congenital hypertrophic pyloric stenosis to treat gastric paresis. In the present work, the authors describe this technique and short-term results after G-POEM in a child who had previously been operated on for gastroesophageal reflux.Material and methods. Peroral submucosal pyloromyotomy was performed in a girl of 5 y.o. with impaired motor-evacuation function of the stomach after surgical treatment of gastroesophageal reflux disease at the age of two . For 3 years, the child had therapy which included antiemetics and H2-receptor blockers. However, clinical symptoms constantly recurred, and it was decided to make a thorough examination of the patient. At the contrast examination of upper gastrointestinal tract, stomach enlargement and slow transit of the contrast preparation into the duodenum were seen. Fibrogastroduodenoscopy confirmed the normal function of the fundoplication cuff and found a cause of impaired gastric emptying. A contracted gastric outlet as a spasmodic pylorus was found to be an obstacle for normal stomach evacuation function. A narrow hole in the pylorus was found. A 5.4 mm gastroscope could pass through it. The patient had a complete peroral endoscopic submucosal pyloromyotomy. The technique of this surgery consisted in creating a submucosal tunnel at 4 cm before the pylorus and in dissecting the hypertrophied muscle layer by Ramstedt incision using an electrocoagulation knife. After the end of surgery, the incision on the mucous layer was closed with special clamps.Results. Surgical time lasted for 45 minutes. There were no intraoperative complications: bleedings and mucosal perforation . The patient began to eat in 6 hours after the surgery. The transition to full enteral feeding lasted for 24 hours. The child was discharged from the hospital next day in good condition. At the follow-up examination 6 months after surgery, the girl had weight and height typical for her age. There were no signs of dysphagia, abdominal distension, nausea and vomiting any more . There were no post-operative scarring on the child’s abdominal wall.Conclusion. Peroral submucosal pyloromyotomy is technically implementable, safe and effective for treating disorders of stomach evacuation function in children. Further research is needed to find the place of this technique in the treatment of gastric outlet obstruction.

The Most Influential Publications on Endoscopic Submucosal Dissection: A Bibliometric Analysis

Background/Aims: Endoscopic submucosal dissection (ESD) is the first-line treatment for superficial gastrointestinal neoplasms with negligible lymph node metastasis. It has evolved through improvements in expertise and equipment, increased understanding of indications and short- and long-term outcomes, and better management of complications. This study aimed to assess and characterize the most influential publications in ESD research.Materials and Methods: We searched the top 50 most cited articles using Web of Science Core Collection (WoSCC) and Google Scholar (GS) from the inception of these services to January 2019. The top 50 Altmetric Attention Score (AAS) articles based on online media mentions were also searched. Each article was evaluated for the number of citations, title, journal, and publication year.Results: The number of citations for the top 50 WoSCC articles on ESD ranged from 37 to 199; Endoscopy published the most articles (20%). Among the top 50 GS articles, Gastrointestinal Endoscopy published the most ESD articles (34%) and the most shared AAS articles (42.6%). PubMed Central article citations in WoSCC or GS showed significant correlation with those from each metric, unlike AAS. The words with the highest relevance scores were “submucosal tunnel dissection,” “guideline,” “novel submucosal gel,” “adhesive material,” “cell sheet,” “esophageal ulcer,” “hemospray,” and “endoscopic closure,” while the following words were influential: “meta-analysis,” “esophageal stricture,” “perforation,” “bleeding,” “fibrin glue,” “artificial ulcer,” “porcine model” and “esophageal squamous cell neoplasia,” excluding “ESD.”Conclusions: This study presents a detailed list of influential articles, journals, and topic words.

First successful experience of the Zenker's diverticulum endoscopic therapy in Kazakhstan

Zenker's diverticulum tends to occur in the elderly and is generally a relatively rare disorder; the prevalence of Zenker's diverticulum is 1.5–5% of all esophageal diverticula. Men are affected 2-3 times more frequently than women. To date, Zenker's diverticulum is treated mostly by surgery in Kazakhstan, however, with the development of endoscopy the minimally invasive method, endoscopic diverticuloesophagostomy, is being implemented. The transoral treatment is aimed at creating the common cavity between the esophagus and the diverticulum in order to prevent food accumulation in the diverticulum. The anterior wall between these two structures consists of the diverticular wall, m. сricopharyngeus and esophagus wall, the septum transsection automatically ensures myotomy. Both open surgery and endoscopic transoral treatment of Zenker's diverticulum result in reduced symptoms in 94–100% of patients. The paper reports the first successful experience of the Zenker's diverticulum treatment by endoscopic submucosal tunnel dissection in Kazakhstan.

The Study of Prognostic Factors when Performing Ureteral Reconstruction with a Tubularized Boari Flap

Surgical correction of the pathology of the middle and lower third of the ureter in most cases is a complex technical problem, especially in the situation of extended iatrogenic defects of this organ. The purpose of the work was to determine the effectiveness of the Boari operation in the correction of ureteral defects and to demonstrate the prognostic factors of this intervention. Material and methods. The study included 81 patients. Their average age was 47.4±12.2 years. Iatrogenic problems prevailed in the whole group (98.8%). Right-sided changes took place in 40 (49.4%) cases, left-sided were diagnosed in 41 (50.6%) cases. Patients with bilateral injuries accounted for 9.9% (8 patients) of the total studied contingent. In accordance with the length of the tubularized vesicular flap, all patients were divided into two groups: Group 1 (short flap) had reconstruction of the lower third of the ureter to the level of its intersection with the iliac vessels (34 / 42.0% of the patient); Group 2 (long flap) had reconstruction of the lower and middle third of the ureter to the level above its intersection with the iliac vessels (47 / 58.0% of the patient). The technique of the performed surgical interventions somewhat differed from the classical Boari operation due to the use of a minimum number of sutures to connect the ureter with the vesicular flap and the absence of fixation of the flap to the psoas muscle. It included the introduction of 250-300 ml of saline into the bladder, mobilization of the apex and lateral surfaces of the bladder. The volume of bladder mobilization depended on the length of the flap. If it was necessary to cut a flap more than 5 cm long, the contralateral and posterior parts of the bladder were isolated. The width of the distal part of the flap was not less than 2.0 cm; the width of the base of the flap was not less than 4.0 cm. In most cases (77 patients – 95.1%), a submucosal tunnel with a length of at least 10 mm was created in the distal part of the flap. The ureter with a stent was passed through the tunnel and fixed to the bladder mucosa using one interrupted suture. After that, the flap was tubularized and fixed to the adventitia of the ureter with four interrupted sutures. In 4 (4.9%) cases, a simple anastomosis was used between the flap and the ureter without the formation of a submucosal tunnel. Kidney mobilization was performed in 32 (39.5%) patients. To reconstruct the ureter to the level of its middle or upper third, an original modification of Boari's operation was used, which consists in forming a flap of optimal length and width due to its multiple transverse incisions. The effectiveness of Boari operation was assessed retrospectively by analyzing complications and long-term results of treatment to predict which univariate logit regression analysis was used in all studied samples. Results and discussion. The length of the bladder flap varied from 4 to 21 cm and averaged 11.2±5.4 cm. The overall incidence of intraoperative complications did not exceed 14.8%. The rate of postoperative complications reached 45.7%, but their gradation, with the exception of one case, corresponded to I or II according to Clavien-Dindo. The total number of positive long-term results (good + satisfactory result) was 88.9%. The complication rate was objectively associated with the presence of a ureteral-vaginal fistula in patients (p <0.049). A significant prognostic value in relation to long-term results of treatment was found only in one factor, i.e. the volume of the bladder less than 350 ml (p <0.039). Conclusion. Boari operation allows to restore not only lower and middle third of the ureter patency, but also to perform total ureteral reconstruction in individual patients with good functional results. A negative factor in the prognosis of complications of this operation is the presence of a ureteral-vaginal fistula, and long-term results – the volume of the bladder is less than 350 ml