Two-Endoscope Technique of Endoscopic Mucosal Resection for the Treatment of Gastric Intestinal Metaplasia
Main Article Content
Kum Shiu Lam
http://orcid.org/0000-0002-5396-989X
George Ka Kit Lau
http://orcid.org/0000-0002-8928-3769
http://orcid.org/0000-0002-5396-989X
George Ka Kit Lau
http://orcid.org/0000-0002-8928-3769
Abstract
Background and Aim: Gastric intestinal metaplasia (GIM) is precancerous with a worldwide prevalence of 25%. Eradicating Helicobacter pylori prevented about half of gastric cancers; failure to prevent the rest was attributed to GIM. GIM is irreversible and often extensive. There is no treatment. Existing endoscopic mucosal resection (EMR) is designed to treat early gastric cancer of usually <2 cm. A two‐endoscope technique of EMR for extensive GIM had been designed and successfully applied. Our aim is to describe the technique in detail.
Two-endoscope technique of endoscopic mucosal resection: Patients with histologically confirmed moderate to severe GIM (operative link on GIM [OLGIM] classification) received the treatment in a daycare center. Chromoendoscopy with methylene blue was first performed to disclose and mark the GIM. Submucosal saline injections were used to lift the stained mucosa to form multiple safety cushions, which were then transformed into artificial polyps by suction and ligation, using a cap for ligation of esophageal varices. EMRs were then achieved by snare polypectomy. By rotating two gastroscopes, one designated to perform lift and snare and the other to perform suction and ligation, cycles of lift–ligate–snare were carried out until all stained mucosa was removed. Assessment chromoendoscopy with ≥seven biopsies was performed at 6 months.
Results: A total of 227 EMRs were performed in 40 patients, with a median of 3.5 per patient. Bleeding was uncommon and minimal. Gastric perforation ascribable to loss of a safety cushion occurred in one patient. Chromoendoscopy at 6 months in 36 willing patients showed no recurrence of GIM.
Conclusion: The two‐endoscope technique of EMR for GIM was essentially safe and effective, with no recurrence at 6 months. It could be performed by endoscopists with standard skills.
Article Details
How to Cite
LAM, Kum Shiu; LAU, George Ka Kit.
Two-Endoscope Technique of Endoscopic Mucosal Resection for the Treatment of Gastric Intestinal Metaplasia.
Medical Research Archives, [S.l.], v. 11, n. 11, nov. 2023.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/4679>. Date accessed: 16 may 2024.
doi: https://doi.org/10.18103/mra.v11i11.4679.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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18. Pittayanon, R, Rerknimitr, R, Klaikaew, N, et al. The risk of gastric cancer in patients with gastric intestinal metaplasia in 5‐year follow‐up. Aliment Pharmacol Ther 2017; 46: 40– 45. doi: doi.org/10.1111/apt.14082.
19. Schlemper RJ, Riddell RH, Kato Y, Borchard F, Cooper HS, Dawsey SM, et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut. 2000;47: 251–255. doi:10.1136/gut.47.2.251, pmid:10896917.
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27. Shichijo S., Hirata Y., Niikura R., Hayakawa Y., Yamada A., Ushiku T., Fukayama M., Koike K. Histologic intestinal metaplasia and endoscopic atrophy are predictors of gastric cancer development after Helicobacter pylori eradication. Gastrointestinal Endosc 2016;8: 618–624. PMID: 26995689, doi: 10.1016/j.gie.2016.03.791.
28. Rokkas T, Rokka A, Portincasa P. A systematic review and meta-analysis of the role of Helicobacter pylori eradication in preventing gastric cancer. Ann Gastroenterol 2017;30:414–423. doi:10.20524/aog.2017.0144.
29. Zullo A, Hassan C, Romiti A, et al. Follow-up of intestinal metaplasia in the stomach: When, how and why. World J Gastrointest Oncol 2012;4(3):30–36. doi:10.4251/wjgo.v4.i3.30.
30. Kiriyama Y, Tahara T, Shibata T, al. (2016) Gastric-and-Intestinal Mixed Intestinal Metaplasia Is Irreversible Point with Eradication of Helicobacter pylori. Open J Pathol 2016; 6: 93-104. doi: dx.doi.org/10.4236/ojpathology.2016.62012.
31. Liu KSH, Wong IOL, Leung WK. Helicobacter pylori associated gastric intestinal metaplasia: Treatment and surveillance. World J Gastroenterol 2016; 22(3): 1311-1320. doi:dx.doi.org/10.3748/wjg.v22.i3.1311.
32. Correa P, Fontham ET, Bravo JC, Bravo LE, Ruiz B, Zarama G, Realpe JL, Malcom GT, Li D, Johnson WD, Mera R. Chemoprevention of gastric dysplasia: randomized trial of antioxidant supplements and anti-helicobacter pylori therapy. J Natl Cancer Inst 2000;92:1881–8. PMID: 11106679, doi: 10.1093/jnci/92.23.1881.
33. Wong BCY, Zhang L, Ma J, et al. Effects of selective COX-2 inhibitor and Helicobacter pylori eradication on precancerous gastric lesions. Gut 2012;61:812–818. PMID: 21917649, doi: 10.1136/gutjnl-2011-300154.
34. Lam SK and Lau GKK. Novel two-endoscope technique of treatment for gastric intestinal metaplasia, a precursor to cancer. JGH Open 2020;4(4):569-573. doi: 10.1002/jgh3.12318.
35. Dixon MF, Genta RM, Yardley JH, Gorrea P. Classification and grading of gastritis. The updated Sydney system. Am. J. Surg. Pathol. 1996; 20: 1161– 81.
36. Trivedi PJ, Braden B. Indications, stains and techniques in chromoendoscopy. QJM: An Internat J Med 2013;106:117–131. doi:10.1093/qjmed/hcs186.
37. Zhao Y, Wang C. Long‐term clinical efficacy and perioperative safety of endoscopic submucosal dissection versus endoscopic mucosal resection for early gastric cancer: an updated meta‐analysis. Biomed. Res. Int. 2018; 2018: 3152346.
38. Sugano K. Screening of gastric cancer in Asia. Best Pract. Res. Clin. Gastroenterol. 2015; 29: 895– 905.
39. You W‐C, Li J‐Y, Blot WJ et al. Evolution of precancerous lesions in a rural Chinese population at high risk of gastric cancer. Int. J. Cancer. 1999; 83: 615– 19.
40. Li Y, Wu JH, Meng Y, Zhang Q, Gong W, Liu SD. New devices and techniques for endoscopic closure of gastrointestinal perforations. World J. Gastroenterol. 2016; 22: 7453– 62.
41. Zhao Y, Wang C. Long‐term clinical efficacy and perioperative safety of endoscopic submucosal dissection versus endoscopic mucosal resection for early gastric cancer: an updated meta‐analysis. Biomed. Res. Int. 2018; 2018: 3152346.
42. de Vries AC, Haringsma J, de Vries RA et al. The use of clinical, histologic, and serologic parameters to predict the intragastric extent of intestinal metaplasia: a recommendation for routine practice. Gastrointest. Endosc. 2009; 70: 18– 25.
43. Cassaro M, Rugge M, Gutierrez O, Leandro G, Graham DY, Genta RM. Topographic patterns of intestinal metaplasia and gastric cancer. Am. J. Gastroenterol. 2000; 95: 1431– 8.
44. Tava F, Luinetti O, Ghigna MR et al. Type or extension of intestinal metaplasia and immature/atypical “indefinite‐for‐dysplasia” lesions as predictors of gastric neoplasia. Hum. Pathol. 2006; 37: 1489– 97.
45. Venerito M, Malfertheiner P. Preneoplastic conditions in the stomach: always a point of no return? Dig Dis. 2015;33(1):5-10. doi: 10.1159/000369185. Epub 2014 Dec 17. PMID: 25531491.
46. Mladenova I. Clinical Relevance of Helicobacter pylori Infection. J Clin Med. 2021 Aug 6;10(16):3473. doi: 10.3390/jcm10163473. PMID: 34441769; PMCID: PMC8396975.
2. Yan X, Lei L, Li H, Cao M, Yang F, He S, Zhang S, Teng Y, Li Q, Xia C, Chen W. Stomach cancer burden in China: Epidemiology and prevention. Chin J Cancer Res. 2023 Apr 30;35(2):81-91. doi: 10.21147/j.issn.1000-9604.2023.02.01. PMID: 37180831; PMCID: PMC10167608.
3. Shao L, Li P, Ye J, Chen J, Han Y , Cai J, Lu X. Risk of gastric cancer among patients with gastric intestinal metaplasia. Int J Cancer 2018;143:1671–1677. PMID: 29707766, doi:10.1002/ijc.31571.
4. You W-C. Contribution from Cancer Epidemiological Studies in China. Chin J Cancer Res 2011;23:1–2. doi: 10.1007/s11670-011-0001-y.
5. Gupta S, Li D, El Serag HB, Davitkov P, Altayar O, Sultan S, Falck-Ytter Y, Mustafa RA. AGA Clinical Practice Guidelines on Management of Gastric Intestinal Metaplasia. Gastroenterology 2020;158:693-702. doi: 10.1053/j.gastro.2019.12.003. Epub 2019 Dec 6. PMID: 31816298; PMCID: PMC7340330.
6. Marques-Silva L, Areia M, Elvas L, Dinis-Ribeiro M. Prevalence of gastric precancerous conditions: a systematic review and meta-analysis. European J Gastroenterol Hepatol 2014 26:378–387. doi: 10.1097/MEG.0000000000000065.
7. Sonnenberg A, Lash RH, Genta RM. A national study of Helicobactor pylori infection in gastric biopsy specimens. Gastroenterology. 2010;139(6):1894–1901. doi:10.1053/j.gastro.2010.08.018.
8. Olmez S , Aslan M , Erten R , et al . The prevalence of gastric intestinal metaplasia and distribution of Helicobacter pylori infection, atrophy, dysplasia, and cancer in its subtypes. Gastroenterol Res Pract 2015;2015:1–6. doi:10.1155/2015/434039.
9. Eriksson NK, Kärkkäinen PA, Färkkilä MA, Arkkila PE. Prevalence and distribution of gastric intestinal metaplasia and its subtypes. Dig Liver Dis 2008;40:355–60. doi: 10.1016/j.dld.2007.12.012.
10. Eidt S, Stolte M. Prevalence of intestinal metaplasia in Helicobacter pylori gastritis. Scand J Gastroenterol 1994;29:607–10. PMID: 7939396, doi: 10.3109/00365529409092480.
11. Asaka M, Sugiyama T, Nobuta A, Kato M, Takeda H, Graham DY. Atrophic gastritis and intestinal metaplasia in Japan: results of a large multicenter study. Helicobacter 2001;6:294–9. doi: 10.1046/j.1523-5378.2001.00042.x.
12. Kim HJ, Choi BY, Byun TJ, Eun CS, Song KS, Kim YS, et al. The prevalence of atrophic gastritis and intestinal metaplasia according to gender, age and Helicobacter pylori infection in a rural population. J Prev Med Public Health 2008;41:373–9. PMID: 19037166, doi: 10.3961/jpmph.2008.41.6.373.
13. Du Y, Bai Y, Xie P, et al. Chronic gastritis in China: a national multi-center survey. BMC Gastroenterol 2014;14:21. PMID: 24502423, PMCID: PMC3922313, doi:10.1186/1471–230X-14-21.
14. Malik TH, Zhao C, AlAhmed JM, Alam SA, Xu H. Gastric Intestinal Metaplasia Is the Most Common Histopathological Phenotype among Endoscopically Diagnosed Atrophic Gastritis Patients in North-East China. Open J Gastroenterol 2017;7:65–74. doi.org/10.4236/ojgas.2017.72008.
15. Chen, S., Ying, L., Kong, M., Zhang, Y. and Li, Y. The Prevalence of Helicobacter pylori Infection Decreases with Older Age in Atrophic Gastritis. Gastroenterol Res Pract 2013, Article ID: 494783. doi.org/10.1155/2013/494783.
16. Capelle LG, de Vries AC, Haringsma J, et al. The staging of gastritis with the OLGA system by using intestinal metaplasia as an accurate alternative for atrophic gastritis. Gastrointest Endosc 2010;71:1150–1158. PMID: 20381801, doi: 10.1016/j.gie.2009.12.029.
17. Matsukura N, Suzuki K, Kawachi T, et al. Distribution of marker enzymes and mucin in intestinal metaplasia in human stomach and relation to complete and incomplete types of intestinal metaplasia to minute gastric carcinomas. J Natl Cancer Inst 1980;65:231–40. PMID: 6931245, doi: doi.org/10.1093/jnci/65.2.231
18. Pittayanon, R, Rerknimitr, R, Klaikaew, N, et al. The risk of gastric cancer in patients with gastric intestinal metaplasia in 5‐year follow‐up. Aliment Pharmacol Ther 2017; 46: 40– 45. doi: doi.org/10.1111/apt.14082.
19. Schlemper RJ, Riddell RH, Kato Y, Borchard F, Cooper HS, Dawsey SM, et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut. 2000;47: 251–255. doi:10.1136/gut.47.2.251, pmid:10896917.
20. Sung JK . Diagnosis and management of gastric dysplasia. Korean J Intern Med 2016;31:201–9. doi:10.3904/kjim.2016.021.
21. Lauwers GY, Riddell RH. Gastric epithelial dysplasia. Gut 1999;45:784–790. doi: dx.doi.org/10.1136/gut.45.5.784.
22. Zhao G, Xue M, Hu Y, Lai S, Chen S, Wang L. How Commonly Is the Diagnosis of Gastric Low Grade Dysplasia Upgraded following Endoscopic Resection? A Meta-Analysis. PLOS ONE 2015;10: e0132699. doi: doi.org/10.1371/journal.pone.0132699.
23. Cho SJ, Choi IJ, Kim CG, etal. Risk factors associated with gastric cancer in patients with a duodenal ulcer. Helicobacter 2010;15:516–523. doi: 10.1111/j.1523-5378.2010.00805.x.
24. Correa P. Human gastric carcinogenesis: a multistep and multifactorial process--First American Cancer Society Award Lecture on Cancer Epidemiology and Prevention. Cancer Res 1992; 52(24):6735–40 (ISSN: 0008-5472). PMID: 1458460.
25. Lee YC, Chiang TH, Chou CK, Tu YK, Liao WC, Wu MS, et al. Association between helicobacter pylori eradication and gastric cancer incidence: a systematic review and meta-analysis. Gastroenterology 2016;150:1113–24. PMID: 26836587, doi: 10.1053/j.gastro.2016.01.028.
26. Wong, B. C., S. K. Lam, W. M. Wong, J. S. Chen, T. T. Zheng, R. E. Feng, K. C. Lai, W. H. Hu, S. T. Yuen, S. Y. Leung, D. Y. Fong, J. Ho, C. K. Ching, and J. S. Chen. Helicobacter pylori eradication to prevent gastric cancer in a high-risk region of China: a randomized controlled trial. JAMA 2004;291:187–194. PMID: 14722144, doi: 10.1001/jama.291.2.187.
27. Shichijo S., Hirata Y., Niikura R., Hayakawa Y., Yamada A., Ushiku T., Fukayama M., Koike K. Histologic intestinal metaplasia and endoscopic atrophy are predictors of gastric cancer development after Helicobacter pylori eradication. Gastrointestinal Endosc 2016;8: 618–624. PMID: 26995689, doi: 10.1016/j.gie.2016.03.791.
28. Rokkas T, Rokka A, Portincasa P. A systematic review and meta-analysis of the role of Helicobacter pylori eradication in preventing gastric cancer. Ann Gastroenterol 2017;30:414–423. doi:10.20524/aog.2017.0144.
29. Zullo A, Hassan C, Romiti A, et al. Follow-up of intestinal metaplasia in the stomach: When, how and why. World J Gastrointest Oncol 2012;4(3):30–36. doi:10.4251/wjgo.v4.i3.30.
30. Kiriyama Y, Tahara T, Shibata T, al. (2016) Gastric-and-Intestinal Mixed Intestinal Metaplasia Is Irreversible Point with Eradication of Helicobacter pylori. Open J Pathol 2016; 6: 93-104. doi: dx.doi.org/10.4236/ojpathology.2016.62012.
31. Liu KSH, Wong IOL, Leung WK. Helicobacter pylori associated gastric intestinal metaplasia: Treatment and surveillance. World J Gastroenterol 2016; 22(3): 1311-1320. doi:dx.doi.org/10.3748/wjg.v22.i3.1311.
32. Correa P, Fontham ET, Bravo JC, Bravo LE, Ruiz B, Zarama G, Realpe JL, Malcom GT, Li D, Johnson WD, Mera R. Chemoprevention of gastric dysplasia: randomized trial of antioxidant supplements and anti-helicobacter pylori therapy. J Natl Cancer Inst 2000;92:1881–8. PMID: 11106679, doi: 10.1093/jnci/92.23.1881.
33. Wong BCY, Zhang L, Ma J, et al. Effects of selective COX-2 inhibitor and Helicobacter pylori eradication on precancerous gastric lesions. Gut 2012;61:812–818. PMID: 21917649, doi: 10.1136/gutjnl-2011-300154.
34. Lam SK and Lau GKK. Novel two-endoscope technique of treatment for gastric intestinal metaplasia, a precursor to cancer. JGH Open 2020;4(4):569-573. doi: 10.1002/jgh3.12318.
35. Dixon MF, Genta RM, Yardley JH, Gorrea P. Classification and grading of gastritis. The updated Sydney system. Am. J. Surg. Pathol. 1996; 20: 1161– 81.
36. Trivedi PJ, Braden B. Indications, stains and techniques in chromoendoscopy. QJM: An Internat J Med 2013;106:117–131. doi:10.1093/qjmed/hcs186.
37. Zhao Y, Wang C. Long‐term clinical efficacy and perioperative safety of endoscopic submucosal dissection versus endoscopic mucosal resection for early gastric cancer: an updated meta‐analysis. Biomed. Res. Int. 2018; 2018: 3152346.
38. Sugano K. Screening of gastric cancer in Asia. Best Pract. Res. Clin. Gastroenterol. 2015; 29: 895– 905.
39. You W‐C, Li J‐Y, Blot WJ et al. Evolution of precancerous lesions in a rural Chinese population at high risk of gastric cancer. Int. J. Cancer. 1999; 83: 615– 19.
40. Li Y, Wu JH, Meng Y, Zhang Q, Gong W, Liu SD. New devices and techniques for endoscopic closure of gastrointestinal perforations. World J. Gastroenterol. 2016; 22: 7453– 62.
41. Zhao Y, Wang C. Long‐term clinical efficacy and perioperative safety of endoscopic submucosal dissection versus endoscopic mucosal resection for early gastric cancer: an updated meta‐analysis. Biomed. Res. Int. 2018; 2018: 3152346.
42. de Vries AC, Haringsma J, de Vries RA et al. The use of clinical, histologic, and serologic parameters to predict the intragastric extent of intestinal metaplasia: a recommendation for routine practice. Gastrointest. Endosc. 2009; 70: 18– 25.
43. Cassaro M, Rugge M, Gutierrez O, Leandro G, Graham DY, Genta RM. Topographic patterns of intestinal metaplasia and gastric cancer. Am. J. Gastroenterol. 2000; 95: 1431– 8.
44. Tava F, Luinetti O, Ghigna MR et al. Type or extension of intestinal metaplasia and immature/atypical “indefinite‐for‐dysplasia” lesions as predictors of gastric neoplasia. Hum. Pathol. 2006; 37: 1489– 97.
45. Venerito M, Malfertheiner P. Preneoplastic conditions in the stomach: always a point of no return? Dig Dis. 2015;33(1):5-10. doi: 10.1159/000369185. Epub 2014 Dec 17. PMID: 25531491.
46. Mladenova I. Clinical Relevance of Helicobacter pylori Infection. J Clin Med. 2021 Aug 6;10(16):3473. doi: 10.3390/jcm10163473. PMID: 34441769; PMCID: PMC8396975.