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이매지나 제품의 특장점 IMAGINA CLINICAL CASES 회사 소개

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IMAGINA LEADERS STOMACH Prof. Jun Haeng Lee CASE 1

STOMACH

Prof. Jun Haeng Lee

Prof. Yong Hwan KWON

Prof. Woo Chul CHUNG

Prof. Seong Woo JEON

image
  • Prof. Jun Haeng LEE
  • Division of Gastroenterology
  • Department of Internal Medicine
  • Samsung Medical Center
  • Sungkyunkwan University School of Medicine
  • Area of Interest
  • Endoscopic treatment of early gastric cancer and gastroesophageal reflux disease
  • Personal homepage: http://endotoday.com
  • Quality and patient safety in medicine
  • (Deputy Director of Department of Quality Innovation at Samsung Medical Center)

CASE 1

CASE 2

CASE 3

CASE 4

How do I use PENTAX IMAGINA in my clinical endoscopy cases :

“In my GI endoscopy unit of hospital, there are 4 PENTAX Medical IMAGINA Video Endoscope Systems with 16 gastroscopes and 12 colonoscopes.
The first time IMAGINA system were installed in 2020, some endoscopists experienced minor difficulties in controlling the new endoscope due to some differences (e.g.: close position of the buttons, i-scan, feeling from the shaft, i-pad style touch panel, et al.) from existing ones of the other supplier.
But I easily get used to the PENTAX Medical IMAGINA endoscope system before long.
The major advantages of clinical case with IMAGINA are the excellent quality of close-up image and the function of high degree angulation. It is convenient to make high quality video clips using the 2 USB ports (please don't forget to use the most recent version of USB memory).”

Cascade Stomach

Patient History

Screening endoscopy of a 48-year-old female without any symptom and sign.

Endoscopic Findings

When the endoscope was introduced into the stomach, the lumen of the gastric body was seen at the upper right corner.
After infusion of some air into the stomach, a ridge between the gastric fundus and upper body can be seen.
The ridge runs from the posterior wall of the cardia toward the anterior wall of the stomach, crossing the greater curvature.
When the stomach has a prominent ridge between the fundus and high body, it is called as the cascade stomach (CS). The clinical significance of CS is still uncertain.

Image 1

image

The timing of entering the stomach is very different between endoscopists.
Some endoscopists rapidly pass the esophagus without entering a lot of air.
In that situation, the stomach is not initially expanded at all.
For the other endoscopists, who carefully observe the esophagus before entering the stomach, there will be already an air in the stomach.
With a plenty of air in the stomach, the angulation between the fundus and high body can be changed, so the findings of Cascade stomach (a ridge between the gastric fundus and upper body) may be different.
In this case, the ridge runs from the posterior wall of the cardia toward the anterior wall of the stomach, crossing the greater curvature.
The clinical significance of this finding is unclear.

Image 2

image

In this retroflection view, the ridge from the cardia is so prominent that I was not able to see the base of the fundus.
In this situation, it is quite easy to miss the lesion.
The base of the fundus and the posterior wall of the lower body are known as blind areas.
Before finishing the stomach observation, you need to rotate the endoscope counter-clockwise,
so that you can see the base of the fundus en face.

Image 3

Video clip available

Summary

  • Cascade stomach is an atypical form of hourglass stomach characterized radiographically by a drawing up of the posterior wall;
  • an opaque medium first fills the upper sac and the cascades into the lower sac.
  • This entity was originally studied with barium gastrography in patient with functional dyspepsia (FD).
  • In FD patients with cascade stomach in barium study, ingested food and fluid or swallowed air would initially be collected in the fundus.
  • After filling the fundus, the food/fluid would flow rapidly into the gastric body, which could be related to FD symptoms.
  • As transient LES relaxation (TLESR) is triggered by fundus distention, cascade stomach may be related with gastroesophageal reflux diseases.
  • With endoscopy, however, it is difficult to interpret the findings of cascade stomach. Just after entering the stomach with some air infusion,
  • a ridge between the gastric fundus and upper body can be seen in some patients.
  • The ridge runs from the posterior wall of the cardia toward the anterior wall of the stomach, crossing the greater curvature.
  • These findings are greatly influenced by the amount of air infused during the examination.
  • So, the clinical significance of cascade stomach still needs to be investigated.
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How do I use PENTAX IMAGINA in my clinical endoscopy cases :

“In my GI endoscopy unit of hospital, there are 4 PENTAX Medical IMAGINA Video Endoscope Systems with 16 gastroscopes and 12 colonoscopes.
The first time IMAGINA system were installed in 2020, some endoscopists experienced minor difficulties in controlling the new endoscope due to some differences (e.g.: close position of the buttons, i-scan, feeling from the shaft, i-pad style touch panel, et al.) from existing ones of the other supplier.
But I easily get used to the PENTAX Medical IMAGINA endoscope system before long.
The major advantages of clinical case with IMAGINA are the excellent quality of close-up image and the function of high degree angulation. It is convenient to make high quality video clips using the 2 USB ports (please don't forget to use the most recent version of USB memory).”

Advanced Gastric Cancer, Borrmann Type IV

Patient History

A 49-year-old female with symptom of early fullness and with the sign of weight loss.

Endoscopic Findings

The result of endoscopic forceps biopsy was poorly cohesive carcinoma.
Abdominal CT images showed diffuse wall thickening mass of the upper body and fundus of stomach with mild per-gastric infiltration.
The preoperative diagnosis was the advanced gastric cancer, Borrmann type IV.

Patient Outcome and Follow-ups

Surgical consultation was done for the exploratory laparotomy.
However, there were multiple seeding nodules found in the laparoscopy.
Palliative chemotherapy was done.

Image 1

image

Image of the high body greater curvature and posterior wall:
The gastric folds are diffusely thickened.
The interval between folds was narrowed and some folds were conglomerated to form an ill-defined flat elevated area.
The surface was diffusely hyperemic and shows mosaic pattern, which means the accentuation of the normal area gastricae.
The lumen of the stomach was slightly expanded by air but not enough.
There was no definite ulcer or erosion.

Image 2

image

Image enhanced endoscopy by i-Scan:
The surface mosaic pattern is more clearly seen.

Image 3

Video clip available

Initially you can see the thickened folds and narrowed interval between folds.
The antrum does not seem to be involved by the diffuse type malignancy.
. The border between the involved and normal areas looks
like somewhere between lower body and proximal antrum.
In the retroflection view, the whole area of the fundus and the cardia was involved.
There was no ulcer or erosion.

Summary

  • Advanced gastric cancer Borrmann type IV is the most important disease entity in terms of endoscopic examination of the stomach.
  • It is easy for endoscopists to miss due to the lack of definite mucosal lesion. It is more common in young woman even in the 30’s and 40’s.
  • Ulcerative lesion is found in about 30% of cases. In cases without ulcer or erosion, it is difficult to decide where to do the biopsies.
  • The sensitivity of the biopsy is very low in this situation.
  • When it is clinically suspected, the surgical exploration is necessary even without histological evidence.
  • The curative surgical resection is possible in less than 30% of the cases, and the long-term survival cases are rare.
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How do I use PENTAX IMAGINA in my clinical endoscopy cases :

“PENTAX Medical IMAGINA i10c gastroscope was originally developed as a multifunctional upper endoscope not only for diagnosis but also for therapeutic purposes.

(1) It has a very wide working channel (inner diameter = 3.2mm), so suction of the air is available during the therapeutic procedures. Recent gastroscope models from other supplier have 2.8mm inner diameter on the working channel, which makes suctioning air with catheters in the working channel impossible.

(2) It has a waterjet function, so that irrigation during the procedure is possible. (There is one major limitation in this aspect. The water line is single use only.)

(3) The angulation is so good that the procedures for the lesions in the difficult locations are relatively easy and save times.

(4) The weight of the i10c scope is much decreased from the previous PENTAX version and relatively light in comparison with products from different suppliers. It may be an ideal endoscope for me, a therapeutic endoscopists in 50s looking for the ergonomic design to relieve the pain on shoulders and wrists."

APC Ablation for Adenoma

Patient History

A 68-year-old male with no symptom and sign (referred for the treatment of incidental gastric adenoma found in the screening endoscopy)

Endoscopic Findings

In the screening endoscopy, about 1.5cm sized ill-defined mucosal irregularity was found in the lesser curvature of the midbody.
Background gastric mucosal was atrophic.

Patient Outcome and Follow-ups

The biopsy showed adenoma with low grade dysplasia.
Ablation treatment using Argon Plasma Coagulation apparatus was done.
After treatment, PPI was given for two weeks.

Image 1

image

i-scan image of the adenoma with low grade dysplasia in the lesser curvature of the lower body.
It is small, pale and flat, so endoscopic ablation can be an option.
Background gastric mucosa is atrophic.

Image 2

image

Just after ablation treatment with argon plasma coagulation (APC),
the lesion is changed into the white necrotic areas.
When you do follow-up endoscopy a few days later,
this lesion would be changed into a deep ulcer,
which is a mechanism of ablation treatment.

Image 3

Video clip available

Summary

  • The ideal management for gastric adenoma is still uncertain.
  • In adenoma with high grade dysplasia, the chance of malignancy in the resected stomach is about 33% to 50%, so endoscopic resection
  • (ESD or EMR) is strongly recommended.
  • It is considered just like a small gastric cancer limited in the mucosal layer.
  • However, the management of adenoma with low-grade dysplasia is still controversial.
  • When the low-grade adenoma is big, ulcerative or hyperemic, the chance of worse histology is rather high,
  • so endoscopic resection is recommended rather than endoscopic ablation.
  • In low grade adenomas without such worrisome findings, endoscopic ablation or careful strategic observation is also considered.
  • I prefer endoscopic ablation treatment with APC instrument rather than simple observation without treatment.
  • APC ablation is easy and can be done in outpatient settings.
  • After ablation treatment, bleeding complications possibly occur in about 2-3% of patients so a short course of anti-acid treatment with
  • PPI or P-CAB (tegoprazan) is my routine. Some patients experience pain for a couple of days and acetaminophen is given as needed.
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How do I use PENTAX IMAGINA in my clinical endoscopy cases :

“PENTAX Medical IMAGINA i10c gastroscope was originally developed as a multifunctional upper endoscope not only for diagnosis but also for therapeutic purposes.

(1) It has a very wide working channel (inner diameter = 3.2mm), so suction of the air is available during the therapeutic procedures. Recent gastroscope models from other supplier have 2.8mm inner diameter on the working channel, which makes suctioning air with catheters in the working channel impossible.

(2) It has a waterjet function, so that irrigation during the procedure is possible. (There is one major limitation in this aspect. The water line is single use only.)

(3) The angulation is so good that the procedures for the lesions in the difficult locations are relatively easy and save times. For gastric ESD cases, I choose Splash M-Knife, Splash M-Knife has lots of advantages during ESD. In the extended position of distal tip, there is a knife disk which can be hooked. I usually perform ESD using this hooking mechanism. The hooking mechanism is very useful for a lesions on difficult locations. Besides, Splash M-Knife has a superior hemostasis function. If the distal tip is in retracted position, distal tip and metal plate become like one body. By forming 1.5 cm or more round plate in this position, hemostasis is also possible and effective. When I perform submucosal injection in the middle of the ESD procedure, I don’t need to change the knife and the procedure time is much saved due to the water jet function.”

ESD for EGC using Splash M Knife Only

Patient History

A 62 years old male patient visited my clinic due to a small gastric lesion found in the screening endoscopy.


Outside pathology report was 'tubular adenoma with high grade dysplasia, suspicious of adenocarcinoma'.
Outside pathology slide was reviewed by an in-house pathologist of Samsung Medical Center and the final pathology was 'adenocarcinoma, moderately differentiated’.
The CT scan was negative for metastasis.

Endoscopic Finding, Treatment and Pathology Result

Stomach, EGC of proximal antrum, ESD with Splash M-Knife by PENTAX Medical
Location : antrum, greater curvature
Gross type : EGC type IIc+IIa
Histologic type : tubular adenocarcinoma, moderately differentiated
Histologic type by Lauren : intestinal
Size of carcinoma : longest diameter as 11 mm, vertical diameter as 10 mm
Depth of invasion : invades mucosa (muscularis mucosa) (pT1a)
Resection margin : free from carcinoma(N); safety margin : distal 14 mm, proximal 10 mm, anterior 10 mm, posterior 10 mm, deep 200 ㎛
Lymphatic invasion : not identified(N)
Venous invasion : not identified(N)
Perineural invasion : not identified(N)
Microscopic ulcer : absent
Histologic heterogeneity: absent

Image 1

image

Image 2

image

ESU: ERBE VIO300D (mainly EndoCut I 3-3-3)
Bleeding control : Splash M-Knife (hemostatic forceps not used)
Sedation: Pethidine 25mg + Midazolam 5mg IV

Image 3

Video clip available

Summary

  • Endoscopic submucosal dissection (ESD) for a small early gastric cancer lesion was successfully done with PENTAX i10c gastroscope and Splash M-Knife from also PENTAX Medical. High maneuverability of the i10c gastroscope and excellent hemostatic function of the Splash M-Knife made the procedure simple and quick. After the ESD procedure, proton pump inhibitor (PPI) was given for 4 weeks, and the follow up endoscopy was recommended after 2 months.
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IMAGINA LEADERS STOMACH Prof. Yong Hwan KWON CASE 1

STOMACH

Prof. Jun Haeng Lee

Prof. Yong Hwan KWON

Prof. Woo Chul CHUNG

Prof. Seong Woo JEON

image
  • Prof. Yong Hwan KWON
  • Division of Gastroenterology & Hepatology/li>
  • Department of Medicine
  • Kyungpook National University Hospital
  • Area of Interest
  • Endoscopic therapy
  • Gastric cancer and carcinogenesis
  • Helicobacter pylori

CASE 1

CASE 2

How do I use PENTAX IMAGINA in my clinical endoscopy cases :

“HD+ and i-scan supported the characterization of the epithelial surface and vascularization of gastric mucosal lesions and can assist treatment and surveillance decisions.“

Gastric Adenoma

Patient History

A 74-year-old female was referred for the EGD through incidental finding on health examination.

Endoscopic Findings

20mm sized type IIa lesion at lesser curvature of mid-body.
i-scan SE and TE helped to demarcate the borders or the leision.

Endoscopic Treatment and Pathology Results

The lesion was dissected via gastric ESD.
The final pathology indicated early gastric adenoma, lower grade dysplasia.

Patient Outcome and Follow-ups

The lesion was resected en-bloc. During the procedure, no major bleeding occurred and no perforation could be spotted.

Image 1

image

Image 2

image

Image 3

Video clip available

Summary

  • This case shows that HD+ and i-scan led to the appropriate treatment of the patient and to the resection of the lesion en-bloc.
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How do I use PENTAX IMAGINA in my clinical endoscopy cases :

“ I used the PENTAX Medical IMAGINA when the gastric ulcer bleeding was suspected.
The i-scan mode can help to discriminate whether the morphology of ulcer is benign or malignant based on change of color, vascularity and pit-pattern.“

Aspirin Induced Benign Gastric Ulcers

Patient History

A 78-year-old female visited emergency room for 3 days melena.
The patient had previous angina history and took aspirin for several years. Laboratory finding

Endoscopic Findings

CBC WBC 8600/㎛ Hb 8.7g/dL Hct 27% Plt 114K/㎕ Chemical and electrolyte battery Protein/Alb 6.6/3.8 g/dL AST/ALT 23/28IU/L ALP 96 U/L TB/DB 1.2/0.8mg/dL BUN/Cr 30.2/1.2 mg/dL Na/K 137/3.6 mmoL/L ESR 22mm/hr CRP 1.3mg/dL

Endoscopic Findings

The noted multiple ovoid ulcers surrounded with edematous mucosa at antrum, however, no active bleeding was seen in endoscopic finding.
The ulcers were shown smooth and regular shapes, even bases, clearly demarcated and regular edges.
The ulcer stage was A2 by Sakita-Miwa classification.

Patient Outcome and Follow-ups

Benign gastric ulcer and CLOtest (-)

Image 1

Video clip available

Summary

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin cause frequently gastrointestinal injuries.
  • In the acute phase of NSAIDs damage, endoscopic findings of gastroduodenal injuries are observed as acute gastroduodenal mucosal lesion (AGDML).
  • In the chronic phase of NSAIDs damage, multiple antral erosions and/or ulcers with oozing, and punched-out antral ulcers are characteristic findings.
  • Characteristic images of gastrointestinal injuries induced by NSAIDs are multiple erosions and ulcers with bleeding without symptoms.
  • It is most important asking about use of NSAIDs if we see such endoscopic images.
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IMAGINA LEADERS STOMACH Prof. Woo Chul CHUNG CASE 1

STOMACH

Prof. Jun Haeng Lee

Prof. Yong Hwan KWON

Prof. Woo Chul CHUNG

Prof. Seong Woo JEON

image
  • Prof. Woo Chul CHUNG
  • Division of Gastroenterology
  • Department of Internal Medicine
  • The Catholic University School of Medicine
  • St. Vincent’s Hospital
  • Area of Interest
  • Therapeutic endoscopy
  • Gastric cancer
  • Helicobacter pylori

CASE 1

CASE 2

How do I use PENTAX IMAGINA in my clinical endoscopy cases :

“IMAGINA video endoscope is suitable for therapeutic endoscopy and the image was sharper and crisper without losing focus. I can practice IMAGINA for various therapeutic endoscopy cases. Prejudice about PENTAX Medical endoscopes can be released I think.”

Gastric Adenoma

Patient History

A 73-year-old male with no medical history was referred for the endoscopic evaluation.

Endoscopic Findings

Large sliding hernia with erosive esophagitis (LA classification B) and 0.7cm sized sessile elevated mucosal lesion (Yamada type I polyp) were observed.

Endoscopic Treatment and Pathology Results

The microsopic diagnosis was gastric epithelial dysplasia – low grade.

Patient Outcome and Follow-ups

Annual endoscopic surveillance with biopsy.

Image 1

image

By endoscope of ‘O’ brand

image

Image 2

image

By endoscope of PENTAX Medical IMAGINA

image

Summary

  • As for the development of intestinal-type gastric adenocarcinoma, the carcinogenic cascade model was proposed by Correa,
  • which was a multi-step process from normal gastric epithelium to chronic gastritis, chronic atrophic gastritis, intestinal metaplasia, gastric epithelial dysplasia (low and high grade), followed by gastric cancer.
  • The recommended treatment guidelines for gastric epithelial dysplasia are endoscopic submucosal dissection for high grade dysplasia (HGD) and annual endoscopic surveillance with biopsy for low grade dysplasia (LGD).
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How do I use PENTAX IMAGINA in my clinical endoscopy cases :

“During a case of endoscopic hemostasis with APC for the gastric angiodysplasia, there was no losing image quality from the argon smoke.
The near focus image was clearly visualized.“

Comparison of endoscopic hemostasis with PENTAX Medical IMAGNA (A) and the other company’s endoscopy (B)

(A) image image image
(B) image image image

Active Bleeding in Gastric Angiodysplasia

Patient History

A 73-year-old male patient with hypertension was referred for taking out foreign matter (drug package) which was swallowed together with medicine.

Endoscopic Findings

The drug package was observed at mid esophagus. We used a protective device - endoscopic cap, in order to avoid esophagogastric/pharyngeal damage during endoscopic extraction of sharp-pointed foreign body. (image 1)
Successful removal and laceration wounds were observed. (image 2)

Endoscopic Treatment and Pathology Results

Foreign body removal by endoscopy

Patient Outcome and Follow-ups

The procedure performed successfully without any event.

Image 1

image
image

Image 2

image
image

Summary

  • Gastric angiodysplasia is a unique mucosal vascular lesion that causes acute or recurrent gastrointestinal bleeding.
  • It is considered as the differential diagnosis of UGIB and may occasionally cause severe bleeding, but it can also be found in symptom-free patients.
  • There have been studies that multiple angiodysplastic lesions and anticoagulant agents predict an increased risk of recurrent bleeding.
  • But the bleeding risk from angiodysplasia itself was related to the size of lesion and not related to anticoagulant agents.
  • Endoscopic methods of treatment reported to be of value including injection therapy, such as injection of epinephrine; ablative therapy,
  • such as electrocautery or argon plasma coagulation; (APC) and mechanical therapy, such as endoclips or banding.
  • In this case, active bleeding from gastric angiodysplasia was successfully treated by endoscopy with APC.
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IMAGINA LEADERS STOMACH Prof. Seong Woo JEON

STOMACH

Prof. Jun Haeng Lee

Prof. Yong Hwan KWON

Prof. Woo Chul CHUNG

Prof. Seong Woo JEON

image
  • Prof. Seong Woo JEON
  • Division of Gastroenterology & Hepatology
  • Department of Medicine
  • Kyungpook National University Hospital
  • Area of Interest
  • Therapeutic endoscopy in esophageal, gastric and colon cancer
  • Prevention and screening of early gastric cancer
  • Development of novel endoscopic devices
  • Helicobacter pylori diagnosis and treatment

How do I use PENTAX IMAGINA in my clinical endoscopy cases :

“I use PENTAX IMAGINA in daily clinical endoscopy practice. One of our endoscopy purpose is surveillance after endoscopic resection of gastric dysplasia or cancer.
The local recurrence is one of important subjects in follow up endoscopy. This could be diagnosed with endoscopic biopsy usually,
but as a therapeutic endoscopist, it is important to define the candidates for repeat ESD in the case of recurrence.
I assume that PENTAX IMAGINA TE mode is useful in this aspect. The PENTAX IMAGINA system have clear resolution and it can let me help the clear diagnosis. “

Endoscopic Delineation of Early Gastric Cancer

Patient History

The patient is a 74-year-old female with a history of undergoing endoscopic submucosal dissection (ESD) in other hospital.
The initial diagnosis was early gastric cancer of moderately differentiated adenocarcinoma with 10mm in size and uncertain resection margin.
She was transferred to out center to ask second opinion for additional surgery.
I recommend her following up endoscopy to check recurrence of cancer.

Endoscopic Findings

The endoscopic findings took 3months after ESD showed post ESD ulcer scar at LC of MB.
Also there noted slightly hyperemic ill-defined type llb lesion at PW of MB.
The biopsy revealed high grade dysplasia or well differentiated adenocarcinoma.

Endoscopic Treatment and Pathology Results

Repeat ESD was planned for the treatment of recurrent tumor.
The patient underwent gastric ESD 2 weeks later.
There was no complication related to this procedure. Final pathology was mucosal confined well differentiated adenocarcinoma,
measuring 4cm in maximal diameter.

Patient Outcome and Follow-ups

Regular EGD follow up would be provided to the patient.

Image 1,2 & 3

image image

The endoscopy findings with i-scan SE shows that post ESD ulcer scar at LC of MB.
The adjacent mucosa at posterior site had surface hyperemia and loss of regular pit pattern.
The size of the lesion was not definite on SE image (image 2),
and the margin of the lesion was uncheckable due to ill-defined border.
However, the i-scan TE shows clear margin with enhanced reddish mucosal lesion (image 3).
This could help define the exact border of the lesion and achieve curative resection.

Summary

  • HD endoscopy coupled with optical chromoendoscopy such as i-scan TE is useful to study the characteristics of the stomach mucosa,
  • especially in the aspect of determining margin of the lesion.
  • Delineation of the exact margin of lesion is extremely important in ESD procedure, because it is directly related to curative resection.
  • The definition of non-curative resection is as follows;
  • En bloc resection (-)
  • Any of follows (+): HM1, VM1, ly(+), v(+)
  • M cancer with UL (+), >3cm
  • Undifferentiated type cancer with UL (+)
  • Differentiated type cancer, > 3cm, > SM1
  • Abbreviations: HM: horizontal margin, UL: ulcer,
  • VM: vertical margin, M: mucosa,
  • ly: lymphatic invasion, SM: submucosa
  • v: vascular invasion,
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STOMACH Prof. Jun Haeng Lee

STOMACH

< image >
  • Prof. Jun Haeng LEE
  • Division of Gastroenterology
  • Department of Internal Medicine
  • Samsung Medical Center
  • Sungkyunkwan University School of Medicine
  • Area of Interest
  • Endoscopic treatment of early gastric cancer and gastroesophageal reflux disease
  • Personal homepage: http://endotoday.com
  • Quality and patient safety in medicine
  • (Deputy Director of Department of Quality Innovation at Samsung Medical Center)

CASE 1

CASE 2

CASE 3

CASE 4

How do I use
PENTAX IMAGINA
in my clinical endoscopy
cases :

“In my GI endoscopy unit of hospital, there are 4 PENTAX Medical IMAGINA Video Endoscope Systems with 16 gastroscopes and 12 colonoscopes.
The first time IMAGINA system were installed in 2020, some endoscopists experienced minor difficulties in controlling the new endoscope due to some differences (e.g.: close position of the buttons, i-scan, feeling from the shaft, i-pad style touch panel, et al.) from existing ones of the other supplier.
But I easily get used to the PENTAX Medical IMAGINA endoscope system before long.
The major advantages of clinical case with IMAGINA are the excellent quality of close-up image and the function of high degree angulation. It is convenient to make high quality video clips using the 2 USB ports (please don't forget to use the most recent version of USB memory).”

Cascade Stomach

Patient History

Screening endoscopy of a 48-year-old female without any symptom and sign.

Endoscopic Findings

When the endoscope was introduced into the stomach, the lumen of the gastric body was seen at the upper right corner.
After infusion of some air into the stomach, a ridge between the gastric fundus and upper body can be seen.
The ridge runs from the posterior wall of the cardia toward the anterior wall of the stomach, crossing the greater curvature.
When the stomach has a prominent ridge between the fundus and high body, it is called as the cascade stomach (CS). The clinical significance of CS is still uncertain.

Image 1

image

The timing of entering the stomach is very different between endoscopists.
Some endoscopists rapidly pass the esophagus without entering a lot of air.
In that situation, the stomach is not initially expanded at all.
For the other endoscopists, who carefully observe the esophagus before entering the stomach, there will be already an air in the stomach.
With a plenty of air in the stomach, the angulation between the fundus and high body can be changed, so the findings of Cascade stomach (a ridge between the gastric fundus and upper body) may be different.
In this case, the ridge runs from the posterior wall of the cardia toward the anterior wall of the stomach, crossing the greater curvature.
The clinical significance of this finding is unclear.

Image 2

image

In this retroflection view, the ridge from the cardia is so prominent that I was not able to see the base of the fundus.
In this situation, it is quite easy to miss the lesion.
The base of the fundus and the posterior wall of the lower body are known as blind areas.
Before finishing the stomach observation, you need to rotate the endoscope counter-clockwise,
so that you can see the base of the fundus en face.

Image 3

Video clip available

Summary

  • Cascade stomach is an atypical form of hourglass stomach characterized radiographically by a drawing up of the posterior wall;
  • an opaque medium first fills the upper sac and the cascades into the lower sac.
  • This entity was originally studied with barium gastrography in patient with functional dyspepsia (FD).
  • In FD patients with cascade stomach in barium study, ingested food and fluid or swallowed air would initially be collected in the fundus.
  • After filling the fundus, the food/fluid would flow rapidly into the gastric body, which could be related to FD symptoms.
  • As transient LES relaxation (TLESR) is triggered by fundus distention, cascade stomach may be related with gastroesophageal reflux diseases.
  • With endoscopy, however, it is difficult to interpret the findings of cascade stomach. Just after entering the stomach with some air infusion,
  • a ridge between the gastric fundus and upper body can be seen in some patients.
  • The ridge runs from the posterior wall of the cardia toward the anterior wall of the stomach, crossing the greater curvature.
  • These findings are greatly influenced by the amount of air infused during the examination.
  • So, the clinical significance of cascade stomach still needs to be investigated.
qrcode

How do I use
PENTAX IMAGINA
in my clinical endoscopy
cases :

“In my GI endoscopy unit of hospital, there are 4 PENTAX Medical IMAGINA Video Endoscope Systems with 16 gastroscopes and 12 colonoscopes.
The first time IMAGINA system were installed in 2020, some endoscopists experienced minor difficulties in controlling the new endoscope due to some differences (e.g.: close position of the buttons, i-scan, feeling from the shaft, i-pad style touch panel, et al.) from existing ones of the other supplier.
But I easily get used to the PENTAX Medical IMAGINA endoscope system before long.
The major advantages of clinical case with IMAGINA are the excellent quality of close-up image and the function of high degree angulation. It is convenient to make high quality video clips using the 2 USB ports (please don't forget to use the most recent version of USB memory).”

Advanced Gastric Cancer, Borrmann Type IV

Patient History

A 49-year-old female with symptom of early fullness and with the sign of weight loss.

Endoscopic Findings

The result of endoscopic forceps biopsy was poorly cohesive carcinoma.
Abdominal CT images showed diffuse wall thickening mass of the upper body and fundus of stomach with mild per-gastric infiltration.
The preoperative diagnosis was the advanced gastric cancer, Borrmann type IV.

Patient Outcome and Follow-ups

Surgical consultation was done for the exploratory laparotomy.
However, there were multiple seeding nodules found in the laparoscopy.
Palliative chemotherapy was done.

Image 1

image

Image of the high body greater curvature and posterior wall:
The gastric folds are diffusely thickened.
The interval between folds was narrowed and some folds were conglomerated to form an ill-defined flat elevated area.
The surface was diffusely hyperemic and shows mosaic pattern, which means the accentuation of the normal area gastricae.
The lumen of the stomach was slightly expanded by air but not enough.
There was no definite ulcer or erosion.

Image 2

image

Image enhanced endoscopy by i-Scan:
The surface mosaic pattern is more clearly seen.

Image 3

Video clip available

Initially you can see the thickened folds and narrowed interval between folds.
The antrum does not seem to be involved by the diffuse type malignancy.
. The border between the involved and normal areas looks
like somewhere between lower body and proximal antrum.
In the retroflection view, the whole area of the fundus and the cardia was involved.
There was no ulcer or erosion.

Summary

  • Advanced gastric cancer Borrmann type IV is the most important disease entity in terms of endoscopic examination of the stomach.
  • It is easy for endoscopists to miss due to the lack of definite mucosal lesion. It is more common in young woman even in the 30’s and 40’s.
  • Ulcerative lesion is found in about 30% of cases. In cases without ulcer or erosion, it is difficult to decide where to do the biopsies.
  • The sensitivity of the biopsy is very low in this situation.
  • When it is clinically suspected, the surgical exploration is necessary even without histological evidence.
  • The curative surgical resection is possible in less than 30% of the cases, and the long-term survival cases are rare.
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How do I use
PENTAX IMAGINA
in my clinical endoscopy
cases :

“PENTAX Medical IMAGINA i10c gastroscope was originally developed as a multifunctional upper endoscope not only for diagnosis but also for therapeutic purposes.

(1) It has a very wide working channel (inner diameter = 3.2mm), so suction of the air is available during the therapeutic procedures. Recent gastroscope models from other supplier have 2.8mm inner diameter on the working channel, which makes suctioning air with catheters in the working channel impossible.

(2) It has a waterjet function, so that irrigation during the procedure is possible. (There is one major limitation in this aspect. The water line is single use only.)

(3) The angulation is so good that the procedures for the lesions in the difficult locations are relatively easy and save times.

(4) The weight of the i10c scope is much decreased from the previous PENTAX version and relatively light in comparison with products from different suppliers. It may be an ideal endoscope for me, a therapeutic endoscopists in 50s looking for the ergonomic design to relieve the pain on shoulders and wrists."

APC Ablation for Adenoma

Patient History

A 68-year-old male with no symptom and sign (referred for the treatment of incidental gastric adenoma found in the screening endoscopy)

Endoscopic Findings

In the screening endoscopy, about 1.5cm sized ill-defined mucosal irregularity was found in the lesser curvature of the midbody.
Background gastric mucosal was atrophic.

Patient Outcome and Follow-ups

The biopsy showed adenoma with low grade dysplasia.
Ablation treatment using Argon Plasma Coagulation apparatus was done.
After treatment, PPI was given for two weeks.

Image 1

image

i-scan image of the adenoma with low grade dysplasia in the lesser curvature of the lower body.
It is small, pale and flat, so endoscopic ablation can be an option.
Background gastric mucosa is atrophic.

Image 2

image

Just after ablation treatment with argon plasma coagulation (APC),
the lesion is changed into the white necrotic areas.
When you do follow-up endoscopy a few days later,
this lesion would be changed into a deep ulcer,
which is a mechanism of ablation treatment.

Image 3

Video clip available

Summary

  • The ideal management for gastric adenoma is still uncertain.
  • In adenoma with high grade dysplasia, the chance of malignancy in the resected stomach is about 33% to 50%, so endoscopic resection
  • (ESD or EMR) is strongly recommended.
  • It is considered just like a small gastric cancer limited in the mucosal layer.
  • However, the management of adenoma with low-grade dysplasia is still controversial.
  • When the low-grade adenoma is big, ulcerative or hyperemic, the chance of worse histology is rather high,
  • so endoscopic resection is recommended rather than endoscopic ablation.
  • In low grade adenomas without such worrisome findings, endoscopic ablation or careful strategic observation is also considered.
  • I prefer endoscopic ablation treatment with APC instrument rather than simple observation without treatment.
  • APC ablation is easy and can be done in outpatient settings.
  • After ablation treatment, bleeding complications possibly occur in about 2-3% of patients so a short course of anti-acid treatment with
  • PPI or P-CAB (tegoprazan) is my routine. Some patients experience pain for a couple of days and acetaminophen is given as needed.
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How do I use
PENTAX IMAGINA
in my clinical endoscopy
cases :

“PENTAX Medical IMAGINA i10c gastroscope was originally developed as a multifunctional upper endoscope not only for diagnosis but also for therapeutic purposes.

(1) It has a very wide working channel (inner diameter = 3.2mm), so suction of the air is available during the therapeutic procedures. Recent gastroscope models from other supplier have 2.8mm inner diameter on the working channel, which makes suctioning air with catheters in the working channel impossible.

(2) It has a waterjet function, so that irrigation during the procedure is possible. (There is one major limitation in this aspect. The water line is single use only.)

(3) The angulation is so good that the procedures for the lesions in the difficult locations are relatively easy and save times. For gastric ESD cases, I choose Splash M-Knife, Splash M-Knife has lots of advantages during ESD. In the extended position of distal tip, there is a knife disk which can be hooked. I usually perform ESD using this hooking mechanism. The hooking mechanism is very useful for a lesions on difficult locations. Besides, Splash M-Knife has a superior hemostasis function. If the distal tip is in retracted position, distal tip and metal plate become like one body. By forming 1.5 cm or more round plate in this position, hemostasis is also possible and effective. When I perform submucosal injection in the middle of the ESD procedure, I don’t need to change the knife and the procedure time is much saved due to the water jet function.”

ESD for EGC using Splash M Knife Only

Patient History

A 62 years old male patient visited my clinic due to a small gastric lesion found in the screening endoscopy.


Outside pathology report was 'tubular adenoma with high grade dysplasia, suspicious of adenocarcinoma'.
Outside pathology slide was reviewed by an in-house pathologist of Samsung Medical Center and the final pathology was 'adenocarcinoma, moderately differentiated’.
The CT scan was negative for metastasis.

Endoscopic Finding, Treatment and Pathology Result

Stomach, EGC of proximal antrum, ESD with Splash M-Knife by PENTAX Medical
Location : antrum, greater curvature
Gross type : EGC type IIc+IIa
Histologic type : tubular adenocarcinoma, moderately differentiated
Histologic type by Lauren : intestinal
Size of carcinoma : longest diameter as 11 mm, vertical diameter as 10 mm
Depth of invasion : invades mucosa (muscularis mucosa) (pT1a)
Resection margin : free from carcinoma(N); safety margin : distal 14 mm, proximal 10 mm, anterior 10 mm, posterior 10 mm, deep 200 ㎛
Lymphatic invasion : not identified(N)
Venous invasion : not identified(N)
Perineural invasion : not identified(N)
Microscopic ulcer : absent
Histologic heterogeneity: absent

Image 1

image

Image 2

image

ESU: ERBE VIO300D (mainly EndoCut I 3-3-3)
Bleeding control : Splash M-Knife (hemostatic forceps not used)
Sedation: Pethidine 25mg + Midazolam 5mg IV

Image 3

Video clip available

Summary

  • Endoscopic submucosal dissection (ESD) for a small early gastric cancer lesion was successfully done with PENTAX i10c gastroscope and Splash M-Knife from also PENTAX Medical. High maneuverability of the i10c gastroscope and excellent hemostatic function of the Splash M-Knife made the procedure simple and quick. After the ESD procedure, proton pump inhibitor (PPI) was given for 4 weeks, and the follow up endoscopy was recommended after 2 months.
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STOMACH Prof. Yong Hwan KWON

STOMACH

< image >
  • Prof. Yong Hwan KWON
  • Division of Gastroenterology & Hepatology/li>
  • Department of Medicine
  • Kyungpook National University Hospital
  • Area of Interest
  • Endoscopic therapy
  • Gastric cancer and carcinogenesis
  • Helicobacter pylori

CASE 1

CASE 2

How do I use
PENTAX IMAGINA
in my clinical endoscopy
cases :

“HD+ and i-scan supported the characterization of the epithelial surface and vascularization of gastric mucosal lesions and can assist treatment and surveillance decisions.“

Gastric Adenoma

Patient History

A 74-year-old female was referred for the EGD through incidental finding on health examination.

Endoscopic Findings

20mm sized type IIa lesion at lesser curvature of mid-body.
i-scan SE and TE helped to demarcate the borders or the leision.

Endoscopic Treatment and Pathology Results

The lesion was dissected via gastric ESD.
The final pathology indicated early gastric adenoma, lower grade dysplasia.

Patient Outcome and Follow-ups

The lesion was resected en-bloc. During the procedure, no major bleeding occurred and no perforation could be spotted.

Image 1

image

Image 2

image

Image 3

Video clip available

Summary

  • This case shows that HD+ and i-scan led to the appropriate treatment of the patient and to the resection of the lesion en-bloc.
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How do I use
PENTAX IMAGINA
in my clinical endoscopy
cases :

“ I used the PENTAX Medical IMAGINA when the gastric ulcer bleeding was suspected.
The i-scan mode can help to discriminate whether the morphology of ulcer is benign or malignant based on change of color, vascularity and pit-pattern.“

Aspirin Induced Benign Gastric Ulcers

Patient History

A 78-year-old female visited emergency room for 3 days melena.
The patient had previous angina history and took aspirin for several years. Laboratory finding

Endoscopic Findings

CBC WBC 8600/㎛ Hb 8.7g/dL Hct 27% Plt 114K/㎕ Chemical and electrolyte battery Protein/Alb 6.6/3.8 g/dL AST/ALT 23/28IU/L ALP 96 U/L TB/DB 1.2/0.8mg/dL BUN/Cr 30.2/1.2 mg/dL Na/K 137/3.6 mmoL/L ESR 22mm/hr CRP 1.3mg/dL

Endoscopic Findings

The noted multiple ovoid ulcers surrounded with edematous mucosa at antrum, however, no active bleeding was seen in endoscopic finding.
The ulcers were shown smooth and regular shapes, even bases, clearly demarcated and regular edges.
The ulcer stage was A2 by Sakita-Miwa classification.

Patient Outcome and Follow-ups

Benign gastric ulcer and CLOtest (-)

Image 1

Video clip available

Summary

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin cause frequently gastrointestinal injuries.
  • In the acute phase of NSAIDs damage, endoscopic findings of gastroduodenal injuries are observed as acute gastroduodenal mucosal lesion (AGDML).
  • In the chronic phase of NSAIDs damage, multiple antral erosions and/or ulcers with oozing, and punched-out antral ulcers are characteristic findings.
  • Characteristic images of gastrointestinal injuries induced by NSAIDs are multiple erosions and ulcers with bleeding without symptoms.
  • It is most important asking about use of NSAIDs if we see such endoscopic images.
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STOMACH Prof. Woo Chul CHUNG

STOMACH

< image >
  • Prof. Woo Chul CHUNG
  • Division of Gastroenterology
  • Department of Internal Medicine
  • The Catholic University School of Medicine
  • St. Vincent’s Hospital
  • Area of Interest
  • Therapeutic endoscopy
  • Gastric cancer
  • Helicobacter pylori

CASE 1

CASE 2

How do I use
PENTAX IMAGINA
in my clinical endoscopy
cases :

“IMAGINA video endoscope is suitable for therapeutic endoscopy and the image was sharper and crisper without losing focus. I can practice IMAGINA for various therapeutic endoscopy cases. Prejudice about PENTAX Medical endoscopes can be released I think.”

Endoscopic Delineation of Early Gastric Cancer

Patient History

A 73-year-old male with no medical history was referred for the endoscopic evaluation.

Endoscopic Findings

Large sliding hernia with erosive esophagitis (LA classification B) and 0.7cm sized sessile elevated mucosal lesion (Yamada type I polyp) were observed.

Endoscopic Treatment and Pathology Results

The microsopic diagnosis was gastric epithelial dysplasia – low grade.

Patient Outcome and Follow-ups

Annual endoscopic surveillance with biopsy.

Image 1

image image

By endoscope of ‘O’ brand

Image 2

image image

By endoscope of PENTAX Medical IMAGINA

Summary

  • As for the development of intestinal-type gastric adenocarcinoma, the carcinogenic cascade model was proposed by Correa,
  • which was a multi-step process from normal gastric epithelium to chronic gastritis, chronic atrophic gastritis, intestinal metaplasia, gastric epithelial dysplasia (low and high grade), followed by gastric cancer.
  • The recommended treatment guidelines for gastric epithelial dysplasia are endoscopic submucosal dissection for high grade dysplasia (HGD) and annual endoscopic surveillance with biopsy for low grade dysplasia (LGD).
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How do I use
PENTAX IMAGINA
in my clinical endoscopy
cases :

“During a case of endoscopic hemostasis with APC for the gastric angiodysplasia, there was no losing image quality from the argon smoke.
The near focus image was clearly visualized.“

Comparison of endoscopic hemostasis with PENTAX Medical IMAGNA (A) and the other company’s endoscopy (B)

(A) image image image
(B) image image image

Active Bleeding in Gastric Angiodysplasia

Patient History

A 73-year-old male patient with hypertension was referred for taking out foreign matter (drug package) which was swallowed together with medicine.

Endoscopic Findings

The drug package was observed at mid esophagus. We used a protective device - endoscopic cap, in order to avoid esophagogastric/pharyngeal damage during endoscopic extraction of sharp-pointed foreign body. (image 1)
Successful removal and laceration wounds were observed. (image 2)

Endoscopic Treatment and Pathology Results

Foreign body removal by endoscopy

Patient Outcome and Follow-ups

The procedure performed successfully without any event.

Image 1

image
image

Image 2

image
image

Summary

  • Gastric angiodysplasia is a unique mucosal vascular lesion that causes acute or recurrent gastrointestinal bleeding.
  • It is considered as the differential diagnosis of UGIB and may occasionally cause severe bleeding, but it can also be found in symptom-free patients.
  • There have been studies that multiple angiodysplastic lesions and anticoagulant agents predict an increased risk of recurrent bleeding.
  • But the bleeding risk from angiodysplasia itself was related to the size of lesion and not related to anticoagulant agents.
  • Endoscopic methods of treatment reported to be of value including injection therapy, such as injection of epinephrine; ablative therapy,
  • such as electrocautery or argon plasma coagulation; (APC) and mechanical therapy, such as endoclips or banding.
  • In this case, active bleeding from gastric angiodysplasia was successfully treated by endoscopy with APC.
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STOMACH Prof. Seong Woo JEON

STOMACH

< image >
  • Prof. Seong Woo JEON
  • Division of Gastroenterology & Hepatology
  • Department of Medicine
  • Kyungpook National University Hospital
  • Area of Interest
  • Therapeutic endoscopy in esophageal, gastric and colon cancer
  • Prevention and screening of early gastric cancer
  • Development of novel endoscopic devices
  • Helicobacter pylori diagnosis and treatment

How do I use
PENTAX IMAGINA
in my clinical endoscopy
cases :

“I use PENTAX IMAGINA in daily clinical endoscopy practice. One of our endoscopy purpose is surveillance after endoscopic resection of gastric dysplasia or cancer.
The local recurrence is one of important subjects in follow up endoscopy. This could be diagnosed with endoscopic biopsy usually,
but as a therapeutic endoscopist, it is important to define the candidates for repeat ESD in the case of recurrence.
I assume that PENTAX IMAGINA TE mode is useful in this aspect. The PENTAX IMAGINA system have clear resolution and it can let me help the clear diagnosis. “

Endoscopic Delineation of Early Gastric Cancer

Patient History

The patient is a 74-year-old female with a history of undergoing endoscopic submucosal dissection (ESD) in other hospital.
The initial diagnosis was early gastric cancer of moderately differentiated adenocarcinoma with 10mm in size and uncertain resection margin.
She was transferred to out center to ask second opinion for additional surgery.
I recommend her following up endoscopy to check recurrence of cancer.

Endoscopic Findings

The endoscopic findings took 3months after ESD showed post ESD ulcer scar at LC of MB.
Also there noted slightly hyperemic ill-defined type llb lesion at PW of MB.
The biopsy revealed high grade dysplasia or well differentiated adenocarcinoma.

Endoscopic Treatment and Pathology Results

Repeat ESD was planned for the treatment of recurrent tumor.
The patient underwent gastric ESD 2 weeks later.
There was no complication related to this procedure. Final pathology was mucosal confined well differentiated adenocarcinoma,
measuring 4cm in maximal diameter.

Patient Outcome and Follow-ups

Regular EGD follow up would be provided to the patient.

Image 1,2 & 3

image image

The endoscopy findings with i-scan SE shows that post ESD ulcer scar at LC of MB.
The adjacent mucosa at posterior site had surface hyperemia and loss of regular pit pattern.
The size of the lesion was not definite on SE image (image 2),
and the margin of the lesion was uncheckable due to ill-defined border.
However, the i-scan TE shows clear margin with enhanced reddish mucosal lesion (image 3).
This could help define the exact border of the lesion and achieve curative resection.

Summary

  • HD endoscopy coupled with optical chromoendoscopy such as i-scan TE is useful to study the characteristics of the stomach mucosa,
  • especially in the aspect of determining margin of the lesion.
  • Delineation of the exact margin of lesion is extremely important in ESD procedure, because it is directly related to curative resection.
  • The definition of non-curative resection is as follows;
  • En bloc resection (-)
  • Any of follows (+): HM1, VM1, ly(+), v(+)
  • M cancer with UL (+), >3cm
  • Undifferentiated type cancer with UL (+)
  • Differentiated type cancer, > 3cm, > SM1
  • Abbreviations: HM: horizontal margin, UL: ulcer,
  • VM: vertical margin, M: mucosa,
  • ly: lymphatic invasion, SM: submucosa
  • v: vascular invasion,
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