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Endoscopic mucosal resection (EMR) is increasingly being utilized in the management of early gastric cancer. Metastatic cancer of the stomach is uncommon. We report a case of solitary gastric metastasis from renal cell carcinoma (RCC) that was successfully excised with EMR. A 71-year-old man presented with iron deficiency anemia, he had undergone a radical nephrectomy for RCC 3 years previously. Upper gastrointestinal endoscopy revealed a malignant-appearing 10 × 12 mm polyp in the stomach. Histopathology of the biopsy revealed that it was a metastasis from RCC, confirmed by immunohistochemistry with Vimentin and CAM 5.2 positivity. Computed tomography and bone scanning revealed no other metastases. Simultaneous laparoscopy and upper gastrointestinal endoscopy revealed that the lesion was localized to the gastric mucosa. EMR of the tumor en bloc was performed successfully. Histology confirmed a complete excision. He had an uneventful postoperative course and is well 15 months after surgery, without any tumor recurrence.

BACKGROUNDThere is a lack of suitable models for testing of therapeutic procedures for gastro-oesophageal reflux disease. Endoscopic sewing methods might allow the development of a new less invasive surgical approach to treatment of gastrointestinal disorders.AIMSTo develop an animal model of gastro-oesophageal reflux for testing the efficacy of a new antireflux procedure, endoscopic gastroplasty, performed at flexible endoscopy without laparotomy or laparoscopy.METHODSAt endoscopy a pH sensitive radiotelemetry capsule was sewn to the oesophageal wall, 5 cm above the lower oesophageal sphincter, in six large white pigs. Ambulant pH recordings (48–96 hours; total 447 hours) were obtained. The median distal oesophageal pH was 6.8 (range 6.4–7.3); pH was less than 4 for 9.3% of the time. After one week, endoscopic gastroplasty was performed by placing sutures below the gastro-oesophageal junction, forming a neo-oesophagus of 1–2 cm in length. Postoperative manometry and pH recordings (24–96 hours; total 344 hours) were carried out.RESULTSFollowing gastroplasty, the median sphincter pressure increased significantly from 3 to 6 mm Hg and in length from 3 to 3.75 cm. The median time pH was less than 4 decreased significantly from 9.3% to 0.2%.CONCLUSIONSThese are the first long term measurements of oesophageal pH in ambulant pigs. The finding of spontaneous reflux suggested a model for studying treatments of reflux. Endoscopic gastroplasty increased sphincter pressure and length and decreased acid reflux.

Background: Three antireflux operations—gastroplasty, fundoplication, and anterior gastropexy—were developed for performance at flexible endoscopy without laparotomy or laparoscopy. Methods: An endoscopic sewing machine mounted on a standard gastroscope, endoscopic knotting devices, overtube, and nylon thread were used to perform these operations in adult beagle dogs. Results: Gastroplasty (n = 10) was accomplished by suturing the anterior and posterior wall of the stomach to create a gastric tube (neoesophagus) along the lesser curve. An anatomic arrangement similar to fundoplication (n = 6) was achieved by invaginating the esophagus and fixing it to the stomach 2 cm distal to the cardioesophageal junction. Anterior gastropexy (n = 6) was performed using a technique similar to that used in creating percutaneous gastrostomies. There was no mortality. Ninety percent of sutures were seen atrepeat endoscopy at 4 to 8 week intervals. The gastroplasty group was selected for more extensive evaluation. Manometry using a three-channel perfused catheter system before and after the procedures showed an increase in the lower esophageal sphincter pressure (preoperative median 4.6 mm Hg; postoperative median 13.33 mm Hg, p = 0.008) and cardiac yield pressures (preoperative median 10 mm Hg; postoperative median 19 mm Hg, p = 0.007). Conclusions: This study demonstrates the feasibility of performing antireflux operations at flexible endoscopy, without laparoscopy or laparotomy, by use of endoluminal suturing techniques. (Gastrointest Endosc 1996;44:133-43.)

Hiatus hernia and lower oesophageal sphincter hypotension are often viewed as opposing hypotheses for gastro-oesophageal junction incompetence.To examine the interaction between hiatus hernia and lower oesophageal sphincter hypotension.In seven normal subjects and seven patients with hiatus hernia, the squamocolumnar junction and intragastric margin of the gastro-oesophageal junction were marked with endoscopically placed clips. Axial and radial characteristics of the gastro-oesophageal junction high pressure zone were mapped relative to the hiatus and clips during concurrent fluoroscopy and manometry. Responses to inspiration and abdominal compression were also analysed.In normal individuals the squamocolumnar junction was 0.5 cm below the hiatus and the gastro-oesophageal junction high pressure zone extended 1.1 cm distal to that. In those with hiatus hernia, the gastro-oesophageal junction high pressure zone had two discrete segments, one proximal to the squamocolumnar junction and one distal, attributable to the extrinsic compression within the hiatal canal. Inspiration and abdominal compression mainly augmented the distal one. Simulation of hernia reduction by algebraically summing the proximal segment pressures with the hiatal canal pressures restored normal maximal pressure, radial asymmetry, and dynamic responses of the gastro-oesophageal junction.Hiatus hernia reduces lower oesophageal sphincter pressure and alters its dynamic responsiveness by spatially separating pressure components derived from the intrinsic lower oesophageal sphincter and the extrinsic compression of the oesophagus within the hiatal canal.

Aim : The aim of this study was review the results of endoscopic gastroplasty in a series of patients. Methods : Endoscopic Gastroplasty was performed at flexible endoscopy in 102 patients with Gastroesophageal Reflux Disease uncontrolled by long-term medical therapy and who were offered and declined anti-reflux surgery (open or laparoscopic) or were deemed unfit for general anesthesia due to concurrent illness. GERD was confirmed by preoperative manometry and 24 hour ambulatory pH studies. Using a 9mm diameter endoscopic sewing machine a neo-esophagus of 1-2 cm was created below the cardio-esophageal junction by placing sutures and securing the tissue with 4 half-hitches tied extracorporeally. Results : The operation was performed as a day-case procedure under sedation and the median duration of the procedure was 35 minutes. Post-operative assessment was made at a median of 12 weeks (8-52) with respect to symptoms, manometry and 24 hour ambulatory pH studies. Symptoms assessed by DeMeester symptom score improved from a median of 5 to 1 [p

BACKGROUND: Endoscopic repair of the perforated gut has been reported in rare cases. Various techniques have been used to close the gut perforations via an endoscope. We describe three cases of endoscopic repair of oesophageal and gastric perforations using an endoscopic sewing machine. CASE 1: A 54 year old man had a partial gastrectomy for gastric cancer. A postoperative fistulous leak between the gastrojejunostomy and the chest was demonstrated by contrast study. Six stitches were placed to close the leak using the endoscopic sewing machine. Post procedure contrast x-ray showed that the leak had sealed. CASE 2: A 70 year old man with carcinoma of the oesophagus had a distal oesophageal perforation during Savary dilatation. Three stitches were placed with endoscopic sewing machine to close the perforation. A repeat contrast study showed no leak. Patient died three months later in hospital due to unrelated causes. CASE 3: A 54 year old man with lymphoma of the oesophagus and stomach developed a fistula between the oesophagus and the mediastinum. Covered metal stents were placed twice previously and had fallen into the stomach. A covered Z stent [Wilson Cook] was sewn to the oesophagus using the endoscopic sewing machine. The stent remained in position and the fistula healed nicely. The patient who had been in the intensive care unit for three months was able to leave intensive care unit. CONCLUSION: Successful closure of the gut perforations was possible using endoscopic sewing machine.