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Background: Endoscopic submucosal dissection (ESD) is a new, widely accepted method for the treatment of early gastric cancer and was developed to increase the en bloc resection rate. This study aimed to evaluate the efficacy and safety of ESD compared with conventional endoscopic mucosal resection (EMR) for small rectal carcinoid tumors., Methods: A retrospective study was carried out that included 43 patients with small rectal carcinoid tumors (< 10 mm). The cohort comprised two groups: Group A (N = 23) underwent conventional EMR from January 2004 to August 2005, while group B (N = 20) underwent ESD with needle-knife from September 2005 to December 2006. The rate of curative en bloc resection, the procedure time, and the incidence of complications were evaluated., Results: The en bloc resection rate and the rate of completeness of resection of group B were higher than those of group A (100 vs. 87%, 100 vs. 52.5%, respectively). The average operation time required for resection was significantly longer in group B (28.4 ± 17.2 min) compared with group A (12.3 ± 15.4 min) (p < 0.05). None of the patients had immediate or delayed bleeding during the procedure. Perforation occurred in one case of group B and the patient recovered after several days of conservative treatment. Three patients had local recurrence after EMR, while no patient experienced recurrence after ESD., Conclusion: ESD, compared with conventional EMR, increased en bloc and histologically complete resection rates and may reduce local recurrence rate for small rectal carcinoid tumors. Increased operation time and complication risks with ESD remain problematic. Further technique and investigation are required to confirm the safety and to assess the long-term prognosis of ESD.

Objective: To evaluate the long-term efficacy of endoscopic excision for rectal carcinoids., Methods: Clinical data of 91 patients with rectal carcinoids treated by endoscopic excision from 2000 to 2007 were analyzed retrospectively., Results: The average size of the primary tumor was 0.8 cm(range 0.3 to 2.3 cm). All the tumors were localized within the submucosal layer showing typical histology without lymphatic or vessel infiltration. Follow-up was available for 80 patients with mean 32.5 months (range 6 to 96 months). There was no recurrence in 65 patients with tumor size < 1.0 cm. Recurrence occurred in 3 cases among 25 patients with tumor size from 1.0 to 2.0 cm, and 1 died of hepatic metastasis. The 1-, 3-, and 5-year survival rates of the patients were 100%, 98.0%, and 91.4% respectively., Conclusions: Tumor size and depth of invasion are two important prognostic factors of rectal carcinoids. Endoscopic excision is useful for rectal carcinoid patients with tumor size < 1.0 cm and located within the submucosal layer.

Objective: To evaluate the efficacy of endoscopic self-expanded metal stent for the treatment of gastric outlet obstruction., Methods: Fifty-six cases of gastric outlet obstruction, collected from March 1999 to January 2008, were treated by endoscopic self-expanded metal stents. The success rate, complication rate and survival were evaluated., Results: Among the 56 cases, the male to female ratio was 33 to 23, and the average age was [65+/-14 (24-86)] years. Seventeen cases were gastric cancer, 4 duodenal carcinoma, 7 peri-ampulla carcinoma, 13 metastasis cancer and 15 presented recurrence after operations. The success rate of stent implantation was 98.2% (55/56). Forty-nine cases (87.5%) could eat liquid food 1-3 days after operations and eat semifluid food 4-9 days later. Forty-two cases (76.4%)could eat normal food after 10-16 days. The main complications included 14.5% of cases with pain, 1.8% with stent shift, 25.5% with bleeding and no one with perforation. Until January 20, 2008, 53 cases (96.4%) had been followed up. The mean survival time was [139+/-15 (14-332)] days, and the median survival time was 135 days. The re-stenosis rate was 5.7%, including 3 cases, happened in 143, 158 and 190 days after the operations respectively, and was successfully treated by second stent implantation., Conclusion: Endoscopic implantation of self-expanded metal stent is a micro-invasive, safe, effective method for the treatment of gastric outlet obstruction.

Objective: To summarize the experience of diagnosis and treatment of gastrointestinal lipoma., Methods: The clinical data of 34 patients with gastrointestinal (GI) lipoma from 1993 to 2007 were analyzed retrospectively., Results: GI lipoma produced a variety of symptoms including gastrointestinal bleeding, abdominal pain, anemia, intussusception, and bowel obstruction. The diagnostic accuracy of endoscopic ultrasonography(EUS) for GI lipoma was 93.8%. Twelve GI lipomas were resected under endoscopy, the remainder at laparotomy, partial resection, gastrectomy or enterectomy being performed. Twenty-eight cases were followed up from 1 month to 168 months. No recurrence and metastasis were observed except one case dying of gastric liposarcoma., Conclusions: EUS is an effective method for diagnosing GI lipomas. The treatment of GI lipomas is surgical resection, and endoscopic removal of GI lipomas is safe following the guidance of the present therapeutic strategy.

Objective: To assess the clinical value of endoscopic submucosal dissection(ESD)for rectal carcinoid tumors., Methods: Endoscopic miniprobe ultrasonography was performed in patients with rectal submucosal tumors under colonoscope. ESD was carried out with the needle knife for lesions diagnosed as rectal carcinoid as following: (1)Fluid was injected into the submucosal layer in the rectum to elevate the lesion from the muscle layer. (2)The surrounding mucosa of the lesion was pre-cut. (3)The connective tissue of the submucosa beneath the lesion was dissected., Results: Five rectal carcinoids ranged from 0.4 to 1.2 cm and the mean resected size was 1.1 cm. All rectal carcinoid tumors were verified by pathological examination with lateral and basal resection margins free of tumor. The mean ESD procedure time (from fluid injection to complete dissection) was 35 min (ranged from 20 to 45 min). Minor bleeding occurred in all of the tumors, and none of patients had massive hemorrhage requiring blood transfusion or emergency colonoscopy due to hematochezia after ESD. One patient had subserosal emphysema due to deep tearing of the muscle layer, and recovered after several days' conservative treatment. All patients were followed up with colonoscopy 1 month after ESD,which confirmed the healing of artificial ulcers., Conclusions: ESD is a novel endoscopic treatment that makes it possible to resect the whole rectal carcinoids. Rectal carcinoid tumors can now be treated by ESD to achieve the same therapeutic effect as operation.

Objective: To assess the value of endoscopic submucosal resection with ligation (ESMRL) in rectal carcinoids., Methods: 45 patients with rectal carcinoids, 20 males and 25 females, aged 58 +/- 18 (19 - 73), were treated with ESMRL from April, 2002 to April, 2006. The radical resection rate, complication rate, relapse rate, and metastasis rate were analyzed., Results: Carcinoids accounted for 1.8% of the 24,600 cases undergoing colonoscopy at the same time. All the carcinoids were located 2 - 15 cm from anal border, with a mean diameter of (1.4 +/- 0.3) cm (0.3 - 2.0 cm). The endoscopic ultrasonographic (EUS) characteristic was a hypoechoic solid tumor in the superficial submucosa (24 cases, 53%) or in both the mucosa and submucosa (21 cases, 47%) without involvement of the muscularis propria. All patients received ESMRL of the rectal carcinoids, of which 34 cases (75.6%) needed more hemostasis of the incision margin. The mean operation time was (25 +/- 4) min. 7 cases (15.6%) with tardy bleeding 2 - 7 days after ESMRL needed endoscopic re-hemostasis, of which 3 cases (43%) showed oozing of blood from the muscle layer and another 4 showed oozing of blood or arterial bleeding from the incision border. No perforation or inflammatory was reported. 39 cases (86.7%) had negative margin in pathological examination, and the incision margins of the other 6 patients, as normal submucosal layer could not be seen outside the tumor envelope, could not be evaluated. But the tumor envelope was integrated without involvement of tumor and other biopsy results 7 days after ESMRL was negative. So no more therapies were selected. All 45 patients were followed up for 31 months (6 - 52 months), there was no metastasis, relapse and dead cases., Conclusion: ESMRL is an effective, safe, and minimally invasive method to deal with rectal carcinoids.

Background: Getting directly into the common bile duct (CBD) is the most important step for successful therapeutic biliary endoscopy. In 5%-10% of cases, the CBD remains inaccessible, necessitating pre-cut papillotomy or fistulotomy with a needle-knife. The aim of this study was to assess the value of early application of the needle-knife in difficult biliary cannulation for endoscopic retrograde cholangiopancreatography (ERCP)., Methods: Patients with failed biliary cannulation after 10 minutes or guide wire entering the pancreatic tube 3 times were randomly divided into group of needle-knife cut and group of persistent cannulation by standard techniques. The cannulation times, success rates and complication rates were compared between the two groups., Results: A total of 948 therapeutic biliary ERCP procedures were performed between October 2004 and February 2006. Of 91 patients with difficult biliary cannulation, 43 patients underwent needle-knife cut: the cannulation success rate was 90.7%, the mean cannulation time was 5.6 minutes, and the complication rate was 9.3%. The other 48 patients underwent persistent cannulation by standard techniques: the cannulation success rate was 75%, the mean cannulation time was 10.2 minutes, and the complication rate was 14.6%. Significant differences were observed in cannulation success rate and cannulation time but in complication rate between the two groups., Conclusion: The early application of the needle-knife in difficult biliary cannulation is time-saving, safe and effective, with no increase in complication rate.

Objective: To evaluate stenosis of the lower rectum following PPH with special respect to potential predictive factors or stenotic events., Methods: A retrospective analysis of 554 consecutive patients, which underwent PPH from July 2000 to December 2004 was performed., Results: Only patients with follow-up check were evaluated, thus the analysis includes 489 patients (489/554, 88.3%) with a mean follow-up of (324 +/- 18) days. Rectal stenosis was observed in 12 patients (12/489, 2.5%), the median time to stenosis was 89 - 134 (125 +/- 5) days. All the patients complained of obstructive defecation and underwent strictureplasty with electrocautery or balloon dilation through colonoscopy. A statistical analysis revealed that patients with stenosis had significantly more often prior sclerosis therapy for hemorrhoids (58.3% vs. 20.0%, P = 0.02) and severe postoperative pain (25.0% vs. 6.7%, P = 0.003). Other factors, such as gender (P = 0.32), prior surgery for hemorrhoids (P = 0.11), histological evidence of squamous skin (P = 0.77) or revision (P = 0.53) showed no significance., Conclusion: Rectal stenosis is an uncommon event after PPH. Early stenosis will occur within the first four months after surgery. The majority of the stenosis can be cured through colonoscopy surgery. The predictive factors for stenosis are previous sclerosis therapy for hemorrhoids and severe postoperative pain.

Objective: To evaluate the clinical use of endoscopic ileus tube drainage in preoperative therapy for acute low malignant colorectal obstruction., Methods: From Nov. 2004 to Dec. 2005, 15 cases with acute low malignant colorectal obstruction received emergency colonoscopy and endoscopic ileus tube drainage was performed. Radical resection was then performed after seven days of drainage., Results: Endoscopic ileus tube drainage was successful in 13 cases, and failed in 2 cases because the guide wire cannot be inserted through the tumor in one case, and in the other case the tumor was located in the middle of the transverse colon so that the ileus drainage tube was not long enough. Abdominal girth decreased from (91+/- 4) cm to (82+/- 2) cm after tube drainage. The everyday drainage volume minus rinsing volume ranged from - 600 ml to 3200 ml. Abdominal X ray showed that obstruction was relieved. Intra-operative exploration revealed that colon edema was not evident, which increased resection rate., Conclusion: Endoscopic ileus tube drainage is effective, safe and maybe the first choice of acute low malignant colorectal obstruction.

Objective: To evaluate the feasibility and clinical value of endoscopic interventional treatment of malignant gastrointestinal obstruction., Methods: With the aid of X ray, 32 cases with malignant gastrointestinal obstruction were treated with endoscopic metal stenting. There were 8 cases with gastric outlet obstruction, 7 with duodenal obstruction, 13 with rectal obstruction, and 4 with sigmoid obstruction., Results: Among the 32 patients, metal stenting was successfully performed in 30 cases (93.7%, and obstructive symptoms were relieved within 1-3 days. Metal stent placement was permanent in 15 cases with gastric outlet or duodenal obstruction. Twelve cases with colorectal obstruction received stent placement as palliative treatment, while other 3 cases underwent subsequent elective surgical resection. Metal stent placement failed in one case with recurrent rectal carcinoma, and perforation occurred in another one case with wide spread metastatic sigmoid colon carcinoma and Hartmann operation was performed. During the follow-up period, no stent migration was detected., Conclusion: Endoscopic interventional treatment of malignant gastrointestinal obstruction is a feasible, safe, effective and well tolerated method. It can reduce the patients trauma and pain, and improve the quality of life.

Objective: To investigate the feasibility and safety of percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy(PEJ)., Methods: From June 1996 to April 2005, clinical data of 121 patients treated with PEG or PEJ were analyzed retrospectively., Results: A total of 121 patients experienced 134 times of PEG or PEG plus PEJ, including 90 cases (103 times) treated with PEG and 31 patients treated with PEG plus PEJ. Thirteen patients treated with PEG had fistula replacement 6-10 months after PEG. All patients had quick nutrition recovery after fistula tube insert,therefore parenteral nutrition was not required. No severe complications occurred in all patients after 10 months of following-up. Four patients had subcutaneous infection around fistula 4-10 days after PEG., Conclusion: PEG and PEJ are safe and new methods for gastrointestinal decompression and enteral nutrition, which can be substitutes for nasogastric tube.

Aim: To evaluate the role of miniprobe ultrasonography under colonoscope in the diagnosis of submucosal tumor of the large intestine, and to determine its imaging characteristics., Methods: Thirty-five patients with submucosal tumors of the large intestine underwent miniprobe ultrasonography under colonoscope. The diagnostic results of miniprobe ultrasonography were compared with pathological findings of specimens by biopsy and surgical resection., Results: Lipomas were visualized as hyperechoic homogeneous masses located in the submucosa with a distinct border. Leiomyomas were visualized as hypoechoic homogeneous mass originated from the muscularis propria. Leiomyosarcomas were shown with inhomogeneous echo and irregular border. Carcinoids were presented as submucosal hypoechoic masses with homogenous echo and distinct border. Lymphangiomas were shown as submocosal hypoechoic masses with cystic septal structures. Malignant lymphomas displayed as hypoechoic masses from mucosa to muscularis propria, while pneumatosis cystoids intestinalis originated from submucosa with a special sonic shadow. One large leiomyoma was misdiagnosed as leiomyosarcoma., Conclusion: Endoscopic miniprobe ultrasonography can provide precise information about the size, layer of origin, border of submucosal tumor of the large intestine and has a high accuracy in the diagnosis of submucosal tumor of the large intestine. Pre-operative miniprobe ultrasonography under colonoscope may play an important role in the choice of therapy for submucosal tumor of the large intestine.

Objective: To improve the successful rate of endoscopic biliary drainage., Methods: Three hundred and fifty-two patients with biliary obstruction were given biliary drainage via duodenoscope from January 1998 to December 2002. 258 patients received endoscopic naso-biliary drainage (ENBD), 51 endoscopic retrograde biliary drainage (ERBD), and 43 endoscopic metal biliary endoprothesis (EMBE)., Results: Of the 352 patients with biliary obstruction, 337 succeeded in drainage by endoscopy and 15 failed. Ten ENBD failed patients were handled successfully by readjustment of the site of the naso-biliary tube. In 3 ERBD failed patients, 2 were given plastic stents with appropriate length and got a fluent drainage. Percutaneous transhepatic biliary drainage (PTBD) was performed in one patient after failure of endoscopic management. In 2 patients with failed EMBE, one stent could not exceed the site of tumor stricture and one was obstructed by tumor implantation only one month after EMBE. Placement of another metallic stent and a plastic stent through the previous prothesis for each patient ensured a successful drainage., Conclusions: The effect of endoscopic biliary drainage for biliary obstruction is definite. Drainage failure can be avoided or remedied as early as possible by taking some active measures.

Objective: To assess the safety and effect of endoscopic sphincterotomy (EST) and endoscopic papillary balloon dilatation (EPBD) for choledocholithiasis., Methods: 328 patients with choledocholithiasis were subjected to EST or EPBD; they included 174 patients with single stone, 112 patients with two stones and 42 patients with three stones (one patient with 20 stones). Patients with stones less than 10 mm in diameter underwent EPBD and those with stones larger than 11 mm in diameter underwent EST., Results: EST and EPBD succeeded in 323 patients (98.5%), and failed in 5. Stones in 98 patients were excluded spontaneously after endoscopic therapy. 207 patients were subjected to basket or balloon stone extraction. Stones in 14 patients were discharged by basket lithotripsy. Four patients were given wave lithotripsy. Stones in 22 of the 323 patients were extracted thoroughly after 2-3 times attempts. Total complications were noted in 2.5% of the patients. Hemorrhage from the gastrointestinal tract was seen in one patient, cholangitis in 4 patients, and pancreatitis in 3 patients. In 92 patients receiving digestive tract barium X-ray examination, 86 developed no barium reflux to the baliary tract, 2 pneumobilia, 4 barium reflux to the biliary tract., Conclusion: EST and EPBD are relatively safe and effective in treatment of choledocholithiasis, and have few complications.