Reply to Gyökeres et al.

We are grateful to Dr. Gyökeres and his colleagues for their comments on our recent report, to which we would like to reply here. The merit of the O-ring ligation method is that cutting and sampling are both simple. We believe the risk of bleeding with this method differs little from that with the conventional endoscopic incision. With regard to aspiration and ligation, we cannot see that there is any risk when the cyst has sufficient underlying space.

Endoscopic mucosal resection using a ligation device (EMRL) is an established technique that is widely used in treating early gastric cancers [1] [2]. The underlying space for aspiration, ligation, and resection in EMRL is created by injecting fluid into the submucosal space. Compared with EMRL, there is a wider and safer underlying space when a cystic wall is being resected. However, there is a possibility of complications with the O-ring ligation method if the cyst is less than 2 cm in diameter. The average size of specimens resected using EMRL is reported to be 1.0 - 1.5 cm in diameter. We mentioned in the article that three patients with choledochoceles were treated endoscopically at our hospital. They were treated using a simple endoscopic incision, as the cysts were 1.5 - 2.0 cm in diameter. We recommend that the size and shape of the cyst should be estimated by endoscopic ultrasonography and direct cystography before endoscopic resection.

References

• 1 Lee D K, Lee S W, Kwon S O. et al . Endoscopic mucosectomy using an esophageal variceal ligation device for minute gastric cancer.  Endoscopy. 1996;  28 386-389
• 2 Suzuki Y, Hiraishi H, Kanke K. et al . Treatment of gastric tumors by endoscopic mucosal resection with a ligating device.  Gastrointest Endosc. 1999;  49 192-199