Ayako Tateishi

Technical feasibility of endoscopic submucosal dissection for gastric neoplasms in the elderly Japanese population

Background and Aim:  Endoscopic submucosal dissection (ESD) is gaining acceptance among endoscopists for its efficacy, especially in Japan. Elderly patients often have operative risk due to comorbid diseases, and the feasibility of this treatment for such patients should be investigated. The aim of this study is to evaluate the efficacy and safety of ESD in elderly patients.

Extensive mesenteric vein and portal vein thrombosis successfully treated by thrombolysis and anticoagulation

Abstract Mesenteric vein thrombosis is generally difficult to diagnose and can be fatal. A case of extensive thrombosis of the mesenteric and portal veins was diagnosed early and successfully treated in a 26‐year‐old man with Down syndrome who was admitted to hospital because of abdominal pain, severe nausea and high fever. Ultrasonography revealed moderate ascites, and there was minimal flow in the portal vein (PV) on the Doppler examination. Computed tomography (CT) showed remarkable thickening of the walls of the small intestine and extensive thrombosis of the mesenteric, portal and splenic veins. Because neither intestinal infarction nor peritonitis was seen, combined thrombolysis and anticoagulation therapy without surgical treatment was chosen. Urokinase was administered intravenously and later through a catheter in the superior mesenteric artery. Heparin and antibiotics were given concomitantly. The patients symptoms and clinical data improved gradually. After 10 days, CT revealed that collateral veins had developed and the thrombi in the distal portions of the mesenteric veins had dissolved, although the main trunk of the PV had not recanalized. The only risk factor of thrombosis that was detected was decreased protein S activity.

Submucosal Injection of Normal Saline may Prevent Tissue Damage From Argon Plasma Coagulation: An Experimental Study Using Resected Porcine Esophagus, Stomach, and Colon

Argon plasma coagulation (APC) is considered to be a safe thermocoagulation technique, but some reports show perforation and deformity during and after APC. In this study, we investigated the usefulness of prior submucosal injection for APC. APC over the mucosa was performed on fresh resected porcine esophagus, stomach, and colon with prior submucosal injection of normal saline (injection group) and without it (control group). The depth of tissue damage increased linearly with pulse duration up to the shallower submucosal layer in both groups. After that, tissue damage in the injection group remained confined to the shallower submucosal layer under any condition, whereas that in the control group continued to extend. The tissue damages of the injection groups were significantly (P<0.05) shallower than those of the control groups that reached the deeper submucosal layer in all the organs. Submucosal injection of normal saline before the application of APC may limit tissue damage and prevent perforation and deformity.

MANAGEMENT OF BLEEDING CONCERNING ENDOSCOPIC SUBMUCOSAL DISSECTION WITH THE FLEX KNIFE FOR STOMACH NEOPLASM

Management of bleeding is crucial for a successful endoscopic submucosal dissection (ESD) with the Flex knife for a stomach neoplasm. Medical approaches to suppress gastric acid secretion and keep systolic blood pressure at the level of < 150 mmHg during ESD are tried to lessen bleeding. But, major concerns for bleeding are whether the blood vessels are cut off or not and endoscopic surgeons have to avoid blind application of devices for ESD as much as possible. Even in the situations where blind application for non‐visible vessels in the submucosa is not preventable such as in the steps of marking, submucosal injection, mucosal incision, and snaring, the efforts to lessen bleeding are necessary. When non‐bleeding visible vessels are noticed, ‘prebleeding coagulation’ with appropriate devices is important. Even if unexpected bleeding occurs, it is also controllable using appropriate devices according to the type of bleeding. All endscopists who perform ESD should also be experts in management of bleeding.

Safety of argon plasma coagulation for hemostasis during endoscopic mucosal resection.

Showing the safety of argon plasma coagulation (APC) over mucosal defects during/after endoscopic mucosal resection (EMR), 2 studies using resected pig (ex vivo) and living minipig (in vivo) stomachs were performed. As an ex vivo study, APC was applied over mucosal defects in 2 groups; with prior submucosal saline injection and without injection. Only subtle tissue damage was observed in the injection group, whereas apparent damage was observed in the noninjection group. The damaged distances in depth significantly increased as the pulse duration increased and those at the pulse duration of 4 seconds, which might be maximal in clinical practice, were approximately 1 mm. As an in vivo study, APC was applied over mucosal defects immediately after EMR. Only subtle tissue damage was observed even at the pulse duration of 20 seconds as shown in the ex vivo study. APC can be performed safely over the mucosal defects during/after EMR.

APPROPRIATE MIXTURE OF HYALURONIC ACID, GLUCOSE AND GLYCERIN FOR A SUBMUCOSAL FLUID CUSHION DURING ENDOSCOPIC SUBMUCOSAL DISSECTION IN THE DOG STOMACH

Background:  A mixture of a 1% 1900 KDa hyaluronic acid (HA) preparation (Suvenyl) and a 10% glycerin with 5% fructose and 0.9% saline preparation (Glyceol) to make a 0.125% HA is considered to be the best ready‐made submucosal fluid cushion (SFC). When the concentration of glycerin is changeable, a more appropriate SFC may be created.

Successful Endoscopic EN Bloc Removals of Colorectal Tumors By Endoscopic Submucosal Dissection Using a Flex Knife and a Mixture of High-Molecular-Weight Hyaluronic Acid and a Glycerin Plus Sugar Solution

Successful Endoscopic EN Bloc Removals of Colorectal Tumors By Endoscopic Submucosal Dissection Using a Flex Knife and a Mixture of High-Molecular-Weight Hyaluronic Acid and a Glycerin Plus Sugar Solution Mitsuhiro Fujishiro, Naohisa Yahagi, Naomi Kakushima, Shinya Kodashima, Masanori Nakamura, Hideyuki Miyoshi, Yoshikazu Moriyama, Nobutake Yamamichi, Ayako Tateishi, Katsuya Kobayashi, Takuhei Hashimoto, Keiji Ogura, Masao Omata Background: Endoscopic submucosal dissection (ESD) is a novel therapeutic technique of gastrointestinal tumors. The technique has been developed further by ourselves as a new ESD method using a flex knife (Flexknife , Olympus Co., Tokyo, Japan) and a mixture of 1% high-molecular-weight (1900 KDa) hyaluronic acid (Suvenyl , Chugai Pharmaceutical Co., Tokyo, Japan) and a glycerin plus sugar solution (Glyceol , Chugai Pharmaceutical Co., Tokyo, Japan). The purpose of this study is to investigate our results of ESD for colorectal tumors. Methods: We retrospectively investigated 122 ESD-indicated lesions (a mean tumor size of 27.8 (range: 5-100) mm) in 113 patients those were treated by ESD with our technique at the University Hospital between June 2000 and October 2004. Those underwent ESD because of patients’ desire, etc, even if the lesions were extra-indicated for ESD preoperatively had been excluded beforehand in the data. The 122 lesions were classified into 12 Is-type tumors, 59 laterally spreading tumors with granular type (LSTs-G), 38 LSTs with non-granular type (LSTs-NG), 9 scarring tumors due to previous intensive biopsy or endoscopic therapy, and 4 carcinoid tumors. From the data, we analyzed an en bloc resection rate, final histology, complication, and recurrence. Complication was defined as a life-threatening event such as hemorrhage needed blood transfusion or perforation needed surgical rescue. Results: An overall en bloc resection rate was 92% (113/122) (Is 92%, LST-G 92%, LST-NG 95%, scarring tumors 89%, carcinoid 100%) and all of the tumors could be evaluated by histology. Post-ESD histology revealed 63 adenomas, 44 intramucosal cancers, 11 submucosal invasive cancers, and 4 carcinoid tumors. Three cancers with massive submucosal invasion were additionally treated by surgery with lymph node dissection. No complication needed blood transfusion or surgical rescue occurred. As recurrence, only one rectal adenoma of LST-G with multi-fragmental resection was treated by argon plasma coagulation 2 months after ESD due to Abstracts