Daisuke Horibe

The overall prevalence of metastasis in T1 esophageal squamous cell carcinoma: a retrospective analysis of 295 patients.

Objectives:T1 esophageal squamous cell carcinoma (ESCC) has a low, but still present, risk of lymph node (LN) metastasis. Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is often applied for T1 ESCC. To achieve successful treatment by EMR/ESD, the risk of LN metastases, LN recurrence, and hematological recurrence need to be better understood. The aim of this study was to determine the precise risk for metastasis in T1 ESCC. Methods:We divided 295 patients with T1 ESCC who underwent surgery and/or ESD/EMR into 6 categories (m1, m2, m3, sm1, sm2, and sm3). Their risks of LN metastasis, LN recurrence, hematological recurrence, and the outcome were determined. Results:The rates of LN metastasis and LN recurrence were 0% in m1 and m2, 9% in m3, 16% in sm1, 35% in sm2, and 62% in sm3 cases. The incidence of hematological recurrence was 0% in m1, m2, m3, and sm1 cases; 9% in sm2 cases; and 13% in sm3 cases. The overall risk of metastasis was 9% in m3, 16% in sm1, 38% in sm2, and 64% in sm3 patients. The 5-year disease-specific survival rates were 100% in m1, m2, and m3; 90.9% in sm1; 78.8% in sm2; and 68.6% in sm3 patients. Statistically, both lymphatic and venous invasion were selected as predictive markers for metastasis. In m3 patients, positivity for either of these had an odds ratio for metastasis of 7.333 (P = 0.093). Conclusions:Our study provides a precise assessment of the comprehensive risk of metastasis and feasible predictive markers for T1 ESCC.

Rapid detection of metastasis of gastric cancer using reverse transcription loop-mediated isothermal amplification.

Tailor‐made surgeries for patients with solid malignancies have been under consideration on the basis of the development of new approaches for minor metastatic foci of malignant tumors. Accurate and reliable methods to detect metastases in biopsy specimens with certain rapidity are essential for the performance of these surgeries. The aim of this study was to develop a rapid and practical method to detect metastasis in specimens from patients with gastric carcinoma with the use of reverse transcription loop‐mediated isothermal amplification (RT‐LAMP) reaction, a novel technique for detecting mRNA expressions of targeted sequences with high sensitivity, specificity and rapidity under isothermal conditions. RT‐LAMP primers to detect cytokeratin19 (CK19) mRNA were generated and 92 lymph nodes (LNs) obtained from 9 patients with gastric cancer were tested for tumor metastases with this technique. Among 92 LNs, 15 were metastasis‐positive by routine histopathological examination. RT‐LAMP reaction detected CK19 expression in all of the pathologically positive LNs and in 16 of 77 negative LNs. Nested RT‐PCR assay for CK19 expression was also performed on 2 of the 9 cases including 32 LNs. The agreement rate of CK19 expression detection by RT‐LAMP and RT‐PCR analysis was 31/32 (97%). The RT‐LAMP technique showed similar sensitivity to detect metastases as nested RT‐PCR assay, with a rapidity comparable to that of intraoperative histopathological examination with frozen sectioning and hematoxylin and eosin staining. This method is expected to play an essential role in the performance of tailor‐made surgeries in the near future.

Surgical advantages of gastric SMTs by laparoscopy and endoscopy cooperative surgery.

BACKGROUND/AIMS The treatment of gastric submucosal tumors (SMTs) is strictly surgical and enucleation of the tumor or wedge resection of the stomach is efficient to achieve R0 resection. Laparoscopic and endoscopic cooperative surgery (LECS) can be safely performed with adequate cutting lines. This study describes the initial 16 cases treated by LECS and evaluates the advantages by LECS for gastric SMTs retrospectively. METHODOLOGY Sixteen patients with gastric SMT underwent LECS from June 2007 to December 2010, their surgical data, clinical characteristics and surgical specimens of SMTs were compared. The surgical specimens of 9 gastric SMTs treated by laparoscopic wedge resection (LWR) were compared as a control. RESULTS The median (range) length of operation time, blood loss, hospital stay after surgery were minutes 172 (115- 220), <5mL (<5-115) and 10 days (6-17), respectively. The median (range) ratio of the longest diameter of the tumor divided by the longest diameter of the surgical specimen in LECS and LWR were 0.86 (0.625-1.0) and 0.69 (0.44-1.0), respectively (p=0.0189, Wilcoxon rank sum test). CONCLUSIONS LECS minimizes the surgical specimen while still providing sufficient surgical margins to successfully cure gastric SMTs.

Survival predictors of patients with primary duodenal adenocarcinoma.

This single-institution experience retrospectively reviewed the outcomes in 21 patients with primary duodenal adenocarcinoma. Twelve patients underwent curative surgery, and 9 patients underwent palliative surgery at the Chiba University Hospital. The maximum follow-up period was 8650 days. All pathologic specimens from endoscopic biopsy and surgical specimens were reviewed and categorized. Twelve (57.1%) patients underwent curative surgery (R0): 4 pancreaticoduodenectomies (PD), 4 pylorus-preserving PDs (PpPD), 2 local resections of the duodenum and 2 endoscopic mucosal resections (EMR). Palliative surgery was performed for 9 patients (42.9%) following gastro-intestinal bypass. The median cause-specific survival times were 1784 days (range 160-8650 days) in the curative surgery group and 261 days (range 27-857 days) in the palliative surgery group (P = 0.0003, log-rank test). The resectability of primary duodenal adenocarcinoma was associated with a smaller tumor size, a lower degree of tumor depth invasiveness, and less spread to the lymph nodes and distant organs.

A 3-step gradual dilation method: a new safe technique of percutaneous endoscopic gastrostomy for obstructive esophageal cancer.

Although percutaneous endoscopic gastrostomy (PEG) is the preferred method to provide enteral nutrition for a longer time period, in obstructive esophageal cancer, we cannot safely perform endoscopic access to the stomach even with the ultrathin endoscope. We experienced 1 fatal case due to esophageal perforation caused by balloon dilation, and hence, we developed a safer method. We treated 4 patients with obstructive esophageal cancer using a 3-step gradual dilation method with nasogastric tubes (from 8 to 16 Fr). After about 2 weeks of initial dilation, we could safely perform endoscopic access to the stomach with the ultrathin endoscope and PEG placement using the introducer technique. The 3-step gradual dilation method is a safe and easy procedure for endoscopic access to the stomach. It can be used to provide enteral access as a palliative treatment for patients with obstructive esophageal cancer that is not suitable for conventional PEG placement.

Monitoring salivary amylase activity is useful for providing timely analgesia under sedation

AIM To detect the criteria and cause of elevated salivary amylase activity (sAMY) in patients undergoing endoscopic submucosal dissection (ESD) under sedation. METHODS A total of 41 patients with early gastric cancer removed via ESD under deep sedation (DS) were enrolled. The perioperative sAMY, which was shown as sympathetic excitements (SE), was measured. The time at which a patient exhibited a relatively increased rate of sAMY compared with the preoperative baseline level (IR, %) ≥ 100% (twice the actual value) was assumed as the moment when the patient received SE. Among the 41 patients, we focused on 14 patients who exhibited an IR ≥ 100% at any time that was associated with sAMY elevation during ESD (H-group) and examined whether any particular endoscopic procedures can cause SE by simultaneously monitoring the sAMY level. If a patient demonstrated an elevated sAMY level above twice the baseline level, the endoscopic procedure was immediately stopped. In the impossible case of discontinuance, analgesic medicines were administered. This study was performed prospectively. RESULTS A total of 26 episodes of sAMY eruption were considered moments of SE in the H-group. The baseline level of sAMY significantly increased in association with an IR of > 100% at 5 min, with a significant difference (IR immediately before elevation/IR at elevation of sAMY = 8.72 ± 173/958 ± 1391%, P < 0.001). However, effective intervention decreased the elevated sAMY level immediately within only 5 min, with a significant difference (IR at sAMY elevation/immediately after intervention = 958 ± 1391/476 ± 1031, P < 0.001). The bispectral indices, systolic blood pressure and pulse rates, which were measured at the same time, remained stable throughout the ESD. Forceful endoscopic insertion or over insufflation was performed during 22 of the 26 episodes. Release of the gastric wall tension and/or the administration of analgesic medication resulted in the immediate recovery of the elevated sAMY level, independent of body movement. CONCLUSION By detecting twice the actual sAMY based on the preoperative level, the release of the gastric wall tension or the administration of analgesic agents should be considered.

Gastric Resection Under Retroflexed Endoscopic Guidance: A Reliable Procedure for Totally Laparoscopic Subtotal Gastrectomy

Background/Aims: Totally laparoscopic distal gastrectomy (TLDG) has become a feasible and safe surgical option for early gastric cancer. However, determining the transection line of the stomach without palpation is still difficult. This study aimed to assess the efficacy of TLDG for gastric resection under retroflexed endoscopic guidance (GRREG) in patients with gastric cancer in the middle third of the stomach. Methods: Fifteen patients with gastric cancer underwent TLDG using GRREG. Preoperative tumor localization using endoscopic metal clips was performed in all cases. After lymphadenectomy, two-thirds of the estimated transection line was occluded by an endoscopic stapler, beginning at the lesser curvature. Under gastric occlusion, the gastroscope was passed via the narrow lumen along the greater curvature followed by retroflexion to reveal the occlusion line, marking clips, and tumor in the same field of view. This view verified the safe oncological transection line. Results: All patients had cancer-free margins and did not require additional surgery. The mean (±SD) proximal margin was 23.5 ± 10.4 mm. There were no procedure-related complications. Conclusions: GRREG was a safe and effective technique for TLDG. Ideal transection of the stomach was achieved using a combination of an endoscopic stapler and gastroscope retroflexion.

Lymphoepithelioma-like esophageal carcinoma with macroscopic reduction

Esophageal lymphoepithelioma-like carcinoma (LELC) is extremely rare. We report the first case of esophageal LELC showing macroscopic reduction. A 67-year-old male presented with dysphagia and, by endoscopic examination, was found to have a significantly raised tumor of 10 mm in diameter in the thoracic esophagus. The biopsied material showed esophageal cancer. We performed endoscopic submucosal dissection. However, the tumor became flattened, similar to a scar, in only 2 mo. Histologically, the carcinoma cells had infiltrated the submucosal layer. Prominent infiltration of T lymphoid cells that stained positive for CD8 was observed around the carcinoma cells. Therefore, this lesion was considered to be an LELC with poorly differentiated squamous cells. Because the margin was positive, an esophagectomy was performed. Carcinoma cells were detected in the neck in one lymph node. The staging was T1N0M1b. However, the patient has been well, without adjuvant therapy or recurrence, for more than 5 years.

High-resolution impedance manometric findings after surgery for epiphrenic diverticulum

An epiphrenic diverticulum is a pulsion pseudodiverticulum of the distal esophagus that is frequently associated with esophageal motility disorders. Therefore, a simple diverticulectomy leads to a poor outcome. High-resolution impedance manometry (HRIM), introduced recently, enables easier evaluation of both esophageal pressure and bolus transit dynamics. We report the case of a 40-year-old female diagnosed with an epiphrenic diverticulum with hypertensive lower esophageal sphincter pressure by use of HRIM. She underwent a laparoscopic transhiatal diverticulectomy with a long myotomy and Dor’s fundoplication and was discharged with no complications. Four weeks after the operation, HRIM was performed again, and showed no accumulation of water in the esophagus and improvement of bolus transit. We herein report the usefulness of HRIM for evaluation of esophageal motility disorders for patients with an epiphrenic diverticulum.