Eisai Cho

Diagnosis of submucosal lesions of the upper gastrointestinal tract by endoscopic ultrasonography

The use of endoscopic ultrasonography (EUS) in the diagnosis of submucosal upper gastrointestinal tract lesions was examined in 308 patients. Two-hundred ten submucosal tumors, 89 cases of esophagogastric varices, and 9 cases of non-Hodgkins lymphoma were found. EUS images were interpreted based upon a five-layer EUS structure of the normal gastrointestinal wall. A characteristic EUS image was seen with leiomyoma, cysts, lipoma, and varices. EUS had an accuracy of 80% in staging nine cases of lymphoma. EUS is a valuable technique for the evaluation and diagnosis of submucosal upper gastrointestinal tract lesions.

DIFFERENTIAL DIAGNOSIS OF INTRADUCTAL PAPILLARY-MUCINOUS TUMOR OF THE PANCREAS BY ENDOSCOPIC ULTRASONOGRAPHY AND INTRADUCTAL ULTRASONOGRAPHY

Background:  Intraductal papillary‐mucinous tumor (IPMT) of the pancreas has a broad spectrum of histology ranging from hyperplasia to adenocarcinoma. Therefore, it is important to differentiate between the malignant and benign lesions to determine the therapeutic strategy for IPMT.

Point mutations in the c-K-ras 2 gene in multiple colorectal carcinomas

Abstract The c‐K‐ras 2 gene mutations were examined in colorectal tumours from patients with synchronous or metachronous tumours in order to investigate tumorigenesis. Sixty‐seven colorectal carcinomas from patients with a single lesion, 50 from patients with synchronous lesions, and 12 from patients with metachronous lesions were analysed for the presence of point mutations in codons 12 and 13 of c‐K‐ras proto‐oncogene. In the patients with metachronous or synchronous lesions, the finding of the mutation in one tumour was not associated with a greater frequency of the mutation in other carcinomas from the same patient. In the patients with tumours that each contained the mutation, the mutations were not always the same. In tumours from the patients with original and synchronous lesions, the mutation frequency was significantly lower in advanced carcinomas invading through the entire muscularis propria (10.5%) than in early carcinomas confined to the mucosa (47.8%), and the mutation frequency in carcinomas invading through the entire muscularis propria was significantly lower in patients with synchronous lesions (10.5%) than in patients with a single lesion (37.7%). These results suggest that the tumorigenesis of colorectal carcinomas from patients with synchronous lesions is different from that in patients with a single lesion.

A CASE WITH PERFORATION AFTER ENDOSCOPIC BALLOON DILATATION FOR STRICTURE OF MALIGNANT LYMPHOMA

We have experienced a case with perforation after endoscopic balloon dilatation. The patient was diagnosed as having malignant lymphoma in the terminal ileum, and treated with eradication of H. Pylori and chemotherapy. The severe stenosis appeared at the same site of the tumor after the medical treatment. The first dilatation with a 15 mm balloon was successful. The lower small bowel obstruction occurred 14 months after the first balloon dilatation. The second dilatation with an 18 mm balloon was performed. The stricture site was remarkably dilated and could be passed by the scope. Perforation was confirmed because of the complaint of severe abdominal pain. The laparotomy finding showed the hole at the stricture site and remarkable fibrosis without tumorous tissue. The fragility of the tissue, the excessive inflation of the balloon and the insertion of the scope might be causes of the perforation. The case with severe stricture having almost no flexibility should be considered carefully in the determination of treatment procedures for the balloon dilatation.

Endoscopic Ultrasonography Diagnosis for Colorectal Diseases

We have used endoscopic ultrasonography (EUS) for all the colorectal diseases. For cancer, we determined the treatment method by evaluating the depth of cancer invasion. Moreover, we have applied EUS for submucosal cancer to decide whether the depth of submucosal invasion was superficial and thus to estimate the indication of endoscopic resection. Lymph node metastasis has been examined for staging in cases with invasive cancer. We have performed EUS for active ulcerative colitis in observing the depth of inflammation and determined treatment strategy by diagnosing clinical severity. Submucosal tumorous lesions and extramural lesions have been examined to clarify the site and inner condition. EUS is an essential method that leads to accurate diagnosis of any colorectal disease by delineating pathological conditions precisely. With improvement of the instrumentation, EUS can be used as a routine diagnostic tool as is colonoscopy.

CLINICAL USE OF THE NEWLY DEVELOPED ELECTRONIC RADIAL ULTRASOUND ENDOSCOPE

Background:  Endoscopic ultrasonography (EUS) is widely accepted as a diagnostic tool for bilio‐pancreatic and gastrointestinal tract diseases. Recently, an ultrasound endoscope with an electronic radial scan transducer has been developed. To evaluate the clinical usefulness of this system, its image quality, advantages and disadvantages were evaluated.

EUS IN THE DIAGNOSIS OF ULCERATIVE COLITIS

The ultrasonograms of ulcerative colitis (UC) in active stage show hypoechoic changes of the colorectal wall from the mucosal layer to the deeper layers. These endoscopic ultrasound (EUS) changes of the wall recognized in active stage disappear or normalize in the stage of remission. When the stage of UC is exacerbated, the hypoechoic changes of the wall extend from the mucosal layer to the deeper layers with the increase of wall thickness. These EUS images of active UC are classified into the following types: UC‐M, thickening of the whole wall with the structure preserved; UC‐SM, hypoechoic changes reach the superficial portion of third layer with the thickening of whole wall; UC‐SM deep, hypoechoic changes reach the deeper portion of third layer with the thickening of whole wall; UC‐MP, hypoechoic changes reach the fourth layer with the thickening of whole wall; UC‐SS/SE, hypoechoic changes penetrate through the fourth layer with the thickening of whole wall. With the help of EUS we can demonstrate the severity of inflammation in UC. Moreover, in severe cases of UC, the treatment strategy including emergency surgery can be determined. EUS is a valuable method in the management of UC.

3467 Eus in the management of colorectal cancer: a comparative study with conventional colonocopy.

Background: The colorectal tumors limited within the mucosa or superficial submucosa(sm-small) can be completely treated endoscopically since the probability of lymph node metastasis is almost nil. Histologically, the depth of submucosal tumor invasion was regulated by equally divided three levels of the submucosa in the vertical direction. Tumors of sm-small were defined as those limited within the superficial 1/3 of the submucosa, tumors of sm-massive, extending from the middle 1/3 of the submucosal layer to the deeper portion near the muscularis propria. Therefore, pretherapeutic diagnosis whether the depth of tumor invasion is limited within sm-small or deeper than sm-massive is extremely important for the treatment strategy. Aims: To evaluate the usefulness of EUS in the diagnosis of depth of colorectal cancer invasion, and compare the ability of EUS with conventional colonoscopy in the diagnosis of submucosal cancer invasion. Methods: Between May 1985 and September 1999, EUS was performed in 563 patients with colorectal cancer. All of the tumors were resected and confirmed histologically. Especially, preoperative EUS diagnosis of submucosal cancer staging was investigated in comparison with conventional colonoscopy in 77 patients with colorectal submucosal cancer. EUS criteria for the depth of submucosal cancer invasion were defined as SM-small and SMmassive according to the deepest portion of the hypoechoic tumorous mass compared with the third hyperechoic layer in the vertical direction. Colonoscopic criteria for the SM-massive were based on the following findings; marginal submucosal elevation, erosion or ulceration on the tumor, marked elevation on the tumor and fold convergence. Results: EUS correctly diagnosed pTis in 98 of 118 patients, pT1 in 62 of 80 patients, pT2 in 42 of 84 patients, pT3 in 248 in 276, and pT4 in 5 of 5 patients. The overall accuracy rate of EUS was 81%(455/563) according to TNM classification. Pretherapeutic diagnosis was investigated whether the depth of tumor invasion was sm-small or sm-massive. The accuracy rates of EUS and colonoscopy were 23/31(74%) and 19/31(61%), respectively, in sm-small, and 41/46(89%) and 38/46(83%), respectively, in sm-massive. The overall accuracy rates with EUS and colonoscopy were 83%(64/77) and 74%(57/77), respectively. Conclusion: EUS is a useful diagnostic method for determining the depth of colorectal cancer invasion according to TNM classification and subclassification of submucosal cancer.

Endoscopic mucosal resection for large sessile polyps of the colon

ENDOSCOPIC MUCOSAL RESECTION FOR LARGE SESSILE POLYPS OF THE COLON E. Cho, N. Mochizuki, T. Ashihara, K. Yasuda and M. Nakajima, Department of Gastroenterology, Kyoto Second Red Coss Hospital, Kyoto, Japan With the advances of techniques and instruments, endoscopic electrosurgical polypectomy has become a fundamental procedure in the management of colorectal polypoid lesions. However, large sessile polyps can be technically difficult and sometimes dangerous to endoscopically resect. Recently, endoscopic mucosal resection(EMR) has been developed as a safer method for colorectal polyps. We assessed the usefulness of this technique for large sessile colorectal polyps. From September 1990 to November 1995, we have performed EMR in 32 patients with colorectal sessile polyps larger than 2 cm in size. The procedure was done in a similar fashion of standard snare polypectomy after injection of saline solution into the submucosa just underneath the target lesion. The maximum diameter of resected polyps ranged from 2.0 to 6.0 cm with a mean of 3.1 cm. The procedure was performed in Ii patients with single resection and 21 patients with piecemeal resection. The histological analysis of these lesions consisted of 3 with tubular adenoma, 5 with tubulovillous adenoma, i with villous adenoma, 20 with mucosal carcinoma and 3 with submueosal carcinoma. The complications after EMR occurred in 4 patlents(12.5%) including i patient with bleeding, 2 with transmural burn and i with perforation into the retroperitonetum, all of which required neither transfusion nor laparotomy. Twentyfive of 32 patients underwent colonoscopic management and surveillance. Locally reccurent or persistent neoplasia was discovered in 4 of 25 patients(16%). Three of these four patients subsequently underwent surgical resection. Endoscopic management was ultimately successful in 22 of 25 patients(88%). EMR is a safer and reliable therapeutic procedure for large sessile colorectal polyps. Close follow-up with colonoscopy is essential to evaluate this technique.

TWO CASES OF MUCIN‐PRODUCING CHOLANGIOCARCINOMA DIAGNOSED BY PERORAL CHOLANGIOSCOPY

Mucin‐producing cholangiocarcinoma, which excretes excessive amounts of mucin into the biliary tract and causes obstructive jaundice and cholangitis due to the mucin retention, is rare. In this paper, we report two cases of this disease, which were demonstrated by peroral cholangioscopy (POCS). The radiologic features of these tumors show the diffuse dilatation of the bile ducts demonstrated by computed tomography (CT) and ultrasonography (US), the amorphous filling defects in the dilated bile ducts revealed by cholangiography. Their endoscopic features are mucin flowing out from the papilla of Vater during endoscopic retrograde cholangiography (ERC), and the papillary tumor with contiguous superficial spread in the bile ducts observed by cholangioscopy, although removal of mucin in the biliary tract is sometimes necessary before cholangioscopy in order to examine the lesion sufficiently. According to the previous reports, prognosis after curative resection of these tumors is better than that of ordinary type of cholangiocarcinoma. Therefore, it is important to examine the tumor extension in the bile ducts by cholangioscopy, although a selection of route inserting cholangioscope is controversial.