Fabio Shiguehissa Kawaguti

Endoscopic submucosal dissection versus transanal endoscopic microsurgery for the treatment of early rectal cancer

BackgroundEndoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are minimally invasive procedures that can be used to treat early rectal cancer.ObjectiveThe aim of this study was to compare clinical efficacy between ESD and TEM for the treatment of early rectal cancer.MethodsBetween July 2008 and August 2011, 24 patients with early rectal cancers were treated by ESD (11) or TEM (13) at the Cancer Institute of São Paulo University Medical School (São Paulo, Brazil). Data were analyzed retrospectively according to database and pathological reports, with respect to en bloc resection rate, local recurrence, complications, histological diagnosis, procedure time and length of hospital stay.ResultsEn bloc resection rates with free margins were achieved in 81.8xa0% of patients in the ESD group and 84.6xa0% of patients in the TEM group (pxa0=xa00.40). Mean tumor size was 64.6xa0±xa057.9xa0mm in the ESD group and 43.9xa0±xa030.7xa0mm in the TEM group (pxa0=xa00.13). Two patients in the TEM group and one patient in the ESD group had a local recurrence. The mean procedure time was 133xa0±xa094.8xa0min in the ESD group and 150xa0±xa066.3xa0min in the TEM group (pxa0=xa00.69). Mean hospital stay was 3.8xa0±xa03.3xa0days in the ESD group and 4.08xa0±xa01.7xa0days in the TEM group (pxa0=xa00.81).LimitationsThis was a non-randomized clinical trial with a small sample size and selection bias in treatment options.ConclusionESD and TEM are both safe and effective for the treatment of early rectal cancer.

Endoscopic management and prevention of migrated esophageal stents.

The use of self-expandable metallic stents has increased recently to palliate inoperable esophageal neoplasia and also in the management of benign strictures. Migration is one of the most common complications after stent placement and the endoscopist should be able to recognize and manage this situation. Several techniques for managing migrated stents have been described, as well as new techniques for preventing stent migration. Most stents have a lasso at the upper flange which facilitates stent repositioning or removal. An overtube, endoloop and large polypectomy snare may be useful for the retrieval of stents migrated into the stomach. External fixation of the stent with Shims technique is efficient in preventing stent migration. Suturing the stent to the esophageal wall, new stent designs with larger flanges and double-layered stents are promising techniques to prevent stent migration but they warrant validation in a larger cohort of patients.

Etiology, endoscopic management and mortality of upper gastrointestinal bleeding in patients with cancer

Background The source and outcomes of upper gastrointestinal bleeding (UGIB) in oncologic patients are poorly investigated. Objective The study aimed to investigate these issues in a tertiary academic referral center specialized in cancer treatment. Methods This was a retrospective study including all patients with cancer referred to endoscopy due to UGIB in 2010. Results UGIB was confirmed in 147 (of 324 patients) referred to endoscopy for a suspected episode of GI bleeding. Tumor was the most common cause of bleeding (Nu2009=u200935, 23.8%), followed by varices (Nu2009=u200930, 19.7%), peptic ulcer (Nu2009=u200929, 16.3%) and gastroduodenal erosions (Nu2009=u200916, 10.9%). Among the 32 patients with cancer of the upper GI tract, the main causes of bleeding were cancer (Nu2009=u200927, 84.4%) and peptic ulcer (Nu2009=u20095, 6.3%). Forty-one patients (27.9%) presented with bleeding from the primary tumor or from a metastatic lesion, and seven received endoscopic therapy, with successful initial hemostasis in six (85.7%). Rebleeding and mortality rates were not different between endoscopically treated (Nu2009=u20097) and non-treated (Nu2009=u200934) patients (28.6% vs. 14.7%, pu2009=u20090.342; 43.9% vs. 44.1%, pu2009=u20090.677). Median survival was 20 days, and the overall 30-day mortality rate was 44.9%. There was no predictive factor of mortality or rebleeding. Conclusion Tumor bleeding is the most common cause of UGIB in cancer patients. UGIB in cancer patients correlates with a high mortality rate regardless of the bleeding source. Current endoscopic treatments may not be effective in preventing rebleeding or improving survival.

Esophageal metallic stent fixation with dental floss: a simple method to prevent migration

Use of fully and partially covered selfexpanding metallic esophageal stents (SEMS) is associated with high rates of migration [1]. Stent modification with a silk thread to permit external fixation, proposed by Shim et al., has been shown to reduce migration [2] but this stent may not be routinely available. Therefore we present another modified stent technique that can be used in patients with or at risk for stent migration. A piece of dental floss is grasped with a biopsy forceps (● Fig.1) and advanced to the esophagus. The endoscope is positioned at the upper border of the stent and the forceps carrying the floss is passed through the stent mesh from the outside to the inside and advanced again (● Fig.2). The endoscope is passed further through the stent and the floss is grasped with the forceps and gently pulled back, taking care to avoid stent dislodgment (● Fig.3). Finally, using a method similar to exchange of a nasobiliary drainage catheter (● Fig.4), the dental floss is drawn out through the nose, and, after having tied a knot into it, its loose end is fixed to the patient’s earlobe. Upper endoscopy is repeated 2 weeks after the procedure and, if the proximal uncovered flange of the stent is embedded in the esophageal mucosa and does not separate from the esophagus with air insufflation, the external fixation is removed. This method has been successfully used in eight patients with esophageal malignancies. Of the stents used in these patients, seven were partially covered and one was fully covered. In the patient with the fully covered stent, a needle-knife was used to puncture the sheath, allowing the passage of the dental floss through the mesh. We believe the external fixation using dental floss is a simple and cheap method that can be applied to any kind and size of stent.

Endoscopic removal of migrated esophageal stent--the "grasper and pusher" method.

A 79-year-old man with metastatic adenocarcinoma of the cardia was submitted to palliative chemotherapy and esophageal stenting for relief of dysphagia. After the fourth cycle of chemotherapy he was admitted to the emergency department complaining of dysphagia. At endoscopy a significant regression of the lesion size and migration of the stent into the stomach were noticed. The standard gastroscope (9.8mm) was easily inserted into the gastric chamber. In order to facilitate the use of the proximal lasso system to close the proximal end of the stent, the standard gastroscope was switched to the therapeutical scope, and a 10-Fr biliary stent pusher was inserted into the largest operational channel followed by a grasp forceps (● Fig.1). The lasso was grasped and pulled back into the pusher while the endoscopist’s assistant advanced it against the stent. This maneuver allowed the constraining of the proximal end of the stent, facilitating its removal (● Fig.2 and● Video1). The occurrence of esophageal stentmigration after chemoradiation therapy can be as high as 40% [1]. Esophageal stent migration is not an emergency. Indeed, some authors advocate a “wait and see” approach [2]. On the other hand there are some reports of distal migration with intestinal obstruction and impaction requiring surgery [2–4]. In our view, endoscopic removal of a distally migrated esophageal stent is desirable whenever possible. However, the withdrawal may be a challenging procedure [5]. Many different approaches for safe endoscopic removal of a migrated stent have been described, such as the use of an overtube, a snare combined with a rat-toothed forceps, and an endoloop device [6]. We believe that the “grasper and pusher” method is an elegant and safe technique to deal with a migrated esophageal stent, especially when a significant reduction in tumor size has occurred allowing the passage of a therapeutic endoscope.

Transduodenal Endosonography-Guided Biliary Drainage and Duodenal Stenting for Palliation of Malignant Obstructive Jaundice and Duodenal Obstruction

CONTEXTnEndosonography-guided biliary drainage has been used over the last few years as a salvage procedure when endoscopic retrograde cholangiopancreatography fails. Malignant gastric outlet obstruction may also be present in these patients. We report the results of both procedures during the same session in patients with duodenal and biliary obstruction due to malignant disease.nnnMETHODSnA retrospective review from a prospective collected database.nnnRESULTSnTechnical success was achieved in all five patients; however, only three patients experienced relief of jaundice and gastric outlet obstruction.nnnCONCLUSIONSnEndosonography-guided biliary drainage and duodenal stenting in the same session is feasible. However, severe complications may limit the procedure. This is a challenging procedure and should be done by experts with special attention to patients selection.

Argon plasma coagulation for the endoscopic treatment of gastrointestinal tumor bleeding: A retrospective comparison with a non-treated historical cohort

Background The endoscopic use of argon plasma coagulation (APC) to achieve hemostasis for upper gastrointestinal tumor bleeding (UGITB) has not been adequately evaluated in controlled trials. This study aimed to evaluate the efficacy of APC for the treatment of upper gastrointestinal bleeding from malignant lesions. Methods Between January and September 2011, all patients with UGITB underwent high-potency APC therapy (up to 70 Watts). This group was compared with a historical cohort of patients admitted between January and December 2010, when the endoscopic treatment of bleeding malignancies was not routinely performed. Patients were stratified into two categories, grouping the Eastern Cooperative Oncology Group (ECOG) performance status scale: Category I (ECOG 0–2) patients with a good clinical status and Category II (ECOG 3–4) patients with a poor clinical status. Results Our study had 25 patients with UGITB whom underwent APC treatment and 28 patients whom received no endoscopic therapy. The clinical characteristics of the groups were similar, except for endoscopic active bleeding, which was more frequently detected in APC group. We had 15 patients in the APC group whom had active bleeding, and initial hemostasis was obtained in 11 of them (73.3%). In the control group, four patients had active bleeding. There were no differences in 30-day re-bleeding (33.3% in the APC group versus 14.3% in the control group; pu2009=u20090.104) and 30-day mortality rates (20.8% in the APC group, versus 42.9% in the control group; pu2009=u20090.091). When patients were categorized according to their ECOG status, we found that APC therapy had no impact in re-bleeding and mortality rates (Group I: APC versus no endoscopic treatment: re-bleeding pu2009=u20090.412, mortality pu2009=u20090.669; Group II: APC versus no endoscopic treatment: re-bleeding pu2009=u20090.505, mortality pu2009=u20090.580). Hematemesis and site of bleeding located at the esophagus or duodenum were associated with a higher 30-day mortality. Conclusions Endoscopic hemostasis of UGITB with APC has no significant impact on 30-day re-bleeding and mortality rates, irrespective of patient performance status.

Diagnostic accuracy of probe-based confocal laser endomicroscopy in Lugol-unstained esophageal superficial lesions of patients with head and neck cancer

BACKGROUND AND AIMSnSurveillance programs of patients with head and neck cancer (HNC) detect synchronous or metachronous esophageal squamous cell carcinoma (ESCC) in up to 15% of patients. Noninvasive, probe-based confocal laser endomicroscopy (pCLE) technique may improve the diagnosis allowing acquisition of high-resolution inxa0vivo images at the cellular and microvascular levels. The aim of this study was to evaluate the accuracy of pCLE for the differential diagnosis of nonneoplastic and neoplastic Lugol-unstained esophageal lesions in patients with HNC.nnnMETHODSnTwenty-seven patients with HNC who exhibited Lugol-unstained esophageal lesions at surveillance endoscopy were prospectively included for pCLE. Diagnostic pCLE was followed by subsequent biopsies or endoscopic resection of suspected lesions. A senior pathologist was blinded to the pCLE results.nnnRESULTSnPatients mean age was 59 years (SDxa0= 8.8) and 70.4% were men. All patients were smokers, and 22 patients (81.5%) had a history of alcohol consumption. The locations of HNC were oral cavity (nxa0= 13), larynx (nxa0= 10), and pharynx (nxa0= 4). Thirty-seven lesions in 27 patients were studied. The final diagnoses were ESCC in 17 patients and benign lesions in 20 patients. Sensitivity, specificity, and accuracy of pCLE for the histologic diagnosis of ESCC in patients with HNC were 94.1%, 90.0%, and 91.9%, respectively.nnnCONCLUSIONSnFirst, pCLE is highly accurate for real-time histology of Lugol-unstained esophageal lesions in patients with HNC. Second, pCLE may alter the management of patients under surveillance for ESCC, guiding biopsies and endoscopic resection, avoiding further diagnostic workup or therapy of benign lesions.

Underwater endoscopic resection of a neuroendocrine rectal tumor.

The endoscopic resection of rectal neuroendocrine tumors (NETs) results in good long-term outcomes [1]. Many techniques for the endoscopic resection of rectal NETs have been described, including polypectomy, endoscopic mucosal resection (EMR), and recently EMR with band ligation [2], endoscopic submucosal dissection [3], and even transanal endoscopic microsurgery [4]. Underwater endoscopic resection is a simple and inexpensive new technique that has been used for the treatment of polyps and flat lesions [5]. We present a case of rectal NET resected with an underwater technique (● Video 1). A 51-year-old womanwas referred for the endoscopic treatment of a distal rectal NET. Colonoscopy revealed a yellowish, hardened, 10-mm lesion with a subepithelial aspect, compatible with NET (● Fig.1). Water was infused until the rectum lumen was completely filled (● Fig.2). An opened snare (SnareMaster; Olympus, Tokyo, Japan) was pushed against the rectal wall to capture a safe margin of normal mucosa (● Fig.3). Forced coagulation was used for the initial cutting, and endocut mode (ERBE Elektromedizin, Tübingen, Germany) was then used to complete the resection. In the post-procedural examination, no sign of perforation or residual lesion was observed (● Fig.4). Histologic examination of the specimen revealed a well-differentiated grade 1 NET invading the deep submucosal layer with tumor-free resection margins and without angiolymphatic or perineural invasion. Underwater endoscopic resection of rectal NET can be a new treatment option and was feasible in this case. Case series are needed to confirm the efficacy of this technique.

Self-expandable metal stent for malignant esophagorespiratory fistula: predictive factors associated with clinical failure

BACKGROUND AND AIMSnMalignant esophagorespiratory fistulas (MERFs) usually are managed by the placement of self-expandable metal stents (SEMSs) but with conflicting results. This study aimed to identify risk factors associated with clinical failure after SEMS placement for the treatment of MERFs.nnnMETHODSnThis was a retrospective analysis of a prospectively maintained database used at a tertiary-care cancer hospital, with patients treated with SEMS placement for MERFs between January 2009 and February 2016. Logistic regression was used to identify predictive factors for clinical outcomes and to estimate the odds ratio (OR) and the 95% confidence interval (CI). The Kaplan-Meier method was used for survival analysis, and comparisons were made by using the log-rank test.nnnRESULTSnA total of 71 patients (55 male, mean age 59 years) were included in the study, and 70 were considered for the final analysis (1 failed stent insertion). Clinical failure occurred in 44% of patients. An Eastern Cooperative Oncology Group (ECOG) performance status of 3 or 4 and fistula development during esophageal cancer treatment were associated with an increased risk of clinical failure. ECOG status of 3 or 4, pulmonary infection at the time of SEMS placement, and prior radiation therapy were predictive factors associated with lower overall survival. Dysphagia scores improved significantly 15 days after stent insertion. The overall stent-related adverse event rate was 30%. Stent migration and occlusion caused by tumor overgrowth were the most common adverse events.nnnCONCLUSIONnSEMS placement is a reasonable treatment option for MERFs; however, ECOG status of 3 or 4 and fistula development during esophageal cancer treatment may be independent predictors of clinical failure after stent placement.