Hiroyuki Ono

Endoscopic mucosal resection for treatment of early gastric cancer.

BACKGROUND In Japan, endoscopic mucosal resection (EMR) is accepted as a treatment option for cases of early gastric cancer (EGC) where the probability of lymph node metastasis is low. The results of EMR for EGC at the National Cancer Center Hospital, Tokyo, over a 11 year period are presented. METHODS EMR was applied to patients with early cancers up to 30 mm in diameter that were of a well or moderately histologically differentiated type, and were superficially elevated and/or depressed (types I, IIa, and IIc) but without ulceration or definite signs of submucosal invasion. The resected specimens were carefully examined by serial sections at 2 mm intervals, and if histopathology revealed submucosal invasion and/or vessel involvement or if the resection margin was not clear, surgery was recommended. RESULTS Four hundred and seventy nine cancers in 445 patients were treated by EMR from 1987 to 1998 but submucosal invasion was found on subsequent pathological examination in 74 tumours. Sixty nine percent of intramucosal cancers (278/405) were resected with a clear margin. Of 127 cancers without “complete resection”, 14 underwent an additional operation and nine were treated endoscopically; the remainder had intensive follow up. Local recurrence in the stomach occurred in 17 lesions followed conservatively, in one lesion treated endoscopically, and in five lesions with complete resection. All tumours were diagnosed by follow up endoscopy and subsequently treated by surgery. There were no gastric cancer related deaths during a median follow up period of 38 months (3–120 months). Bleeding and perforation (5%) were two major complications of EMR but there were no treatment related deaths. CONCLUSION In our experience, EMR allows us to perform less invasive treatment without sacrificing the possibility of cure.

Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection - An analysis of risk factors

BACKGROUND AND STUDY AIMnEndoscopic submucosal dissection (ESD) has been reported to be associated with a higher complication rate than standard endoscopic mucosal resection. We aimed to clarify the risk factors for delayed bleeding after ESD for early gastric cancer (EGC).nnnMETHODSn1083 EGCs in 968 consecutive patients undergoing ESD during a 4-year period were reviewed. Post-ESD coagulation (PEC) preventive therapy of visible vessels in the resection area, using a coagulation forceps, was introduced and mostly performed during the later 2 years. Various factors related to patients, tumors, and treatment including PEC were investigated using univariate and multivariate analysis with regard to delayed post-ESD bleeding, evidenced by hematemesis or melena, that required endoscopic treatment.nnnRESULTSnDelayed bleeding occurred after ESD of 63 lesions (5.8 % of all lesions and 6.5 % of patients), controlled in all cases by endoscopic hemostasis; blood transfusion was required in only one case. Tumor location in the upper third of the stomach and PEC were independent factors indicating a lower rate of delayed bleeding according to both univariate and multivariate analysis.nnnCONCLUSIONSnThis retrospective study suggested that preventive coagulation of visible vessels in the resection area after ESD may lead to a lower bleeding rate.

The clinical characteristics and outcome of intraabdominal abscess in Crohn’s disease

BackgroundWe aimed to elucidate the incidence and natural course of abdominal abscess complicating Crohn’s disease (CD).MethodsOf 352 patients with CD who were observed at our hospital between 1985 and October 2001, we studied 35 patients (9.9%) with abscesses in the mid-abdominal region (the abdominal wall, peritoneal cavity, retroperitoneum, and subphrenic region).ResultsThe cumulative incidence of complication with an abscess was 9% and 25%, respectively, 10 and 20 years after CD onset. Of the 35 CD patients with abscess, 60% had had surgery by the time of the present study. The age when the abscess developed was 30.1 ± 8.1 years, and the duration of illness from the onset of CD until development of an abscess was 10.8 ± 6.3 years (range, 0–29 years). The location of involvement was: abdominal wall, n = 14 (40%); peritoneal cavity, n = 10 (29%); retroperitoneum or iliopsoas, n = 9 (26%); and subphrenic region, n = 2 (6%). In terms of location of abscess, it occurred most often on the right side (65.7%). Almost all abscesses occurred near the site of an anastomosis. Diseased segments of the bowel responsible for abscess formation were categorized radiographically as showing mild stenosis (6.5%), intermediate stenosis and/or simple fistula (41.9%), and severe stenosis and/or multiple fistulas (51.6%). Conservative treatment (including drainage of abscess) alone was effective in 7 patients (20%) and surgery was needed in 28 patients (80%). During the 5.3-year follow-up after treatment for the abdominal abscess, 9 of the 35 patients (26%) had recurrence of an abscess, mostly within 3 years.ConclusionsAbscess formation was noted in about 10% of patients with CD, with 46% of abscesses occurring in a diseased bowel segment near an anastomotic site. Of the diseased bowel segments responsible for abscess formation, half had neither severe stenosis nor multiple fistulas. Almost all patients underwent surgery for the abscess, and, in more than a quarter of the patients, there was recurrence within a few years after surgery.

Risk factors for cardiac and pyloric stenosis after endoscopic submucosal dissection, and efficacy of endoscopic balloon dilation treatment.

BACKGROUND AND STUDY AIMSnBleeding and perforation are major complications of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), but post-ESD stenosis represents a severe delayed complication that can result in clinical symptoms such as dysphagia and nausea. The aims of this study were to determine the risk factors and evaluate the clinical treatment for post-ESD stenosis.nnnMETHODSnA total of 2011 EGCs resected by ESD at our institution between 2000 and 2005 were reviewed retrospectively. Resection was defined as cardiac when any mucosal defect was located in the squamocolumnar junction, and as pyloric when any mucosal defect was located < 1 cm from the pylorus ring. Post-ESD stenosis was defined when a standard endoscope could not be passed through the stenosis. We examined the incidence of post-ESD stenosis, its relationship with relevant factors, and the clinical course of post-ESD stenosis patients.nnnRESULTSnPost-ESD stenosis occurred with seven of 41 cardiac resections (17 %) and eight of 115 pyloric resections (7 %). Circumferential extent of the mucosal defect of > 3/4 and longitudinal extent > 5 cm were each significantly related to occurrence of post-ESD stenosis with both cardiac and pyloric resections. All 15 affected patients were successfully treated by endoscopic balloon dilation.nnnCONCLUSIONSnA circumferential extent of the mucosal defect of > 3/4 or longitudinal extent of > 5 cm in length were both demonstrated to be risk factors for post-ESD stenosis, in both cardiac and pyloric resections, and endoscopic balloon dilation was shown to be effective in treating post-ESD stenosis.

Gastric perforation during endoscopic resection for gastric carcinoma and the risk of peritoneal dissemination

The potential risk of peritoneal seeding following perforation caused by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is unknown.

Expression of CD44 variants and prognosis in oesophageal squamous cell carcinoma

BACKGROUND The CD44 variant (CD44v) isoforms have been noted as markers for tumour metastasis and prognosis in several adenocarcinomas. AIMS To investigate whether CD44v, especially the CD44v2 (v2) isoform, may be a useful prognostic factor for patients with oesophageal squamous cell carcinoma, using a recently developed monoclonal antibody against a v2 epitope. PATIENTS 233 patients (211 men and 22 women; mean age 61.9 years), with oesophageal squamous cell carcinomas curatively removed without additional treatment between 1987 and 1996 at the National Cancer Center Hospital, were analysed for CD44v expression. METHODS The expression of CD44v was evaluated immunohistochemically using monoclonal antibodies against epitopes of the standard and variant protein, in paraffin embedded oesophageal squamous cell carcinoma tissue from 233 patients who had undergone cervical, mediastinal, and abdominal lymphadenectomy (three field dissection) for oesophagectomy. The data were evaluated for any correlation with clinicopathological indices or prognosis. RESULTS Although total CD44 and CD44v6 (v6) were respectively observed in 99% and 97% of the cancer specimens, the expression of v2 was only 30%. Patients whose tumours were v2 positive had a significantly better prognosis than those whose tumours were v2 negative (p = 0.031). Furthermore, in patients without lymph node metastasis, v2 positivity alone was a significant independent factor of prognosis (relative risk of death associated with v2 negativity, 4.7; p = 0.037) in multivariate analysis. CONCLUSIONS These results indicate that v2 is a useful marker for clinical prognosis in patients with oesophageal squamous cell carcinoma. Particularly in patients without lymph node metastasis, v2 status may thus have implications for the use of adjuvant chemotherapy and/or radiotherapy in patients with oesophageal cancer at an early stage.

Angiographic management of massive hemobilia due to iatrogenic trauma

Ten patients with massive hemobilia in shock or preshock status were treated with angiography. The hemobilia had been induced by iatrogenic trauma: biliary drainage in seven patients, and surgery, liver biopsy, and angiography in one patient each. Angiography was performed on all patients. Embolization was performed in nine, and in the one remaining patient, spasm of the right anterior hepatic artery and catheter manipulation injured the intima and obliterated the artery. In seven patients with hepatic artery pseudoaneurysm, gelfoam particles were injected in five, however, extravasation could not be prevented in four of these patients. Permanent embolic materials were added and complete hemostatis was obtained. Hemobilia never recurred in any patient. Emergency embolization should be considered as the initial treatment of choice for hemobilia and when pseudoaneurysms are discovered, they should be obliterated by permanent embolic materials. Moreover, tumor thrombus in the portal vein is not a contraindication for this procedure.

Value of virtual computed tomographic colonography for Crohn's colitis: comparison with endoscopy and barium enema.

AbstractBackground: Crohn’s colitis, frequently accompanied by stenosis or narrowing, can be difficult to assess through conventional methods. We evaluated the usefulness of virtual computed tomographic colonography (CTC) for the detection of colonic lesions due to Crohn’s disease.n Methods: Forty-two lesions in 33 patients with Crohn’s disease were examined by CTC and barium enema (BE). Twenty-two patients also were examined by colonoscopy (CS). The visualization ability of CTC was compared with those of the other two methods.n Results: In the visualization of elevated lesions, there was no significant difference between CTC and BE (18 of 20, p = 0.487) or between CTC and CS (15 of 16, p = 0.99); however, ulcerative lesions were less often visualized by CTC. However, CTC enabled identification of serious lesions in the colon proximal to the stenosis in nine patients and was superior to BE and CS in terms of its ability to visualize the proximal site of the stenosis (p = 0.003).n Conclusion: CTC is clinically useful for the evaluation of Crohn’s colitis, especially those with stenotic lesions.

Embolotherapy of massive duodenal hemorrhage

Eleven patients with massive duodenal hemorrhage were treated by emergent embolization. Bleeding originated from duodenal ulcer in three patients, from duodenal tumor in one, from ruptured pancreaticoduodenal artery pseudoaneurysm in three, and from ruptured gastroduodenal artery pseudoaneurysm in four. Complete hemostasis was obtained immediately after embolotherapy in all cases. Three of these patients died during the hospitalization period, one of whom from duodenal infarction and pancreas necrosis induced by embolization. In three patients with duodenal ulcer, complete hemostasis was obtained only by the gastroduodenal artery embolization with Gelfoam particles. Seven patients with pseudoaneurysms of the gastroduodenal artery or its branches required not only blockage of blood flow from the celiac artery but also the superior mesenteric artery for complete hemostasis. Therefore, in patients presenting with duodenal hemorrhage, the possibility of dual blood supply to the duodenum should be considered. Emergent embolization represents a useful alternative to surgery for massive duodenal hemorrhage, but it carries a risk of complications in patients with previous gastroduodenal surgery or significant visceral atherosclerosis.

Clinical outcomes of endoscopic submucosal dissection for early gastric cancer in remnant stomach or gastric tube.

BACKGROUND AND STUDY AIMSnLittle information exists regarding the optimal treatment of early gastric cancer (EGC) in a remnant stomach or gastric tube. The aim of this study was to assess the feasibility and clinical outcomes of endoscopic submucosal dissection (ESD) for EGC in a remnant stomach and gastric tube.nnnPATIENTS AND METHODSnBetween September 2002 and December 2009, ESD was performed in 62 lesions in 59 patients with EGC in a remnant stomach (48 lesions) or gastric tube (14 lesions). Clinicopathological data were retrieved retrospectively to assess the en bloc resection rate, complications, and outcomes. Treatment results were assessed according to the indications for endoscopic resection, and were compared with those of ESD performed in a whole stomach during the same study period.nnnRESULTSnThe en bloc resection rates for lesions within the standard and expanded indication were 100 % and 93 %, respectively. Postoperative bleeding occurred in five patients (8 %). The perforation rate was significantly higher (18 %, 11 /62) than that of ESD in a whole stomach (5 %, 69 /1479). Among the perforation cases, eight lesions involved the anastomotic site or stump line, and ulcerative changes were observed in five lesions. The 3-year overall survival rate was 85 %, with eight deaths due to other causes and no deaths from gastric cancer.nnnCONCLUSIONnA high en bloc resection rate was achieved by ESD for EGC in a remnant stomach or gastric tube; however, this procedure is still technically demanding due to the high complication rate of perforation.