Jae Bum Lee

Can endoscopic submucosal dissection technique be an alternative treatment option for a difficult giant (≥ 30 mm) pedunculated colorectal polyp?

BACKGROUND: Snare polypectomy of a giant pedunculated colorectal polyp is sometimes technically demanding, and, therefore, piecemeal resection is inevitable, despite the relative risk of invasive cancer and postpolypectomy bleeding. OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of endoscopic submucosal dissection in comparison with conventional snare polypectomy for giant pedunculated polyps DESIGN AND SETTINGS: We retrospectively reviewed the clinical outcomes and complications of endoscopic polypectomy for giant pedunculated polyps from October 2006 to November 2011. PATIENTS: All the patients who underwent endoscopic submucosal dissection (n = 23) or snare polypectomy (n = 20) for pedunculated polyps ≥3 cm were enrolled consecutively. In the case of a giant pedunculated polyp with 1) poor visualization of the stalk, 2) technical difficulties in snare positioning for en bloc resection, or 3) need for trimming of the head, we did not attempt piecemeal snare polypectomy, and we performed endoscopic submucosal dissection instead. (These were arbitrarily defined as “difficult” giant pedunculated polyps.) MAIN OUTCOME MEASURES: Data on the patient’s demography, endoscopic and histopathologic findings, clinical outcomes, and complications were analyzed. RESULTS: Among the 43 giant pedunculated polyps, 23 polyps were defined as “difficult” polyps and were removed with endoscopic submucosal dissection. Subpedunculated (stalk <1 cm) type was more common in the “difficult” polyp group (p = 0.01). The overall incidence of cancer was 18.6% (8/43). En bloc resection rates were 100% (23/23) in the endoscopic submucosal dissection group and 90% (18/20) in the snare polypectomy group. The procedure times of snare polypectomy and endoscopic submucosal dissection group did not differ significantly (41.7 ± 13.7 minutes vs 44.9 ± 35.6 minutes, p = 0.70). Postpolypectomy bleeding was noted in 1 case (4.3%) in the endoscopic submucosal dissection group and in 3 cases (15%) in the snare polypectomy group. CONCLUSIONS: Endoscopic submucosal dissection, as well as the snare polypectomy for giant pedunculated polyps, appeared to be effective without major complications and can be an alternative option to achieve en bloc resection, particularly for difficult cases, such as giant subpedunculated polyps.

Endoscopic submucosal dissection for nonpedunculated submucosal invasive colorectal cancer: is it feasible?

Background/aims There have been no definite indications for additional surgical resection after endoscopic submucosal dissection (ESD) of submucosal invasive colorectal cancer (SICC). The aims of this study were to evaluate the feasibility of ESD for nonpedunculated SICC and to determine the need for subsequent surgery after ESD. Patients and methods A total of 150 patients with nonpedunculated SICC in resected specimens after ESD were analyzed. Among them, 75 patients underwent subsequent surgery after ESD. Clinical outcomes of ESD and histopathological risk factors for lymph node (LN) metastasis were evaluated. Results The en-bloc resection and complete resection (R0) rates of ESD were 98% (147/150) and 95.3% (143/150), respectively. None of the patients had delayed bleeding after ESD. Perforations occurred in seven patients (4.7%), which were successfully treated by endoscopic clipping. After subsequent surgery for 75 patients, LN metastases were found in 10 cases (13.3%). The incidence of LN metastasis was significantly higher in tumors featuring submucosal invasion of at least 1500 &mgr;m, lymphovascular invasion, and tumor budding. Multivariate analysis showed that lymphovascular invasion (P=0.034) and tumor budding (P=0.015) were significantly associated with LN metastasis. Among the 150 patients, no local recurrence or distant metastasis was detected, except one patient with risk factors and who refused subsequent surgery, during the overall median follow-up of 34 months (range, 5–63 months). Conclusion ESD is feasible and may be considered as an alternative treatment option for carefully selected cases of nonpedunculated SICC, provided that the appropriate histopathological curative criteria are fulfilled in completely resectable ESD specimens.

Lymph node size is not a reliable criterion for predicting nodal metastasis in rectal neuroendocrine tumours.

The study was designed to assess the correlation between lymph node (LN) size and LN metastasis in patients with rectal neuroendocrine tumours (NETs).

Clinical impact of atypical endoscopic features in rectal neuroendocrine tumors.

AIM To validate the association between atypical endoscopic features and lymph node metastasis (LNM). METHODS A total of 247 patients with rectal neuroendocrine tumors (NETs) were analyzed. Endoscopic images were reviewed independently by two endoscopists, each of whom classified tumors by sized and endoscopic features, such as shape, color, and surface change (kappa coefficient 0.76 for inter-observer agreement). All of patients underwent computed tomography scans of abdomen and pelvis for evaluation of LNM. Univariate and multivariate analyses were performed to identify the factors associated with LNM. Additionally, the association between endoscopic atypical features and immunohistochemical staining of tumors was analyzed. RESULTS Of 247 patients, 156 (63.2%) were male and 15 (6.1%) were showed positive for LNM. On univariate analysis, tumor size (P < 0.001), shape (P < 0.001), color (P < 0.001) and surface changes (P < 0.001) were significantly associated with LNM. On multivariate analysis, tumor size (OR = 11.53, 95%CI: 2.51-52.93, P = 0.002) and atypical surface (OR = 27.44, 95%CI: 5.96-126.34, P < 0.001) changes were independent risk factors for LNM. The likelihood of atypical endoscopic features increased as tumor size increased. Atypical endoscopic features were associated with LNM in rectal NETs < 10 mm (P = 0.005) and 10-19 mm (P = 0.041) in diameter. Immunohistochemical staining showed that the rate of atypical endoscopic features was higher in non L-cell tumors. CONCLUSION Atypical endoscopic features as well as tumor size are predictive factors of LNM in patients with rectal NETs.

A case of Crohn's disease with improvement after azathioprine-induced pancytopenia.

The immunosuppressant azathioprine (AZA) is widely used in the treatment of inflammatory bowel disease (IBD) for both inducing and maintaining remission. However, the adverse effects of AZA can often necessitate a dose reduction or discontinuation. Bone marrow suppression is one of the most serious complications with AZA treatment. On the other hand, some reports have suggested that neutropenia during AZA therapy reduced the relapse rates of IBD patients, and there have been some cases where eradication of the sensitized leukocytes by leukapheresis or bone marrow transplantation improved the IBD, which may explain the relevant role of neutropenia in controlling disease activity. This report describes the case of a 22-year-old male patient who had Crohn’s colitis and complicated perianal fistulas that required immunosuppression; he achieved endoscopically determined remission and showed accelerated mucosal healing as well as clinical remission following the AZA-induced pancytopenia.

Persistent Bleeding Following a Stapled Hemorrhoidopexy

A stapled hemorrhoidopexy (SH) is widely used for treatment of patients with grades III and IV hemorrhoids. The SH is easy to perform, is associated with less pain and allows early return to normal activities. However, complications, whether severe or not, have been reported. Here, we present the case of a female patient with persistent bleeding after a SH. The bleeding was caused by the formation of granulation tissue at the stapler line, diagnosed with sigmoidoscopy, and successfully treated via transanal excision (TAE) under spinal anesthesia. The biopsy showed inflammatory granulation tissue. After the TAE, her symptom was completely gone.

Clinical Characteristics and Incidence of Perianal Diseases in Patients With Ulcerative Colitis

Purpose While perianal disease (PAD) is a characteristic of patients with Crohn disease, it has been overlooked in patients with ulcerative colitis (UC). Thus, our study aimed to analyze the incidence and the clinical features of PAD in patients with UC. Methods We reviewed the data on 944 patients with an initial diagnosis of UC from October 2003 to October 2015. PAD was categorized as hemorrhoids, anal fissures, abscesses, and fistulae after anoscopic examination by experienced proctologists. Data on patients’ demographics, incidence and types of PAD, medications, surgical therapies, and clinical course were analyzed. Results The median follow-up period was 58 months (range, 12–142 months). Of the 944 UC patients, the cumulative incidence rates of PAD were 8.1% and 16.0% at 5 and 10 years, respectively. The incidence rates of bleeding hemorrhoids, anal fissures, abscesses, and fistulae at 10 years were 6.7%, 5.3%, 2.6%, and 3.4%, respectively. The cumulative incidence rates of perianal sepsis (abscess or fistula) were 2.2% and 4.5% at 5 and 10 years, respectively. In the multivariate analyses, male sex (risk ratio [RR], 4.6; 95% confidence interval [CI], 1.7–12.5) and extensive disease (RR, 4.2; 95% CI, 1.6–10.9) were significantly associated with the development of perianal sepsis. Conclusion Although the clinical course of PAD in patients with UC is not serious, in clinical practice, PAD is not rare in such patients. Therefore, careful examination and appropriate management for PAD is needed if the quality of life for patients with UC is to be improved.