Joichiro Horii

Novel EUS-guided gastrojejunostomy technique using a new double-balloon enteric tube and lumen-apposing metal stent (with videos)

BACKGROUNDnSurgical gastrojejunostomy is associated with relatively high morbidity and mortality rates. However, current experimental EUS-guided gastrojejunostomy information is limited.nnnOBJECTIVEnTo evaluate a novel EUS-guided gastrojejunostomy technique using a new enteric balloon and lumen-apposing metal stent.nnnDESIGNnAnimal experiment.nnnSETTINGnAnimal laboratory at a referral center.nnnSUBJECTS AND INTERVENTIONSnIn 5 pigs, gastrojejunostomies were created under EUS guidance. Fully covered lumen-apposing stents were placed between the stomach and the jejunum.nnnMAIN OUTCOME MEASUREMENTSnTechnical success and adverse events of EUS-guided gastrojejunostomy.nnnRESULTSnAll stents, with 1 exception, were successfully deployed without any adverse events. The mean time to stent placement was 44.2 minutes (range 28-64 minutes). All animals showed normal eating behavior without signs of infection for 1 month after the procedure. Endoscopic imaging of the stomach site showed the stent to be patent and stable, without dislodgment, in all of the pigs. Necropsy showed complete adhesion between the stomach and the jejunum wall.nnnLIMITATIONSnPilot study.nnnCONCLUSIONSnCreation of an EUS-guided gastrojejunostomy by using a novel enteric balloon and metal stent appears to be promising as a minimally invasive treatment.

First case of non-exposed endoscopic wall-inversion surgery with sentinel node basin dissection for early gastric cancer

IntroductionNon-exposed endoscopic wall-inversion surgery (NEWS) is a novel technique of endoscopic full-thickness resection without transluminal access mainly designed to treat gastric cancer. Here, we report a successful case of NEWS with sentinel node basin dissection (SNBD) for early gastric cancer (EGC) with the risk of lymph node metastasis.Patient and methodsA 55-year-old female patient with a 2-cm, diffuse-type intramucosal EGC with ulceration was referred to our hospital for a less invasive gastrectomy based on sentinel node navigation surgery. After obtaining informed consent, NEWS with SNBD was applied. After placing mucosal markings, indocyanine green solution was injected endoscopically into the submucosa around the lesion to examine sentinel nodes (SNs). The SN basin (the area of the left gastric artery), including three stained SNs(#3), was dissected, and an intraoperative pathological diagnosis confirmed that no metastasis had occurred. Subsequently, NEWS was performed for the primary lesion. Serosal markings were placed laparoscopically, submucosal injection was added endoscopically, and circumferential sero-muscular incision and suturing were performed laparoscopically, with the lesion inverted toward the inside of the stomach. Finally, the circumferential mucosal incision was performed, and the lesion was retrieved perorally.ResultsThe operation was finished in 270xa0min without complications. The patient was uneventfully discharged 10xa0days after the procedure. The final pathological diagnosis was coincident with the pre- and intraoperative assessment.ConclusionsWe demonstrated the feasibility and safety of NEWS with SNBD with a favorable result. This surgical concept is expected to become a promising, minimally invasive, function-preserving surgery to cure cases of EGC that are possibly node-positive.

Feasibility of non-exposed endoscopic wall-inversion surgery with sentinel node basin dissection as a new surgical method for early gastric cancer : a porcine survival study

Non-exposed endoscopic wall-inversion surgery (NEWS) has been developed as an endoscopic full-thickness resection technique without translumenal communication to avoid intraabdominal infection or tumor seeding. We aimed to investigate the feasibility and safety of NEWS with sentinel node basin dissection (SNBD), which can minimize the area of lymphadenectomy for early gastric cancer (EGC), in 10 porcine survival models. After placing laparoscopic ports and making markings on both the mucosal and serosal sides of a simulated lesion, indocyanine green fluid was endoscopically injected into the submucosa at 4 quadrants around the lesion. An SN basin including the stained SNs was dissected, and a circumferential sero-muscular incision around the lesion and sero-muscular suturing were performed laparoscopically, with the lesion inverted toward the inside of the stomach. Finally, circumferential mucosal incision and transoral retrieval were made endoscopically. In all cases, the lesion was resected in an en bloc fashion, and all pigs survived without adverse events. After 1xa0week of observation, pigs were sacrificed for macroscopic investigation. The average procedural duration was 170xa0min (range 130–253xa0min). Intraoperative perforation occurred in 1 case, which could be safely treated by laparoscopic suturing. The number of dissected SN basins was 1 in 9 cases and 2 in 1 case. Necropsy revealed no signs of severe complication. This animal survival study demonstrated that NEWS with SNBD was safe and feasible. It may provide patients with possibly node-positive EGC a minimally-sized local resection and minimally-ranged lymphadenectomy without the risk of tumor dissemination.

Expanding Indications for ESD: Submucosal Disease (SMT/Carcinoid Tumors)

Endoscopic submucosal dissection (ESD) is useful for submucosal tumors (SMTs) within the superficial submucosal layer, but perforation frequently occurs during ESD for SMTs located at the deeper layer. Endoscopic resection for small esophageal SMTs is acceptable, although candidates for endoscopic removal are rare. Laparoscopic assistance will be effective for minimally invasive endoscopic local resection for certain types of gastric SMT. Endoscopic mucosal resection with a ligation device would be better than ESD for rectal carcinoid in terms of simplicity and effectiveness.

A new endoscopic closure method for gastric mucosal defects: feasibility of endoscopic hand suturing in an ex vivo porcine model (with video).

Background and study aims: More secure endoscopic closure techniques for iatrogenic gastric defects are required for safe endoscopic surgery. We developed a novel endoscopic suturing method, endoscopic hand suturing (EHS), of gastric mucosal defects and determined its feasibility and efficacy ex vivo. Materials and methods: We created 24 mucosal defects (each 2u200acm in diameter) by endoscopic submucosal dissection. The following three techniques were tested: EHS with a 3u200a–u200a0 barbed suture that was grasped with biopsy forceps (nu200a=u200a6) or a prototype through-the-scope needle holder (nu200a=u200a6) by endoscopy, looping with endoloops (nu200a=u200a6) by endoscopy, and clipping with hemoclips (nu200a=u200a6) by hand. The mucosal edges were attached to each other at three points. The closure strength was compared among the three groups, and the procedural duration was compared between the EHS and looping groups. Results: All 12 lesions were completely closed by EHS.u200aThe median strength of the closure, measured with a spring scale, was significantly greater in the EHS group (0.74u200akg) than in the looping group (0.33u200akg, Pu200a=u200a0.0012) or clipping group (0.07u200akg, Pu200a=u200a0.0009). The median procedural duration did not significantly differ between the EHS and looping groups (19.7 vs. 19.8 minutes, Pu200a=u200a1.0000). The use of the needle holder significantly reduced the procedural duration compared with the biopsy forceps. Conclusion: Mucosal defects can be firmly closed with EHS, which may be helpful for establishing a safer and more secure endoscopic surgery.

Which part of a porcine stomach is suitable as an animal training model for gastric endoscopic submucosal dissection

BACKGROUND AND STUDY AIMSnTraining using an animal model is generally recommended before performing endoscopic submucosal dissection (ESD) in humans. This study aimed to clarify the suitability of an isolated porcine stomach as an animal training model for gastric ESD.nnnMATERIALS AND METHODSnStudy 1: six experienced endoscopists performed ESDs of six simulated lesions located in six locations in an isolated porcine stomach (1, lower third [L]/ greater curvature [Gre]; 2, L/ anterior wall [Ant]; 3, L/ posterior wall [Post]; 4, upper third [U]/ Gre; 5, U/Ant; 6, U/Post). The procedure times (s/cm(2)) were compared among the different lesion locations. A questionnaire (scored 1u200a-u200a5) completed by the endoscopists was used to assess the difference in the difficulty compared to the human stomach of the three steps of the ESD procedure (injection, incision and dissection). Study 2: the thicknesses of the mucosal layers were histologically evaluated among the six locations in three porcine and two human stomachs.nnnRESULTSnStudy 1: the procedure speed was significantly slower at L/Gre and U/Gre in the porcine stomachs (Pu200a=u200a0.0004). The questionnaire responses revealed a tendency toward similarity between the lower regions of the human and porcine stomachs at L/Ant, L/Post, U/Ant and U/Post during the dissection step (Pu200a=u200a0.056). In contrast, the injection and incision steps at L/Gre in the porcine stomach were shown to differ in difficultly level (both Pu200a=u200a0.0006). Study 2: the mucosal layers in the porcine stomachs were significantly thicker than those in the human stomachs in the lower areas, especially L/Gre.nnnCONCLUSIONSnThe difficulty of ESD and the histological features of the porcine stomachs were coincident with those of the human stomachs at L/Ant, L/Post, U/Ant and U/Post. These parts of the porcine stomach may be suitable as animal training models for gastric ESD.

Gastric ESD may be useful as accurate staging and decision of future therapeutic strategy

Background and study aimsu2003We sometimes perform gastric endoscopic submucosal dissection (ESD) for total pathologic diagnosis when preoperative diagnosis is difficult. In the present study we analyzed the treatment outcomes and adverse events of diagnostic ESD for early gastric cancer (EGC). Patients and methodsu2003We conducted a retrospective analysis of 18 consecutive cases of EGC in 18 patients with a suspected out-of-indication diagnosis who underwent diagnostic ESD, between June 2010 and November 2014. The following parameters were examined: the average length of the longer axis of the lesion; the procedure time; the rates of en bloc resection (ER), complete en bloc resection (CER), and curative resection (CR) as treatment outcomes; and the rates of perforation, delayed bleeding, aspiration pneumonia, disease-related death, and emergency surgery as adverse events. Resultsu2003The treatment outcomes were as follows: average length of the longer axis of the lesion, 27.4u200a±u200a10.0u200amm; procedure time, 87.0u200a±u200a43.1 minutes; ER rate, 18/18 (100.0u200a%); CER rate, 13/18 (72.2u200a%); CR rate, 4/18 (22.2u200a%). CR rate was achieved 37.5u200a% for the lesions which preoperative diagnosis was more than 30u200amm (>u200a30u200amm) in diameter differentiated type with mucosal layer/submucosal layer 1 invasion and ulceration positive. The adverse events (AEs) were perforation in 1 of 18 (5.5u200a%) patients and delayed bleeding in 1 of 18 (5.5u200a%). There were no other AEs. Conclusionsu2003Diagnostic ESD may be acceptable for future therapeutic strategy when we unconfirmed the pre ESD diagnosis because of lower rate of adverse events and high rate of ER.

Metachronous adenoma on ileorectal anastomosis suture line and submucosal deep invasive cancer suspected of rapid growth in rectal remnant following long‐term interval after curative surgery for advanced colon cancer

There is general agreement as to the value of postoperative surveillance and the effectiveness of colonoscopy in the early detection of metachronous colorectal lesions. In the present case, a 56‐year‐old woman with no family history of colon cancer underwent surveillance colonoscopy in which a metachronous flat adenoma was detected following an interval of 23 years after a colectomy and 20 years subsequent to treatment for uterine cancer. A second metachronous flat lesion histopathologically determined to be a submucosal (sm) deep invasive cancer with lymphovascular involvement was detected 12 months later. This second metachronous lesion was suspected of having developed rapidly in the rectal remnant accounting for its sm deep invasion. The findings of this case suggest colonoscopy surveillance guidelines proposed for individuals at high risk should be evaluatedbased on cancer history and an analysis of possible mismatch repair gene mutations. In addition, the first metachronous lesion was located directly on the suture line of the anastomosis. Endoscopic submucosal dissection (ESD) was indicated despite severe fibrosis into the sm layer. This case also demonstrates the successful use of improved ESD instruments, sm injection agents and technique refinements in the treatment of a technically difficult lesion with a high risk of complications.

Detection of palisade vessels as a landmark for Barrett’s esophagus in a Western population

BackgroundIn Japan, palisade vessels (PV) are used to distinguish the esophagogastric junction (EGJ). Elsewhere, the EGJ is defined by the upper end of the gastric folds (GF) and PV are considered difficult to detect. This study evaluated the detection rate of PV in Western patients with Barrett’s esophagus (BE) using white light imaging (WLI) and narrow band imaging (NBI), and quantified any discordance between Western and Japanese criteria for the EGJ.MethodsIn 25 BE patients, the presence and location of PV and GF were determined and biopsies were obtained. High-quality images of the EGJ were collected under different conditions (insufflations–desufflation, WLI–NBI, forward-retroflex approach), resulting in eight different images per patient. The presence of PV on each still image was assessed by a panel of six Western and Japanese endoscopists with expertise in BE.ResultsPV were observed inxa0≥xa01 images by a majority of the panel (≥xa04 raters) in 100xa0% of patients during insufflation versus 60xa0% during desufflation (pxa0<xa00.001). WLI and NBI detected PV in 100 and 92xa0%, respectively (pxa0=xa00.50). Interobserver agreement of the panel was ‘moderate’ (κxa0=xa00.51). During endoscopy PV were located a median of 1xa0cm distal of the GF in 15 patients (63xa0%), with intestinal metaplasia (IM) in this discordant zone, in 27xa0% of patients.ConclusionsPV are visible in most Western BE patients and are best inspected during insufflation. The location of the GF and PV differed in a substantial group of patients, partially with IM in this discordant zone.

Endoscopic submucosal dissection of colorectal neoplasia located on the suture line of anastomosis

Although endoscopic submucosal dissection (ESD) can remove gastrointestinal neoplasia even with severe fibrosis into the submucosa, the safety and efficacy of ESD for colorectal neoplasia (CRN) located on the suture line of anastomosis (SLA) has not been assessed. The aim of this study was to evaluate the feasibility of ESD for CRN located on the SLA, performed by a highly skilled endoscopist. Three consecutive patients with CRN located on the SLA were treated with ESD. In all cases, ESD was safely performed without any adverse events. The median tumor size of the resected CRN was 30xa0mm (range 12–75xa0mm) and the median procedure time was 150xa0min (range 50–150xa0min). Curative resection was achieved in two cases without local recurrence during a 12-month observation period. In one case, the CRN were resected in an almost en bloc fashion, but a decision was made to spare the edge of the CRN that was directly on the SLA in order to avoid delayed perforation, and this edge was instead removed with hemostatic forceps. Although the surveillance colonoscopy revealed a small residual neoplasia, it was curatively treated by endoscopically. In all cases, ESD managed to avoid the need for repetitive surgery. This case series suggests the feasibility of ESD performed by a highly skilled endoscopist as a curative treatment for the CRN located on the SLA.