Kenta Hamada

Features of electrocoagulation syndrome after endoscopic submucosal dissection for colorectal neoplasm.

Endoscopic submucosal dissection (ESD) is a promising treatment for large gastrointestinal superficial neoplasms, although it is technically difficult, and perforation and delayed bleeding are well‐known adverse events. However, there have been no large studies about electrocoagulation syndrome after colorectal ESD. The aim of this study was to evaluate the incidence and clinical significant risk factors of post‐ESD coagulation syndrome (PECS).

Traction-assisted colonic endoscopic submucosal dissection using clip and line: a feasibility study

Background and study aims: Colonic endoscopic submucosal dissection (ESD) is a challenging procedure because it is often difficult to maintain good visualization of the submucosal layer. To facilitate colonic ESD, we designed a novel traction method, namely traction-assisted colonic ESD using clip and line (TAC), and investigated its feasibility. Patients and methods: We retrospectively analyzed 23 patients with large colonic superficial lesions who had undergone TAC. The main outcome was the procedural success rate of TAC, which we defined as successful, sustained application of clip and line to the lesion until the end of the procedure. Results: The procedural success rate of TAC was 87 % (20/23). In all three unsuccessful cases, the lesions were in the proximal colon and the procedure times over 100 minutes. The overall mean procedure time was 61 min (95 % confidence interval, 18 – 172 min). We achieved en bloc resections of all lesions. There were no perforations or fatal adverse events. Conclusions: TAC is feasible and safe for colonic ESD and may improve the ease of performing this procedure.

Refractory strictures despite steroid injection after esophageal endoscopic resection.

Background: Although steroid injection prevents stricture after esophageal endoscopic submucosal dissection (ESD), some patients require repeated sessions of endoscopic balloon dilation (EBD). We investigated the risk for refractory stricture despite the administration of steroid injections to prevent stricture in patients undergoing esophageal ESD. Refractory stricture was defined as the requirement for more than three sessions of EBD to resolve the stricture. In addition, the safety of steroid injections was assessed based on the rate of complications. Patients and methods: We analyzed data from 127 consecutive patients who underwent esophageal ESD and had mucosal defects with a circumferential extent greater than three-quarters of the esophagus. To prevent stricture, steroid injection was performed. EBD was performed whenever a patient had symptoms of dysphagia. Results: The percentage of patients with a tumor circumferential extent greater than 75 % was significantly higher in those with refractory stricture than in those without stricture (P = 0.001). Multivariate analysis adjusted for age, sex, history of radiation therapy, tumor location, and tumor diameter showed that a tumor circumferential extent greater than 75 % was an independent risk factor for refractory stricture (adjusted odds ratio [OR] 5.49 [95 %CI 1.91 – 15.84], P = 0.002). Major adverse events occurred in 3 patients (2.4 %): perforation during EBD in 2 patients and delayed perforation after EBD in 1 patient. The patient with delayed perforation underwent esophagectomy because of mediastinitis. Conclusions: A tumor circumferential extent greater than 75 % is an independent risk factor for refractory stricture despite steroid injections. The development of more extensive interventions is warranted to prevent refractory stricture.

A Randomized Trial of Monopolar Soft-mode Coagulation Versus Heater Probe Thermocoagulation for Peptic Ulcer Bleeding.

Background and Aim: Endoscopic therapy has been demonstrated to be effective in achieving hemostasis for bleeding peptic ulcers. Thermal coagulation is one of the most commonly used methods, with a high success rate. Recently, endoscopic submucosal dissection for early gastric carcinoma was developed and hemostasis with soft coagulation using hemostatic forceps was introduced. The aim of this study was to compare the hemostatic efficacy of soft coagulation with heater probe thermocoagulation for peptic ulcer bleeding. Methods: Patients who visited our hospital with hematemesis or melena underwent emergency endoscopy. Inclusion criteria were presentation with an actively bleeding ulcer, a nonbleeding visible vessel, or an adherent clot. Patients were excluded if they were unwilling to give written informed consent or had a bleeding gastric malignancy. Patients were randomized to receive endoscopic hemostasis with soft coagulation (Group S) or heater probe thermocoagulation (Group H). The primary endpoint was the primary hemostasis rate and secondary endpoints were rebleeding rate, complications, and the procedure time. Results: Between May 2010 and February 2012, a total of 111 patients (89 gastric ulcers and 22 duodenal ulcers) were enrolled. Primary hemostasis was achieved in 54 patients (96%) in Group S and 37 (67%) in Group H (P<0.0001). Rebleeding occurred in 7 patients in Group H and none in Group S. Of these 7 patients, urgent surgery was performed in 1. Perforation occurred in 2 patients in Group H, which was managed conservatively. Conclusions: For patients with gastroduodenal ulcer bleeding, soft coagulation using monopolar hemostatic forceps is more effective than heater probe thermocoagulation for achieving hemostasis.

Underwater endoscopic mucosal resection for superficial nonampullary duodenal adenomas

BACKGROUND AND STUDY AIM Underwater endoscopic mucosal resection (UEMR) was recently developed in a Western country. A prospective cohort study to investigate the effectiveness of UEMR was conducted in patients with small superficial nonampullary duodenal adenomas. PATIENTS AND METHODS Patients with duodenal adenomas ≤ 20 mm were enrolled. After the duodenal lumen had been filled with physiological saline, UEMR was performed without submucosal injection. Endoclip closure was attempted for all mucosal defects after UEMR. Follow-up endoscopy with biopsy was performed 3 months later. The primary end point was the complete resection rate, defined as neither endoscopic nor histological residue of adenoma at the follow-up endoscopy. RESULTS 30 patients with 31 lesions were enrolled. The mean (SD) tumor size was 12.0 mm (7.3). The complete resection rate was 97 % (90 % confidence interval, 87 % - 99 %). The en bloc resection rate was 87 %. All mucosal defects were successfully closed by endoclips. No adverse events occurred except for one case of mild aspiration pneumonia. CONCLUSIONS UEMR is efficacious for the treatment of small duodenal adenomas, but further large-scale trials are warranted to confirm these results.

Feasibility of Cold Snare Polypectomy for Multiple Duodenal Adenomas in Patients with Familial Adenomatous Polyposis: A Pilot Study

Although the prognosis for patients with familial adenomatous polyposis (FAP) has improved because of preventive proctocolectomy, duodenal adenomas occur in up to 90 % of these patients [1]. The risk of developing duodenal cancer in patients with Spigelman stage IV disease (Table 1) is high at 7–36 % over follow-up periods of 7.6–10 years, compared with in patients with Spigelman stage 0–III disease, at 0.7 % over a similar period [2]. Duodenal, rather than colorectal, cancer is now the main cause of death in patients with FAP after preventive proctocolectomy [1]. Therefore, preventive duodenectomy is recommended for patients with Spigelman stage IV disease; however, duodenectomy is invasive and carries a high mortality risk [3]. As an alternative, endoscopic treatment for duodenal adenomas is theoretically effective in preventing duodenal cancer mortality in patients with FAP; however, while endoscopic treatment for duodenal lesions is less invasive than duodenectomy, it carries a greater risk of complications such as bleeding or perforation [4, 5]. Cold snare polypectomy (CSP) for small colorectal polyps is safer than conventional hot snare polypectomy, and CSP is as effective as hot snare polypectomy [6, 7]. Cold snare piecemeal resection is also safe for large duodenal polyps [8]. Therefore, we hypothesized that CSP is also safe for small multiple duodenal adenomas in patients with FAP, and retrospectively assessed the feasibility of CSP for small multiple duodenal adenomas. Electronic supplementary material The online version of this article (doi:10.1007/s10620-016-4165-7) contains supplementary material, which is available to authorized users.

Efficacy and Safety of Endoscopic Resection Followed by Chemoradiotherapy for Superficial Esophageal Squamous Cell Carcinoma: A Retrospective Study.

OBJECTIVES: The reported 1‐ and 3‐year overall survival rates after esophagectomy for stage I superficial esophageal squamous cell carcinoma (SESCC) are 95–97% and 86%, and those after definitive chemoradiotherapy (CRT) are 98% and 89%, respectively. This study was performed to elucidate the efficacy and safety of another treatment option for SESCC: endoscopic resection (ER) followed by CRT. METHODS: We retrospectively reviewed the overall survival, recurrence, and grade ≥3 adverse events of consecutive patients who refused esophagectomy and underwent ER followed by CRT for SESCC from 1 January 2006 to 31 December 2012. RESULTS: In total, 66 patients with SESCC underwent ER followed by CRT during the study period, and complete follow‐up data were available for all patients. The median age was 67 (range, 45–82) years, and the median observation period was 51 (range, 7–103) months. Local and metastatic recurrences occurred in 2 (3%) and 6 (9%) patients, respectively, and 17 (26%) patients died. The 1‐, 3‐, and 5‐year overall survival rates were 98%, 87%, and 75%, respectively. One of the 23 patients with mucosal cancer and 5 of 43 with submucosal cancer developed metastatic recurrences (P=0.65). Five of the 61 patients with negative vertical resection margin and 1 of 5 with positive vertical resection margin developed metastatic recurrences (P=0.39). None of the 30 patients without lymphovascular involvement developed metastatic recurrences; however, 6 of 36 patients with lymphovascular involvement developed metastatic recurrences (P=0.0098). Grade ≥3 adverse events occurred in 21 (32%) patients and all adverse events were associated with CRT, hematological adverse events in 13 (20%), and non‐hematological adverse events in 9 (14%). CONCLUSIONS: ER followed by CRT provides survival comparable with that of esophagectomy or definitive CRT and has a low local recurrence rate. A particularly favorable outcome is expected for cancers without lymphovascular involvement.

Erratum: Dive to the Underwater World: A Water Immersion Technique for Endoscopic Submucosal Dissection of Gastric Neoplasms

This corrects the article DOI: 10.1038/ajg.2016.595

Pethidine hydrochloride is a better sedation method for pharyngeal observation by transoral endoscopy compared with no sedation and midazolam.

Standard surveillance methods for pharyngeal cancer have not been established. We conducted a randomized controlled trial to investigate the best sedation method for pharyngeal observation using transoral endoscopy.

Endoscopic surveillance of head and neck cancer in patients with esophageal squamous cell carcinoma.

Background and study aims: Multiple squamous cell carcinomas (SCCs) frequently arise in the upper aerodigestive tract, referred to as the field cancerization phenomenon. The aim of this study was to elucidate the detailed clinical features of second primary head and neck (H&N) SCCs arising in patients with esophageal SCC. Patients and methods: A total of 818 patients underwent endoscopic resection for superficial esophageal cancer between January 2006 and December 2013. Of these, 439 patients met our inclusion criteria, and we retrospectively investigated the incidence, primary sites, and stages of second primary H&N SCCs in these patients. Results: A total of 53 metachronous H&N SCCs developed in 40 patients after a median follow-up period of 46 months (range 9 – 109). The cumulative incidence rates of metachronous H&N SCCs at 3, 5, and 7 years were 5.3 %, 9.7 %, and 17.2 %, respectively. These lesions were frequently located at pyriform sinus or in the posterior wall of the pharynx (70 %, 37/53 lesions). Most of the lesions were detected at an early stage, though 4 lesions were associated with lymph node metastasis when their primary sites were detected (1 postcricoid area, 2 posterior wall of hypopharynx, and 1 lateral wall of oropharynx). Conclusions: Patients with esophageal SCC should undergo careful inspection of the pyriform sinus and posterior wall of the pharynx for detection of H&N SCCs. Methods to open the hypopharyngeal space, such as the Valsalva maneuver, should be included in the surveillance program.