Naoyuki Uragami

Hemoclipping for postpolypectomy and postbiopsy colonic bleeding

BACKGROUND Obtaining colonoscopic biopsies and polypectomy can result in hemorrhage. The most effective management of this complication has not been determined. The objective of this study was to evaluate the endoscopic hemoclip in postprocedural colonic bleeding. METHODS Among 9555 consecutive colonoscopies, cases of postprocedural colonic bleeding (postpolypectomy and postbiopsy) requiring treatment were retrospectively reviewed. Endoscopic hemoclipping was initially attempted in each case; the rate of hemostasis after hemoclipping, use of additional hemostatic methods, and clinical outcome (need for transfusion/hospitalization) were analyzed. RESULTS There were 72 cases of bleeding in which treatment was required (45 immediate postpolypectomy, 18 delayed postpolypectomy and 9 postbiopsy). Endoscopic hemostasis was achieved in all cases of immediate postpolypectomy and postbiopsy bleeding and in all but one of the cases with delayed postpolypectomy bleeding. A detachable snare was used in addition to hemoclips in 3 cases of delayed postpolypectomy bleeding. There were no episodes of recurrent bleeding, deaths or need for surgery related to bleeding. CONCLUSION Early endoscopic management of postprocedural bleeding by hemoclipping provides hemostasis in the great majority of cases.

Treatment strategy for rectal carcinoids: a clinicopathological analysis of 229 cases at a single cancer institution.

Background and Aim:  A treatment strategy for tumors with only venous invasion and characteristics of small rectal carcinoids with metastasis have not been clearly documented. The present study aims to determine the risk factors for lymph node metastasis and to elucidate characteristics of small tumors with metastasis.

Risk factors for bleeding after endoscopic submucosal dissection of colorectal neoplasms

AIM To investigate the risk factors for delayed bleeding following endoscopic submucosal dissection (ESD) treatment for colorectal neoplasms. METHODS We retrospectively reviewed the medical records of 317 consecutive patients with 325 lesions who underwent ESD for superficial colorectal neoplasms at our hospital from January 2009 to June 2013. Delayed post-ESD bleeding was defined as bleeding that resulted in overt hematochezia 6 h to 30 d after ESD and the observation of bleeding spots as confirmed by repeat colonoscopy or a required blood transfusion. We analyzed the relationship between risk factors for delayed bleeding following ESD and the following factors using univariate and multivariate analyses: age, gender, presence of comorbidities, use of antithrombotic drugs, use of intravenous heparin, resected specimen size, lesion size, lesion location, lesion morphology, lesion histology, the device used, procedure time, and the presence of significant bleeding during ESD. RESULTS Delayed post-ESD bleeding was found in 14 lesions from 14 patients (4.3% of all specimens, 4.4% patients). Patients with episodes of delayed post-ESD bleeding had a mean hemoglobin decrease of 2.35 g/dL. All episodes were treated successfully using endoscopic hemostatic clips. Emergency surgery was not required in any of the cases. Blood transfusion was needed in 1 patient (0.3%). Univariate analysis revealed that lesions located in the cecum (P = 0.012) and the presence of significant bleeding during ESD (P = 0.024) were significantly associated with delayed post-ESD bleeding. The risk of delayed bleeding was higher for larger lesion sizes, but this trend was not statistically significant. Multivariate analysis revealed that lesions located in the cecum (OR = 7.26, 95%CI: 1.99-26.55, P = 0.003) and the presence of significant bleeding during ESD (OR = 16.41, 95%CI: 2.60-103.68, P = 0.003) were independent risk factors for delayed post-ESD bleeding. CONCLUSION Location in the cecum and significant bleeding during ESD predispose patients to delayed post-procedural bleeding. Therefore, careful and additional management is recommended for these patients.

COMPARISON OF THE DIAGNOSTIC UTILITY OF THE ULTRATHIN ENDOSCOPE AND THE CONVENTIONAL ENDOSCOPE IN EARLY GASTRIC CANCER SCREENING

Currently, transnasal esophagogastroduodenoscopy using an ultrathin endoscope is being widely carried out as a screening test for early gastric cancer. We compared the diagnostic utility of ultrathin esophagogastroduodenoscopy with that of conventional esophagogastroduodenoscopy in detecting 42 lesions of early gastric cancer that had a diameter of ≤20 mm. Only 27 lesions (64%) could be accurately diagnosed using ultrathin esophagogastroduodenoscopy. In nine lesions (22%), we failed to discern whether they were malignant. Six lesions (14%) could not even be detected. We found that the diagnostic utility of ultrathin esophagogastroduodenoscopy was inadequate, especially in the case of lesions that were located in the upper third region of the stomach and variegated lesions. In conclusion, the diagnostic utility of ultrathin esophagogastroduodenoscopy might be lower than that of conventional esophagogastroduodenoscopy in terms of screening for early gastric cancer. The disadvantages of ultrathin esophagogastroduodenoscopy should be taken carefully into consideration while examining lesions.

Endoscopic Diagnosis of Anal Canal Cancer

肛門管癌は，体表に近いにもかかわらず進行癌で発見されるものが多い．その理由は，羞恥心から来院が遅れること，確定診断が遅れることなどが主な原因と考えられる．頻度はそれほど高くはないが，過去3年間に当院で経験した直腸癌380例中肛門管癌は12例(3.2%）で，進行癌が8例，早期癌4例であった．内視鏡診断は，肛門部を注意して観察することで早期診断可能であるが，反転観察が重要である．通常の観察では肛門管は接線方向の観察になり病変部の正面視は不可能である．反転しスコープ軸を回転させることで肛門管の観察は可能となる．さらに，色素撒布と拡大観察を加える腫瘍ピットを観察することで腺癌の診断が可能となる．さらに，NBIを用いた拡大観察を行うことで扁平上皮癌の診断が可能である．すなわち，食道のdysplasiaや癌でみられるものと同様の血管パターンが観察されることから診断可能である．