Noboru Kawata

Preoperative indicators of failure of en bloc resection or perforation in colorectal endoscopic submucosal dissection: implications for lesion stratification by technical difficulties during stepwise training.

BACKGROUND AND AIMS The technical difficulties inherent in endoscopic submucosal dissection (ESD) for colorectal neoplasms may result in the failure of en bloc resection or perforation. The aim of this retrospective study was to assess the predictors of en bloc resection failure or perforation by using preoperatively available factors. METHODS Between September 2002 and March 2013, 716 colorectal ESDs in 673 consecutive patients were performed at a tertiary cancer center. Patient characteristics, tumor location, tumor type, colonoscopy-related factors, and endoscopist experience were assessed based on a prospectively recorded institutional ESD database. Logistic regression analysis was performed to identify predictors of failure of en bloc resection or perforations, with subgroup analyses of ESDs performed by endoscopists less experienced in colorectal ESD (<40 cases) and for colonic lesions only. RESULTS On multivariate analysis, independent predictors of failure of en bloc resection or perforations were the presence of fold convergence (odds ratio [OR] 4.4; 95% confidence interval [95% CI], 1.9-9.9), protruding type (OR 3.6; 95% CI, 1.8-7.1), poor endoscope operability (OR 3.5; 95% CI, 1.8-6.9), right-sided colonic lesions (OR 3.0; 95% CI, 1.5-6.3 vs rectal lesions), left-sided colonic lesions (OR 3.2; 95% CI, 1.7-6.3, vs rectal lesions), the presence of an underlying semilunar fold (OR 2.1; 95% CI, 1.3-3.6), and a less-experienced endoscopist (OR 2.1; 95% CI, 1.3-3.6). Among less-experienced endoscopists, colonic lesions were independent predictors (right-sided colonic lesions 8.1; 95% CI, 2.9-25.1; left-sided colonic lesions 8.1; 95% CI, 2.5-28.3 vs rectal lesions). For colonic lesions, the presence of fold convergence (OR 3.7; 95% CI, 1.6-8.6), poor endoscope operability (OR 3.6; 95% CI, 1.8-7.2), a less-experienced endoscopist (OR 3.0; 95% CI, 1.7-1.8), and the presence of an underlying semilunar fold (OR 2.7; 95% CI, 1.5-4.7) were identified predictors. CONCLUSION This study successfully identified predictors of en bloc resection failure or perforation. Understanding these indicators could help to accurately stratify lesions according to technical difficulty and to appropriately select endoscopists.

A Scoring System to Stratify Curability after Endoscopic Submucosal Dissection for Early Gastric Cancer: "eCura system".

Objectives:Although radical surgery is recommended for patients not meeting the curative criteria for endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) because of the potential risk of lymph node metastasis (LNM), this recommendation may be overestimated and excessive. We aimed to establish a simple scoring system for decision making after ESD.Methods:This multicenter retrospective study consisted of two stages. First, the risk-scoring system for LNM was developed using multivariate logistic regression analysis in 1,101 patients who underwent radical surgery after having failed to meet the curative criteria for ESD of EGC. Next, the system was internally validated by survival analysis in another 905 patients who also did not meet the criteria and did not receive additional treatment after ESD.Results:In the development stage, based on accordant regression coefficients, five risk factors for LNM were weighted with point values: three points for lymphatic invasion and 1 point each for tumor size >30 mm, positive vertical margin, venous invasion, and submucosal invasion ≥500 μm. Then, the patients were categorized into three LNM risk groups: low (0–1 point: 2.5% risk), intermediate (2–4 points: 6.7%), and high (5–7 points: 22.7%). In the validation stage, cancer-specific survival differed significantly among these groups (99.6, 96.0, and 90.1%, respectively, at 5 years; P<0.001). The C statistic of the system for cancer-specific mortality was 0.78.Conclusions:This scoring system predicted cancer-specific survival in patients who did not meet the curative criteria after ESD for EGC. ESD without additional treatment may be an acceptable option for patients at low risk.

Endoscopic and biopsy diagnoses of superficial, nonampullary, duodenal adenocarcinomas.

AIM To investigate the accuracy of endoscopic or biopsy diagnoses of superficial nonampullary duodenal epithelial tumors (NADETs). METHODS Clinicopathological data were reviewed for 84 superficial NADETs from 74 patients who underwent surgery or endoscopic resection between September 2002 and August 2014 at a single prefectural cancer center. Superficial NADETs were defined as lesions confined to the mucosa or submucosa. Demographic and clinicopathological data were retrieved from charts, endoscopic and pathologic reports. Endoscopic reports included endoscopic diagnosis, location, gross type, diameter, color, and presence or absence of biopsy. Endoscopic diagnoses were made by an endoscopist in charge of the examination before biopsy specimens were obtained. Endoscopic images were obtained using routine, front-view, high-resolution video endoscopy, and chromoendoscopy with indigocarmine was performed for all lesions. Endoscopic images were reviewed by at least two endoscopists to assess endoscopic findings indicative of carcinoma. Preoperative diagnoses based on endoscopy and biopsy findings were compared with histological diagnoses of resected specimens. Sensitivity, specificity, and accuracy were assessed for endoscopic diagnosis and biopsy diagnosis. RESULTS The majority (81%) of the lesions were located in the second portion of the duodenum. The median lesion diameter was 14.5 mm according to final histology. Surgery was performed for 49 lesions from 39 patients, and 35 lesions from 35 patients were endoscopically resected. Final histology confirmed 65 carcinomas, 15 adenomas, and 3 hyperplasias. A final diagnosis of duodenal carcinoma was made for 91% (52/57) of the lesions diagnosed as carcinoma by endoscopy and 93% (42/45) of the lesions diagnosed as carcinoma by biopsy. The sensitivity, specificity, and accuracy of endoscopic diagnoses were 80%, 72%, and 78%, respectively, whereas those of biopsy diagnoses were 72%, 80%, and 74%, respectively. Preoperative diagnoses of carcinomas were made in 88% (57/65) of the carcinoma lesions via endoscopy or biopsy. Endoscopic findings associated with carcinoma were red color, depression, and mixed-type morphology. CONCLUSION Preoperative endoscopy and biopsy showed similar accuracies in the diagnosis of carcinoma in patients with superficial NADETs.

Percutaneous endoscopic gastrostomy for decompression of malignant bowel obstruction

Previous reports on percutaneous endoscopic gastrostomy (PEG) for bowel decompression have included a relatively small number of patients and the details of post‐procedural outcomes and complications are lacking. The aim of the present study was to evaluate the outcomes and safety of PEG for bowel decompression in a relatively large number of patients with malignant bowel obstruction.

Endoscopic submucosal dissection for early gastric cancer in cases preoperatively contraindicated for endoscopic treatment

Background and study aims Endoscopic submucosal dissection (ESD) is an optimal treatment for early gastric cancer (EGC) with negligible risk of lymph node metastasis; however, ESD is sometimes performed to treat lesions preoperatively contraindicated for the procedure due to various reasons. Here we aim to evaluate the treatment outcomes of ESD for lesions that were preoperatively contraindicated for ESD. Patients and methods Clinicopathological data of 104 EGC lesions in 104 patients were reviewed retrospectively. The demographic characteristics of patients, reasons for ESD, treatment results, complications, and outcomes were assessed. Results The major reasons for undergoing ESD included advanced age, desire to undergo ESD, and the existence of comorbidities. En-bloc and complete resection rates were 97 and 71%, respectively. Perforation and postoperative bleeding rates were 13 and 9%, respectively. Resection was beyond the expanded Japanese criteria for endoscopic treatment of EGC in 87 patients (84%), 41 (47%) of whom underwent additional therapy, including subsequent gastrectomy (29 patients) and photodynamic therapy (12 patients). The median follow-up period was 47 months, during which seven patients died from recurrent disease. The 5-year overall and disease-specific survival rates were 70 and 91.5%, respectively. Conclusions ESD is a technically demanding procedure for lesions preoperatively contraindicated for endoscopic resection. The curative resection rate was low, but the 5-year disease-specific survival rate of 91.5% was favourable. In experienced hands, ESD may be a treatment option for patients not suitable for radical surgery, and the relevant risk of complications must be considered before treatment.

Utility of the over-the-scope-clip system for treating a large esophageal perforation

We report here a case of esophageal perforation made by an endoscope while treating cicatrical stenosis that developed after wide circumferential dissection of superficial esophageal carcinoma. Perforation closure with a conventional endoclip was difficult as the perforation was large and the surrounding tissue was fragile as a result of steroids administration for stenosis prevention. To avoid surgical intervention, we employed the over-the-scope-clip system and successfully closed the perforation. The favorable outcome suggests the utility of the over-the-scope-clip system for closing perforations when conventional methods are ineffective.

Gastric obstruction after endoscopic submucosal dissection.

Background Bleeding and perforation are two major complications of gastric endoscopic submucosal dissection (ESD). There are only a few reports concerning gastric obstruction related to ESD in the stomach. Objective The aim of this study was to clarify the clinicopathological features of patients who experienced gastric obstruction after gastric ESD. Methods Clinicopathological data of 1878 patients who underwent gastric ESD from September 2002 to December 2010 were retrospectively reviewed. Data of lesion location, circumference, circumferential extent of ESD ulcer, specimen diameter, depth of cancer, ulcer findings within the lesion, curability of ESD, number of simultaneous lesions, and occurrence of post-operative bleeding and perforation were collected. The risk of gastric obstruction regarding lesion and procedure related factors were assessed, and treatment for these patients was studied. Results Gastric obstruction was observed in 2.5% of the patients (47/1878). Symptoms occurred in a median of 24 days after ESD. The incidence among patients with lesions in the upper part of the stomach was 4.7% (17/316), 0.36% (3/818) in the middle, and 3.8% (27/699) in the lower part. In relation to the circumferential extent, the incidence was 50% (33/66) among patients with a resection of >75% of the circumference. Stenosis was observed in 87% (41/47) of patients with gastric obstruction. Endoscopic balloon dilation was performed in 45 patients. Perforation due to EBD occurred in four patients; one was referred to surgery. Conclusions Patients with a wide resection of >75% of the circumference should be considered for early repeat endoscopy after ESD, and dilation should be performed with caution if found to have stenosis.

Metastatic malignant melanoma of the gallbladder diagnosed by cytology of endoscopic naso-gallbladder drainage fluid

An 82-year-old man was referred to our institutionfor an examination on his cheek skin pigmentationwhich directly infiltrating to the parotid gland. Thepatient did not complain of any symptoms otherthan the recent increase in size of his skin lesion(Fig. 1a), and his physical condition was good. Hisdisease history was unremarkable, and there was nofamily history of MM. On admission, his blood testrevealed normal hepatic enzymes including lacticdehydrogenase (LDH) and tumor markers such ascarcinoembryonic antigen (CEA) and carbohydrateantigen 19-9 (CA19-9), however, only serum 5-S-cysteinyldopa was abnormally high (18.5 nmol/L

Diagnosis of bile duct cancer by bile cytology: usefulness of post-brushing biliary lavage fluid

Background: Pathologic evidence of biliary diseases can be obtained from cytology in addition to endoscopic retrograde cholangiopancreatography (ERCP); however, the diagnostic effectiveness is not satisfactory. Study aim: This retrospective, single-center study evaluated the efficacy of various sampling methods for the cytologic diagnosis of bile duct cancer. Patients and methods: Biliary samples included bile that was simply aspirated, brush smear, brush-rinsed saline, and post-brushing biliary lavage fluid. A set of samples was compared for cytologic efficacy in 76 patients with surgically proven bile duct cancer and in 50 patients with benign biliary stricture. Results: The cytologic sensitivity for diagnosing biliary cancer was 34 % with aspirated bile, 32 % with brush smear, 43 % with brush-rinsed saline, and 70 % with post-brushing biliary lavage fluid, in contrast to the null false-positive result in the benign cases. The sensitivity of cytology was significantly higher with post-brushing lavage fluid than with the other three sampling methods (P < 0.0001), and post-brushing lavage fluid improved the cumulative sensitivity by 24 % (P = 0.002). The sensitivity of biliary cytology was also associated with the amount of aspirated bile (P = 0.01) and with the aspiration site (P = 0.03). The rate of cancer positivity in a cytology set differed according to the tumor macroscopic type (85 % in the protruding type vs. 40 % in the flat type; P = 0.003), and according to the size of the cancer (87 % for tumors ≥ 50 mm vs. 66 % for tumors < 50 mm; P = 0.02). Conclusions: Post-brushing biliary lavage fluid cytology provides superior diagnostic efficacy, and its addition to ERCP procedures is recommended for obtaining cytologic evidence of bile duct cancer.

Pancreatic cystic lesions with atypical steroid response should be carefully managed in cases of autoimmune pancreatitis

Pancreatic cysts have been reported in cases with autoimmune pancreatitis (AIP) and are often treated by corticosteroid; however, their response to steroid has not been determined fully. We aimed to see the incidence and steroid response of pancreatic cysts and the features of cysts without proper response in cases with AIP.