Norifumi Numata

Endoscopic submucosal dissection for residual early gastric cancer after endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) has become a standard treatment for early gastric cancer (EGC). 1-12 ESD involves circumferential mucosal incision and direct submucosal dissection, making it possible to resect en bloc even large tumors with endoscopically clear margins in any part of the stomach. The reported incomplete ESD resection rate is 7.4% to 26.3%, 1,2,13-19 and the reported local recurrence rate after ESD is 0% to 3%. 1,18-20 Incomplete resection leading to recurrent cancer in the stomach therefore continues to be problematic. Additional treatment is necessary in patients with incompletely resected lesions. We have reported ESD for residual/local recurrent EGC after EMR to be a safe, minimally invasive, effective procedure. 21 There are few published reports on the treatment of local recurrences of EGC after ESD, and it is difficult to carry out a second ESD because of scar formation resulting from the initial ESD. Between June 2005 and August 2012, we performed a second ESD in 12 patients with residual EGC lesions after having been treated with ESD, and we conducted a retrospective evaluation of the safety and efficacy of this method of treatment.

Carbon dioxide insufflation is useful for obtaining clear images of the bile duct during peroral cholangioscopy (with video)

BACKGROUND Peroral cholangioscopy (POCS) is useful for the diagnosis of various bile duct lesions. However, it is often difficult to obtain clear images because of bile or biliary sludge in the bile duct, even after vigorous irrigation of the bile duct with saline solution. Therefore, this study investigated whether inflation with carbon dioxide (CO(2)) yields clearer images of the bile duct than conventional saline solution irrigation during POCS. OBJECTIVE To evaluate the clinical utility and safety of CO(2) insufflation into the bile duct to obtain clear images in POCS observations by comparing this method with conventional saline solution irrigation. SETTING A single center. DESIGN Case-control study. PATIENTS Nineteen patients with suspected biliary diseases. INTERVENTIONS CO(2) insufflation into the bile duct during POCS. MAIN OUTCOME MEASUREMENTS The quality and safety of this method. RESULT The quality of the images of the bile duct lumen with CO(2) insufflation (10 patients) was significantly superior to those with saline solution irrigation (9 patients) in both clarity (P < .05) and color (P < .05). In particular, extremely clear images could be obtained from the middle part of common bile duct to the right and left hepatic duct. No serious POCS-related complications occurred. There was no significant change in the venous partial pressure of the CO(2) level during the procedure. LIMITATIONS The number of patients examined was small. CONCLUSIONS CO(2) insufflation is useful for obtaining clear images of the bile duct during POCS, which makes it possible to determine the qualitative diagnosis and the extent of various bile duct lesions.

Clinical outcomes of endoscopic submucosal dissection for early gastric cancer in patients with chronic kidney disease

Endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric cancer (EGC), and the number of ESD performed for EGC in patients with chronic kidney disease (CKD) is increasing. Although patients undergoing hemodialysis tend to bleed and are at high risk for cardiovascular disease, the effectiveness and safety of ESD for EGC in patients with CKD in particular have not been established. The aim of this study was to evaluate the effectiveness and potential adverse effects of ESD for EGC in patients with CKD undergoing hemodialysis.

Characteristics of Metachronous Gastric Tumors after Endoscopic Submucosal Dissection for Gastric Intraepithelial Neoplasms

Background. Recently, endoscopic submucosal dissection (ESD) has become a standard treatment method for early gastric cancer and concurrent stomach preservation. However, metachronous recurrences have become a major problem. We evaluated the incidence and clinicopathologic features of and examined the risk factors for metachronous gastric tumors. Methods. A total of 357 patients who underwent ESD for gastric tumors (245 early gastric cancers and 112 adenomas) and were followed up for more than 12 months without recurrence within the first 12 months were enrolled. We investigated the incidence and clinicopathologic features of metachronous tumors after ESD. We also analyzed the potential risk factors for metachronous tumors using the Kaplan-Meier method and Coxs proportional hazards model. Results. The annual incidence of metachronous tumors after ESD was 2.4%. The median period until discovery after initial ESD was 26.0 months, and the median observation period was 52.6 months. Male patients developed metachronous tumors more frequently (P = 0.04), and the hazard ratio of female to male patients was 0.36 (95% confidence interval: 0.11–0.89). Conclusions. Patients with a previous history of gastric tumors have a high risk of subsequent gastric tumor development and male patients should be carefully followed up after ESD for gastric tumor.