Shinsuke Kiriyama

Comparison of endoscopic submucosal dissection with laparoscopic-assisted colorectal surgery for early-stage colorectal cancer: a retrospective analysis.

BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD) is increasingly being used to resect early colorectal carcinoma, despite the technical difficulties associated with the procedure. Laparoscopic-assisted colorectal surgery (LAC) is an alternative to open surgery for colorectal cancers, and ESD was recently introduced as another alternative. In this study, we compared ESD with LAC as minimally invasive treatments for early colorectal cancer. PATIENTS AND METHODS The study included 589 patients (297 patients with colorectal intramucosal or slightly submucosal invasive cancers undergoing ESD; 292 patients with T1 colorectal cancers undergoing LAC) who were treated at National Cancer Center Hospital in Tokyo, Japan, between January 1998 and September 2008. The clinical outcomes of ESD and LAC were evaluated retrospectively and compared on the basis of data that were originally collected prospectively. RESULTS In the ESD group, mean tumor size was 37 mm, mean procedure time was 106 minutes, and the en bloc and curative resection rates were 87 % and 80 %, respectively. There were 14 perforations (4.7%) and 5 cases of postprocedure bleeding (1.7%); all complications were successfully managed endoscopically except for one of the perforations, which required emergency surgery. In the LAC group, mean tumor size was 20 mm, mean operation time was 206 minutes, and complications included 31 wound infections, 2 pelvic abscesses, 3 anastomotic leakages, and 1 anastomotic bleed. Stomas were necessary in 93 % of the patients who underwent LAC for rectal cancers located below the peritoneal reflection. CONCLUSIONS ESD was associated with a lower complication rate than LAC, with favorable en bloc and curative resection rates. The safety profile and possibility of curative treatment with colorectal ESD provide advantages for the treatment of early colorectal cancers with nul risk of lymph node metastasis.

Comparing endoscopic submucosal dissection with transanal resection for non-invasive rectal tumor: a retrospective study.

Background and Aim:  Endoscopic submucosal dissection (ESD) is an alternative to transanal resection (TAR) in treating rectal adenomas, intramucosal cancers, and superficial submucosal cancers. The purpose of this study is to compare the clinical efficacy between ESD and TAR for non‐invasive rectal tumors.

Pilot study to assess the safety of local lidocaine injections during endoscopic submucosal dissection for early gastric cancer

BackgroundIn Japan, endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is performed by endoscopists on patients under sedation. There is an increased risk of anesthesia-related complications due to the higher sedative doses required during lengthier ESDs, so we sought to determine whether a local pain control method could safely reduce such doses.MethodsTwenty EGC patients enrolled in this study received local lidocaine injections during ESDs at our hospital (lidocaine group; LG). Electrocardiography, heart rate, oxygen saturation, and blood pressure were monitored during and after the ESDs, along with the doses of midazolam and pentazocine. Pain assessments were recorded for LG patients on the day of their ESDs and the following day.ResultsThe mean volume of lidocaine injection solution was 55.4 ml and the mean dose of lidocaine was 236 mg (range, 100–300 mg). The mean size of the resected specimens was 39.3 mm and mean procedure time was 66.0 min. There were no lidocaine-related complications, and electrocardiography, heart rate, oxygen saturation and blood pressure measurements were normal. In comparison to 157 consecutive patients (control group; CG), who had similar characteristics and had undergone ESDs previously with submucosal injections of conventional normal saline solution, the mean ± SD pentazocine dose of 15.8 ± 10.3 mg in the LG was significantly lower (P < 0.01) than the dose of 23.1 ± 9.5 mg in the CG, and none of the LG patients complained of abdominal pain on the day of their ESDs, whereas such pain was reported by 17% (27/157) of the CG.ConclusionLocal lidocaine injections into the submucosal layer were safe when administered during ESDs performed on EGC patients under sedation.

Ectopic Sebaceous Glands in the Esophagus: Endoscopic Findings over Three Years

Sebaceous glands in the esophagus are rare and are of particular interest because of their as yet unknown origin. We report a case with ectopic sebaceous glands diagnosed by esophageal endoscopy and biopsy, with follow-up endoscopic examinations for 3 years. Few cases with follow-up endoscopic findings have been reported. In our case, there were no significant overall changes during 3 years of follow-up, but the lesions fluctuated over time. While taking the endoscopic findings of the present or past cases into account, we discuss the possible pathogenic mechanisms of this condition.

A Case of Very Well-Differentiated Adenocarcinoma With Carcinoid Tumor in the Ascending Colon

Malignant tumors with mixed glandular and neuroendocrine characteristics with at least 30% of each component are classified as mixed adenoneuroendocrine carcinoma (MANEC) by the World Health Organization 2010 classification. We report here a case of very well-differentiated adenocarcinoma accompanied by carcinoid tumor, categorized as MANEC. A 41-year-old Japanese man was clinically diagnosed with ascending colon cancer and underwent right hemicolectomy. Using an immunohistologic technique, the pathologic diagnosis was very well-differentiated adenocarcinoma accompanied by carcinoid tumor and marked eosinophil infiltration, which was categorized as MANEC. By immunohistochemical analysis, tumor cells of the carcinoid component exhibited very low proliferation activity. Our case was thought to be MANEC without high malignant potential. MANEC as per the World Health Organization 2010 classification seems to include tumors with diverse grades of malignancy, and it might need to have subclassifications according to the malignancy potential of the tumor cells.

Comparison of Narrowband Imaging with Autofluorescence Imaging for Endoscopic Visualization of Superficial Squamous Cell Carcinoma Lesions of the Esophagus

Aim. To compare narrowband imaging (NBI) and autofluorescence imaging (AFI) endoscopic visualization for identifying superficial esophageal squamous cell carcinoma (SCC). Methods. Twenty-four patients with superficial esophageal carcinomas diagnosed at previous hospitals were enrolled in this study. Lesions were initially detected using white-light endoscopy and then observed with both NBI and AFI. Endoscopic images documented each method, and three endoscopists experienced in esophageal imaging retrospectively reviewed respective images of histologically confirmed esophageal SCCs. Images were assessed for quality in identifying superficial SCCs and rated as excellent, fair, or poor by the three reviewers with interobserver agreement calculated using kappa (κ) statistics. Results. Thirty-one lesions histologically confirmed as superficial esophageal SCCs were detected in 24 patients. NBI images of 27 lesions (87%) were rated as excellent, three as fair, and one as poor compared to AFI images of 19 lesions (61%) rated as excellent, 10 as fair and two as poor (P < 0.05). Moderate interobserver agreement (κ = 0.42, 95% CI 0.24–0.60) resulted in NBI while fair agreement (κ = 0.35, 95% CI 0.18–0.51) was achieved using AFI. Conclusion. NBI may be more effective than AFI for visualization of esophageal SCC.

A case of mixed adenoneuroendocrine carcinoma of the stomach with focal intestinal metaplasia and hypergastrinemia.

Among neuroendocrine neoplasms, mixed exocrine and endocrine characteristics with at least 30% of each component are classified into mixed adenoneuroendocrine carcinoma (MANEC), according to the 2010 World Health Organization classification. We experienced a rare case of MANEC of the stomach with focal intestinal metaplasia and hypergastrinemia. A 76-year-old Japanese male was diagnosed as having gastric adenocarcinoma and underwent total gastrectomy. The pathologic diagnosis was MANEC of the stomach accompanied by unusual mucosal atrophy without Helicobacter pylori infection, the characteristics of which were different from both type A and type B atrophic gastritis. The patient has a history of long-term use of a proton pump inhibitor. Additional serum chemistry examination using preoperatively obtained plasma from the patient revealed hypergastrinemia. The mechanism of gastric MANEC carcinogenesis is still unclear, but that might be correlated with unusual intestinal metaplasia and hypergastrinemia in this case.

Propofol sedation during endoscopic treatment for early gastric cancer compared to midazolam

Endoscopic submucosal dissection (ESD) has been proposed as the gold standard in the treatment of early gastric cancer because it facilitates a more accurate histological assessment and reduces the risk of tumor recurrence. However, the time course of ESD for large gastric tumors is frequently prolonged because of the tumor size and technical difficulties and typically requires higher doses of sedative and pain-controlling drugs. Sedative or anesthetic drugs such as midazolam or propofol are used during the procedure. Therapeutic endoscopy of early gastric cancers can often be performed with only moderate sedation. Compared with midazolam, propofol has a very fast onset of action, short plasma half-life and time to achieve sedation, faster time to recovery and discharge, and results in higher patient satisfaction. For overall success, maintaining safety and stability not only during the procedure but also subsequently in the recovery room and ward is necessary. In obese patients, it is recommended that the injected dose be based on a calculated standard weight. Cooperation between gastroenterologists, surgeons, and anesthesiologists is imperative for a successful ESD procedure.

Recurrent, Spontaneous Esophageal Ruptures Associated With Antiphospholipid Antibody Syndrome: Report of a Case

A 52-year-old man was admitted to our hospital with a spontaneous esophageal rupture (Boerhaave syndrome) and was successfully treated. Eight years after the first incident, he was readmitted with a recurrent rupture. Recurrence of Boerhaave syndrome is extremely rare, with only 7 cases reported in the English literature. During treatment, the patient was also diagnosed with antiphospholipid syndrome (APS). Although APS is known to cause a variety of symptoms due to vascular thrombosis, recurrence of Boerhaave syndrome, coincident with APS, has never been reported. The pathogenesis of Boerhaave syndrome has not been clearly determined. This report serves to increase awareness of the risk of APS, which results in an increased risk of spontaneous rupture of the esophagus.

Evaluation of Pharyngeal Function between No Bolus and Bolus Propofol Induced Sedation for Advanced Upper Endoscopy

This study aimed to assess pharyngeal function between no bolus and bolus propofol induced sedation during gastric endoscopic submucosal dissection. A retrospective study was conducted involving consecutive gastric cancer patients. Patients in the no bolus group received a 3 mg/kg/h maintenance dose of propofol after the initiation of sedation without bolus injection. All patients in the bolus group received the same maintenance dose of propofol with bolus 0.5 mg/kg propofol injection. Pharyngeal functions were evaluated endoscopically for the first 5 min following the initial administration of propofol. Fourteen patients received no bolus propofol induction and 13 received bolus propofol induction. Motionless vocal cords were observed in 2 patients (14%) in the no bolus group and 3 (23%) in the bolus group. Trachea cartilage was not observed in the no bolus group but was apparent in 6 patients (46%) in the bolus group (P < 0.01). Scope stimulated pharyngeal reflex was observed in 11 patients (79%) in the no bolus group and in 3 (23%) in the bolus group (P < 0.01). Propofol induced sedation without bolus administration preserves pharyngeal function and may constitute a safer sedation method than with bolus.