Shun Ishiyama

Treatment of Internal Hemorrhoids by Endoscopic Sclerotherapy with Aluminum Potassium Sulfate and Tannic Acid

Objective. A new sclerosing agent for hemorrhoids, aluminum potassium sulfate and tannic acid (ALTA), is attracting attention as a curative treatment for internal hemorrhoids without resection. The outcome and safety of ALTA sclerotherapy using an endoscope were investigated in the present study. Materials and Methods. Subjects comprised 83 internal hemorrhoid patients (61 males and 22 females). An endoscope was inserted and retroflexed in the rectum, and a 1st-step injection was applied to the upper parts of the hemorrhoids. The retroflexed scope was returned to the normal position, and 2nd–4th-step injections were applied to the middle and lower parts of the hemorrhoids under direct vision. The effects of endoscopic ALTA sclerotherapy were determined by evaluating the condition of the hemorrhoids using an anoscope and interviewing the patient 28 days after the treatment. Results. A cure, improvement, and failure were observed in 54 (65.1%), 27 (32.5%), and 2 (2.4%) patients, respectively, treated with ALTA. Complications developed in 4 patients (mild fever in 3 and hematuria in 1). Recurrence occurred in 9.6%. Conclusions. The results of the present study suggest that endoscopic ALTA has the potential to become a useful and minimally invasive approach for ALTA sclerotherapy.

Clinical pathway to discharge 3 days after colorectal endoscopic submucosal dissection

Colorectal endoscopic submucosal dissection (ESD) is a useful treatment method; however, no index has been established for time for patient to start food ingestion or be discharged after ESD. We investigated the potential of a clinical pathway in which patients started food ingestion on day 2 after ESD and were discharged on day 3.

A case of clear cell adenocarcinoma arising from endometriosis of the rectum treated by laparoscopic surgery.

Highlights • Clear cell adenocarcinoma arising from endometriosis is very rare.• Preoperative diagnosis of the malignant transformation in endometriosis is very difficult.• The patient was undergone low anterior resection under the diagnosis of rectal carcinoma.• Sampsons criteria are useful for diagnosis of the malignant transformation in endometriosis.• The prognosis of malignant transformation in endometriosis is poor.

Massive melena caused by a carcinoid of the small intestine: report of a case.

We report a case of massive melena caused by a carcinoid of the small intestine. A 28-year-old woman was admitted to our department after presenting with massive melena. The source of the bleeding could not be localized by upper or lower gastrointestinal endoscopy, computed tomography (CT), or labeled red blood cell scintigraphy. Enteroscopy allowed visualization only up to the jejunum, and we could not localize the lesion. The melena subsided with conservative treatment, but the patient was readmitted 4 months later when she suffered another episode of massive melena. A contrast CT scan performed immediately showed extravascular leakage and the retention of contrast medium in the ileum. Thus, she underwent an emergency surgery, during which endoscopy confirmed a small ileal tumor accompanied by pulsating bleeding from the exposed blood vessels at its center. The small intestine was partially resected, including the swollen lymph nodes, the size of small beans. Pathological examination confirmed a carcinoid tumor 1 cm in diameter, with an arterial rupture at its center and lymph node metastasis.

Impact of chromosome 17q deletion in the primary lesion of colorectal cancer on liver metastasis

Colorectal cancer is a prevalent malignancy worldwide, and investigations are required to elucidate the underlying carcinogenic mechanisms. Amongst these mechanisms, de novo carcinogenesis and the adenoma to carcinoma sequence, are the most understood. Metastasis of colorectal cancer to the liver often results in fatality, therefore, it is important for any associated risk factors to be identified. Regarding the treatment of the disease, it is important to manage not only the primary colorectal tumor, but also the liver metastases. Previously, through gene variation analysis, chromosomal loss has been indicated to serve an important role in liver metastasis. Such analysis may aid in the prediction of liver metastasis risk, alongside individual responses to treatment, thus improving the management of colorectal cancer. In the present study, we aimed to clarify a cause of the liver metastasis of colorectal cancer using comparative genomic hybridization analysis. A total of 116 frozen samples were analyzed from patients with advanced colorectal cancer that underwent surgery from 2004 to 2011. The present study analyzed mutations within tumor suppressor genes non-metastatic gene 23 (NM23), deleted in colorectal carcinoma (DCC) and deleted in pancreatic carcinoma, locus 4 (DPC4), which are located on chromosomes 17 and 18 and have all been reported to affect liver metastasis of colorectal cancer. The association between chromosomal abnormalities (duplication and deletion) and liver metastasis of colorectal cancer was evaluated using comparative genomic hybridization. Cluster analysis indicated that the group of patients lacking the long arm of chromosome 17 demonstrated the highest rate of liver metastasis. No significant association was observed between the frequency of liver metastases for synchronous and heterochronous colorectal cancer cases and gene variation (P=0.206). However, when these liver metastasis cases were divided into the synchronous and heterochronous types, the ratio of each was significantly different between gene variation groups, classified by the existence of the 17q deletion (P=0.023). These results indicate that the deletion of 17q may act as a predictive marker of liver metastasis in postoperative states.

Successful Retrieval of a Retained Capsule Endoscope with Single Incision Laparoscopic Surgery

Capsule endoscopy (CE) is commonly used for examining and diagnosing gastrointestinal disease, especially small bowel disease. Capsule retention is a well-known and significant complication of CE and requires surgical or endoscopic removal. Most reports described the retrieval of retained CE via laparotomy. We report a case of successful retrieval of the capsule using single incision laparoscopic surgery.

Investigation of free cancer cells in peripheral blood using CEA mRNA expression in perioperative colorectal cancer patients

The aim of this study was to evaluate the impact of laparoscopic surgery (Lap) on circulating free tumor cells in colorectal cancer patients. In this study, we selected carcinoembryonic antigen (CEA) mRNA expression in peripheral blood as the marker of the circulating tumor cells and compared this marker between Lap and open colectomy (OC), to investigate differences due to surgical approach. A total of 50 patients underwent curative surgery for solitary colorectal cancer at our department, between June, 2008 and February, 2011. The patients were divided into OC and Lap groups (25 patients each). Total RNA was extracted subsequent to peripheral blood collection prior to surgery, immediately following surgery and 1, 3 and 7 days after surgery. CEA mRNA was detected with reverse transcription polymerase chain reaction (RT-PCR) and the association between peripheral blood CEA mRNA-positive rate, surgical findings and clinicopathological characteristics was investigated. The peripheral blood CEA mRNA-positive rate was significantly increased immediately after surgery, compared to the preoperative rate (P=0.001), but decreased over time. No significant differences were observed at any blood-sampling time point after postoperative day 1. The positive rate was significantly increased in the OC group immediately after surgery, compared to the preoperative rate (P=0.004). However, there were no significant differences between the rates prior to and immediately after surgery in the Lap group. The patients were then divided into those who were peripheral blood CEA mRNA-positive and -negative after surgery (postoperative positive and negative groups, respectively) and the clinicopathological characteristics were compared. Significant differences were identified between the groups in lower rectal cancer patients and patients with a large intraoperative blood loss (P=0.001 and P=0.01, respectively). In conclusion, in colorectal cancer patients, there were no significant differences in the perioperative peripheral blood CEA mRNA-positive rate or its short-term changes between patients undergoing OC and Lap surgery. It was suggested that Lap is equivalent to OC with regard to free cancer cells.

Ascending Colon Cancer Associated with Dermatomyositis Which Was Cured after Colon Resection

A 76-year-old woman with muscle ache, weakness of the extremities, and skin rash was diagnosed with dermatomyositis (DM). Upon the diagnosis of DM, a systemic survey of malignancy revealed an advanced carcinoma of the ascending colon. The patient underwent right hemicolectomy approximately 2 months after the onset of DM. The symptoms and signs of DM disappeared after the surgery without additional therapy. DM is an idiopathic systemic inflammatory disease characterized by muscle ache, muscle weakness, and skin rash. In some cases, DM develops as paraneoplastic syndrome, and it is assumed that 30% of DM patients have cancer. Symptoms and signs of DM can be attenuated by treatment of the malignancy, and they reappear if the malignancy recurs. It is essential to perform a systemic survey of malignancy in DM patients, and treatment of the malignancy has to precede treatment of DM.

Combined laparoscopic abdominoperineal resection and robotic-assisted prostatectomy for synchronous double cancer of the rectum and the prostate.

Here we report a combined laparoscopic abdominoperineal resection and robotic‐assisted prostatectomy. A 74‐year‐old man was diagnosed with T4b low rectal and prostate cancer. The operation was performed after neoadjuvant chemotherapy for the rectal cancer. The procedure used eight ports in total, five for laparoscopic abdominoperineal resection and six for robotic‐assisted prostatectomy. First, laparoscopic total mesorectal excision including division of the inferior mesenteric artery was performed, and then, robotic dissection of the prostate was performed. The en bloc specimen was removed through the perineal wound. Then, robotic urethrovesical anastomosis was performed. An extraperitoneal end colostomy was created to finish the operation. The operating time was 545 min, and blood loss was 170 mL. The postoperative course was uneventful, and the patient discharged on postoperative day 17. The combined laparoscopic abdominoperineal resection and robotic‐assisted prostatectomy were performed safely without any additional technical difficulty, as both procedures shared port settings and patient positions.

Complete Endoscopic Submucosal Dissection of a Giant Rectal Villous Adenocarcinoma with Electrolyte Depletion Syndrome

An 81-year-old female consulted a local physician due to diarrhea. Since general fatigue and body weight loss were observed, she was admitted for detailed examination and treatment. Colonoscopy revealed a circumferential giant tumor with a maximum diameter of 10 cm in the rectum, and biopsy findings indicated villous adenoma. The tumor secreted a large amount of mucus, and a diagnosis of electrolyte depletion syndrome causing electrolyte disorders was made. We performed endoscopic submucosal dissection (ESD) as a less invasive procedure. The tumor was so big that the procedure had to be completed in two separate steps and it took 1,381 min in total. The tumor was histologically diagnosed as well-differentiated adenocarcinoma in high-grade adenoma located in the lower to upper rectum, invading into the mucosa without lymphatic or venous invasion. The stump of the resected specimen was negative for adenocarcinoma, however the horizontal stump was positive for adenoma. We administered steroid suppositories to prevent stenosis. After ESD, general fatigue and diarrhea disappeared and electrolyte disorders resolved. The patient had good clinical outcome without recurrence or stenosis.