Takanori Shimizu

Endoscopic submucosal dissection for small submucosal tumors of the rectum compared with endoscopic submucosal resection with a ligation device

AIM To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for small rectal submucosal tumors (SMTs). METHODS Between August 2008 and March 2016, 39 patients were treated with endoscopic submucosal resection with a ligation device (ESMR-L) (n = 21) or ESD (n = 18) for small rectal SMTs in this study. Twenty-five lesions were confirmed by histological evaluation of endoscopic biopsy prior to the procedure, and 14 lesions were not evaluated by endoscopic biopsy. The results for the ESMR-L group and the ESD group were retrospectively compared, including baseline characteristics and therapeutic outcomes. RESULTS The rate of en bloc resection was 100% in both groups. Although the rate of complete endoscopic resection was higher in the ESD group than in the ESMR-L group (100% vs 95.2%), there were no significant differences between the two groups (P = 0.462). In one patient in the ESMR-L group with a previously biopsied tumor, histological complete resection with a vertical margin involvement of carcinoid tumor could not be achieved, whereas there was no incomplete resection in the ESD group. The mean length of the procedure was significantly greater in the ESD group than in the ESMR-L group (14.7 ± 6.4 min vs 5.4 ± 1.7 min, P < 0.05). The mean period of the hospitalization was also significantly longer in the ESD group than in the ESMR-L group (3.7 ± 0.9 d vs 2.8 ± 1.5 d, P < 0.05). Postoperative bleeding was occurred in one patient in the ESMR-L group. CONCLUSION Both ESMR-L and ESD were effective for treatment of small rectal SMTs. ESMR-L was simpler to perform than ESD and took less time.

Endoscopic submucosal dissection for early gastric cancer without interruption of warfarin and aspirin

Many guidelines for the management of antithrombotic therapy in endoscopic procedures state that warfarin should be replaced by heparin in high risk endoscopic procedures. However, heparin bridging therapy is costly, requires a long hospital stay, and is indicated as a risk factor for bleeding after endoscopic submucosal dissection (ESD). It is not yet clear whether it is better to perform gastric ESD on continuous warfarin therapy or heparin bridging therapy. We report the case of a 65-year-old Japanese man who had been diagnosed with early gastric cancer. He had a past medical history of metallic valve replacement for mitral valve regurgitation, coronary artery disease with bare metal stent, and coronary artery bypass graft. Warfarin and low dose aspirin had been used to prevent thromboembolic events in the metallic mitral valve and coronary artery stent. We performed gastric ESD safely on continuous warfarin and low dose aspirin without any complications.

Ligation-assisted endoscopic submucosal resection with circumferential mucosal incision for duodenal carcinoid tumor.

Here we present the case of a 64-year-old female with a duodenal carcinoid tumor treated by ligation-assisted endoscopic submucosal resection (ESMR-L) with circumferential mucosal incision (CMI). Band ligation was effective in resecting the duodenal carcinoid tumor after CMI, with an uneventful post-procedural course. Histopathological examination showed clear tumor margins at deeper tissue levels. Thus, in the present case, ESMR-L with CMI was useful for the treatment of duodenal carcinoid tumor.

Continuous use of low-dose warfarin for gastric endoscopic submucosal dissection: a prospective study

Background and study aimsu2002Patients who receive warfarin usually require heparin bridge therapy (HBT) to prevent thromboembolic events during endoscopic submucosal dissection (ESD); however, clinical evidence demonstrating the safety and efficacy of HBT during gastric ESD is limited. Conversely, warfarin can be continuously used as a substitute for HBT to endoscopic procedures which have a low risk of bleeding. This study aimed to clarify the safety and efficacy of continuous low-dose warfarin (LDW) for gastric ESD. Patients and methodsu2002This was a prospective observational study at a single institution. A total of 22 patients who received warfarin between December 2014 and January 2016 were enrolled. The patients were treated with gastric ESD with a low dose of warfarin (u200a≤u200a4u200amg) at approximately 1.6u200a–u200a2.6 of the international normalized ratio (INR) levels. Furthermore, we analyzed a total of 23 patients with HBT who underwent gastric ESD between January 2011 and November 2014. Resultsu2002The average of warfarin dose and the INR level on the day of gastric ESD in the continuous LDW group were 2.3u200amg/day (range 0.5u200a–u200a4.0) and 1.87 (range 1.41u200a–u200a2.75), respectively. Two of the 22 patients (9.1u200a%) in the continuous LDW group and 5 of the 23 patients (21.7u200a%) in the HBT group had postoperative bleeding after gastric ESD. Although the postoperative bleeding rate in the continuous LDW group was lower than that in the HBT group, no significant difference was observed between the 2 groups (Pu200a=u200a0.414). Conclusionsu2002Gastric ESD with continuous LDW as a substitute for HBT was feasible and may be acceptable.

Clinical impact of prophylactic clip closure of mucosal defects after colorectal endoscopic submucosal dissection

Background and study aims u2002Endoscopic submucosal dissection (ESD) is useful for en bloc resection of superficial colorectal neoplasms to ensure accurate histologic diagnoses. However, colorectal ESD is associated with a high frequency of adverse events (AEs). We aimed to investigate the effectiveness of prophylactic clip closure (PCC) of mucosal defects for AEs after colorectal ESD. Patients and methods u2002This study included 197 patients with 211 lesions who underwent colorectal ESD between June 2010 and August 2016.u200aPatients who had delayed perforation, delayed bleeding, abdominal pain, or fever were defined as AEs after colorectal ESD. Complete PCC was defined as completely sutured mucosal defect using endoclips following colorectal ESD, whereas incomplete PCC was defined as the mucosal defects that did not enable PCC or were partially sutured. Clinical records were retrospectively reviewed and clinical outcomes evaluated. Resultsu2002 AEs occurred in 29 lesions (13.7 %), including 12 with delayed bleeding, 12 with fever, 2 with abdominal pain, 2 with fever and abdominal pain, and 1 with delayed bleeding and fever. Delayed perforation was not observed in any patient. The frequency of AEs was significantly lower in the group with complete PCC than in the group with incomplete PCC (7.3u200a% [9/123] vs. 22.7u200a% [20/88]; P u200a<u200a0.001). Multivariate analysis revealed that AEs after colorectal ESD were significantly associated with tumor size and submucosal fibrosis. Subgroup analysis among the resected specimen size ofu200a<u200a40u200amm revealed that there was no significant difference in AEs between the 2 groups (5.6u200a% [6/107] vs. 17.8u200a% [8/45]; P u200a=u200a0.069). However, the frequency of fever with complete PCC was significantly lower than that with incomplete PCC (2.8u200a% [3/107] vs. 13.3u200a% [6/45]; P u200a=u200a0.020). Conclusionsu2002 Tumor size and submucosal fibrosis were independent risk factors for AEs after colorectal ESD. PCC may be effective in minimizing AEs after colorectal ESD, especially the frequency of fever.

A Flat Elevated Lesion of Well-differentiated Adenocarcinoma with Lymphoid Stroma of the Colon

Here, we present a rare case of a 78-year-old male with well-differentiated adenocarcinoma with lymphoid stroma of the colon. Colonoscopy revealed a type 0-IIa-like lesion located at the descending colon. We performed endoscopic submucosal dissection of the lesion. Histological examination of the resected specimen revealed that the tumor was comprised of well-differentiated adenocarcinoma with lymphoid cell infiltration accompanied by submucosal lymphoid follicle formation. Because of a positive for vertical resection margin, we performed an additional surgical resection. However, we found no residual tumor or lymph node metastases. To the best of our knowledge, this is a rare report describing a case of dome-type carcinoma with lymphoid stroma of the colon for which magnifying endoscopy with crystal violet staining and narrow-band imaging was performed.

Inverted frontal view method facilitates bile duct cannulation via the intact papilla in patients with Roux-en-Y anastomosis.

successfully removed after balloon sphincteroplasty, and the chronic pancreatitis was treated with balloon dilation of strictures and pancreatic duct stenting for 3 months (Video 1, available at giejournal.org). He has been symptom-free for 9 months. Pancreatic duct stone formation in a disconnected bile duct is an unusual finding and likely results from reflux of pancreatic juice into the disconnected bile duct, where stasis, caused by a long common channel, results in stone formation.

Endoscopic submucosal dissection for venous lake in the submucosa of the transverse colon.

lake in the submucosa of the transverse colon Submucosal tumors of the transverse colon that are found incidentally during screening colonoscopy are rare. It is possible for a tiny hypoechoic mass detected in the submucosa of the colorectum by endoscopic ultrasonography (EUS) to be a neuroendocrine tumor (NET). A 51-year-old manwas referred to our department for examination of a submucosal lesion in the transverse colon. Colonoscopy revealed a slightly elevated lesion and normal yellowish mucosa (● Fig.1). On EUS, the lesionwas a 5-mm hypoechoic uniform mass with a regular margin in the submucosal layer. Because a diagnosis of NET could not be ruled out, we performed endoscopic submucosal dissection (ESD) after obtaining written informed consent from the patient. Recent studies have reported that ESD is efficacious for submucosal tumors that have not spread beyond the submucosa because the dissection line during ESD is precisely determined under direct vision [1,2]. First, to elevate the tumor, we injected sodium hyaluronate into the submucosa. After lifting the mucosa, we used a Flush Knife BT (DK2618JB; Fujifilm, Tokyo, Japan) to make a hemicircumferential mucosal incision around the tumor. Following the mucosal incision, we dissected the submucosa with a knife. Direct observation of the submucosal layer during ESD showed the lesion to be an approximately 5-mm spheroidal white mass (● Fig.2, ● Fig.3; ● Video1). The lesion was resected endoscopically en bloc. No major adverse events occurred. Histopathological examination revealed a venous lake with thrombus, organized vasculature, and no neoplastic tissue (● Fig.4). Fig.3 There is a spheroidal white mass in the center of the specimen obtained from endoscopic submucosal dissection. Fig.2 On direct observation of the submucosal layer during endoscopic submucosal dissection, the lesion appears as a 5-mm spheroidal white mass. Fig.1 Colonoscopy in a 51-year-old man reveals a slightly elevated lesion and normal yellowish mucosa in the transverse colon.