Takanori Suganuma

Long-term outcomes of endoscopic submucosal dissection for undifferentiated-type early gastric cancer.

BACKGROUND AND STUDY AIM Endoscopic submucosal dissection (ESD) of undifferentiated-type early gastric cancer (UD-EGC) is technically feasible; however, the long-term clinical outcomes of the procedure have not yet been fully investigated. The aim of our study was to elucidate long-term outcomes of ESD for UD-EGC. PATIENTS AND METHODS Between September 2003 and October 2009, a total of 153 patients were diagnosed endoscopically as having UD-EGC fulfilling the expanded criteria for ESD. After informed consent was obtained, 101 patients were selected to undergo ESD and 52 to undergo surgical operation. We assessed the clinical outcomes of ESD in 101 consecutive patients with 103 UD-EGC lesions who were undergoing ESD for the first time. The overall mortality and disease-free survival rates after ESD were evaluated as the long-term outcomes. RESULTS The rates of en bloc and curative resection were 99.0% (102/103) and 82.5% (85/103), respectively. We encountered one patient with nodal metastasis detected by computed tomography before diagnostic ESD, although curative resection of the primary lesion was achieved based on routine histological examination. Among the 78 patients without a past history of malignancy within the previous 5 years in whom curative resection of the primary lesion was achieved, no cases of local recurrence or distant metastasis were observed during follow-up; however, 1 synchronous and 2 metachronous lesions were detected in 2 patients (2.6%) after primary ESD. Thus, estimated over a median follow-up period of 40.0 months (range 19-92 months) and 36.0 months (range 9-92 months), the 3-and 5-year overall mortality rates were 1.9% and 3.9%, respectively, and the 3-and 5-year overall disease-free survival rates were both 96.7%. CONCLUSIONS Although our single-center retrospective study may be considered to be only preliminary, our data indicate that ESD for UD-EGC may yield good long-term outcomes.

Endoscopic mucosal resection and endoscopic submucosal dissection for en bloc resection of superficial pharyngeal carcinomas

BACKGROUND AND STUDY AIM Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are being used increasingly to treat superficial oropharyngeal and hypopharyngeal carcinomas. The aim of this study was to clarify whether ESD provided better results than EMR for en bloc and complete resection of superficial pharyngeal carcinomas. PATIENTS AND METHODS A total of 76 superficial pharyngeal carcinomas in 59 consecutively treated patients were included. Patients underwent either conventional EMR (using a transparent cap or strip biopsy) (n = 45 lesions) or ESD (n = 31 lesions) between October 2006 and January 2011. The rates of en bloc resection, complete resection (defined as en bloc resection with tumor-free margins), major complications, and local recurrence were evaluated retrospectively as the therapeutic outcomes. RESULTS ESD yielded significantly higher rates of both en bloc and complete resection compared with EMR (en bloc 77.4 % [24/31] vs. 37.8 % [17/45], P = 0.0002; complete 54.8 % [17/31] vs. 28.9 % [13/45], P = 0.0379). ESD was more frequently complicated by severe laryngeal edema (4/21 [19.0 %] vs. 1/31 [3.2 %], P = 0.1446) and was also more time-consuming (124.9 ± 65.1 minutes vs. 57.2 ± 69.6 minutes; P = 0.0014). Local recurrence was observed more often after EMR than after ESD (3/45 [6.7 %] vs. 0/31 [0 %]), although this difference did not reach statistical significance (P = 0.2658). CONCLUSIONS ESD appears to be a superior method of endoscopic resection of superficial pharyngeal carcinomas for achieving both en bloc and complete resection, although these benefits were also associated with a higher incidence of complications and a significantly longer procedure time. Large prospective studies are needed to compare ESD with conventional EMR for superficial pharyngeal carcinomas.

Risk factors for bleeding after endoscopic submucosal dissection of colorectal neoplasms

AIM To investigate the risk factors for delayed bleeding following endoscopic submucosal dissection (ESD) treatment for colorectal neoplasms. METHODS We retrospectively reviewed the medical records of 317 consecutive patients with 325 lesions who underwent ESD for superficial colorectal neoplasms at our hospital from January 2009 to June 2013. Delayed post-ESD bleeding was defined as bleeding that resulted in overt hematochezia 6 h to 30 d after ESD and the observation of bleeding spots as confirmed by repeat colonoscopy or a required blood transfusion. We analyzed the relationship between risk factors for delayed bleeding following ESD and the following factors using univariate and multivariate analyses: age, gender, presence of comorbidities, use of antithrombotic drugs, use of intravenous heparin, resected specimen size, lesion size, lesion location, lesion morphology, lesion histology, the device used, procedure time, and the presence of significant bleeding during ESD. RESULTS Delayed post-ESD bleeding was found in 14 lesions from 14 patients (4.3% of all specimens, 4.4% patients). Patients with episodes of delayed post-ESD bleeding had a mean hemoglobin decrease of 2.35 g/dL. All episodes were treated successfully using endoscopic hemostatic clips. Emergency surgery was not required in any of the cases. Blood transfusion was needed in 1 patient (0.3%). Univariate analysis revealed that lesions located in the cecum (P = 0.012) and the presence of significant bleeding during ESD (P = 0.024) were significantly associated with delayed post-ESD bleeding. The risk of delayed bleeding was higher for larger lesion sizes, but this trend was not statistically significant. Multivariate analysis revealed that lesions located in the cecum (OR = 7.26, 95%CI: 1.99-26.55, P = 0.003) and the presence of significant bleeding during ESD (OR = 16.41, 95%CI: 2.60-103.68, P = 0.003) were independent risk factors for delayed post-ESD bleeding. CONCLUSION Location in the cecum and significant bleeding during ESD predispose patients to delayed post-procedural bleeding. Therefore, careful and additional management is recommended for these patients.

COMPARISON OF THE DIAGNOSTIC UTILITY OF THE ULTRATHIN ENDOSCOPE AND THE CONVENTIONAL ENDOSCOPE IN EARLY GASTRIC CANCER SCREENING

Currently, transnasal esophagogastroduodenoscopy using an ultrathin endoscope is being widely carried out as a screening test for early gastric cancer. We compared the diagnostic utility of ultrathin esophagogastroduodenoscopy with that of conventional esophagogastroduodenoscopy in detecting 42 lesions of early gastric cancer that had a diameter of ≤20 mm. Only 27 lesions (64%) could be accurately diagnosed using ultrathin esophagogastroduodenoscopy. In nine lesions (22%), we failed to discern whether they were malignant. Six lesions (14%) could not even be detected. We found that the diagnostic utility of ultrathin esophagogastroduodenoscopy was inadequate, especially in the case of lesions that were located in the upper third region of the stomach and variegated lesions. In conclusion, the diagnostic utility of ultrathin esophagogastroduodenoscopy might be lower than that of conventional esophagogastroduodenoscopy in terms of screening for early gastric cancer. The disadvantages of ultrathin esophagogastroduodenoscopy should be taken carefully into consideration while examining lesions.

Successful en bloc resection of a 5 cm symptomatic sessile gastric lipoma by endoscopic submucosal dissection.

Gastric lipomas can usually be resected endoscopically or surgically, but there has yet to be an established treatment method. Here we report a case of a 5 cm sessile gastric lipoma that was successfully removed by en bloc resection using endoscopic submucosal dissection (ESD). A 70-year-old woman presented with nausea, obstruction and abdominal pain that were caused by a sessile gastric submucosal tumor that was 5 cm in diameter and occupied the anterior wall of the gastric antrum; the tumor resulted in ball valve syndrome. Endoscopic ultrasound revealed a well-circumscribed, hyperechoic mass that was mainly located in the third layer of the gastric wall without infiltrating the muscularis propria. We diagnosed the submucosal tumor as a clinically suspicious of gastric lipoma.We selected the ESD method as a less-invasive alternative to surgery. The ESD procedure was performed using a needle knife and an IT Knife2 (KD-611L; Olympus, Tokyo, Japan) (Fig. 1). Complete en bloc resection was achieved in 75 min. There were no specific technical difficulties or complications. We withdrew the complete resected specimen orally with a large caliber, soft, oblique cap while sucking by grasping it with the forceps. The size of the tumor was 50 ¥ 38 ¥ 28 mm. The en bloc specimen enabled us to accurately evaluate the histopathological diagnosis, and the tumor was proven to be a lipoma (Fig. 2). The patient’s abdominal symptoms disappeared completely after ESD, and she was discharged on postoperative day 7.To our knowledge, there have been no other reports of sessile gastric lipomas over 5 cm that have been removed by endoscopic en bloc resection. There are only three reported cases of endscopic resection for sessile gastric lipomas greater than 4 cm in diameter. Based on our experience and past reports, ESD is a feasible option for diagnostic treatment with minimal invasiveness for sessile gastric lipomas up to 5 cm in diameter. This method could become the standard treatment.

Successful Use of Endoscopic Argon Plasma Coagulation for Hemorrhagic Radiation Cystitis: A Case Report

Hemorrhagic radiation cystitis is an example of a typical radiotherapy-induced adverse event. However, the optimal treatment for hemorrhagic radiation cystitis is not known. There are limited data regarding the use of argon plasma coagulation for hemorrhagic radiation cystitis. Here, we present the use of argon plasma coagulation using a gastrointestinal endoscope to treat hemorrhagic radiation cystitis. The patient was a 75-year-old male patient with hemorrhagic radiation cystitis due to external beam irradiation for prostate adenocarcinoma. Six years after radiotherapy, the patient presented with macroscopic hematuria over the preceding 4 months, and laboratory investigations revealed a low hemoglobin level. The hematuria was not controlled with 2 days of bladder irrigation using normal saline. Thus, argon plasma coagulation using an upper gastrointestinal endoscope was considered for treatment of the hemorrhagic radiation cystitis. The cystoscopic examination revealed diffuse radiation cystitis with oozing telangiectasia and coagula. All of the bleeding sites and telangiectasia were coagulated using argon plasma coagulation. Following treatment, the patients clinical symptoms improved and did not recur. The hemoglobin level also recovered. No complications associated with the treatment were observed during the 6-month follow-up period. Thus, argon plasma coagulation using a gastrointestinal endoscope is a safe and effective treatment for hemorrhagic radiation cystitis.

A significant increase in the pepsinogen I/II ratio is a reliable biomarker for successful Helicobacter pylori eradication

Background Helicobacter pylori (H. pylori) eradication is usually assessed using the 13C-urea breath test (UBT), anti-H. pylori antibody and the H. pylori stool antigen test. However, a few reports have used pepsinogen (PG), in particular, the percentage change in the PG I/II ratio. Here, we evaluated the usefulness of the percentage changes in serum PG I/II ratios for determining the success of eradication therapy for H. pylori. Materials and methods In total, 650 patients received eradication therapy from October 2008 to March 2013 in our Cancer Institute Hospital. We evaluated the relationship between H. pylori eradication and percentage changes in serum PG I/II ratios before and 3 months after treatment with CLEIA® (FUJIREBIO Inc, Tokyo, Japan). The gold standard of H. pylori eradication was defined as negative by the UBT performed 3 months after completion of eradication treatment. Cut-off values for percentage changes in serum PG I/II ratios were set as +40, +25 and +10% when the serum PG I/II ratio before treatment was below 3.0, above 3.0 but below 5.0 and 5.0 or above, respectively. Results Serum PG I and PG II levels were measured in 562 patients with H. pylori infection before and after eradication therapy. Eradication of H. pylori was achieved in 433 patients studied (77.0%). The ratios of first, second, third-line and penicillin allergy eradication treatment were 73.8% (317/429), 88.3% (99/112), 75% (12/16) and 100% (5/5), respectively. An increasing percentage in the serum levels of the PG I/II ratios after treatment compared with the values before treatment clearly distinguished success from failure of eradication (108.2±57.2 vs. 6.8±30.7, p<0.05). Using the above cut-off values, the sensitivity, specificity and validity for determination of H. pylori were 93.1, 93.8 and 93.2%, respectively. Conclusion In conclusion, the percentage changes in serum PG I/II ratios are useful as evaluation criteria for assessing the success of eradication therapy for H. pylori.

Endoscopic Resection for Undifferentiated-Type Early Gastric Cancer

Currently, endoscopic resection (ER) is the standard treatment for early gastric cancer (EGC), not only in Japan but also in other parts of the world. (Gotoda T et al., 2006) A new endoscopic resection procedure, called endoscopic submucosal dissection (ESD), allows the direct dissection of the submucosa and has made en bloc resection of large intramucosal or ulcerated lesions feasible. However, at present, the indications for use of ER are limited to EGC without lymph node metastasis. Gotoda et al. studied surgically resected specimens from EGC patients and decided upon the following four indication criteria for endoscopic resection of EGC without lymph node metastasis. (Gotoda T et al.,2000) (Fig 1) 1. differentiated intramucosal cancer without ulceration, regardless of size 2. differentiated intramucosal cancer with ulceration, 30mm or less in size 3. differentiated minute submucosal penetrative cancer (SM1), 30mm or less in size 4. undifferentiated intramucosal cancer without ulceration, 20mm or less in size