Won Joong Jeon

A new technique for gastric endoscopic submucosal dissection: peroral traction-assisted endoscopic submucosal dissection

BACKGROUND Compared with conventional EMR, endoscopic submucosal dissection (ESD) has a higher en bloc resection rate and complete resection rate, regardless of tumor size, in treating gastric neoplasms. However, ESD leads to more complications, such as bleeding or perforation, and, in particular, needs more procedure time than a conventional EMR. OBJECTIVE To report a new technique for ESD, peroral traction-assisted ESD with suture material, to perform easier and more rapid procedures in treating gastric neoplasms and to report the techniques early results. DESIGN A case series. SETTING A tertiary medical center. PATIENTS AND METHODS A total of 15 patients with gastric adenomas or early gastric cancers larger than 10 mm in diameter were consecutively enrolled. After marking around the periphery of the lesion, submucosal injection, followed by circumferential mucosal incision with a Flex-knife and an insulation-tipped knife, was conducted. After that, one hemostatic clip, tied by using a white silk suture, was applied at a site of the lesion suitable for oral traction. During submucosal dissection, the applied suture material was pulled to the oral side. Additional tractions were applied as needed. MAIN OUTCOME MEASUREMENTS En bloc resection rate, procedure time, complications. RESULTS All lesions were resected en bloc with free lateral and vertical margins by using this technique. The mean longest lesion size and specimen size were 18.1 mm (range 11-28 mm) and 43.7 mm in diameter (range 25-64 mm), respectively. The mean procedure time was 49.6 minutes (range 28-90 minutes). There was no significant bleeding that required blood transfusion or perforation related to the procedures. LIMITATIONS Single endoscopist, small patient number. CONCLUSION Peroral traction-assisted ESD with suture material is useful in treating gastric neoplasms located in various regions of the stomach. It may make ESD procedures easier, faster, and safer under better direct vision of the submucosal layer.

Worldwide experiences of endoscopic submucosal dissection: Not just Eastern acrobatics

The high incidence of gastric cancer has led to the initiation of cancer screening programs. As a result, the number of early gastric cancer cases has increased and consequentially, the cancer mortality rate has decreased. Moreover, the development of minimally invasive endoscopic treatment has been introduced for these early lesions. Endoscopic submucosal dissection (ESD) is now recognized as one of the preferred treatment modalities for premalignant gastrointestinal epithelial lesions and early gastric cancer without lymph node metastasis. We review the results of ESD including experiences in Japan and Korea, as well as western countries.

The experience of transumbilical endoscopic appendectomies

Minimally invasive surgery is being widely accepted in various fields of surgery. Although several appendectomy techniques have been reported but, there is no standardization. We report here the experiences of transumbilical endoscopic appendectomy in humans. Between July 2008 and September 2010, ten patients with appendicitis successfully underwent transumbilical endoscopic appendectomies. There were 7 cases of suppurative, 2 cases of gangrenous and 1 case of perforated in operative findings. The ages of the patients were 13-56 years (mean age, 32.7 ± 15.4 years). Under general anesthesia, a 15-mm port was inserted through the umbilicus and then a two-channel endoscope was inserted in the peritoneal cavity. After appendix identification, counter-traction of the appendix with a direct abdominal wall puncture using a straight round needle prolene was performed to achieve good visualization of the operative field. Tissue dissection was performed using an endoscopic needle knife. Tissue grasping and resected appendix retrieval were done with endoscopic forceps. The average operation time was 79.5 ± 23.6 minutes (range, 45 to 110 minutes). No procedures were converted to laparoscopic or open appendectomy. Hospital stay was 4-6 days. All patients completely recovered without complications. As it is highly maneuverable, we believe transumbilical endoscopic appendectomy can be a feasible method. And, as surgeons want to proceed from laparoscopic surgery to natural orifice transluminal endoscopic surgery, this procedure could be a triable method.

Successful Hemostasis with Recombinant Activated Factor VII in a Patient with Massive Hepatic Subcapsular Hematoma

Recombinant activated coagulation factor VII (rFVIIa) is known to be effective in the management of acquired deficiencies of factor VII and platelet function defects. But recently, rFVIIa has been successfully used to treat ongoing bleeding in disseminated intravascular coagulopathy (DIC) condition. The patient reported here was suspected to be suffering from toxic hepatitis on admission. After percutaneous liver biopsy, bleeding occurred and did not stop even after right hepatic artery embolization. The patient developed a severe hemorrhage that resulted in hypovolemic shock, hemoperitoneum, and a massive subcapsular hematoma. The patient then developed DIC due to massive transfusion, as well as acute liver necrosis. The patient was given 400 μg/kg of rFVIIa. Recombinant factor VIIa was administered in an attempt to control the bleeding. This stabilized the hemoglobin levels of the patient. The patient gradually recovered in 4 months. In conclusion, this case suggests that rFVIIa can be successfully used for the hemostasis of uncontrolled bleeding in DIC.

A case of hepatocellular carcinoma in the caudate lobe successfully treated by transcatheter arterial chemoembolization using drug-eluting beads

Hepatocellular carcinoma (HCC) in the caudate lobe remains one of the most intricate locations where various treatments tend to pose problems with regard to the optimal approach. Surgical resection has been regarded as the most effective treatment; however, isolated resection of the caudate lobe is strenuous and associated with a high rate of early recurrence. Percutaneous ablation might be technically difficult or impossible to perform due to the deep location of tumors and adjacent large vessels. Treatment with drug-eluting beads (DEB) can potentially enhance the therapeutic efficacy for patients with unresectable HCC by drawing on the slower, more consistent drug delivery process. We described a case of a 62-year-old man with HCC in the caudate lobe who was successfully treated by DEB.