Yasuhiro Onozato

Endoscopic treatment of rectal carcinoid tumors.

BACKGROUND: Various methods have been reported for the endoscopic treatment of rectal carcinoid tumors. The present study was designed to identify the optimal treatment strategy for an endoscopic resection. METHODS: Forty rectal carcinoid tumors of 38 patients were treated endoscopically. The indication criteria, complete resection rate, selection of treatment, local recurrence, distant metastases, and complications were analyzed. All tumors were estimated to measure 1 cm or less in diameter, without muscular invasion, atypical features, and lymph node metastases to the pararectal region. RESULTS: Complete resection of the lesions was obtained in 75.0% (30/40). The complete resection rates were 20.0% (1/5) by conventional polypectomy, 84.6% (22/26) by a two-channel endoscopic mucosal resection, and 77.8% (7/9) by endoscopic submucosal dissection. The 10 cases that did not show a clear submucosal layer after initial endoscopic treatment received additional endoscopic microwave coagulation therapy. There were no local or distant recurrences in the followed-up periods (median, 6.4 years). No difference was observed in the complete resection rate between two-channel endoscopic mucosal resection and endoscopic submucosal dissection. CONCLUSIONS: Small carcinoid tumors measuring less than 1 cm in diameter can therefore be managed endoscopically with no recurrence or spread. The selection of endoscopic treatment should be made after taking such factors as cost-effectiveness, expertise, and experience into careful consideration.

STRICTURE AFTER ENDOSCOPIC SUBMUCOSAL DISSECTION FOR EARLY GASTRIC CANCERS AND ADENOMAS

Background and Aim:  Stricture is a complication that may occur after endoscopic submucosal dissection (ESD) of gastric neoplasms. The goal of the present study was to investigate the incidence, risk factors and management of gastric stricture after ESD.

FEASIBILITY OF ENDOSCOPIC SUBMUCOSAL DISSECTION FOR ELDERLY PATIENTS WITH EARLY GASTRIC CANCERS AND ADENOMAS

Background:  Endoscopic submucosal dissection (ESD) has the advantage of permitting en bloc and histologically complete resection for early gastric cancer. Elderly patients often have surgical operative risks due to disease, and the feasibility of this treatment for such patients will improve the quality of life. The aim of the present study is to evaluate the efficacy and safety of ESD in elderly patients.

CLINICAL CHARACTERISTICS AND TREATMENT FOR PATIENTS PRESENTING WITH BLEEDING DUODENAL VARICES

Background and Aim:  Bleeding from ectopic varices, including duodenal varices, is uncommon, but it can be difficult to manage. The clinical data of patients diagnosed and treated for duodenal varices were reviewed to investigate the strategy for treatment.

Can endoscopic submucosal dissection be safely performed in a smaller specialized clinic

AIM To investigate whether endoscopic submucosal dissection (ESD) can be safely performed at small clinics, such as the Shirakawa Clinic. METHODS One thousand forty-seven ESDs to treat gastrointestinal tumors were performed at the Shirakawa Clinic from April 2006 to March 2011. The efficacy, technical feasibility and associated complications of the procedures were assessed. The ESD procedures were performed by five endoscopists. Sedation was induced with propofol for esophagogastorduodenal ESD. RESULTS One thousand forty-seven ESDs were performed to treat 64 patients with esophageal cancer (E), 850 patients with gastric tumors (G: 764 patients with cancer, 82 patients with adenomas and four others), four patients with duodenal cancer (D) and 129 patients with colorectal tumors (C: 94 patients with cancer, 21 patients with adenomas and 14 others). The en bloc resection rate was 94.3% (E: 96.9%, G: 95.8%, D: 100%, C: 79.8%). The median operation time was 46 min (range: 4-360 min) and the mean size of the resected specimens was 18 mm (range: 2-150 mm). No mortal complications were observed in association with the ESD procedures. Perforation occurred in 12 cases (1.1%, E: 1 case, G: 9 cases, D: 1 case, C: 1 case) and postoperative bleeding occurred in 53 cases (5.1%, G: 51 cases, D: 1 case, C: 1 case); however, no case required either emergency surgery or blood transfusion. All of the perforations and postperative bleedings were resolved by endoscopic clipping or hemostasis. The other problematic complication observed was pneumonia, which was treated with conservative therapy. CONCLUSION ESD can be safely performed in a clinic with established therapeutic methods and medical services to address potential complications.

A large flat adenoma located on the pylorus ring successfully treated by endoscopic submucosal dissection.

Endoscopic mucosal resection (EMR) is a recognized treatment for early gastric cancer and is beneficial for patients because of its low level of invasiveness [1–3]. A one-piece resection is considered to be the gold standard of EMR, as it provides an accurate histological assessment and reduces the risk of local recurrence [1–3]. However, it is difficult to resect large and ulcerative lesions by conventional EMR techniques so a new technique of endoscopic submucosal dissection (ESD) has been developed [4–7]. The primary aim of this technique is to obtain one-piece resection during EMR. ESD has the advantage of permitting en bloc and histological complete resection. On the other hand, this method has the disadvantage of a long performance time and high frequency of complications as well as the need for a high level of technical skill [2, 4–7]. We experienced here a large flat adenoma located on the pylorus ring which was successfully treated with ESD. Endoscopic findings during ESD are presented and the treatment for such lesions is discussed.

Intense accumulation of gallium-67 citrate in pancreatic endocrine tumor

We report intense accumulation of gallium-67 (Ga-67) citrate in a pancreatic endocrine tumor. A 69-year-old woman was admitted because of cough, fever, and weight loss. An abdominal enhanced computed tomography (CT) scan revealed a large tumor located between the liver and pancreas as well as swollen paraaortic lymph nodes. Whole-body scintigraphy with Ga-67 revealed intense accumulation in the upper abdomen corresponding to the mass, as well as in the midabdomen and the mediastinal lesion. Percutaneous needle biopsy was performed, and the diagnosis was adenocarcinoma of the pancreas. The patients condition deteriorated, and she died 2 months after admission. The pathological examination at autopsy revealed a pancreatic endocrine tumor. No report has described findings of Ga-67 citrate scintigraphy of pancreatic endocrine tumors. Pancreatic endocrine tumor should be included in a differential diagnosis when such scintigraphic findings are encountered.

What Is This in the Orifice of the Appendix Vermiformis

Question: A 3-year-old boy presented to the emergency department 3 hours after having ingested 5 ball-shaped magnetic beads. He had no symptoms of abdominal pain or vomiting, and his clinical examination was normal. An abdominal x-ray showed 5 round magnetic balls attached together in a string-like formation, located in the body of the stomach (Figure A). Should the magnets be retrieved urgently? Look on page 1044 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Mesalazine for ulcerative colitis complicated with diabetic nephropathy

excluded, and she was diagnosed as having active ulcerative colitis. Mesalazine was started, at a daily dose of 1500mg, after she and her family had been informed about the necessity for and the drawbacks of mesalazine in her present condition; rescue plans, including possible emergency hemodialysis, were described, and the patient and her family gave their consent to the treatment. The plasma concentrations of 5-ASA and its acetylated metabolite, acetyl-5-ASA, were carefully monitored by high-performance liquid chromatography (HPLC) before and after hemodialysis (Table 1). No obvious accumulation of 5-ASA was found, but the plasma concentration of acetyl-5-ASA was progressively elevated. On day 56, her clinical and endoscopic findings were consistent with remission, and so mesalazine was reduced to a daily dose of 750 mg; it was discontinued on day 69. Consequently, acetyl-5-ASA in the plasma was not detected on day 99. After the treatment, no recurrence of colitis was noted. Corticosteroid hormones are unfavorable for patients with complicated diabetes mellitus, so we decided to use mesalazine after we had obtained the patient’s informed consent. Mesalazine is nephrotoxic when given intravenously, at a high dosage, to rats. In patients taking mesalazine orally, renal impairment of any severity may occur in up to 1 in 100 patients, with clinically significant interstitial nephritis occurring in fewer than 1 in 500 patients.1 Mesalazine constantly releases 5-ASA throughout the whole length of the bowel.2 A steadystate plasma concentration of 5-ASA was reached on day 5 in normal healthy volunteers who had taken mesalazine, 500 mg three times daily.2 During the steady state, the concentrations of plasma 5-ASA and acetyl-5ASA are 0.3–1.1 and 0.9–1.5μg/ml, respectively.3 There have been no previous reports concerning 5ASA administration for patients on hemodialysis. In our patient, the plasma concentration of 5-ASA was maintained within an almost normal range with the daily dose of 1500 mg of mesalazine; while, in contrast, 5-Aminosalicylic acid (5-ASA) is commonly employed and is efficacious for the treatment of inflammatory bowel disease, but the potential nephrotoxicity of 5ASA requires special care in patients with renal impairment.1 We experienced a patient with ulcerative colitis complicated with diabetic nephropathy requiring maintenance hemodialysis; she was successfully and safely induced into remission of the ulcerative colitis with mesalazine, a 5-ASA agent, with the plasma concentration of 5-ASA and its metabolite being monitored. A 64-year-old woman with diabetic nephropathy was referred to our hospital because of diarrhea, fever, and melena of more than 3 weeks’ duration. She had been on maintenance hemodialysis three times a week for 2 years. Her laboratory data on admission showed renal dysfunction (blood urea nitrogen [BUN], 38 mg/dl; creatinine, 6.8 mg/dl), anemia (hemoglobin, 7.5g/dl), leukocytosis (white blood cell count, 9900/mm3), elevated C-reactive protein level (5.2 mg/dl), and hypoalbuminemia (2.3 g/dl). Repeated stool examinations were negative for pathogenic bacteria and parasites. Colonoscopy revealed friable mucosa, multiple shallow ulcers, erosions, redness, and bleeding, features that were continuously and uniformly observed throughout the entire colon without intervening areas of normal mucosa. No longitudinal ulcers or segmental lesions were observed. Mucosal specimens showed a marked infiltration of inflammatory cells, with crypt abscesses and goblet cell depletion. There were no findings of granuloma or hemosiderin deposition. In the patient’s history of the present illness, she had not received antibiotics or nonsteroidal anti-inflammatory drugs (NSAIDs). Thus, other diseases, such as infectious colitis, ischemic colitis, drug-induced colitis, and Crohn’s disease colitis were