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 case of groove pancreatitis (segmental form) presented with obstructive jaundice associated with pancreatobiliary maljunction].

A 52-year-old-man was admitted to our hospital for obstructive jaundice. Percutaneous transhepatic cholangio drainage (PTCD) and endscopic retrograde cholangiopancreatography (ERCP) were performed, and pointed out stenosis of lower common bile duct (CBD) and pancreatobiliary maljunction. Brushing cytology of this lesion was negative for malignancy. CT and MRI revealed chronic inflammatory change in groove lesion with no mass formation suggesting tumor. So we diagnosed groove pancreatitis (segmental form) associated with pancreatobiliary maljunction, and operation (resection of the bile duct and biliary reconstruction by Roux-en-Y) was done. Resected specimen was revealed stenosis of the bile duct formed by fibrous tissue with no malignancy compatible to groove pancreatitis pathologically. This is first reported case of groove pancreatits associated with pancreatobiliary maljunction.

Metastasis of hepatocellular carcinoma to the supramaxillary gingiva and right ventricle.

We describe a rare double metastasis of hepatocellular carcinoma to the supramaxillary gingiva and papillary muscle of the right ventricle. The patient was a 72-year-old woman who underwent three sessions of transcatheter arterial embolization for the primary lesions. Control of bleeding from the supramaxillary gingival metastasis was difficult by conservative treatment such as compression with gauze soaked in epinephrine. Therefore, radiotherapy was performed, but it failed to control the bleeding. The patient subsequently died due to hepatic failure. Autopsy revealed metastases of hepatocellular carcinoma to the papillary muscle of the right ventricle and paraaortic lymph node in the abdomen in addition to the supramaxillary gingival metastasis. Histopathological examination showed moderately differentiated hepatocellular carcinoma of both the primary site and metastatic sites to the gingiva and the heart and poorly differentiated in the paraaortic lymph node.