Pancreas-sparing partial duodenectomy as an alternative to emergency pancreaticoduodenectomy for a major duodenal perforation: a case report.

A 71-year-old woman underwent endoscopic submucosal dissection for early duodenal cancer at the second portion of the duodenum and developed acute peritonitis due to delayed duodenal perforation. Emergency laparotomy was performed. A huge perforation formed at the descending duodenum without ampulla involvement. Pancreas-sparing partial duodenectomy (PPD) with gastrojejunostomy was performed (250 min operative time) with 50 mL of intraoperative blood loss. She required intensive care for 3 days and was discharged on postoperative day 21 with no severe complications. Emergency treatment for a major duodenal injury or perforation remains challenging because of high morbidity and mortality. An appropriate treatment should be considered according to the nature of the defect. Although PPD is an acceptable procedure for patients with a duodenal neoplasm, its use in emergency surgery is rarely reported. PPD is more reliable than primary repair or anastomosis using a jejunal wall, and less invasive than pancreaticoduodenectomy, for emergency treatment. We performed PPD in this patient because the duodenal perforation was too large to reconstruct and did not involve the ampulla. PPD can be a safe and feasible alternative surgical procedure to pancreaticoduodenectomy for a major duodenal perforation, especially in patients with a duodenal perforation that does not involve the ampulla.

Perigastric abscess caused by delayed perforation after gastric endoscopic submucosal dissection: successful conservative treatment without perforation closure: a case report.

BACKGROUND: Perigastric abscess caused by delayed perforation after endoscopic submucosal dissection is a very rare complication. In principle, delayed perforation after endoscopic submucosal dissection is treated surgically. Herein, we report a case of perigastric abscess caused by delayed perforation after gastric endoscopic submucosal dissection that was treated conservatively, without perforation closure, and in which the patient was discharged from hospital in a short period. CASE PRESENTATION: A-74-year-old Asian man was diagnosed with having early gastric cancer on follow-up endoscopy and was admitted to our hospital for endoscopic resection. Endoscopic submucosal dissection was performed without intraoperative complications. On postoperative day 2, the patient complained of a slight abdominal pain localized to the epigastric region and a small amount of melena. A computed tomography scan revealed the presence of free air in the peritoneal cavity, and a little fluid collection abutting the dorsal area of the stomach. An endoscopy examination showed a deep ulcer with the accumulation of pus, suggesting a perforation in the post-endoscopic submucosal dissection ulcer. We diagnosed a perigastric abscess, caused by delayed perforation after endoscopic submucosal dissection, and opted for conservative treatment, leaving the perforation site open to allow spontaneous drainage from the abscess into the stomach. A follow-up computed tomography scan revealed an encapsuled and localized perigastric abscess on postoperative day 5, and the disappearance of the free air and the regression of the perigastric abscess on postoperative day 7. A follow-up endoscopy examination on postoperative day 7 showed the closure of the perforation. Finally, surgery was avoided, and the patient was discharged on postoperative day 14, after a relatively short hospital stay. CONCLUSION: Regarding the treatment of perigastric abscess, caused by delayed perforation after endoscopic submucosal dissection, leaving the perforation site open to allow spontaneous drainage may shorten the conservative treatment period.

Endoscopic submucosal dissection using an ultrathin endoscope for superficial pharyngeal cancer: a prospective feasibility study (with video).

Background and study aims Endoscopic submucosal dissection (ESD) of pharyngeal cancers with conventional endoscopes often is difficult, not only because of the narrow working space, but also because endoscope maneuverability in the pharynx is poor due to interference from the endotracheal tube and/or hyoid bone. However, we hypothesized that those problems could possibly be resolved by use of an ultrathin endoscope for ESD of superficial pharyngeal cancer. The aim of this prospective interventional study was to investigate the feasibility of ESD for superficial pharyngeal cancer using an ultrathin endoscope. Patients and methods This feasibility study was conducted at NTT Medical Center Tokyo between June 2020 and September 2021, and data from a total of 20 consecutively superficial pharyngeal cancers were analyzed. The primary outcome measure was the R0 resection rate. The ESD completion rate, en bloc resection rate, procedure time, and frequency of intraoperative and postoperative adverse events (AEs) were also evaluated as secondary outcome measures. Results Data from 16 patients with 20 lesions were included in the analysis. All of the lesions were successfully resected by ultrathin endoscope ESD, and the en bloc and R0 resection rates were 100 % and 85.0 % (17/20), respectively; the procedure time was 37.8 ±â€Š28.2 minutes. No intraoperative or postoperative AEs were encountered in any cases. Conclusions ESD using an ultrathin endoscope is feasible for superficial pharyngeal cancers and has potential to be a safe and effective treatment option for these cancers.

Gastric-type duodenal neoplasms with rapid growth: A report of two cases.

While duodenal neoplasms of the gastric phenotype are uncommon and their natural history is unknown, gastric neoplasms of gastric phenotype reportedly grow rapidly and can invade the submucosa. Several studies suggest that duodenal neoplasms of gastric phenotype might have a high risk of deep invasion and lymph node metastasis. Duodenal neoplasms of gastric phenotype might also have a high biological malignancy and likely require early treatment if detected. Here, we report two cases of intramucosal duodenal carcinoma with a gastric phenotype that grew rapidly but was successfully resected endoscopically.

Early gastric mixed neuroendocrine-non-neuroendocrine neoplasms with endoscopic findings of neuroendocrine cell carcinoma components exposed on the mucosal surface: a case report.

BACKGROUND: Gastric mixed neuroendocrine-non-neuroendocrine neoplasms are rare malignant tumors. The lack of specific findings makes it difficult to diagnose endoscopically. We report the case of early gastric mixed neuroendocrine-non-neuroendocrine neoplasms treated by endoscopic submucosal dissection. CASE PRESENTATION: An 81-year-old Japanese female underwent esophagogastroduodenoscopy for screening and was treated with endoscopic submucosal dissection for the diagnosis of early gastric cancer. Histopathologically, the lesion was diagnosed as mixed neuroendocrine-non-neuroendocrine neoplasms (tubular adenocarcinoma 2 60%, endocrine cell carcinoma 40%), pT1b(submucosa (SM) 900 µm), pUL(-), Ly(+), v(-), pHM0, pVM0. After additional surgical resection without adjuvant chemotherapy, she has had no recurrences or metastases for 3 years. CONCLUSIONS: Comparing narrow-band imaging magnified endoscopic findings with pathological findings, the depressed area with a lack of surface structure was consistent with the neuroendocrine cell carcinoma component, while narrow-band imaging magnification findings showed non-network vessels. In this case, we examined endoscopic findings of early stage mixed neuroendocrine-non-neuroendocrine neoplasms in detail and compared it with the pathological findings. We believe that these endoscopic findings contribute to the diagnosis of mixed neuroendocrine-non-neuroendocrine neoplasms and can lead to its early detection.

Endoscopic submucosal dissection: the first reported experience from a New Zealand centre.

AIM: Endoscopic submucosal dissection (ESD) is internationally accepted as a minimally invasive procedure to treat early gastrointestinal cancers endoscopically. Uptake of this procedure in the West is limited. No published data are available in New Zealand. We aimed to evaluate outcomes of this procedure at North Shore Hospital, Auckland. METHODS: Following an overseas fellowship training period, we prospectively collected clinical outcomes, complications and defined quality indicators for patients undergoing ESD referred following a multidisciplinary meeting. RESULTS: Between January 2020 until July 2021, 29 ESD procedures were performed in 27 patients, including 14 gastric, five oesophageal and 10 colorectal cases. The mean age was 72 (standard deviation (SD) 10.6). The majority of cases (62%) were done under general anaesthesia. The median lesion size resected was 30mm (interquartile range (IQR) 20-58mm). The pre-endoscopic diagnosis was accurate as confirmed on final histology in 93% of cases. Thirty-four percent of lesions were T1 adenocarcinoma and completely resected. The median total duration of the procedure was 90 minutes (IQR 55-180). 86% of lesions were resected en-bloc. R0 resection was achieved in 72% of cases. All cases with R0 resection were curative except one. Muscular defects without perforation were seen and clipped at the time of endoscopy in 34% of cases. Two perforations were identified and sealed at the time of endoscopy. There were no cases of delayed bleeding, perforation or mortality. CONCLUSION: These data demonstrate clinical success, efficacy and safety of ESD at our centre. A larger study, comparison with other centres and longer clinical follow-up is required to confirm findings and further improve outcomes.

Successful esophageal endoscopic submucosal dissection with intraoperative release of stenosis due to previous endoscopic submucosal dissection scarring.

Endoscopic submucosal dissection (ESD) is the standard endoscopic treatment for early esophageal cancer. Esophageal stricture often occurs at the site of ESD for large lesions. When treating a metachronous lesion appearing at the severe stricture, it may be difficult to negotiate a conventional endoscope through the stricture. Using a thin endoscope may be a useful strategy for such lesions, though ESD using a thin endoscope is challenging because of poor maneuverability. Herein, we report a case of successful ESD for early esophageal cancer at the severe stricture, using a conventional endoscope. A 72-year-old man with a previous history of ESD for esophageal cancer and a post-ESD esophageal stricture was referred to our hospital for metachronous early esophageal cancer. The lesion, 10 mm in diameter, was located at the stricture with a slight distal extension. Conventional endoscopes could not be negotiated through stricture. Therefore, submucosal dissection was performed from the oral to the anal aspect of the lesion, as far as possible. After completion of submucosal dissection of the oral aspect of the lesion and part of the lesion located on the stricture, the severe stricture was released, allowing the passage of conventional endoscope, and ESD of the entire lesion was completed en bloc. Histopathological examination showed squamous cell carcinoma, pT1a-LPM. Stricture due to scarring may occur during the regeneration process of the defective mucosa, muscularis mucosa, and submucosal layer. Therefore, incision and dissection of the contracted mucosa, mucularis mucosa, and submucosal layer would release the stenosis.

Safety and Efficacy of Cold Snare Polypectomy Without Submucosal Injection for Large Sessile Serrated Lesions: A Prospective Study.

BACKGROUND & AIMS: Cold snare polypectomy (CSP) has become the standard resection method for small colorectal polyps (<10 mm). Sessile serrated lesions (SSL) have low prevalence of advanced histology irrespective of size, and thus could be amenable to CSP. In this study, we evaluated the safety and efficacy of CSP for SSLs ≥10 mm. METHODS: Between November 2018 and January 2020, we prospectively enrolled 300 consecutive patients who underwent CSP for 474 SSLs ≥10 mm. To delineate SSL borders, indigo carmine chromoendoscopy and/or image-enhanced endoscopy was conducted. Piecemeal CSP (pCSP) was performed in cases where en-bloc resection was difficult. Biopsy specimens were obtained from the margins of the post-polypectomy defect to confirm complete resection. Surveillance colonoscopy was performed to screen for local recurrence. RESULTS: All lesions were successfully resected using CSP without submucosal injection. The median diameter of the resected lesions was 14 mm, and pCSP was used to resect 106 (22%) lesions. Post-polypectomy biopsies revealed residual serrated tissue in only one case (0.2%). Adverse events included immediate bleeding in 8 (3%) patients; no delayed bleeding events occurred, irrespective of the use of antithrombotic drugs. During a 7-month median follow-up period, surveillance colonoscopies were performed for 384 lesions (81%), and no local recurrences were detected. CONCLUSIONS: CSP without submucosal injection is a safe and effective treatment for SSLs ≥10 mm. UMIN Clinical Trials, Number: UMIN000034763.

Successful endoscopic submucosal dissection for a tumor located completely within a colonic diverticulum after inversion of the diverticulum using a traction device.

Video 1Successful endoscopic submucosal dissection for a tumor completely located within a colonic diverticulum after inversion of the diverticulum using a traction device. After reconfirming that the diverticulum could be inverted into the lumen with forceps, the first endoclip grasping a ring-thread made of dental floss was fixed on the mucosa in the diverticulum. Immediately afterward, a second endoclip was used to grasp the ring-thread and fix it to the opposite colonic wall. By insufflating with air, the lesion within the inverted diverticulum was pulled out of the diverticulum into the colonic lumen, establishing a good field of view for dissection. After local injection of hyaluronic acid, a circumferential incision and dissection were performed using a DualKnife, and the lesion was promptly removed en bloc. The wound was completely closed with endoclips, along with the diverticulum. The total procedure time was 10 minutes, and there were no adverse events.

Endoscopic transcecal appendectomy under laparoscopic single-port assistance.

Video 1Endoscopic transcecal appendectomy under laparoscopic single-port assistance.

A new classification for the diagnosis of superficial non-ampullary duodenal epithelial tumors using endocytoscopy: A prospective study.

BACKGROUND AND AIM: Although the frequency of endoscopic diagnosis of superficial non-ampullary duodenal epithelial tumors (SNADETs) has been increasing in recent years, no criteria for the endoscopic diagnosis of these tumors have been established yet. The aim of this study was to assess the usefulness of endocytoscopy for diagnosis SNADETs and to establish new criteria. METHODS: This prospective study was conducted at the NTT Medical Center Tokyo from May 2019 to July 2020, and a total of 100 consecutive SNADETs were enrolled. All the endocytoscopic images of the lesions and surrounding normal mucosa were classified into three groups according to the degree of structural atypia and the nuclear morphology and size. The endocytoscopic diagnoses using endocytoscopic classification was compared with the final histopathological diagnoses. RESULTS: Data of 93 patients with 98 lesions were included in the analysis. The preoperative diagnosis by endocytoscopy coincided with the final histopathological diagnosis in 85 (86.7%) of 98 SNADETs. In addition, the sensitivity and specificity for VCL 4/5 were 87.7% and 85.4%, respectively. In contrast, the accuracy, sensitivity, and specificity of preoperative diagnosis by biopsy were 64.3%, 50.9%, and 82.9%, respectively. Preoperative diagnosis by endocytoscopy showed significantly superior accuracy and sensitivity as compared with preoperative biopsy diagnosis (P < 0.001, respectively). CONCLUSIONS: This new classification (endocytoscopic classification) allows prediction of the tumor histopathology in real time, during endocytoscopy without biopsy, and is expected to be of help in determining the appropriate therapeutic strategies for individual cases of SNADETs. (Clinical trial registration number: UMIN000038643.).

Endoscopic and histological features of Helicobacter pylori-negative differentiated gastric adenocarcinoma arising in the antrum.

BACKGROUND AND AIM: With the increasing prevalence of persons without Helicobacter pylori (HP) infection, cases of HP-negative gastric cancer are increasing. Although rare, cases of differentiated adenocarcinoma of the antrum have been reported in HP-negative patients. We collected cases with such lesions and investigated their endoscopic and histological features. METHODS: Of 1965 consecutive patients with early gastric cancer who underwent endoscopic resection between January 2009 and December 2017, we extracted 9 cases of HP-negative differentiated adenocarcinoma located in the antrum (HPN-DAA). The clinical data, endoscopic findings, and histopathological findings were reviewed. RESULTS: Of the nine patients with HPN-DAA, seven were male, and the median age was 53.8 years. The tumor arose from the pyloric gland mucosa in all cases. According to the endoscopic findings, the lesions were flat-elevated or depressed, mimicking varioliform gastritis. Magnifying endoscopy with narrow-band imaging showed the absence of a clear demarcation line or an irregular microvessel/surface pattern. As for the histopathological findings, eight of the nine lesions were diagnosed as high-grade dysplasia/intraepithelial neoplasia, while the remaining case was diagnosed as tubular adenocarcinoma with submucosal infiltration. The findings of immunohistochemistry confirmed that three cases were of the intestinal mucin phenotype and six were of the mixed gastric and intestinal mucin phenotype. CONCLUSION: HPN-DAA is a very rarely occurring cancer that had never been recognized earlier. They belong to the new category of HP-negative cancers, and there seems to be a certain number of such cases.

Large duodenal pyloric gland adenoma successfully resected by endoscopic submucosal dissection.

A 71-year-old woman was given a barium meal examination as part of a workup for recurring melena and iron deficiency anemia (IDA), and it revealed a large duodenal polyp measuring 60 mm in diameter. Subsequent upper gastrointestinal endoscopy showed a large pedunculated polyp in the duodenal bulb. Magnifying endoscopy with narrow-band imaging (NBI) showed that the lesion consisted of a regular enlarged intervening part between crypts of the epithelium that resembled gastric mucosa. Although the lesion was suspected of being benign, it was resected by endoscopic submucosal dissection (ESD) to prevent the progression of the IDA. The pathology examination revealed the proliferation of mildly irregular-shaped or dilated glands lined by cuboidal cells and low columnar cells in the submucosa. The gastric glands were immunohistochemically positive for MUC6, suggesting pyloric gland differentiation. The lesion was covered by a foveolar-type epithelium, and we made a diagnosis of pyloric gland adenoma (PGA). PGAs are most common in the stomach, and they are rare in the duodenum, where endoscopic treatment is technically challenging. Here we report a case of large duodenal PGA successfully resected by ESD. Since part of PGAs has been reported to be associated with adenocarcinoma, minimally invasive treatment strategies are desirable to reduce the risk of progression to carcinoma.