Useful condition of chromoendoscopy with indigo carmine and acetic acid for identifying a demarcation line prior to endoscopic submucosal dissection for early gastric cancer.

BACKGROUND: Identifying a precise demarcation line (DL) is indispensable for pathological complete en bloc endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We evaluated the useful condition of chromoendoscopy with indigo carmine and acetic acid for marking dots around lesions before ESD for EGC. METHODS: We examined 98 consecutive patients with 109 intramucosal EGCs (mean diameter, 17.8 ± 12.4 mm; main histologic type, 96 intestinal and 13 diffuse) resected by en bloc ESD after chromoendoscopy with indigo carmine and acetic acid between December 2012 and February 2014. The DL was identified by this technique just before ESD (mean chromoendoscopy observation time, 71.6 s); subsequently, marking dots were placed around the EGC. EGCs were classified into two groups: useful for identifying the DL or useless. Clinicopathological characteristics and clinical outcomes were evaluated in each group. RESULTS: Forty-two of the 109 cases (38.5 %) were determined useful for chromoendoscopy with indigo carmine and acetic acid. Multivariate analysis with logistic regression showed that macroscopic type (protruded or flat elevated-type) and atrophic border (the oral side of tumor) were independently associated with the usefulness of chromoendoscopy using indigo carmine and acetic acid for identifying the DL of EGCs (P < 0.05). The histologically positive horizontal margin after ESD was 0 % (0/42) in useful cases, and 7.5 % (5/67) in useless cases. CONCLUSIONS: Before ESD, chromoendoscopy with indigo carmine and acetic acid can be used for creating precise markings in protruded or flat elevated-type EGC or at the atrophic border on the oral side of EGCs.

Long-term prognosis after endoscopic submucosal dissection for early gastric cancer in super-elderly patients.

BACKGROUND: No previous study has confirmed the safety of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in the super-elderly patient population. The current study aimed to evaluate the validity of ESD for EGC in super-elderly patients aged ≥85 years with comorbidities. METHODS: Our study group included 85 super-elderly patients (102 EGCs) who were diagnosed at Hiroshima University Hospital between April 2002 and October 2014. We evaluated the en bloc resection rates, R0 resection rates, complication rates, and prognosis in relation to the degree of comorbidities (group A-H, patients with high-risk comorbidities; group A-L, patients with low-risk comorbidities; group B, patients without comorbidities; and group C, patients followed without ESD). RESULTS: The en bloc resection rates were 100, 96, and 100 % in groups A-H, A-L, and B, respectively. R0 resection rates were 94, 96, and 94 % in groups A-H, A-L, and B, respectively. There were no severe complications related to ESD. During the follow-up period, there was a significantly higher frequency of death in group A than in group B (p < 0.01), and there were no significant differences between groups A-H and A-L. However, there were no cases of death related to gastric cancer. CONCLUSIONS: ESD was performed safely, and death related to gastric cancer was prevented in super-elderly patients with comorbidities, regardless of the degree of the disease. However, patients with comorbidities are at a high risk of poor prognosis.

Risk factors and management of positive horizontal margin in early gastric cancer resected by en bloc endoscopic submucosal dissection.

BACKGROUND: Although endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric cancer (EGC), there is no consensus regarding the management of positive horizontal margin (HM) despite en bloc ESD. The aim of the current study was to identify the risk factors and optimal management of positive HM in EGCs resected by en bloc ESD. METHODS: A total of 890 consecutive patients with 1,053 intramucosal EGCs resected by en bloc ESD between April 2005 and June 2011. Clinicopathological data were retrieved retrospectively to assess the positive HM rate, local recurrence rate, risk factors for positive HM, and outcomes of treatment for local recurrent tumor. Positive HM was defined as a margin with direct tumor invasion (type A), the presence of cancerous cells on either end of 2-mm-thick cut sections (type B), or an unclear tumor margin resulting from crush or burn damage (type C). RESULTS: The positive HM rate was 2.0% (21/1,053). The local recurrence rate was 0.3% (3/1,053). All local recurrent tumors were intramucosal carcinomas, and were resected curatively by re-ESD. Multivariate analysis with logistic regression showed tumor location in the upper third of the stomach and lesions not matching the absolute indication to be independent risk factors for positive HM. CONCLUSION: The risk factors for HM positivity in cases of EGC resected by en bloc ESD are tumor location in the upper third of the stomach and dissatisfaction of the absolute indication for curative ESD.

Characteristics of metachronous gastric tumors after endoscopic submucosal dissection for gastric intraepithelial neoplasms.

Background. Recently, endoscopic submucosal dissection (ESD) has become a standard treatment method for early gastric cancer and concurrent stomach preservation. However, metachronous recurrences have become a major problem. We evaluated the incidence and clinicopathologic features of and examined the risk factors for metachronous gastric tumors. Methods. A total of 357 patients who underwent ESD for gastric tumors (245 early gastric cancers and 112 adenomas) and were followed up for more than 12 months without recurrence within the first 12 months were enrolled. We investigated the incidence and clinicopathologic features of metachronous tumors after ESD. We also analyzed the potential risk factors for metachronous tumors using the Kaplan-Meier method and Cox's proportional hazards model. Results. The annual incidence of metachronous tumors after ESD was 2.4%. The median period until discovery after initial ESD was 26.0 months, and the median observation period was 52.6 months. Male patients developed metachronous tumors more frequently (P = 0.04), and the hazard ratio of female to male patients was 0.36 (95% confidence interval: 0.11-0.89). Conclusions. Patients with a previous history of gastric tumors have a high risk of subsequent gastric tumor development and male patients should be carefully followed up after ESD for gastric tumor.

Clinical validity of the expanded criteria for endoscopic resection of undifferentiated-type early gastric cancer based on long-term outcomes.

BACKGROUND: According to the Japanese Gastric Cancer Treatment Guidelines, the expanded criteria for endoscopic resection (ER) of undifferentiated-type early gastric cancer (UEGC) is ulcer-negative, intramucosal cancer 20 mm or less in diameter without lymphovascular invasion. The aim of this study was to confirm validity of the expanded criteria for curative ER of UEGC. METHODS: Subjects were 125 patients from whom 125 UEGCs were resected endoscopically between April 1990 and March 2011. Endoscopic mucosal resection (EMR) (28 lesions, 28 patients) or endoscopic submucosal dissection (ESD) (97 lesions, 97 patients) was performed. We determined the complete resection rate, post-ER bleeding rate, perforation rate, and outcome in both groups, and analyzed the survival outcomes of 84 patients who were followed for more than 5 years (mean, 101.9 months) according to the indication for ER [expanded criteria for curative (n = 52) vs. criteria for noncurative (n = 32)]. RESULTS: Complete resection rates for EMR and ESD were 54 % (15 of 28) and 89 % (86 of 97), respectively, with that for ESD being significantly higher (p < 0.01). Outcomes after ER were as follows: among 52 cases of UEGC meeting the expanded criteria, additional surgical resection was performed in 11 cases of incomplete resection. No local recurrence or lymph node metastasis was observed. Forty-eight patients who were simply surveyed clinically (93.6 ± 38.4 months) after ER survived without recurrence; the remaining 7 patients died of other causes. Among the 32 cases of UEGC meeting the criteria for noncurative resection, additional surgical resection was performed in 13 cases. Among the 19 follow-up cases (108.3 ± 38.7 months), death due to metastasis of the primary disease occurred in 3 cases, death from other causes occurred in 5 cases, and local residual submucosal recurrence occurred in 1 case. CONCLUSIONS: ESD is a useful technique for complete resection as a total excisional biopsy compared with EMR and radical cure of UEGCs meeting the expanded criteria.

Continued use of low-dose aspirin does not increase the risk of bleeding during or after endoscopic submucosal dissection for early gastric cancer.

BACKGROUND: Although recent guidelines for endoscopic submucosal dissection (ESD) as treatment for early gastric cancer (EGC) recommend noninterruption of low-dose aspirin (LDA) perioperatively, this strategy is controversial. It was our practice to interrupt LDA therapy 5-7 days before to ESD until December 2010, when we instituted the new guidelines and performed ESD without interrupting LDA therapy. Our purpose in this study was to confirm the validity of noninterrupted use of LDA in patients undergoing ESD for EGC. METHODS: We studied 78 consecutive patients with 94 EGCs who were routinely taking LDA and were treated by ESD at Hiroshima University Hospital between April 2005 and June 2012. The patients were of two groups: those in whom LDA was interrupted perioperatively (53 patients with 66 EGCs) and those in whom LDA was continued perioperatively (25 patients with 28 EGCs). RESULTS: The complete resection rate was 92.4 % (61/66) in the LDA-interrupted group and 100 % (28/28) in the LDA-continued group. Incidences of poor bleeding control during the procedure and bleeding after procedure were 10.6 % (7/66) and 4.8 % (3/66), respectively, in the LDA-interrupted group and 7.1 % (2/28) and 3.6 % (1/28) in the LDA-continued group. Two patients in the interrupted-LDA group suffered cerebrovascular infarction before ESD, and 2 patients in this group suffered acute myocardial infarction after ESD. CONCLUSIONS: Our data suggest that continued use of LDA does not increase the risk of bleeding during or after ESD for EGC and does decrease the risk of ischemic events.

Clinical outcomes of endoscopic submucosal dissection for early gastric cancer in patients with chronic kidney disease.

BACKGROUND AND AIM: Endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric cancer (EGC), and the number of ESD performed for EGC in patients with chronic kidney disease (CKD) is increasing. Although patients undergoing hemodialysis tend to bleed and are at high risk for cardiovascular disease, the effectiveness and safety of ESD for EGC in patients with CKD in particular have not been established. The aim of this study was to evaluate the effectiveness and potential adverse effects of ESD for EGC in patients with CKD undergoing hemodialysis. METHODS: Sixty-three consecutive CKD patients in whom 79 EGCs were treated by ESD between October 2004 and January 2012; 15 of the 63 patients were hemodialysis patients. Complete en bloc resection rate and ESD-related complications in hemodialysis patients versus non-hemodialysis patients were evaluated. RESULTS: The complete en bloc resection rate was 100% (15/15) in the hemodialysis patients and 87.5% (56/64) in the non-hemodialysis patients, respectively. The post-ESD bleeding rate was 33% (5/15) and 9% (6/64), respectively (P < 0.05). Perforation occurred only in non-hemodialysis patients; the incidence was 5% (3/64). Two ESD-related deaths occurred among hemodialysis patients (13%, 2/15); femoral artery infarction triggered post-ESD bleeding in one of these two patients, and alveolar hemorrhage occurred in the other. CONCLUSION: Hemodialysis poses a risk of post-ESD bleeding. We must understand this risk and provide countermeasures for post-ESD bleeding in hemodialysis patients.

[Endoscopic diagnosis of early gastric cancer].

It is relatively difficult to detect minute depressed (0-IIc) and flat (0-IIb) type early gastric cancers (EGCs) with ordinary endoscopic observation. Good preparation and washing out the mucus in the stomach are necessary for detection and correct diagnosis with chromoendoscopy using indigocarmine. It is important to diagnose whether EGC infiltration is submucosal (SM) deep or not, because the indication of endoscopic resection depends on the depths of the EGC. The characteristic endoscopic features of SM deep invasion in EGCs are related to macroscopic type, tumor size, histological type, fold convergency and endoscopic rigidity of the lesion area.

[Classification of the bleeding pattern in colonic diverticulum is useful to predict the risk of bleeding or re-bleeding after endoscopic treatment].

We examined the re-bleeding rate after endoscopic hemostasis according to the bleeding pattern in patients with an acute lower gastrointestinal hemorrhage from colonic diverticula in 34 patients with active bleeding (Type 1) and 49 patients with exposed vessels and/or erosions in the base of diverticulum and no active bleeding (Type 2). Endoscopic hemostasis was performed by clipping the exposed vessel or erosions (direct method) or the entire diverticular orifice (reefing method). The incidence of re-bleeding was significantly higher in the Type 1 group than in the Type 2 group (p=0.002). All Type 1 cases were treated by the reefing method. In contrast, 14 of the 49 Type 2 cases were treated by the direct method, and no re-bleeding was observed in these cases. Of the other 35 Type 2 cases treated by reafing, rebleeding was seen in 5 cases. More effective endoscopic treatment is needed to prevent early re-bleeding, especially for Type 1 patients. The direct method may therefore reduce the rate of re-bleeding in Type 2 patients.

[Cerebral sinus thrombosis complicating ulcerative colitis].

A 40-year-old woman with ulcerative colitis (UC) was admitted to our hospital because of diminution of consciousness and left palsy. UC had been diagnosed 6 years before, but had not been treated. MRI revealed complete obstruction of the superior sagittal sinus. Cerebral sinus thrombosis, as a complication of UC, was diagnosed. We started anticoagulant therapy, but she passed away 5 days later. UC has been reported to show hypercoagulation status, leading to deep vein thrombosis within the body which sometimes causes pulmonary infarction, but occurrence of cerebral sinus thrombosis is rare.

[Dynamic computed tomography is useful for the diagnosis and colonoscopic treatment of colonic diverticular bleeding].

We investigated whether emergency dynamic computed tomography (CT) is helpful to identify bleeding colonic diverticulum treatable by colonoscopy. We enrolled 95 consecutive patients given diagnoses of colonic diverticular bleeding at Hiroshima City Hospital in the present study, of whom 60 underwent CT before colonoscopy (CT group), and 35 underwent colonoscopy alone (CS group). In the CT group, bleeding diverticula were identified and treated by colonoscopy in 31 of 32 (96.9%) patients in whom extravasation was detected by CT. The interval between bleeding being recognized and CT (median 1.0 hours) in patients in whom extravasation was detected by CT was shorter than that in whom extravasation was not detected (median 5.0 hours). To identify and treat bleeding diverticula by colonoscopy, the use of emergency dynamic CT prior to colonoscopy is recommended.

[A case of gangliocytic paraganglioma with lymphoid metastasis].

We report a 67-year-old woman who had stiff shoulders and anemia. Upper gastrointestinal endoscopy revealed a pedunclated nodular submucosal tumor with erosions and surface ulcers in the second portion of the duodenum. These endoscopic findings were thought to be characteristic of gangliocytic paraganglioma. CT scan revealed suspected lymph node metastasis, thus the tumor was resected with pancreaticoduodenectomy and was found to be a gangliocytic paraganglioma associated with lymph nodal metastasis. Due to the rarity of the disease there is no consensus regarding treatment. Although this tumor is considered benign, the possibility exists for regional lymph nodal spread. The treatment should be well planned with continuous careful evaluation.

Carbon dioxide insufflation is useful for obtaining clear images of the bile duct during peroral cholangioscopy (with video).

BACKGROUND: Peroral cholangioscopy (POCS) is useful for the diagnosis of various bile duct lesions. However, it is often difficult to obtain clear images because of bile or biliary sludge in the bile duct, even after vigorous irrigation of the bile duct with saline solution. Therefore, this study investigated whether inflation with carbon dioxide (CO(2)) yields clearer images of the bile duct than conventional saline solution irrigation during POCS. OBJECTIVE: To evaluate the clinical utility and safety of CO(2) insufflation into the bile duct to obtain clear images in POCS observations by comparing this method with conventional saline solution irrigation. SETTING: A single center. DESIGN: Case-control study. PATIENTS: Nineteen patients with suspected biliary diseases. INTERVENTIONS: CO(2) insufflation into the bile duct during POCS. MAIN OUTCOME MEASUREMENTS: The quality and safety of this method. RESULT: The quality of the images of the bile duct lumen with CO(2) insufflation (10 patients) was significantly superior to those with saline solution irrigation (9 patients) in both clarity (P < .05) and color (P < .05). In particular, extremely clear images could be obtained from the middle part of common bile duct to the right and left hepatic duct. No serious POCS-related complications occurred. There was no significant change in the venous partial pressure of the CO(2) level during the procedure. LIMITATIONS: The number of patients examined was small. CONCLUSIONS: CO(2) insufflation is useful for obtaining clear images of the bile duct during POCS, which makes it possible to determine the qualitative diagnosis and the extent of various bile duct lesions.