Endoscopic submucosal dissection of early colorectal tumors using a grasping-type scissors forceps: a preliminary clinical study.

To reduce the risk of complications related to endoscopic submucosal dissection (ESD), we developed a new grasping-type scissors forceps (GSF), which can grasp and incise the targeted tissue using an electrosurgical current. We prospectively evaluated the efficacy and safety of ESD using GSF for the removal of colorectal tumors in 10 consecutive patients. After the submucosa had been injected with a solution, the lesion was separated from the surrounding normal mucosa by complete incision around the lesion using the GSF. A piece of submucosal tissue was grasped and cut with the GSF using an electrosurgical current to achieve submucosal excision. All lesions were treated easily and safely with no unexpected incisions. No delayed hemorrhage or perforation occurred. En bloc resection was obtained in all cases. The tumor-free lateral/basal margins were obtained in eight out of 10 patients. ESD using GSF appears to be an easy, safe, and technically efficient method for resecting early colorectal tumors.

Clinical and endoscopic characteristics of acute haemorrhagic rectal ulcer, and endoscopic haemostatic treatment: a retrospective study of 95 patients.

AIM: Acute haemorrhagic rectal ulcer (AHRU) is characterized by sudden onset of painless and massive rectal bleeding in elderly bedridden patients who have serious illness. Endoscopic diagnosis and management of AHRU is, however, still controversial. We retrospectively investigated 95 AHRU patients to elucidate the clinical characteristics, endoscopic findings and haemostatic strategies. METHOD: Between January 1999 and March 2007, 95 patients were diagnosed with AHRU in our hospital. Medical records and colonoscopy files were reviewed. Clinical features, colonoscopic findings, haemostatic treatment and outcome of the patients were evaluated. RESULTS: Eighty per cent of the patients were bedridden at the onset. The most frequent underlying disorder was cerebrovascular disease (36.8%). Hypoalbuminaemia (< 3.5 g/dl) was seen in 92.6% of the patients. Endoscopic findings of AHRU were classified as circumferential ulcer (41.1%), linear or nearly round small ulcer(s) (44.2%), circumferential and small ulcer(s) (7.4%) and Dieulafoy-like ulcer (7.4%). Primary endoscopic haemostatic treatment was performed in 45.3% of cases. Recurrent bleeding occurred in 24.2% of patients. Permanent haemostasis was achieved by secondary endoscopic treatment in 82.6% of re-bleeding patients. CONCLUSION: Understanding the typical clinical and endoscopic findings and careful endoscopic examination are important for the accurate diagnosis of AHRU, and endoscopic haemostatic therapy may be effective for bleeding patients.

Endoscopic submucosal dissection using a novel grasping type scissors forceps.

Endoscopic submucosal dissection (ESD) with a knife is a technically demanding procedure that is associated with a high complication rate. The shortcoming of this method is the difficulty in fixing the knife to the target lesion. This difficulty can lead to unexpected incision, resulting in major complications such as perforation and bleeding. To reduce the risk of complications related to ESD, we developed a new grasping type scissors forceps (GSF), which can grasp and incise the targeted tissue using an electrosurgical current. The ESD procedure using the GSF was carried out in an animal model (resected porcine stomachs in vitro). After marking the lesion and injecting a solution into the submucosa, the lesion was separated from the surrounding normal mucosa following complete incision around the lesion using the GSF. A piece of submucosal tissue was grasped and cut with the GSF using an electrosurgical current to achieve submucosal exfoliation. ESD using the GSF was carried out safely and easily without unintentional incision. ESD using GSF appears to be an easy, safe, and technically efficient method for resecting gastrointestinal neoplasms.

Endoscopic band ligation therapy for upper gastrointestinal bleeding related to Mallory-Weiss syndrome.

BACKGROUND: No consensus exists as to the best endoscopic treatment for Mallory-Weiss syndrome. Endoscopic band ligation is a readily available and easily learned technique. This prospective study evaluated the efficacy and safety of endoscopic band ligation therapy for Mallory-Weiss syndrome. METHODS: From August 1998 to June 2005, a clinical trial assessed 37 patients with a diagnosis of Mallory-Weiss syndrome who had active bleeding, exposed vessels, or both. Their lesions were treated using endoscopic band ligation. RESULTS: Endoscopic band ligation was successful in 36 of 37 cases, with a follow-up period ranging from 1 to 24 months. The remaining patient had severe liver failure and disseminated intravascular coagulation. The patient bled again at 12 h and subsequently died. Except for this case, no recurrent bleeding, perforation, or other complications occurred. CONCLUSIONS: The study results suggest that endoscopic band ligation is an effective, safe, and easily learned procedure for treating upper gastrointestinal bleeding related to Mallory-Weiss syndrome.

EUS-guided endoscopic resection using band ligation of oesophageal granular cell tumour: report of a case.

A 60-year-old Japanese man was referred for treatment of a polypoid oesophageal tumour. Radiographic examination of the upper gastrointestinal tract disclosed a nodule with central depression in the lower esophagus. By endoscopy the nodule was yellowish and appeared submucosal. Endoscopic ultrasonography demonstrated a hypoechoic solid tumour limited in submucosa without lymph node involvement. Endoscopic resection using band ligation was performed under guidance by endoscopic ultrasonography. By histologic examination the tumour consisted of large cells arranged in nests. These cells had abundant granular cytoplasm and small round nuclei. They expressed S-100 protein and were CD68, and periodic acid-Schiff positive. No expression of alpha-smooth muscle actin was noted. The tumour was limited in submucosa. Findings were consistent with complete endoscopic resection. This report may be the first concerning an oesophageal granular cell tumour successfully treated with EUS-guided endoscopic resection using band ligation.

Colonic muco-submucosal elongated polyp: diagnosis with endoscopic ultrasound.

Colonic muco-submucosal elongated polyp is a new clinical entity first reported in 1998. The purpose of this report is to determine the value of endoscopic ultrasound in the diagnosis of this condition. We reviewed the endosonographic and histological findings of seven colonic muco-submucosal elongated polyps that were removed completely by endoscopic resection or surgery. The lesions appeared as pedunculated submucosal tumours, measuring 1-4 cm in maximal diameter. Endosonographically, all lesions consisted of mucosal and submucosal layers, and microcystic components were found in the submucosal layer. There were no echogenic masses or muscularis propria within the polyps. These endosonographic features corresponded to histological findings of this type of polyp which was covered with normal mucosa and composed of submucosal layer alone. The submucosal layer consisted of oedematous, loose, connective tissue and/or fibrous tissue, accompanied by dilated blood vessels and lymphatics. Endoscopic ultrasound enabled differentiation of colonic muco-submucosal elongated polyp from other submucosal lesions.

Transit endoscopic ultrasound of colorectal cancer using a 12 MHz catheter probe.

The objective of this study was to examine the accuracy of a 12 MHz ultrasound catheter probe in the pre-operative staging of colorectal cancer by assessing the depth of tumour infiltration and involvement of pericolonic lymph nodes. 159 patients with colorectal cancer who underwent ultrasound examination with a 12 MHz catheter probe were studied prospectively. The results of this imaging procedure were compared with the histological findings of the resected specimens. The accuracy of the 12 MHz ultrasound catheter probe for depth of invasion (T category) was 85% (131/154) for all tumours, 87% (46/53) for pT1 tumours, 60% (9/15) for pT2 tumours, 89% (74/83) for pT3 tumours and 67% (2/3) for pT4 tumours. The accuracy for tumours of the rectum and colon was 81% and 89%, respectively. The accuracy of the probe for nodal staging (N category) was 67% (76/114) overall. The sensitivity was 70% (33/47), the specificity 64% (43/67), the positive predictive value 58% (33/57) and the negative predictive value 75% (43/57). Endoscopic ultrasound using a 12 MHz catheter probe accurately assessed tumour stage, although nodal staging remained suboptimal. This method may aid in the selection of treatment for patients with colorectal cancer.

A comparison of an open and laparoscopic appendectomy for patients with liver cirrhosis.

Liver cirrhosis is a critical factor contributing to morbidity and mortality in abdominal surgery, because patients with cirrhosis have a particularly high risk of developing bleeding, infection, and ascites. Laparoscopic appendectomy (LA) recently has gained a lot of attention around the world; however, comparisons between the benefits of LA and those of conventional open appendectomy (OA) for patients with liver cirrhosis have yet to be sufficiently compiled. In the present retrospective study, 40 patients with liver cirrhosis who were diagnosed with acute appendicitis before surgery underwent an appendectomy (OA in 25 patients and LA in 15 patients). This study focused on the operative time, amount of postoperative pain, use of analgesics, the restart of a normal diet, number of complications, length of hospital stay, and cost-effectiveness of the procedure in such patients. The amount of postoperative pain and the length of hospital stay were significantly smaller in the LA group. The mean values of the serum C-reactive protein on postoperative days 1, 3, and 7 were significantly less in the LA group. The number of wound infections and wound bleeding was also less in the LA group. The difference in the total cost of hospitalization was not significant. The cost of the operation was greater in the LA group than in the OA group, whereas the hospitalization cost in the LA group was less than that in the OA group. The results of this study suggest that LA may be superior to OA for the treatment of postoperative pain and postoperative complications for patients with liver cirrhosis. Long-term follow-up studies are still necessary, however, to determine any possible decrease in the number of late complications.

Intraductal papillary-mucinous tumors of the pancreas: differential diagnosis between benign and malignant tumors by endoscopic ultrasonography.

OBJECTIVES: Recently, intraductal papillary-mucinous tumor (IPMT) of the pancreas has increasingly been recognized. However, differential diagnosis between benign and malignant IPMT is often difficult using conventional imaging modalities. The purpose of this study was to retrospectively investigate the value of endoscopic ultrasonography (EUS) for differentiating malignant from benign IPMT. METHODS: A total of 51 patients with IPMT were preoperatively examined by EUS. The endosonograhic findings were compared with histopathological findings of the resected specimens. RESULTS: In main duct type IPMT, the diameter of the main pancreatic duct (MPD) was > or =10 mm in seven of the eight malignant tumors, compared with two of the seven benign tumors (p < 0.05). In branch duct type IPMT, three of the four large tumors (>40 mm) with irregular thick septa were malignant lesions. In both main duct type IPMT and branch duct IPMT, eight patients had large mural nodules (>10 mm); seven of the eight tumors were malignant and one of the eight tumors was benign. When the tumor was diagnosed as malignant according to above three findings, EUS was able to differentiate between malignant and benign IPMT with an accuracy of 86%. CONCLUSIONS: Main duct type tumors with > or =10 mm dilated MPD, branch duct type tumors (>40 mm) with irregular septa, and large mural nodules (>10 mm) strongly suggest malignancy on EUS. EUS would be a useful modality for differentiating between benign and malignant IPMT.

Preoperative evaluation of submucosal invasive colorectal cancer using a 15-MHz ultrasound miniprobe.

BACKGROUND AND STUDY AIMS: Recently, it was reported that focal submucosal invasive colorectal cancer could be treated by polypectomy or endoscopic mucosal resection (EMR) because of the rarity of lymph-node metastasis. Our objective was to examine the accuracy and efficacy of a 15-MHz ultrasound miniprobe in the preoperative evaluation of the degree of submucosal invasion in colorectal cancer. PATIENTS AND METHODS: A total of 35 patients with submucosal invasive colorectal cancer who underwent ultrasonography with a miniprobe were studied prospectively. The results of this imaging were compared with the histologic findings in resected specimens. RESULTS: Although the accuracy of the miniprobe in categorizing submucosal invasion into three subclasses (SM1, invasion limited to the upper third; SM2, limited to the middle third; SM3, limited to the lower third) was low (37.1%; 13/35), the accuracy in differentiation between < or = SMI (M and SMI) and > or = SM2 (SM2, SM3, MP, and S) was 85.7 % (30/35). CONCLUSIONS: The miniprobe can be useful for therapeutic decision-making in submucosal invasive colorectal cancer.

The therapeutic strategies in performing emergency surgery for gastroduodenal ulcer perforation in 130 patients over 70 years of age.

BACKGROUND/AIMS: Gastroduodenal ulcer is a very common illness in Japan. As the number of elderly persons in Japan increases the same as in Europe and America, the number of such patients requiring a gastroduodenal emergency operation has also increased. Regarding the complications of peptic ulcer, a perforation remains the most important fatal complication. The aim of this study is to investigate the operative risk factors and the long-term recurrence rates and to define the optimal surgical procedures in emergency situations in elderly patients. METHODOLOGY: From April 1988 through March 1997, 130 patients over 70 years of age with a perforated gastroduodenal ulcer (a duodenal ulcer perforation in 50 patients and a gastric ulcer perforation in 80 patients) were operated on in an emergency situation in our clinic. We investigated the following items; medical illness, preoperative risk factor, optimal surgical procedure, postoperative organ failure and the cumulative recurrence-free rates after surgical treatment. RESULTS: A significant correlation with mortality was observed in patients with established comorbidity in the following organs: lung (P = 0.03), heart (P = 0.02), kidney (P = 0.04), and diabetes (P = 0.03). The highest postoperative mortality rate was recorded in patients who underwent a simple closure of a duodenal ulcer perforation (4 patients; 26.7%), while the lowest postoperative mortality rate was recorded in patients who underwent a simple closure and vagotomy of a duodenal ulcer perforation (3 patients; 12.5%). In gastric ulcers, the mortality rate in patients with a gastrectomy was significantly higher than in patients with a simple closure. The practical application of the three risk factors (preoperative shock, delay to surgery over 24 hours, and medical illness) was shown by the progressive rise in the mortality rate with the increasing number of risk factors. Based on the 5 postoperative years after treating a perforated duodenal ulcer, the cumulative recurrence rate after a simple closure (63.6%) was significantly higher than that after a simple closure and vagotomy (38.1%) (n = 0.02) or after gastrectomy (0%) (P < 0.001). At 5 years postoperatively, the cumulative recurrence rate after a simple closure (41.2%) was significantly higher than that after a gastrectomy (15.9%) (P < 0.01). CONCLUSIONS: In conclusion, in an emergency situation, elderly patients are in a highly unfavorable prognostic condition due to their advanced age, and comorbidity, which thus leads to poorer results, not only worldwide, but also in Japan. Based on our findings, in duodenal ulcer cases, a simple closure and vagotomy is recommended because of its low mortality and minimal stress, except for cases with a giant perforation measuring over 20 mm in diameter at the perforation hole or with severe duodenal stenosis. In stomach ulcer cases, a gastrectomy may be recommended because of its low recurrence rate.

Two cases of colonic adenomatous polyps accompanied by a migrated surgical suture.

A 56-year-old man and a 70-year-old woman, with histories of left colectomy and appendectomy respectively, were admitted to our hospital. In both cases, colonoscopy showed a pedunculated colonic polyp in the ascending colon, and a silk suture became visible in the stalk during polypectomy. The histological diagnosis was adenoma. These two cases constitute the first report of colonic adenomatous polyps accompanied by suture migration.

Preoperative staging of rectal cancer using a 7.5 MHz front-loading US probe.

BACKGROUND: Conventional echoendoscopes have disadvantages when used for staging colorectal cancer including the inability to pass the instrument through tight stenosis and limited maneuverability. This study evaluated the preoperative use of a newly developed 7.5 MHz front-loading ultrasound probe (FLUP) for local staging of rectal cancer. METHODS: A 7.5 MHz FLUP, diameter 7.3 mm, was used in this study. The mechanical shaft portion of the probe can be passed in retrograde fashion through the accessory channel of a standard colonoscope. Thirty-nine patients with rectal cancer underwent ultrasonography with this probe. The tumors were staged using the TNM system, and the results were compared with the histologic findings of the resected specimens. RESULTS: The FLUP proved to be satisfactory, with respect to maneuverability, for traversing stenosis and accurate recognition of small tumors under direct endoscopic control. The accuracy of the FLUP for T staging was 82% (32 of 39) for all tumors, 90% in pT1, and 79% in pT2 to pT4 tumors. The accuracy of the FLUP for N staging was 72% (23 of 32) overall. The sensitivity was 83%, the specificity was 65%, the positive predictive value was 59%, and the negative predictive value was 87%. CONCLUSIONS: The 7.5 MHz FLUP appears to be useful for preoperative local staging of rectal cancer. This system makes it technically easier to image small cancers as well as advanced rectal cancers.