Multibending scope use for reduction of perforation risks in endoscopic submucosal dissection.

AIMS: To identify areas that are difficult to access by the single scope at the time of endoscopic submucosal dissection (ESD) and examine the effectiveness, en-bloc, R0 resection, and perforation rate after changing to multibending scope at the same site. MATERIAL AND METHODS: When the direct visualization of the submucosal layer became impossible with Q260J or in the position where the device became vertical and peeling became impossible in parallel, we decided to change to the multibending 2TQ260M scope to record the position where the change was effective and the perforation rate. RESULTS: A total of 315 lesions were studied. Of the 12 sites, ESD was completed using the Q260J alone at four sites. The 2TQ260M scope was used with greater frequency at the fornix (88.9%) and on the line of the lesser curvature of the stomach (37.1%). In the cases with observed perforations (0.9%), the submucosal layer was not elevated due to the adhesion caused by strong fibrosis. None of the cases involving the change to 2TQ260M was ineffective, nor were perforations observed, and all resected specimens were en-bloc and R0 resections. CONCLUSIONS: The success rate of this scope may help clinicians perform ESD with greater understanding.

Procedure Time for Gastric Endoscopic Submucosal Dissection according to Location, considering Both Mucosal Circumferential Incision and Submucosal Dissection.

Background. Previous assessments of technical difficulty and procedure time for endoscopic submucosal dissection (ESD) of gastric neoplasms did not take into account several critical determinants of these parameters. However, two key phases of ESD determine the total procedure time: the mucosal circumference incision speed (CIS) and submucosal dissection speed (SDS). Methods. We included 302 cases of en bloc and R0 resection of gastric neoplasms performed by 10 operators who had completed the training program at our hospital. Twelve locations were classified based on multiple criteria, such as condition of surrounding mucosa, lesion vascularity, presence of submucosal fat, ulcers, scars, fibrosis, and scope and device maneuverability. Lesions in different locations were classified into three groups based on the length of the procedure: fast, moderate, or late. Results. A significant difference was found in CIS and SDS for each location (p < 0.01), which demonstrates the validity of this classification system. In several locations, CIS and SDS were not consistent with each other. Conclusion. CIS and SDS did not correspond to each other even for lesions in the same location. Consideration of ESD procedure time for gastric neoplasms requires a more elaborate classification system than that previously reported.

Youngest case of an early gastric cancer after successful eradication therapy.

A 28-year-old woman visited our clinic with a chief complaint of epigastralgia. She had received successful Helicobacter pylori (H. pylori) eradication therapy 5 years before. We repeated esophagogastroduodenoscopy, and a discolored depressed area with reddish spots and converging folds, 20 mm in size, was detected. No atrophic change including intestinal metaplasia or nodular gastritis was seen endoscopically. Two endoscopic biopsies revealed undifferentiated adenocarcinoma. No H. pylori was found, and the (13)C-urea breath test was also negative. Abdominal computed tomography demonstrated no nodal involvement, distant metastasis or fluid collection. She underwent a laparoscopy-assisted distal gastrectomy. Histologically, the resected specimen revealed an early undifferentiated gastric cancer that had invaded deeply into the submucosal layer. Nodal involvement was histologically confirmed. No atrophic change or H. pylori infection was evident histologically. This is the youngest patient ever reported to have developed a node-positive early gastric cancer after eradication of H. pylori.

Invasive rectal cancer treated with a combination of endoscopic submucosal dissection and chemoradiation.

A 68-year-old man underwent total colonoscopy because of a positive fecal occult blood test. A polypoid lesion (Is + IIa), 20 mm in size, was detected in the very lower part of the rectum. A large reddish nodule suggesting invasive carcinoma was seen on conventional view. Magnifying chromoendoscopy, however, disclosed a non-invasive pit pattern in that part. Moreover, magnifying narrow band imaging showed a type IIIA capillary pattern. Therefore, endoscopic submucosal dissection was successfully conducted for en bloc resection. Histologically, it was a rectal submucosal invasive carcinoma deeply invading into the submucosal layer with vascular invasion. Although additional surgical treatment was suggested, the patient refused the proposal and received chemoradiation therapy to avoid a permanent colostomy. Periodic evaluation revealed no local or distant metastasis 3 years thereafter.

Development and clinical usability of a new traction device "medical ring" for endoscopic submucosal dissection of early gastric cancer.

BACKGROUND: Although various traction devices exist for endoscopic submucosal dissection (ESD), the effects of the material used in the devices on the human body has not been considered. Moreover, there has been no report on a device that facilitates dissection both on the oral and anal side of the lesion. We made a traction device that has no deleterious effects on the body and is noninvasive, easy to use, and enables a bilateral approach in ESD. We report the process of its creation and a prospective evaluation of its usage in actual ESD procedures. METHODS: This study is prospective case control study. Thirty-seven patients for whom the device would be used were consecutively and prospectively enrolled (device used group). Control subjects in whom the device would not be used and who had lesions matched for size and location with those of the device used group were randomly selected (device not used group). Both groups were classified into three subgroups according to treatment difficulty: group A: easy; group B: intermediate; and group C: difficult. The dissection time per cm(2) in each group was examined. RESULTS: Dissection times in the device not used group/device used group were as follows: group A, 5.8/2.1 min/cm(2) (p < 0.01); group B, 6.1/3.8 min/cm(2) (p < 0.05); and group C, 7.9/3.6 min/cm(2) (p < 0.01), respectively. CONCLUSIONS: The newly developed medical ring was shown to be feasible and safe and allowed excellent visualization through suitable tension and facilitated rapid gastric ESD.

Endoscopic retrieval of a gastric trichobezoar.

A 9-year-old girl presented with a chief complaint of abdominal pain. Esophagogastroduodenal endoscopy (EGD) identified a long and large gastric trichobezoar extending into the duodenum. We attempted endoscopic retrieval after informed consent was obtained from the patient's mother. Initially, a gasper with 5-prolongs, commonly used for retrieval of endoscopically excised polyps, failed to remove the whole trichobezoar. When a net was used instead, it proved impossible to remove the trichobezoar completely. Therefore, we withdrew the scope from the mouth, leaving the net grasping the tricobezoar firmly in the stomach. Subsequently, we were able to retrieve about 70% of the trichobezoar manually by grasping the snare part of the net directly. A second pass found no deep laceration or perforation endoscopically. The remaining trichobezoar was completely retrieved with the net. The procedure was completed within 15 min. The retrieved specimens were 34 cm in length and 100 g in weight. The patient was discharged uneventfully 5 d thereafter. She was advised to visit a psychiatrist to avoid suffering from a relapse. Follow-up EGD showed no trichobezoar, and the patient's frontal hair grew back.

A novel endoscopic ablation of gastric antral vascular ectasia.

An 80-year-old woman was admitted to our hospital because of tarry stool with iron deficiency anemia. Her past history included autoimmune hepatitis. Esophagogastroduodenal endoscopy was performed to investigate the bleeding source and revealed multiple linear gastric vascular malformations in the antrum and cardia, compatible with Gastric antral vascular ectasia (GAVE). Endoscopic ablation was carried out with the tip of the hot biopsy forceps without opening at soft coagulation mode of 80W. The patient tolerated the procedure well and there were no complications associated with endoscopic therapies. After two sessions of endoscopic ablation her anemia improved to around 10 g/dL, an increase of 3.6 g/dL. Various endoscopic treatments have been described to manage GAVE. The most popular is argon plasma coagulation (APC), although APC is associated with over-distension induced by the argon plasma gas. To avoid over-distension and to reduce the abdominal discomfort/pain of this patient, we have used hot biopsy forceps instead of APC. Our case suggests that this procedure is effective, easy and convenient, as no special equipment or skill is necessary.

Peeling a giant ileal lipoma with endoscopic unroofing and submucosal dissection.

Lipoma is relatively common in the colon but is less often in the small intestine. Most lipomas are incidentally detected at endoscopy and are usually small and asymptomatic. However, some of them can present with obstruction and/or intussusceptions. Surgical resection is commonly recommended to remove such significant lipomas with a limited pedicle and larger than 2 cm in size, as endoscopic resection may result in unfavorable complications such as intestinal perforations. We report a case of 62-year-old man presenting with hematochezia. Colonoscopy showed a submucosal tumor, about 50 mm in size, in the terminal ileum. A clinical diagnosis of lipoma was established based on the findings of colonoscopy and abdominal computed tomography (CT). As the patient complained of hematochezia and mild iron deficiency anemia associated with repeated tumor prolapse, we decided to remove his lipoma. Consequently, the lesion was completely removed en bloc. Although abdominal CT immediately after removal of the lesion showed a small amount of free air, conservative treatment was successfully carried out for the perforation. Histologically, the removed lesion was a lipoma.