Early oesophageal carcinoma with a defect of the oesophageal muscularis propria: a rare case report.

We herein report a rare case of early oesophageal cancer combined with an oesophageal muscularis propria defect discovered under endoscopic submucosal dissection. The surgeon did not damage the muscularis propria during endoscopic resection; however, we observed the mediastinal cavity as well as the later occurrence of subcutaneous emphysema. Consequently, the patient was considered to have a muscularis propria defect. This phenomenon has not been reported in the literature to date.

Adenoma Recurrence after Endoscopic Piecemeal Mucosal Resection of Colorectal Flat Lesions: Applicability of the Sydney EMR Recurrence Tool in a Non-Tertiary Centre.

Introduction: Endoscopic mucosal resection (EMR) is the treatment of choice for non-invasive colorectal flat lesions. When endoscopic piecemeal mucosal resection (EPMR) is performed, endoscopic surveillance is necessary due to the risk of recurrence. The Sydney EMR Recurrence Tool (SERT) is a 0-4 scale that classifies lesions according to size, occurrence of intraprocedural bleeding (IPB) and presence of high-grade dysplasia (HGD). Our goal is to evaluate the applicability of SERT in predicting adenoma recurrence (AR) after EPMR. Methods: This is a retrospective single-centre study with inclusion of lateral spreading lesions ≥20 mm, consecutively resected by EPMR from March 2010 to February 2018, with at least 1 endoscopic re-evaluation. Results: A total of 181 lesions were included, corresponding to 174 patients with a mean age of 68 years and male gender predominance (61%; n = 106). The most frequent location was the ascending colon (34%; n = 62). Lesions were assessed according to Paris Classification (PC): 0-IIa: 39% (n = 71); 0-IIb: 24% (n = 43); 0-IIa + Is: 23% (n = 42); 0-IIa + IIb: 6% (n = 11); 0-IIa + IIc: 2% (n = 3). The mean size of the lesions was 33 ± 11 mm, with 25 (14%) being ≥40 mm. IPB occurred in 9 cases (5%), and 44 lesions (24%) displayed HGD. Sixty-six lesions (36.5%) were classified as SMSA (size, morphology, site, and access score) level 4. Adjunctive therapy with argon plasma coagulation (APC) was used in 37% (n = 67) of cases. The 6-month AR rate was 16% (n = 29). According to SERT groups, the AR rate was: SERT 0: 12% (14/120); SERT 1: 17% (6/35); SERT 2: 25% (3/12); SERT 3: 30% (3/10); SERT 4: 75% (3/4). Two of the three SERT variables (size ≥40 mm and IPB) were associated with recurrence at 6 months (p < 0.05). HGD and the remaining tested variables (age, gender, localization, accessibility, PC, use of APC/biopsy forceps and occurrence of delayed bleeding) were not associated with AR. SERT 0 lesions showed an inferior risk of 6-month AR (adjusted OR = 2.62; p = 0.035), with a negative predictive value of 88%. SMSA correlated with SERT (p < 0.001) and SMSA level 4 was associated with 6-month AR (p = 0.007). Lesions classified both as SERT 0 and SMSA level <4 had the lowest 6-month recurrence rate (9.2%). The 24-month recurrence rate was 23% (n = 41). When applying the Kaplan-Meier method, cumulative recurrence was significantly lower in SERT 0 lesions (p = 0.006, log-rank test). Discussion/Conclusion: Resection of flat colorectal lesions by EPMR has a considerable risk of recurrence, mostly in SERT 1-4 lesions. SERT 0 lesions, especially with SMSA level <4, show a lower risk of recurrent adenoma, which might allow longer intervals to first endoscopic surveillance in the future.

Introdução: A mucosectomia endoscópica é a terapêutica de eleição nas lesões colorretais planas não invasivas e, quando fragmentada, obriga a vigilância endoscópica, dado o risco de recorrência. O Sydney Endoscopic Mucosal Resection Recurrence Tool (SERT) é uma escala de 0 a 4 que classifica as lesões em função da dimensão, ocorrência de hemorragia imediata na sua excisão (HI) e presença de displasia de alto grau (DAG). Pretende-se avaliar a aplicabilidade do SERT na predição de adenoma recorrente (AR) após mucosectomia fragmentada. Métodos: Estudo retrospetivo unicêntrico com inclusão de todas as lesões planas ≥20 mm excisadas por mucosectomia fragmentada, entre Março/2010 e Fevereiro/2018, com pelo menos uma vigilância endoscópica. Resultados: Incluídas 181 lesões, correspondentes a 174 doentes com idade média de 68 anos e predomínio do sexo masculino (61%; n = 106). A localização mais frequente foi o cólon ascendente (34%; n = 62). As lesões foram avaliadas segundo a classificação de Paris (CP): 0-IIa: 39% (n = 71); 0-IIb: 24% (n = 43); 0-IIa + Is: 23% (n = 42); 0-IIa + IIb: 6% (n = 11); 0-IIa + IIc: 2% (n = 3). O tamanho médio foi 33 ± 11 mm, tendo 25 (14%) dimensões ≥40 mm. Verificou-se HI em 9 casos (5%) e DAG em 44 (24%). O nível SMSA (size, morphology, site, and access score) foi 4 em 66 lesões (36.5%). Realizou-se terapêutica com árgon plasma (APC) em 37% (n = 67) dos casos.A taxa de AR aos 6 meses foi: SERT 0: 12% (14/120); SERT 1: 17% (6/35); SERT 2: 25% (3/12); SERT 3: 30% (3/10); SERT 4: 75% (3/4); global: 16% (29/181). O AR aos 6 meses associou-se à dimensão ≥40 mm e à HI (p < 0.05). A DAG não mostrou relação com a recorrência, assim como a idade, sexo, localização, acessibilidade, CP, terapêutica adju-adjuvante (APC/pinça de biópsias) e ocorrência de hemorragia tardia. As lesões SERT 0 apresentaram menor risco de AR aos 6 meses (OR ajustado = 2.62; p = 0.035), com um valor preditivo negativo de 88%. O SMSA correlacionou-se com o SERT (p < 0.001), estando o nível SMSA 4 associado à recorrência aos 6 meses (p = 0.007). As lesões classificadas como SERT 0 e nível SMSA <4 apresentaram a menor taxa de AR (9.2%). A taxa de recorrência aos 24 meses foi 23% (n = 41). Aplicando o método de Kaplan Meier, a recorrência cumulativa foi menor nas lesões SERT 0 (p = 0.006, teste log-rank). Discussão/Conclusão: A excisão de lesões planas por mucosectomia fragmentada apresenta uma taxa de recorrência considerável, sobretudo em lesões SERT 1­4. As lesões SERT 0, particularmente se nível SMSA <4, apresentam menor risco de recidiva, o que poderá possibilitar um prolongamento do intervalo até à primeira vigilância endoscópica.

Delayed perforation after endoscopic resection of a colonic laterally spreading tumor: A case report and literature review.

BACKGROUND: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been widely used for the treatment of early gastrointestinal cancer. Endoscopic piecemeal mucosal resection (EPMR) is derived from the combination of EMR and ESD. Delayed perforation with peritonitis after colonic EPMR is a rare but severe complication, sometimes requiring surgery. There are some associated risk factors, including patient- (location, diameter, and presence of fibrosis) and procedure-related factors. Early recognition and timely treatment are crucial for its management. CASE SUMMARY: We report a case in which delayed perforation with peritonitis was treated using endoscopic closure. A 54-year-old man was diagnosed with a 30-mm-diameter laterally spreading tumor in the colonic hepatic curvature. Fifteen hours after endoscopic resection, peritonitis caused by delayed perforation occurred and gradually aggravated. Conservative treatment was ineffective and no obvious perforation was observed. After timely endoscopic closure, the patient was discharged on postoperative day 4. CONCLUSION: In occasion of localized peritonitis aggravating without macroscopic perforation, endoscopic closure is an effective treatment for delayed perforation with stable vital signs in the early stage.

Colorectal ESD: current indications and latest technical advances.

The number of medical facilities that perform colorectal endoscopic submucosal dissection (ESD) has been growing, and its effectiveness has been increasingly reported in recent years. Indications approved by the Japanese government's medical insurance system are early colorectal cancers with a maximum tumor size of 2-5 cm. ESD was an effective procedure for treating noninvasive colorectal tumors difficult to resect en bloc by conventional EMR, resulting in a higher en bloc resection rate that is less invasive than surgery. Based on the excellent clinical results of colorectal ESDs, the Japanese health care insurance system has approved colorectal ESD for coverage.