Systematic review and meta-analysis of endoscopic submucosal dissection versus transanal endoscopic microsurgery for large noninvasive rectal lesions.

BACKGROUND: For almost 30 years, transanal endoscopic microsurgery (TEM) has been the mainstay treatment for large rectal lesions. With the advent of endoscopic submucosal dissection (ESD), flexible endoscopy has aimed at en bloc R0 resection of superficial lesions of the digestive tract. This systematic review and meta-analysis compared the safety and effectiveness of ESD and full-thickness rectal wall excision by TEM in the treatment of large nonpedunculated rectal lesions preoperatively assessed as noninvasive. METHODS: A systematic review of the literature published between 1984 and 2010 was conducted (Registration no. CRD42012001882). Data were integrated with those from the original databases requested from the study authors when needed. Pooled estimates of the proportions of patients with en bloc R0 resection, complications, recurrence, and need for further treatment in the ESD and TEM series were compared using random-effects single-arm meta-analysis. RESULTS: This review included 11 ESD and 10 TEM series (2,077 patients). The en bloc resection rate was 87.8 % (95 % confidence interval [CI] 84.3-90.6) for the ESD patients versus 98.7 % (95 % CI 97.4-99.3 %) for the TEM patients (P < 0.001). The R0 resection rate was 74.6 % (95 % CI 70.4-78.4 %) for the ESD patients versus 88.5 % (95 % CI 85.9-90.6 %) for the TEM patients (P < 0.001). The postoperative complications rate was 8.0 % (95 %, CI 5.4-11.8 %) for the ESD patients versus 8.4 % (95 % CI 5.2-13.4 %) for the TEM patients (P = 0.874). The recurrence rate was 2.6 % (95 % CI 1.3-5.2 %) for the ESD patients versus 5.2 % (95 % CI 4.0-6.9 %) for the TEM patients (P < 0.001). Nevertheless, the rate for the overall need of further abdominal treatment, defined as any type of surgery performed through an abdominal access, including both complications and pathology indications, was 8.4 % (95 % CI 4.9-13.9 %) for the ESD patients versus 1.8 % (95 % CI 0.8-3.7 %) for the TEM patients (P < 0.001). CONCLUSIONS: The ESD procedure appears to be a safe technique, but TEM achieves a higher R0 resection rate when performed in full-thickness fashion, significantly reducing the need for further abdominal treatment.

Carbon dioxide insufflation reduces the discomfort due to colonoscopy as objectively analyzed by salivary stress markers.

BACKGROUND: Carbon dioxide (CO2) insufflation has been shown to reduce the procedure-related pain and discomfort during colonoscopy. However, the effects of CO2 insufflation on the improvement of participant's stress had not been objectively analyzed. METHODS: Using a randomized, double-blinded design, 100 consecutive patients undergoing colonoscopy were assigned to have their examination performed with either CO2 or air insufflation. Patients completed a questionnaire to grade their discomfort using a visual analogue scale (VAS). The salivary alpha-amylase (SAA) level was also measured at these times as a marker of stress. RESULTS: The total VAS score did not show any statistically significant differences between the CO2 and air insufflation groups. However, the VAS score for abdominal fullness significantly decreased in the CO2 insufflation group in comparison to the air insufflation group in the patients who had a longer examination. The titer of the maximum SAA was significantly increased by colonoscopy (P <0.01). CO2 insufflation significantly reduced the total SAA after the colonoscopy in comparison with air insufflation (P < 0.05). The examination time and SAA tended to have a positive relationship in the air insuflation group. However, no such relationship was observed in the CO2 insufflation group. CONCLUSIONS: CO2 insufflation significantly reduced the post-examination discomfort, as indicated by a salivary stress marker. The use of CO, rather than air insufflation reduced the patients' stress and may contribute to better acceptance of colonoscopy. The usefulness of CO2 insufflation was more prominent when a longer examination was necessary.

Overexpression of IL-6 by gene transfer stimulates IL-8-mediated invasiveness of KYSE170 esophageal carcinoma cells.

Interleukin-6 (IL-6) has been associated with disease progression and poor prognosis in esophageal carcinoma. The aim of this study was to investigate the possible influence of IL-6 on the biological activities of esophageal carcinoma cells in terms of invasiveness. The human esophageal carcinoma cell line, KYSE170, was transfected with a plasmid vector expressing IL-6, and a stable transfectant overexpressing IL-6 was established. Invasiveness was evaluated by an invasion assay and compared between IL-6 and control transfectants. The invasiveness of the IL-6 transfectant was significantly higher than that of the control transfectant, and was significantly reduced by IL-6-specific siRNA. In reverse transcriptase-polymerase chain reaction (RT-PCR) analysis, IL-8 expression was significantly higher in the IL-6 transfectant than in the control transfectant, whereas the expression of Hepatocyte growth factor (HGF) and Vascular endothelial growth factor (VEGF) was not different. IL-8 expression in the IL-6 transfectant was significantly inhibited by IL-8-specific siRNA, whereas IL-6 expression was not. In addition, the invasiveness of the IL-6 transfectant was significantly reduced by IL-8-specific siRNA. These results indicate that the overexpression of IL-6 increases the invasiveness of KYSE170 esophageal carcinoma cells and IL-6-induced IL-8 plays a predominant role in increasing invasiveness.

COX-2 overexpression Induced by gene transfer reduces sensitivity of TE13 esophageal carcinoma cells to 5-fluorouracil and cisplatin.

Previous clinicopathological studies demonstrated that overexpression of cyclooxygenase-2 (COX-2) is associated with a poor treatment response of esophageal carcinoma. The aim of this study was to elucidate the role of COX-2 overexpression in the chemosensitivity of esophageal carcinoma cells. TE13 human esophageal squamous cell carcinoma cells were transfected with a COX-2 constitutive expression vector, and stable transfectants overexpressing COX-2 were established. COX-2 overexpression in COX-2 transfectants was confirmed with western blotting and prostaglandin-E(2) (PGE(2)) assay. Chemosensitivity testing revealed that sensitivity of COX-2 transfectants to 5-fluorouracil and cisplatin was significantly lower than in control vector-only transfectants, and that sensitivity of COX-2 transfectants was restored by the transfection of COX-2-specific siRNA. In addition, expression of antiapoptotic B-cell lymphoma-extra large (BCL-xL) and myeloid cell leukaemia-1 (MCL-1) was increased in COX-2 transfectants. These results indicate that COX-2 overexpression may reduce the chemosensitivity of esophageal carcinoma cells through up-regulation of the expression of antiapoptotic BCL-2 family proteins.

Functional gastrointestinal disorders in adolescents and quality of school life.

BACKGROUND AND AIM: The prevalence of functional gastrointestinal disorders (FGID) in adolescents and their relationship to quality of school life (QOSL) are not fully understood. This study investigated the relationship between FGID and QOSL. METHODS: Adolescents (10-17 years) were recruited from 40 schools. FGID diagnoses were based on the Questionnaire on Pediatric Gastrointestinal Symptoms-Rome III version (QPGS-RIII). QOSL was evaluated by a questionnaire and calculated as the QOSL score. RESULTS: Five hundred and fifty-two of the 3976 students (13.9%) met the FGID criteria for one or more diagnoses according to the QPGS-RIII: 12.3% met the criteria for one, 1.5% for two or more. Irritable bowel syndrome (IBS) was the most common diagnosis (5.9%) followed by functional abdominal pain (3.1%). The prevalence of FGID was significantly higher in the female students in comparison to male students (P < 0.01). The prevalence of FGID was 9.5% in elementary school, 15.4% in junior high school, 26.0% in high school students, respectively. The prevalence of FGID was significantly increased with age (P < 0.01). The QOSL score of the patients with FGID was 10.9 ± 4.5 and that without FGID was 8.2 ± 2.8, respectively. The QOSL score of the patients with FGID was significantly worse than those without FGID (P < 0.01). The QOSL scores with IBS, aerophagia, and cyclic vomiting syndrome were significantly worse among the FGID (P < 0.01). CONCLUSIONS: The prevalence of FGID in adolescents was relatively high. The presences of FGID worsen the QOSL score. Medical intervention and/or counseling are needed for such students to improve the QOSL.

[Analysis of community medicine cooperation by using the "ohisama-system"].

BACKGROUND: In Japan, because of an increase in the elderly population, End-Of-Life care is of increasingconcern. In the future, the demand for home healthcare is expected to increase further. However, it is difficult to prepare numerous reports and to share accurate information rapidly because of the small-scale support for home medical care from clinics and visiting nursingstations, pharmacies, and various other establishments. METHOD: We used an information technology tool called the "Ohisama-system" to start our own information sharing system between doctors in different groups. Herein, we report and discuss the future issues for community medicine cooperation when usinginformation technology. RESULTS: Electronic medical records written by doctors only are not suitable for viewingand sharingwith multiple groups workingin the filed of home healthcare. A variety of detailed information that has not been described in the medical records, such as the floor plan of the home, the wishes of the family, and use of other services is important for the home healthcare team. CONCLUSIONS: The Ohisama-system is very useful for sharingpatient information to enable community medicine cooperation. However, it is also more important to maintain face-to-face communication.

Analysis of colonoscopic perforations at a local clinic and a tertiary hospital.

AIM: To define the clinical characteristics, and to assess the management of colonoscopic complications at a local clinic. METHODS: A retrospective review of the medical records was performed for the patients with iatrogenic colon perforations after endoscopy at a local clinic between April 2006 and December 2010. Data obtained from a tertiary hospital in the same region were also analyzed. The underlying conditions, clinical presentations, perforation locations, treatment types (operative or conservative) and outcome data for patients at the local clinic and the tertiary hospital were compared. RESULTS: A total of 10  826 colonoscopies, and 2625 therapeutic procedures were performed at a local clinic and 32  148 colonoscopies, and 7787 therapeutic procedures were performed at the tertiary hospital. The clinic had no perforations during diagnostic colonoscopy and 8 (0.3%) perforations were determined to be related to therapeutic procedures. The perforation rates in each therapeutic procedure were 0.06% (1/1609) in polypectomy, 0.2% (2/885) in endoscopic mucosal resection (EMR), and 3.8% (5/131) in endoscopic submucosal dissection (ESD). Perforation rates for ESD were significantly higher than those for polypectomy or EMR (P < 0.01). All of these patients were treated conservatively. On the other hand, three (0.01%) perforation cases were observed among the 24  361 diagnostic procedures performed, and these cases were treated with surgery in a tertiary hospital. Six perforations occurred with therapeutic endoscopy (perforation rate, 0.08%; 1 per 1298 procedures). Perforation rates for specific procedure types were 0.02% (1 per 5500) for polypectomy, 0.17% (1 per 561) for EMR, 2.3% (1 per 43) for ESD in the tertiary hospital. There were no differences in the perforation rates for each therapeutic procedure between the clinic and the tertiary hospital. The incidence of iatrogenic perforation requiring surgical treatment was quite low in both the clinic and the tertiary hospital. No procedure-related mortalities occurred. Performing closure with endoscopic clipping reduced the C-reactive protein (CRP) titers. The mean maximum CRP titer was 2.9 ± 1.6 mg/dL with clipping and 9.7 ± 6.2 mg/dL without clipping, respectively (P < 0.05). An operation is indicated in the presence of a large perforation, and in the setting of generalized peritonitis or ongoing sepsis. Although we did not experience such case in the clinic, patients with large perforations should be immediately transferred to a tertiary hospital. Good relationships between local clinics and nearby tertiary hospitals should therefore be maintained. CONCLUSION: It was therefore found to be possible to perform endoscopic treatment at a local clinic when sufficient back up was available at a nearby tertiary hospital.

Analysis of ABC (D) stratification for screening patients with gastric cancer.

AIM: To evaluate the value of ABC (D) stratification [combination of serum pepsinogen and Helicobacter pylori (H. pylori) antibody] of patients with gastric cancer. METHODS: Ninety-five consecutive patients with gastric cancer were enrolled into the study. The serum pepsinogen I (PG I)/pepsinogen II (PG II) and H. pylori antibody levels were measured. Patients were classified into five groups of ABC (D) stratification according to their serological status. Endoscopic findings of atrophic gastritis and histological differentiation were also analyzed in relation to the ABC (D) stratification. RESULTS: The mean patient age was (67.9 ± 8.9) years. Three patients (3.2%) were classified into group A, 7 patients (7.4%) into group A', 27 patients (28.4%) into group B, 54 patients (56.8%) into group C, and 4 patients (4.2%) into group D, respectively. There were only three cases in group A when the patients taking acid proton pump inhibitors and those who had undergone eradication therapy for H. pylori (group A') were excluded. These three cases had mucosal atrophy in the grey zone according to the diagnostic manual of ABC (D) stratification. Histologically, the mean age of the patients with well differentiated adenocarcinoma was significantly higher than that of the patients with poorly differentiated adenocarcinoma (P < 0.05). There were no differences in the pattern of atrophy in the endoscopies between the well differentiated and poorly differentiated groups. CONCLUSION: ABC (D) stratification is a good method for screening patients with gastric cancers. Endoscopy is needed for grey zone cases to check the extent of mucosal atrophy.

Long-term survivors of esophageal carcinoma with distant lymph node metastasis.

BACKGROUND/AIMS: Clinical extra-regional lymph node metastasis, M1 lymph node metastasis (M1 LYM), has been recognized as a far advanced condition in esophageal cancer. However, some patients with M1 LYM survive long-term. The purpose of this study was to identify the clinicopathological features of those patients with M1 LYM achieving long-term survival. METHODOLOGY: Between 2002 and 2008, 31 patients with squamous cell carcinoma of the thoracic esophagus with M1 LYM were treated at our institution. Of the 31 patients, four survived for more than three years. These four patients were examined retrospectively. RESULTS: Cervical lymph node metastasis was the cause of M1 LYM and no regional nodal metastasis was detected in any of the four patients. Primary lesions were non-T4 and located at the middle or lower thoracic esophagus in these patients. Two patients underwent radical esophagectomy with three-field lymphadenectomy and complete resection was confirmed by pathological examination. The other two patients underwent definitive chemoradiotherapy and complete response was confirmed. Three patients are alive without recurrence but one, who underwent definitive CRT, died of local recurrence. CONCLUSION: Solitary metastasis localized at the cervical node might be targeted specifically in an effort to improve the prognosis of M1 LYM patients with esophageal cancer.

Topical application of glycyrrhizin preparation ameliorates experimentally induced colitis in rats.

AIM: To examine the efficacy of glycyrrhizin preparation (GL-p) in the treatment of a rat model of ulcerative colitis (UC). METHODS: Experimental colitis was induced by oral administration of dextran sodium sulfate. Rats with colitis were intrarectally administered GL-p or saline. The extent of colitis was evaluated based on body weight gain, colon wet weight, and macroscopic damage score. The expression levels of pro-inflammatory cytokines and chemokines in the inflamed mucosa were measured by cytokine antibody array analysis. The effect of GL-p on myeloperoxidase (MPO) activity in the inflamed mucosa and purified enzyme was assayed. RESULTS: GL-p treatment significantly ameliorated the extent of colitis compared to sham treatment with saline. Cytokine antibody array analysis showed that GL-p treatment significantly decreased the expression levels of pro-inflammatory cytokines and chemokines, including interleukin (IL)-1ß, IL-6, tumor necrosis factor-α, cytokine-induced neutrophil chemoattractant-2, and monocyte chemoattractant protein-1 in the inflamed mucosa. Furthermore, GL-p inhibited the oxidative activity of mucosal and purified MPO. CONCLUSION: GL-p enema has a therapeutic effect on experimental colitis in rats and may be useful in the treatment of UC.

Calcineurin inhibition by polaprezinc in rats with experimentally-induced colitis.

AIMS: We investigated the therapeutic effect of polaprezinc (PZ), N-(3-aminopropionyl)-L-histidinato zinc, in rats with experimentally-induced colitis by focusing on calcineurin (CN) inhibition. CN plays a crucial role in T-cell activation and cytokine gene expression and is targeted by immunosuppressants such as cyclosporine and FK506. MAIN METHODS: Colitis was induced into male Wistar rats by trinitrobenzene sulfonic acid and was treated with intrarectally administered PZ. The inflammation was assessed by the macroscopic damage score, colon wet weight, and proinflammatory mediator expression by RT-PCR analysis. Protein expression of calcineurin and the activation of its substrate, the nuclear factor of activated T cells (NFAT) transcription factor, were also studied. Calcineurin inhibition by PZ was investigated in in vitro experiments using colonic mucosa, purified calcineurin enzyme, and Jurkat T cells. KEY FINDINGS: CN was activated in the colitic mucosa; PZ treatment inhibited CN activation, the expression of proinflammatory cytokines in the mucosa, and thereby ameliorated the experimental colitis in rats. In in vitro experiments, PZ inhibited CN activity, NFAT activation, interleukin-2 expression, and the growth of Jurkat T cells. In the effective concentrations, PZ did not affect cell viability. SIGNIFICANCE: Our results suggest that PZ can be used as an immunosuppressive agent for the treatment of colitis through its inhibitory effect on CN activity.

Overexpression of Interleukin-6 suppresses cisplatin-induced cytotoxicity in esophageal squamous cell carcinoma cells.

Interleukin-6 (IL-6) expression at local tumor sites or in systemic circulation is associated with disease progression and poor prognosis of esophageal cancer. The aim of this study was to investigate the possible influence of IL-6 on biological activities of esophageal cancer cells in terms of chemosensitivity. Human esophageal cancer cell lines TE13 and KYSE170 were transfected with a plasmid vector expressing IL-6 and stable transfectants overexpressing IL-6 were thus established. The sensitivity of IL-6 transfectants to cisplatin was evaluated using a WST-8 assay and cell-cycle analysis. In addition, the inhibitory effects of IL-6-specific siRNAs were investigated. IL-6 transfectants showed significantly reduced sensitivity to cisplatin compared to control transfectants. In addition, the reduced cisplatin sensitivity of IL-6 transfectants was restored by pretreatment with IL-6-specific siRNA. These results suggest that intracellular IL-6 expression in tumor cells may acts as a resistance factor against cisplatin-based treatments for esophageal cancer.

Elevated serum CRP levels after induction chemoradiotherapy reflect poor treatment response in association with IL-6 in serum and local tumor site in patients with advanced esophageal cancer.

BACKGROUND AND OBJECTIVES: Elevated serum CRP levels are associated with tumor progression and poor prognosis of esophageal cancer. The aim of this study was to clarify the clinical significance of CRP in relation to response to chemoradiotherapy in patients with esophageal cancer. METHODS: The relationship between serum CRP levels and response to chemoradiotherapy and prognosis was analyzed in 34 patients with advanced esophageal squamous cell carcinoma who underwent induction chemoradiotherapy followed by surgery. The relationship between response to chemoradiotherapy and interleukin-6 (IL-6) expression in sera and tumor tissues was also analyzed. RESULTS: Although elevated serum CRP levels were associated with poor response to chemoradiotherapy, significant difference in CRP levels between pathological responders (n = 18) and non-responders (n = 16) was observed after chemoradiotherapy, but not before. Patients with elevated CRP levels had shorter cause-specific survival, but significant difference was observed only after chemoradiotherapy. In addition, serum levels of IL-6 were also associated with poor treatment response following chemoradiotherapy and were correlated with residual tumor volume. IL-6 expression was detected in residual tumor tissues by immunohistochemistry. CONCLUSIONS: Elevated serum CRP levels after chemoradiotherapy may predict poor response to chemoradiotherapy more accurately than before chemoradiotherapy, and IL-6 may be a possible target associated with chemoradiotherapy resistance.

Stricture after endoscopic submucosal dissection for early gastric cancers and adenomas.

BACKGROUND AND AIM: Stricture is a complication that may occur after endoscopic submucosal dissection (ESD) of gastric neoplasms. The goal of the present study was to investigate the incidence, risk factors and management of gastric stricture after ESD. METHODS: The medical records of 308 patients who underwent ESD for gastric neoplasms were reviewed. Stricture is defined as having symptoms caused by an obstruction through which a 1-cm diameter endoscopic fiber cannot be passed. RESULTS: Stricture was identified in six of 308 patients (1.9%). Three of the six lesions were located in the prepylorus, two cases in the antrum and one in the cardia. The mean longitudinal distance and the mean area of the resected specimens in the six cases with stricture (7.8 ± 2.0 cm, 34.0 ± 15.8cm(2) , respectively) was significantly larger than in those without stricture (4.5 ± 1.4cm, 12.7 ± 8.3cm(2) , respectively, P<0.01). The ratio of the resected circumference/whole circumference was 83.3±7.5% in those with stricture in comparison to 25.4 ± 16.3% in those without stricture (P<0.01). All six patients underwent endoscopic balloon dilations, and obtained relief from stricture. However, one patient experienced a gastric perforation and recovered following conservative therapy. CONCLUSION: Sub-circumferential resection over 75% of the circumference by ESD in the prepylorus, antrum and cardia is a risk factor for the occurrence of stricture. Early intervention might be considered for this high-risk group to avoid a perforation during balloon dilation.

[Early prediction of treatment response by serum CRP levels in patients with advanced esophageal cancer who underwent definitive chemoradiotherapy].

Serum CRP has been shown to be associated with the progression of esophageal cancer. The purpose of this study was to examine the relationship between treatment response and serum CRP levels in time course during definitive chemoradiotherapy (CRT) in terms of early prediction of CRT response by serum CRP. The subjects of this study were 36 patients with cT3/cT4 esophageal squamous cell carcinoma who underwent definitive CRT in our hospital. Serum CRP levels during definitive CRT (pretreatment, 1W, 2W and 3W after CRT initiation) were compared between CR and non-CR group. In addition, partition model was constructed to discriminate CR with non-CR and the prediction accuracy was evaluated. The patients were consisted of 28 males and 8 females. At pretreatment diagnosis, tumors were categorized as T3 (n=21) and T4 (n=15). Thirty four patients received FP-based chemotherapy and 2 patients received docetaxel-based chemotherapy. Treatment responses were categorized as CR (n=8), PR (n=14), NC (n=2) and PD (n=12). Serum CRP levels at the time of 2W after CRT initiation (CRT2W) in CR group were low compared to those in non-CR group (p=0.071). The partition model was constructed based on CRP levels at CRT2W. The prediction accuracies to discriminate CR from non-CR by CRP≤0.1 were 50%, 82%, and 75% in sensitivity, specificity and accuracy, respectively. Serum CRP is a useful biomarker for an early prediction of CRT response.

[PSK-mediated growth suppression and enhancement of 5-FU/docetaxel-induced cytotoxicity in human esophageal cancer cell lines].

PSK, a protein-bound polysaccharide, is widely used for treating cancer patients as an immunostimulant. However, its direct action on cancer cells is not fully understood. In the present study, we investigated direct effects of PSK alone or in combination with 5-FU, CDDP and docetaxel on tumor growth by using esophageal cancer cell lines, KYSE170 and TE13. Cells were incubated with different concentrations of PSK for 72 hour, and cell viability was determined by WST-8 assay, and cell cycle was analyzed by flow cytometry. As a result, PSK of 100 microg/mL induced growth suppression dose-dependently in the both cell lines, and flow cytometric analysis showed a PSK dose-dependent increase of sub-G1 cells indicating apoptotic cells. In addition, when cells were incubated with different concentrations of 5-FU and docetaxel in the presence of PSK at the dose of 5 microg/mL showing no growth suppression, cytotoxicity induced by 5-FU and docetaxel was significantly enhanced. These results indicate that PSK not only shows tumor growth suppression by apoptosis induction, but also enhances 5-FU and docetaxel-induced cytotoxicity.

[The IL-6 and COX-2 expression related to sensitivity of chemoradiotherapy and prognosis in esophageal carcinoma].

Chemoradiation therapy (CRT) for esophageal cancer induces inflammatory responses within tumor tissues. Inflammatory cells infiltrated into the tumor tissues may modulate the CRT responses via inflammation-related molecules such as IL-6 or COX-2. In the present study, we investigated a relationship between IL-6/COX-2 expression and CRT responses for esophageal cancer. A surgical resection following CRT was performed, and the specimens from the patients with cT3/T4 esophageal squamous cell examined for IL-6/COX-2 expression in both residual cancer and stromal cells by immunohistochemical staining. CRT responses were divided into responder group (Grade 1b and Grade 2) and non-responder group (Grade 1a). COX-2 in cancer cells and IL-6 in stromal cells were associated with non-responder and responder, respectively. In addition, IL-6 in stromal cells was significantly correlated with overall survival. Our data suggest that inflammatory responses concomitant with CRT responses could play a role in chemoradiation responses and prognosis.

[Surgically resected local recurrence after endoscopic submucosal dissection of esophageal cancer--a case report].

We report a case of surgically resected esophageal cancer which was locally recurred after endoscopic submucosal dissection. A 66-year-old man was admitted to our hospital because of further examination and a treatment of superficial esophageal cancer. A type 0-IIb+IIa cancer occupying the whole circumference of the lumen of the middle to lower esophagus was revealed. The depth of the invasion was judged to be T1a-EP or LPM by endoscopic ultrasonography, and no metastasis to other organs or lymph nodes was detected. Endoscopic submucosal dissection (ESD) was performed. However, macroscopic residual cancer didn't seem to exist. Pathological diagnosis was squamous cell carcinoma, moderately differentiated, the depth of tumor invasion was T1a-LPM. The presence of the residual cancer of the horizontal cut margin could not be judged because en bloc resection could not be achieved. After that, endoscopic balloon dilatation of the esophageal stenosis was performed repeatedly for about one year. Then, he was diagnosed as the local recurrence of the squamous cell carcinoma of the esophagus. Thoraco-abdominal esophagectomy reconstructed by stomach tube via a retrosternal route was undergone. The final stage of the lesion was judged T3N1M0 (Stage III, UICC) by the histological examination from the resected specimen. After the operation, he is receiving adjuvant chemotherapy and alive without recurrence. When endoscopic resection of the esophageal cancer is performed to the lesion, which relatively indicated to endoscopic resection or outside the guideline criteria for endoscopic resection, it is important that we choose the appropriate treatment protocol obtaining an informed consent from the patient sufficiently.

[Radiofrequency ablation for postoperative recurrent of metastatic lesions of esophageal cancer].

Radiofrequency ablation (RFA) was performed for the postoperative recurrent of metastatic lesions of esophageal cancer in 6 patients. All patients were males, and the median age was 59. Surgical curativities were A (3 cases), B (2) and C (1). The recurrent sites were intramediastinal omentum of gastric tube (2 cases), rt lung (2), rt adrenal grand (1) and liver (1). Four cases had a single recurrent lesion and the two had multiple lesions consisted of a single lesion as RFA target, and the lesions in a different site that were simultaneously treated by other therapeutic modalities. The median time of recurrence was 12 months after esophagectomy. RFA was performed once in the 3 cases, and twice in the other 3 cases. Therapeutic effect evaluated by CT was CR (2 cases), PR (3) and SD (1). No serious complications associated with RFA procedure were observed. Three patients died due to cancer recurrence within 7 months after RFA. However, RFA-treated lesions were well controlled to the end. RFA are safe and minimally invasive, thus, can be repeatedly performed technique that can induce a good local control of the target lesion equivalent to surgical resection. RFA is applicable as an effective local therapy for the recurrent or metastatic lesions of esophageal cancer.

[Crohn's disease complicating psoas abscess treated by drainage and infliximab administration].

A 19-year old man was admitted for treatment of a right psoas abscess. He was first diagnosed as Crohn's disease with ileocolitis and fistula, which caused the abscess. Following the drainage of the abscess and conservative treatment including administration of antibiotics, total parenteral nutrition and medication, his symptoms were temporarily improved. After recurrence, additional therapy with infliximab successfully induced remission. He has remained free from abdominal symptoms and recurrence of the abscess. It seems that conservative treatment including infliximab administration is useful for induction as well as maintenance of remission and avoiding surgical treatment.