Artificial Intelligence System to Determine Risk of T1 Colorectal Cancer Metastasis to Lymph Node.

BACKGROUND & AIMS: In accordance with guidelines, most patients with T1 colorectal cancers (CRC) undergo surgical resection with lymph node dissection, despite the low incidence (∼10%) of metastasis to lymph nodes. To reduce unnecessary surgical resections, we used artificial intelligence to build a model to identify T1 colorectal tumors at risk for metastasis to lymph node and validated the model in a separate set of patients. METHODS: We collected data from 3134 patients with T1 CRC treated at 6 hospitals in Japan from April 1997 through September 2017 (training cohort). We developed a machine-learning artificial neural network (ANN) using data on patients' age and sex, as well as tumor size, location, morphology, lymphatic and vascular invasion, and histologic grade. We then conducted the external validation on the ANN model using independent 939 patients at another hospital during the same period (validation cohort). We calculated areas under the receiver operator characteristics curves (AUCs) for the ability of the model and US guidelines to identify patients with lymph node metastases. RESULTS: Lymph node metastases were found in 319 (10.2%) of 3134 patients in the training cohort and 79 (8.4%) of /939 patients in the validation cohort. In the validation cohort, the ANN model identified patients with lymph node metastases with an AUC of 0.83, whereas the guidelines identified patients with lymph node metastases with an AUC of 0.73 (P < .001). When the analysis was limited to patients with initial endoscopic resection (n = 517), the ANN model identified patients with lymph node metastases with an AUC of 0.84 and the guidelines identified these patients with an AUC of 0.77 (P = .005). CONCLUSIONS: The ANN model outperformed guidelines in identifying patients with T1 CRCs who had lymph node metastases. This model might be used to determine which patients require additional surgery after endoscopic resection of T1 CRCs. UMIN Clinical Trials Registry no: UMIN000038609.

Operational effectiveness of three-dimensional flexible endoscopy: an ex vivo study using a new model.

BACKGROUND AND OBJECTIVES: Two-dimensional (2D) images lack depth information and thus provide probabilistic recognition that do not completely match the actual three-dimensional (3D) information. Here, we investigated the operability of 3D endoscopes. METHODS: A 3D operation model was developed by passing 20 silk threads through upper and lower plates at 2-mm intervals in front and back rows separated by 1 mm. We evaluated accuracy and time of operating an electrosurgical knife. A successful operation was defined as pulling only a front-row thread; an unsuccessful operation was defined as pulling no thread (miss) or simultaneously pulling front- and back-row threads. Endoscopists (four experts, six trainees) repeated the operation under 2D and 3D conditions until individually accumulating 10 successful attempts under each condition. RESULTS: Operation accuracy was significantly higher for 3D compared with 2D in all endoscopists (88.5% vs. 61.3%; p < 0.01) and in both experience groups (trainees: 84.5% vs. 61.2%; experts: 95.2% vs. 61.5%; both p < 0.01). Operation time was significantly shorter for 3D compared with 2D in all endoscopists (12.5 ± 4.1 s vs. 14.8 ± 4.7 s; p < 0.01) and in both experience groups (trainees: 12.8 ± 4.2 s vs. 15.2 ± 4.9 s; experts: 12.1 ± 4.0 s vs. 14.3 ± 4.3 s; both p < 0.01). DISCUSSION: Compared with 2D endoscopy, 3D endoscopy significantly improved operation accuracy and shortened operation time, suggesting that 3D endoscopy enables accurate operation by depth information, aiding spatial recognition.

Comparison of 3D endoscopy and conventional 2D endoscopy in gastric endoscopic submucosal dissection: an ex vivo animal study.

BACKGROUND AND OBJECTIVES: Conventional endoscopy provides two-dimensional (2D) information without depth information. This study compared three-dimensional (3D) endoscopy and 2D endoscopy using an endoscopic submucosal dissection (ESD) training model to evaluate the utility of 3D endoscopy. METHODS: Porcine stomach specimens (7 × 7 cm) were prepared from commercially available resected porcine stomachs and a 10-mm hypothetical lesion was marked at the center of each specimen. Specimens were individually placed in an ESD training model, and subjected to either 2D or 3D ESD. En bloc resection rate, perforation rate, incision time, dissection time, and levels of five eyestrain symptoms (fatigue, pain, blurred vision, head-heaviness, and headache; 100-mm visual analog scale) were compared between the 2D and 3D procedures. In a crossover design, 8 endoscopists each performed two 2D and two 3D procedures. RESULTS: All 32 lesions were resected en block, but perforation occurred in one 2D procedure. Incision time was significantly shorter in 3D ESD than in 2D ESD (102.8 ± 42.1 s vs. 135.8 ± 65.7 s, p < 0.05). Dissection time was also significantly shorter in 3D ESD than in 2D ESD (366.3 ± 187.6 s vs. 517.8 ± 282.3 s, p < 0.05). Differences in levels of all symptoms except blurred vision between before and after ESD were larger in 3D ESD than in 2D ESD. CONCLUSIONS: Incision time and dissection time were significantly shorter in 3D ESD compared with 2D ESD, but eyestrain was increased. Depth information from 3D images appears to facilitate rapid and stable ESD maneuvers.

Esophageal Motility after Extensive Circumferential Endoscopic Submucosal Dissection for Superficial Esophageal Cancer.

BACKGROUND/AIMS: Endoscopic submucosal dissection (ESD) for superficial esophageal cancer is sometimes extensive, and in our experience, patients not infrequently present with dysphagia after ESD even in the absence of esophageal stricture. The aim of this study was to evaluate esophageal motility using high-resolution manometry (HRM) in patients with and without dysphagia after extensive circumferential ESD. METHODS: HRM was performed in a total of 52 patients who had undergone ESD for superficial esophageal cancer and a mucosal defect after ESD exceeded more than two-thirds of the esophageal circumference. The frequency and type of esophageal dysmotility and the relationship between esophageal motility and dysphagia were evaluated. RESULTS: Esophageal dysmotility was observed in 13 patients (25%): jackhammer esophagus in 4, esophagogastric junction outflow obstruction in 4, absent contractility in 2, and distal esophageal spasm, ineffective esophageal motility, and fragmented peristalsis in 1 patient each. Of the 22 patients with dysphagia after ESD, 9 (41%) had esophageal dysmotility. Of the 30 patients without dysphagia after ESD, 4 (13%) had esophageal dysmotility. The relationship between dysmotility and dysphagia was significant (p = 0.025). CONCLUSIONS: Esophageal dysmotility exists in approximately one-quarter of patients after extensive circumferential ESD, which is associated with dysphagia in the absence of esophageal stricture.

Characterization of Helicobacter pylori-Naïve Early Gastric Cancers.

AIM: Helicobacter pylori-naïve gastric cancers(GCs) have not been well documented. We aimed to characterize early H. pylori-naïve GCs. SUBJECTS AND METHODS: Of 666 patients with GC resected by endoscopic submucosal dissection, H. pylori-naïve patients were extracted according to the definition: no H. pylori eradication history, negative for serum H. pylori-antibody and current H. pylori-infection tests, and no gastric atrophy by pepsinogen (PG) test, endoscopy, and histology. RESULTS: It was found that 16 GCs were H. pylori-naïve, and classified into undifferentiated and differentiated type adenocarcinoma. All 9 undifferentiated type GCs were pale, depressed, mucosal pure signet ring cell adenocarcinoma except one of them and 7 differentiated type GCs were classified into 3 fundic gland type GCs and 4 foveolar type GCs. All fundic gland type GCs positive for PG-1 were cardia small submucosal tumor (SMT)-like protrusions with dilated vessels on the surface. All 4 foveolar type GCs were composed of dysplastic clear cells resembling foveolar epithelium, negative for PG-1 but positive for mucin 6 (MUC6) and MUC5AC. Endoscopically, all were laterally spreading elevations with papillary or villous surface. CONCLUSIONS: H. pylori-naïve GCs were infrequent at 2.5%, and classified into 3 types: a small pale depression of signet ring cell adenocarcinoma, a small SMT-like protrusion of fundic gland type GC, and a large laterally spreading elevation of foveolar type GC.

Postoperative bleeding after gastric endoscopic submucosal dissection in patients receiving antithrombotic therapy.

BACKGROUND AND AIMS: It is controversial whether antithrombotic therapy increases the risk of bleeding after endoscopic submucosal dissection (ESD). The aim of this study was to evaluate the effects of antithrombotic therapy on gastric ESD. METHODS: Patients who underwent gastric ESD at Toranomon Hospital between April 2005 and July 2014 were enrolled. The risk of post-ESD bleeding was evaluated by multivariate logistic regression analysis. RESULTS: Of 1781 patients enrolled, 253 were taking an antithrombotic; 186 discontinued taking a single antithrombotic (n = 150) or multiple antithrombotics (n = 36) before ESD, whereas 15 continued taking a single antiplatelet agent and another 52 switched to heparin alternative therapy during the peri-ESD period. Post-ESD bleeding occurred in 101 patients (5.7 %): 68 patients (3.8 %) who did not take an antithrombotic, 11 patients (7.3 %) who discontinued taking a single antithrombotic, six patients (16.7 %) who discontinued taking multiple antithrombotics, one patient (6.7 %) who continued taking a single antiplatelet agent, and 15 patients (28.8 %) who switched to heparin therapy. In multivariate analysis, heparin alternative therapy [odds ratio (OR) 10.04, 95 % confidence interval (CI) 4.35-23.16], discontinuation of the use of multiple antithrombotics before ESD (OR 5.44, 95 % CI 2.00-14.79), tumor location in the lower third of the stomach (OR 2.17, 95 % CI: 1.32-3.58), and a long procedure time (100 min or greater; OR 2.00, 95 % CI 1.25-3.20) were independent risk factors for post-ESD bleeding. Among 52 subjects who switched to heparin therapy, one developed acute renal infarction and one developed cerebral bleeding. CONCLUSIONS: Because heparin alternative therapy significantly increases the risk of post-ESD bleeding and may not decrease the risk of thromboembolic events, other options should be considered for patients receiving anticoagulation therapy.

Feasibility Study of the Three-Dimensional Flexible Endoscope in Endoscopic Submucosal Dissection: An ex vivo Animal Study.

BACKGROUND/AIM: Clinical application of 3-dimensional (3D) technology for flexible endoscopes has not been reported. We developed a 3D flexible endoscope and conducted a feasibility study of endoscopic submucosal dissection (ESD) in porcine stomach. METHODS: Four endoscopists used a 3D flexible endoscope to perform a total of 8 ESD procedures on resected porcine stomachs. We assessed the en bloc resection rate, perforation rate, and mechanical issues that arise during ESD. A visual analog scale (0, 2D superior; 100, 3D superior) was used to evaluate the depth perception, sense of security of the procedure, and eyestrain of 3D visualization. RESULTS: En bloc resection was achieved in all cases and there were no cases of perforation or mechanical issues. Depth perception and sense of security were rated 85.5 ± 12.4 and 70.7 ± 9.7 respectively (mean ± SDs). Eyestrain was rated high for 3D visualization (mean ± SDs, 12.6 ± 8.6). CONCLUSIONS: ESD using a 3D flexible endoscope was technically feasible. The endoscopists reported good depth perception and a high sense of security when using 3D visualization but also noted strong eyestrain.

Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection for Non-Ampullary Superficial Duodenal Tumor.

BACKGROUND: Endoscopic submucosal resection (ESD) and endoscopic mucosal resection (EMR) are well established as curable and safety procedures for treating superficial tumors of the stomach, esophagus and colon. However, a majority of endoscopic resection strategies for non-ampullary superficial duodenal tumors (NASDTs) remains undefined. The aim of this study was to clarify which was the right method for NASDT treatment - EMR or ESD. SUMMARY: We analyzed 129 consecutive endoscopic resection (74 ESD and 55 EMR) procedures performed with NADSTs and divided the ESD group into 49 large ESD groups (more than 20 mm in diameter) and 25 small ESD groups (less than 20 mm in diameter). With respect to the technical outcomes of EMR/ESD for small size NASDTs, EMR was safer than ESD, but its nature of curability was inferior to that of ESD. The rates of complication such as perforation or delayed bleeding were significantly higher in both ESD groups than in the EMR group. However, the prophylactic endoscopic closure of large mucosal defects after ESD was useful for resolving those complications. The limitations of our study were involvement of a single-center, limited sample size, short follow-up duration and the retrospective design, which may have introduced selection bias. However, the present findings suggest that adequate endoscopic treatment strategy for NASDTs can lead to favorable outcomes and an excellent prognosis. Key Message: It is necessary to select EMR or ESD adequately for R0 resection of small NASDTs, according to their size and location. For large NASDTs, duodenal ESD with essential management is feasible and useful as a therapeutic procedure.

Clinicopathological Outcomes of Patients with Early Gastric Cancer after Non-Curative Endoscopic Submucosal Dissection.

BACKGROUND: Endoscopic submucosal dissection (ESD) was developed to resect early gastric cancer (EGC), which could not be resected by conventional endoscopic mucosal resection, and the indications for ESD are expanding to include more types of EGCs. Favorable long-term outcomes of ESD for EGCs that meet the expanded curability criteria have been reported. However, the outcomes of non-curative ESD are not known in detail. SUMMARY: We analyzed the outcomes of 165 EGCs in 165 patients after non-curative ESD, as well as the clinical course. Of these patients, 109 underwent additional surgical resection (group S) and 56 patients were followed up without additional surgery (group F). The complete resection rate was 90.7% (39/43) for intramucosal cancer (M), 97.3% (36/37) for minimally submucosal invasive cancer (SM1), and 74.1% (63/85) for deep submucosal invasive cancer (SM2). The lymph node metastasis rate was 0% for M, 5.4% for SM1, and 10.6% for SM2 cancers. Regarding long-term survival, although the number of patients who died of another disease was significantly higher in group F than in group S, there was no significant difference in overall survival between the groups. KEY MESSAGE: The resectability of ESD for ECGs with an invasion depth of M to SM1 after non-curative ESD was excellent, and lesions without lymphovascular invasion did not metastasize or recur, resulting in a favorable prognosis. Our data may help in deciding whether additional surgery should be performed for borderline lesions after non-curative ESD. Furthermore, we suggest the possibility of further expanding the indications for ESD.

Conventional White Light Endoscopic Features of Small Superficial Barrett's Esophageal Adenocarcinoma.

BACKGROUND: Superficial Barrett's esophageal adenocarcinoma (BEA) arising from short-segment Barrett's esophagus (SSBE) is visualized as a reddish lesion located on the right or anterior side wall of the esophagogastric mucosal junction (EGJ) and showing an elevated macroscopic appearance under conventional white light endoscopy (WLE). However, because the form and color are variable, misdiagnosis as reflux esophagitis or SSBE is frequent under WLE. The aim of this study is to clarify conventional WLE features of small superficial BEA. SUMMARY: We retrospectively analyzed 30 lesions ≤20 mm in diameter in 30 patients who underwent endoscopic mucosal resection or endoscopic submucosal dissection at Toranomon Hospital between 2002 and 2014. Mean age of patients with small superficial BEA arising from SSBE was 64.3 ± 11.2 years, and mean tumor size was 12.0 ± 4.8 mm. Small superficial BEA fell into the following 4 categories based on WLE features: EGJ polyp type, 43.3% (13 of 30 lesions); triangular SSBE type, 43.3% (13 of 30 lesions); cardiac erosion type, 10.0% (3 of 30 lesions); and unclassified or mixed type, 3.4% (1 of 30 lesions). EGJ polyp-type tumors were located on the right or anterior side wall of the EGJ, and no tumors showed invasion to the submucosal layer. On the other hand, triangular SSBE-type tumors were located anywhere in the EGJ, and 38.5% showed submucosal invasion (5 of 13 lesions). KEY MESSAGES: We consider this classification significantly contributes to the detection of small superficial BEA arising from SSBE under WLE.

Endocytoscopy is a promising modality with high diagnostic accuracy for gastric cancer.

BACKGROUND AND STUDY AIM: Endocytoscopy (ECS) enables in vivo microscopic imaging, which allows analysis of mucosal structures at the cellular level; however, limited data are available on the validity of ECS in the stomach. The aim of this study was to evaluate the feasibility of ECS in the diagnosis of early gastric cancer. PATIENTS AND METHODS: Gastric lesions that were the targets of histopathological diagnosis by endoscopic submucosal dissection or biopsy specimen were prospectively enrolled and evaluated using a single charge-coupled device-integrated endocytoscope, following double staining with crystal violet and methylene blue. High grade ECS atypia was defined according to specific irregularities in gland structure and cell nuclei. The primary end point was the accuracy of ECS diagnosis for gastric cancer, using histopathological diagnosis as the gold standard. RESULTS: A total of 82 lesions were investigated, including 23 early gastric cancers, 10 gastric adenomas, and 49 non-neoplastic lesions. Ten lesions could not be clearly observed by ECS because of poor staining due to viscous mucus or plaque; thus, assessability rates with ECS were 88 % in total and 91 % for gastric cancer. High grade ECS atypia was observed in 86 % of assessable gastric cancers, but not in any cases of gastric adenomas or non-neoplastic lesions. The sensitivity, specificity, positive and negative predictive values of high grade ECS atypia as the criterion for the diagnosis of gastric cancer were 86 %, 100 %, 100 %, and 94 %, respectively. No serious complications occurred during or after the examinations. CONCLUSION: ECS is a clinically feasible modality to obtain in vivo histology, with high diagnostic accuracy in gastric cancer.

Ex vivo comparison study of smart Shooter®, a new endoscopic device for safe and speedy treatment.

BACKGROUND: In many endoscopic procedures, the operative view can be compromised when manipulating the treatment device because the endoscopists must release their hand from the endoscope. We have developed a new device called the Smart Shooter® (SS) for simultaneous manipulation of the endoscope and treatment device, and evaluated the utility of the SS compared with the conventional method. METHODS: The SS is a semirigid, loop-shaped channel extender that enables endoscopists to manipulate the treatment device with the thumb of the right hand while holding the endoscope with the same hand. We conducted a comparative study of gastric endoscopic submucosal dissection (ESD) and esophageal injection sclerotherapy (EIS) in a porcine model to compare the utility of the SS method with the conventional method. RESULTS: In gastric ESD, all lesions were resected en bloc with no perforation. The mean operative time was significantly shorter with the SS method than with the conventional method (287.5 ± 155.4 vs. 403.5 ± 215.6 s, p = 0.04). In esophageal EIS, 4 paravenous injections were given with the SS method and 5 were given using the conventional method. Similarly, the mean operative time was significantly shorter with the SS method than with the conventional method (19.0 ± 7.8 vs. 23.8 ± 10.0 s, p = 0.04). CONCLUSION: Use of the SS enabled a shorter operative time for gastric ESD and esophageal EIS with no adverse events. The present results suggest that the SS can contribute to safe and speedy endoscopic treatment.

Delayed bleeding after endoscopic submucosal dissection for non-ampullary superficial duodenal neoplasias might be prevented by prophylactic endoscopic closure: analysis of risk factors.

BACKGROUND AND AIM: Duodenal endoscopic submucosal dissection (ESD) is technically challenging because of anatomical specificities and, to date, has not been validated concerning the high rate of complications such as perforation and delayed bleeding. In the present study, the risk factors for delayed bleeding after duodenal ESD are presented with the goal of establishing preventive measures. METHODS: We analyzed 63 patients with non-ampullary superficial duodenal neoplasias treated by ESD from April 2005 to March 2014. To analyze the risk factors of delayed bleeding after duodenal ESD, we divided the patients into a delayed bleeding group and a non-bleeding group. To verify the risk factors of delayed bleeding after duodenal ESD, we analyzed various patient-, lesion-, and treatment-related factors. RESULTS: Delayed bleeding was experienced in 11 patients (17.5%) Univariate analysis of patient-related risk factors of delayed bleeding indicated no significant risk factor. Univariate analysis of lesion-related and treatment-related risk factors indicated only endoscopic closure as a significant risk factor. Multivariate analysis also identified endoscopic closure (not done > done: P = 0.049) as an independent factor significantly associated with delayed bleeding after duodenal ESD. Hypertension (present > absent: P = 0.055) showed a non-significant tendency of association by multivariate analysis. CONCLUSIONS: This retrospective evaluation found that endoscopic closure was associated with a reduced risk of delayed bleeding after duodenal ESD. Delayed bleeding after duodenal ESD might be prevented by prophylactic endoscopic closure.

A new device for simultaneous manipulation of an endoscope and a treatment device during procedures: an ex vivo animal study.

BACKGROUND AND STUDY AIMS: Endoscopists must maneuver both endoscope and treatment device during procedures, requiring them to release their hand from the scope to manipulate the treatment device. Aiming to improve this situation, we developed a new device called the Thumb Drive. PATIENTS AND METHODS: The Thumb Drive comprises a controller and catheter. After attaching the controller to the endoscope's grip, the catheter is inserted into the forceps channel. The treatment device is then inserted into the Thumb Drive and fixed with its tip protruding from the endoscope tip. A single endoscopist resected 10 lesions in a porcine stomach by endoscopic submucosal dissection (ESD) using the Thumb Drive. RESULTS: All lesions were resected en bloc using this new device without any perforations. The mean incision, dissection, and operative times were 97.2 ± 48.7 seconds, 121.6 ± 53.6 seconds, and 218.8 ± 67.8 seconds, respectively. CONCLUSIONS: The Thumb Drive enables the endoscopist to manipulate the treatment device with the thumb while handling the endoscope with the right hand during ESD. Its utility should be examined in in vivo studies as a next step.

Secondary endoscopic submucosal dissection for residual or recurrent tumors after gastric endoscopic submucosal dissection.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a widely accepted technique for the management of gastric tumors. However, residual or recurrent tumors can occur after ESD; currently, there is no adequate management strategy for these tumors. Thus, the aim of the present study was to establish a strategy of secondary ESD (sESD) for cases with positive lateral margins (LM+), which cause post-ESD residual or recurrent tumors. METHODS: Fifty-three lesions that were subjected to ESD were diagnosed as LM+ with suspected local residual tumor. The short- and long-term outcomes of early sESD (performed shortly after the initial ESD in LM+ cases to prevent local recurrence) were retrospectively compared with those of late sESD (performed after the detection of recurrent tumors). RESULTS: Of the 53 LM+ cases, the local residual positive rate was 38.5 % (10/26) in those undergoing early sESD or additional surgery and the local recurrence rate was 29.6 % (8/27) in those that were not treated. Thus, the overall incidence of residual or recurrent tumors in LM+ cases was 34.0 % (18/53). Both early and late sESD had favorable outcomes with no severe complications: 100 % of early sESD resections were curative, compared with 86.7 % of late sESD resections, over the course of a mean (±SD) observation period of 50.8 ± 16.7 months. The performance of early sESD was significantly greater than that of late sESD (in terms of dissection speed). CONCLUSIONS: Early sESD is more reliable than late sESD as a therapeutic strategy for salvaging residual tumors and for preventing recurrence. However, if a tumor has already recurred, late sESD remains useful.

Clinicopathological features of patients with acute graft-versus-host disease of the upper digestive tract.

BACKGROUND AND AIMS: Acute graft-versus-host disease (GVHD) occurring within 100 days post-transplant is one of critical factors influencing prognosis in transplant recipients. Among cases of GVHD of the gastrointestinal (GI) tract, GVHD rarely affects the upper GI. In this study, we retrospectively examined the frequency of upper GI GVHD and diagnostic accuracy. PATIENTS AND METHODS: From among 868 patients who underwent allogeneic hematopoietic stem cell transplantation at our hospital between January 2005 and June 2012, 115 of whom underwent biopsy for upper GI symptoms. The endoscopic findings and histologic diagnosis from these 115 patients were retrospectively analyzed. RESULTS: GVHD was histologically diagnosed in 85 patients overall (9.8% of all 868 transplant recipients). Although gastric mucosal exfoliation was not commonly observed, this endoscopic finding when used as a diagnostic predictor had both a specificity and positive predictive value (PPV) of 100%. When using redness, luster, and mucosal change as predictors, specificity and PPV were relatively high, suggesting that these gastric endoscopic findings are useful in the diagnosis of upper GI GVHD. Among the duodenal endoscopic findings, erosion as a diagnostic predictor had both a high specificity and PPV. The biopsy results often lead to a diagnosis of GVHD even in cases judged to be endoscopically normal. CONCLUSIONS: Among the gastric endoscopic findings, mucosal exfoliation, although rare, and redness, luster, and mucosal change are likely to be useful diagnostic predictors of upper GI GVHD. GVHD was frequently diagnosed in patients with endoscopically normal duodenum, suggesting that biopsies are important for definitive diagnosis.

Feasibility and safety of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors, including esophagogastric junction tumors.

BACKGROUND AND AIM: Recently, the use of endoscopic submucosal dissection (ESD) for gastric submucosal tumor (gSMT) and the development of laparoscopic and endoscopic cooperative surgery (LECS) have enabled either preservation of the stomach or minimization of the extent of partial resection. In the present study, the outcomes following the recent introduction of LECS for gSMT are presented. The aim of this retrospective study was to evaluate the feasibility and safety of LECS for gSMT, including esophagogastric junction (EGJ) SMT. METHODS: LECS is indicated for lesions that have an intragastric growth pattern, or for which fundusectomy can be avoided despite an extragastric growth pattern. We retrospectively evaluated the outcome of LECS carried out in 25 patients including five EGJ SMT. RESULTS: Surgery was completed achieving an R0 resection rate of 100% with no postoperative complications. Mean tumor size was 32.3 ± 13.5 mm and mean resected specimen size was 37.6 ± 13.5 mm. Resection margins were tumor-free in all cases, with adequate minimum surgical margins, and precise conclusive diagnosis was achieved with perfect operative specimens. Endoscopic confirmation of the EGJ enabled the extent of resection to be minimized and the stomach to be preserved, avoiding fundusectomy. Although there were significant differences in tumor size and resected specimen size between EGJ SMT and non-EGJ SMT, there were no significant differences in outcomes of the LECS procedure. CONCLUSION: LECS is feasible and safe for cases with gSMT including lesions adjacent to the EGJ.

Safety and efficacy of secondary endoscopic submucosal dissection for residual gastric carcinoma after primary endoscopic submucosal dissection.

BACKGROUND/AIMS: In endoscopic submucosal dissection (ESD), misdiagnosis of the tumor margin may lead to residual carcinoma, which we treat by secondary ESD (sESD) for local control. METHODS: 1,458 lesions of early gastric carcinoma were treated by ESD between July 2006 and November 2011. 33 lesions were resected with positive lateral margins. Among them, 13 patients were treated by surgery, 12 patients were followed up, and 8 patients were treated by sESD. sESD was defined as resection of residual carcinoma surrounding the ulcer of primary ESD (pESD). Safety and efficacy of sESD were retrospectively evaluated. RESULTS: Mean interval between two ESDs was 8.4 days. The mean specimen area was 14.9 cm(2) in pESD and 23.9 cm(2) in sESD. The mean procedure time was 107.3 and 193.0 min, and mean dissection area was 15.9 and 11.6 mm(2)/min, respectively. There were no significant differences and no serious complications occurred during sESD. There was no local recurrence after a mean follow-up period of 896 days. Meanwhile, 4 cases of local recurrence were detected after ESD with a positive lateral margin. CONCLUSION: The results suggest that sESD may be technically feasible and favorable for local control of residual gastric carcinoma.

[A case of fulminant amoebic colitis with an abscess in the abdominal cavity rescued by conservative management].

A 75-year-old man was admitted because of watery diarrhea, hematochezia and right lower abdominal pain. Many deep undermining colonic ulcers were found by colonoscopy, and we detected trophozoite amoeba pathologically. Metronidazole was administered orally from 3 days after admission. However, since CT demonstrated a huge abscess in the abdominal cavity, we performed percutaneous drainage from 17 days after admission. On day 157, the patient was discharged, because the colonic ulcers had almost healed, and trophozoite amoebas were not recognized pathologically.

[Idiopathic mesenteric phlebosclerosis associated with long-term use of Chinese herbs: a case report].

A 59-year-old woman had been admitted to our hospital every two months for over a past year because of severe right abdominal pain. Colonoscopy revealed dark blue mucosa extending from the cecum to the transverse colon, and abdominal computed tomography showed wall thickening and linear calcification along the wall from the cecum to the transverse colon. Based on these findings, the patient was given a diagnosis of idiopathic mesenteric phlebosclerosis. Subsequently, we found that she had been a long-term user of a Chinese herbal product containing Gardeniae fructus for allergic rhinitis. After discontinuing the product, the patient has been free of abdominal pain for a year.