Histopathological vertical margin positivity in cold snare polypectomy and mucosal resection for sessile serrated lesions.

BACKGROUND AND AIMS: Evidence regarding the status of the vertical margin of sessile serrated lesions (SSLs) resected using cold snare polypectomy (CSP) is lacking, and whether a histopathologically positive vertical margin is related to recurrence remains unclear. Therefore, this preliminary study aimed to clarify the rates of positive or unevaluable vertical and horizontal margins and the rate of muscularis mucosae resection in SSLs treated using CSP compared with those treated with endoscopic mucosal resection (EMR). METHODS: Histological outcomes of patients treated with CSP or EMR for SSL were evaluated in this single-center observational study. The primary outcome was the incidence of histopathologically positive vertical margins in CSP and EMR. Furthermore, the comparisons were adjusted for confounding factors using propensity score matching. RESULTS: Overall, 82 patients with SSLs were included in the CSP and EMR groups after matching. The incidence of positive histological vertical margins in the CSP and EMR groups were 67.1% and 2.4%, respectively (p<0.001). Regarding the evaluation of the presence of muscularis mucosae, 29.3% and 98.8% of the patients in the CSP and EMR groups, respectively, had a complete muscularis mucosae resection (p<0.001). CONCLUSIONS: A rigorous histopathologic evaluation revealed that for SSLs, CSP more frequently leads to positive vertical margins than EMR.

Delayed Perforation of Colorectal Endoscopic Submucosal Dissection Treated by Endoscopic Ultrasound-Guided Drainage.

We report a case of a 70-year-old male with delayed perforation in the cecum treated by endoscopic ultrasonography-guided drainage for a pelvic abscess. The lesion was a 50-mm laterally spreading tumor, and endoscopic submucosal dissection (ESD) was performed. No perforation was detected during the operation, and en bloc resection was achieved. He had fever and abdominal pain on postoperative day (POD) 2. Computed tomography (CT) revealed the intra-abdominal free air, leading to a diagnosis of delayed perforation after ESD. Vital signs were stable, the perforation was considered minor, and endoscopic closure was attempted. The colonoscopy under fluoroscopy showed no perforation in the ulcer and no leakage of the contrast medium. He was managed conservatively with antibiotics and nothing per os. Symptoms improved; however, a follow-up CT on POD 13 revealed a 65-mm pelvic abscess, and endoscopic ultrasound (EUS)-guided drainage was successfully performed. The follow-up CT on POD 23 showed the reduction of abscess, and the drainage tubes were removed. Emergent surgical treatment is crucial in delayed perforation because it has a poor prognosis, and reports of conservative therapy for colonic ESD with delayed perforation are few. The present case was managed with antibiotics and EUS-guided drainage. Thus, EUS-guided drainage can be a treatment option for delayed perforation after colorectal ESD, if the abscess is localized.

Delayed Perforation after Endoscopic Detachable Snare Ligation for Colonic Diverticular Hemorrhage.

A 74-year-old man was admitted to our hospital with severe hematochezia. Abdominal enhanced computed tomography (CT) demonstrated extravasation of contrast material from the descending colon. Colonoscopy revealed recent bleeding in the descending colon diverticulum. Bleeding was stopped using detachable snare ligation. Eight days later, the patient developed abdominalgia, and CT revealed free air caused by delayed perforation. The patient underwent emergency surgery. Perforation at the ligation site was detected using intraoperative colonoscopy. This report is the first to describe a case of delayed perforation after endoscopic detachable snare ligation for colonic diverticular hemorrhage.

Neuroendocrine tumor of the ampulla of Vater treated with endoscopic papillectomy: A case report.

We report the case of a 62-year-old female with a 6.3-mm low-grade neuroendocrine tumor of the ampulla of Vater, who underwent an endoscopic papillectomy. An endoscopic papillectomy was performed without complications. In the 26 months of follow-up, no local recurrence or metastasis occurred. Endoscopic treatment of ampullary neuroendocrine tumors is controversial. However, endoscopic papillectomy may be considered a treatment option if neuroendocrine tumors are small (<10 mm), have a low grade (G1), or do not have muscle layer or bile duct invasion.

Endoscopic Detachable Snare Ligation Therapy for Colonic Diverticular Hemorrhage Improves Procedure Time Compared to Endoscopic Band Ligation.

BACKGROUND: The clipping method is widely used in endoscopic hemostasis for colonic diverticular hemorrhage. Recently, rebleeding was shown to be less common in ligation therapy than in clipping. Ligation methods include endoscopic band ligation (EBL) and endoscopic detachable snare ligation (EDSL). No studies have compared procedure times for EBL and EDSL. The present study aimed to compare EDSL and EBL in terms of procedure time. METHODS: In this single-center retrospective observational cohort study, we evaluated the data of 39 patients who underwent EBL or EDSL for colonic diverticular hemorrhage. The primary and secondary outcomes measured were the total procedure time and early rebleeding rate, respectively. RESULTS: Among the 39 patients included in the study, 18 underwent EBL, and 21 underwent EDSL for hemostasis. The median total pro- cedure times for the EBL and EDSL groups were 50 (range, 30-80) minutes and 35 (range, 18-55) minutes, respectively, demonstrating that the total colonoscopy time was significantly shorter in the EDSL group (P < .001). The early rebleeding rate was 11.1% (2/18) in the EBL group and 4.8% (1/21) in the EDSL group (P = .246). CONCLUSION: Important improvements in procedure time were achieved in the EDSL group. Based on our results, we believe that EDSL may reduce patient and endoscopist burden.

[A case of rectum metastasis of breast cancer].

A 53-year-old woman visited the hospital of this study complaining of constipation. Colonoscopy revealed a circumferential tumor with severe stenosis, and a computed tomography scan showed neoplastic lesions in the rectum and right breast area. Histology was poorly differentiated adenocarcinoma, requiring differentiation between type 4 and metastatic rectal cancer. Additional immunohistochemical tests were performed and a rectal metastasis of breast cancer diagnosis was made. Hormonal therapy was effective and the tumor volume was significantly reduced. Rectal metastasis of breast cancer is said to be rare. However, in the case of patients diagnosed with breast cancer or with a history of breast cancer, considering the possibility of gastrointestinal metastasis using histopathological examination is important.

Clinical benefit of the multibending endoscope for gastric endoscopic submucosal dissection: a randomized controlled trial.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a technically difficult and time-consuming procedure. We aimed to investigate the efficacy and safety of ESD using a multibending endoscope to treat superficial gastrointestinal neoplasms. METHODS: Patients with a single early gastric cancer who met the absolute or expanded indications for ESD according to the Japanese gastric cancer treatment guidelines were enrolled and randomly assigned to undergo ESD using a conventional endoscope (C-ESD) or a multibending endoscope (M-ESD). Randomization was stratified by ESD operator experience and tumor location. The primary outcome was ESD procedure time, calculated as the time from the start of submucosal injection to complete removal of the tumor. RESULTS: 60 patients were analyzed (30 C-ESD, 30 M-ESD). The mean (standard deviation [SD]) ESD procedure times for M-ESD and C-ESD were 34.6 (SD 17.2) and 47.2 (SD 26.7) minutes, respectively (P = 0.03). Muscle layer damage occurred significantly less frequently with M-ESD (0.2 [SD 0.7] vs. 0.7 [SD 1.0]; P = 0.04). There were no significant differences between the two techniques in procedure time or damage to muscle layers for tumors located in the lower third of the stomach. CONCLUSIONS: ESD procedure time was significantly shorter with the multibending endoscope and fewer muscles were damaged. We recommend multibending endoscopy for ESD in the upper and middle thirds of the stomach to reduce procedure time and incidence of complications.

A case of complete remission of advanced hepatocellular carcinoma with type III portal vein tumor thrombosis treated using transarterial chemoembolization with microspheres and radiation therapy.

Portal vein tumor thrombosis (PVTT) is an extremely locally advanced form of hepatocellular carcinoma. The natural median survival time of patients with hepatocellular carcinoma with PVTT is 2.7 to 4.0 months. A 63-year-old woman visited our clinic complaining of abdominal distention and appetite loss, which she had had for 3 weeks prior to admission. A contrast-enhanced computed tomography scan showed double hepatocellular carcinomas with Type III PVTT and massive ascites caused by arterio-portal shunts within the PVTT. The ascites could not be treated by concentrated ascites reinfusion therapy or diuretics. Transarterial embolization using microspheres followed by radiation therapy against PVTT and five courses of transarterial chemoembolization using microspheres and cisplatin led to the maintaining of complete remission of both ascites and tumors for over 12 months after treatment. Fluoroglucose accumulation of PVTT showed 11.2 as a maximum standard uptake value on positron emission tomography before treatment. No fluoroglucose accumulation within PVTT was observed for over 12 months following treatment. Transarterial chemoembolization using microspheres followed by radiation therapy against Type III PVTT may result in drastic anti-cancer effects and improvement of both serum albumin and intractable ascites after treatment of arterio-portal shunts within the PVTT causing portal hypertension.

[A Case of Endoscopic Submucosal Dissection for Recurrent Gastric Cancer after Chemotherapy with Arterial Infusion].

The patient was a 90-year-old male. For early gastric cancer on the posterior wall of the upper gastric body, which is not indicated for endoscope treatment, chemotherapy with arterial infusion was carried out at other facilities at the request of the patient and his family. Thereafter, he suffered a relapse during follow-up, for which our hospital carried out endoscopic submucosal dissection(ESD). The outcome was a resection without cure. Taking into consideration his age and the fact that the scoring system for early gastric cancer with excised lesions without cure by ESD indicated a medium risk, we carried out no additional treatment but did conduct a follow-up. There has been no recurrence for 15 months following surgery. ESD does not provide evidence with regard to recurrence after other treatments. This patient had a scar following arterial infusion chemotherapy and a local injection solution was not infused into the submucosa right under the lesion. Although the treatment of exfoliation was difficult due to fibrosis of the submucosa, en-bloc resection was possible without any complications.

Characteristic Radiological Features of Retrospectively Diagnosed Pancreatic Cancers.

OBJECTIVES: The aim of this study was to assess the characteristic radiological features of early-stage pancreatic cancer (PC). METHODS: Between 2009 and 2016, 510 PC patients were selected from our hospital cancer registry database based on International Classification of Diseases for Oncology-3 (C25). Among them, 64 patients (42 males and 22 females; median age, 74 [range, 59-91]) had received repeated abdominal radiological examinations before their diagnosis of PC and were retrospectively investigated for specific radiological findings. The subjects underwent the following imaging examinations: computed tomography, magnetic resonance imaging, and fluoroglucose-positron emission tomography. RESULTS: Characteristic radiological features before diagnosis of PC were classified into the following 9 features: pancreatic duct ectasia (n = 16), focal low-density area (n = 15), change of cyst size (n = 8), localized tissue atrophy (n = 7), distal atrophy (n = 4), mass in pancreatic lipomatosis tissue (n = 2), mass concomitant with the already known cyst (n = 2), protrusion (n = 1), and parenchymal disproportion (n = 1). Fifty-three cases (84%) had more than one characteristic radiological feature before diagnosis of PC, and their median observation period until diagnosis was 24 (range, 1-120) months. CONCLUSIONS: The 9 characteristic radiological features provide an opportunity to diagnose PC at an early stage.

An elderly man with progressive focal nodular hyperplasia.

Patients with focal nodular hyperplasia (FNH) develop benign hepatocellular nodules. FNH most frequently occurs in young women. There are no reports of the onset of FNH in elderly men. We report a case of FNH in an elderly man, whose nodules increased in number and size. The patient underwent surgery for carcinoma of the left renal pelvis at 69 years of age; no liver masses were noted on yearly follow-up contrast-enhanced computed tomography (CECT). Ten years later, CECT revealed a hepatic mass, and magnetic resonance imaging suggested FNH. The nodules increased in number and size in subsequent follow-up examinations.

Efficacy of long-term rifaximin treatment for hepatic encephalopathy in the Japanese.

BACKGROUND: Hepatic encephalopathy (HE) is a complication of liver cirrhosis and can result in neuropsychological and neuromuscular dysfunctions in patients. Rifaximin, an antibiotic, has been reported to decrease the occurrence of overt HE and also improve cognitive function in studies from Europe and the United States of America. There is not enough evidence of the relationship between the long-term use of rifaximin and its clinical effects in the Japanese. AIM: To determine the clinical effects of long-term rifaximin therapy in decompensated liver cirrhosis patients, with overt HE or hyperammonemia. METHODS: In this single-center retrospective observational cohort study, we reviewed the data of 38 patients who had taken rifaximin at the dose of 1200 mg/d for more than 24 wk. The primary outcome measured was the efficacy of long-term rifaximin use, and secondary outcome measured was the safety of its long-term use as determined by its influence on portosystemic shunts as well as Escherichia coli-related infections. Moreover, we compared the prognosis between the rifaximin group and control cases, matched for hepatic elasticity assessed by magnetic resonance ela-stography, age, and Child-Pugh classification. RESULTS: Of the 38 patients included in the study, 12 (31.6%) had overt HE, 27 (71.1%) had complications of esophageal varices, and 9 (23.7%) had hepatocellular carcinoma (HCC). The control group was matched for age, Child-Pugh classification, liver stiffness, and presence of HCC. The median of serum ammonia level before treatment was 104 µg/dL (59-297), and 2 wk after treatment, it significantly decreased to 85 µg/dL (34-153) (P = 0.002). A significantly low value of 80.5 µg/dL (44-150) was maintained 24 wk after treatment. The long-term use of rifaximin did not cause a decline in liver function. Diarrhea occurred in 2 patients, who improved with the administration of probiotics, and there were no cases of aborted rifaximin therapy owing to adverse events. In patients with Child C, the survival was short, but there was no significant difference compared with that of the control group. CONCLUSION: Rifaximin therapy improves overt HE. The long-term use of rifaximin in the Japanese is effective and safe.

Shear wave elastography predicts hepatocellular carcinoma risk in hepatitis C patients after sustained virological response.

AIM: To evaluate the relationship between fibrosis and HCC after sustained virological response (SVR) to treatment for chronic hepatitis C (HCV). METHODS: This single-center study retrospectively evaluated 196 patients who achieved SVR after HCV infection. The associations of risk factors with HCC development after HCV eradication were evaluated using univariate and multivariate Cox proportional hazards regression models. RESULTS: Among the 196 patients, 8 patients (4.1%) developed HCC after SVR during a median follow-up of 26 months. Multivariate analyses revealed that HCC development was independently associated with age of ≥75 years (risk ratio [RR] = 35.16), α- fetoprotein levels of ≥6 ng/mL (RR = 40.30), and SWE results of ≥11 kPa (RR = 28.71). CONCLUSIONS: Our findings indicate that SWE may facilitate HCC surveillance after SVR and the identification of patients who have an increased risk of HCC after HCV clearance.

Early post-transplant hyperbilirubinemia is a possible predictive factor for developing neurological complications in pediatric living donor liver transplant patients receiving tacrolimus.

The cause of post-transplant CNI-NCs is multifactorial and not ascribed solely to CNI toxicity. A total of 90 children (aged <20 years) who underwent LDLT were evaluated to investigate the predictive factors associated with CNI-NCs. Twelve patients (13.3%) developed CNI-NCs after LDLT (age range, 2-15 years). The symptoms of CNI-NCs were seizures, VD, and stupor. The median onset of CNI-NCs was 10 days (range, 5-30 days) post-transplant. In the univariate analysis, higher recipient age at LDLT, donor age and recipient's BW, lower actual GV/SLV and TAC dosage/BW, and higher mean T-Bil and sodium level for 7 days after transplantation were independently significantly associated with TAC-NCs. Multivariate analysis showed that the T-Bil level in the first week after LDLT was the only significant independent predictive factor for TAC-NCs (HR, 1.588; 95% CI, 1.042-2.358; P=.031). In conclusion, CNI-NCs occurred most frequently in children over 5 years and were associated with hyperbilirubinemia for 7 days post-transplant, regardless of TAC levels. The transplant team should refer to a neurologist to define the diagnosis and to collaborate to resolve the neurological problems.

[A Case of an Abdominal Desmoplastic Small Round Cell Tumor with Metastasis in the Medulla Oblongata].

A desmoplastic small round cell tumor(DSRCT)is a very rare malignant tumor that mainly occurs in the intra-abdominal cavity in young adults.This neoplasm has an extremely poor prognosis, with a clinical course characterized by rapid progression and metastasis.We present a 31-year-old man who presented with chief complaints of dysphagia, ataxic gait, and hoarseness.He first underwent surgical resection of a tumor in the medulla oblongata; however, the lesion was suspected to be a metastatic neoplasm.Following a thorough medical examination, the patient was diagnosed with retroperitoneal DSRCT with multiple metastatic lesions.He received multidisciplinary treatment including debulking surgery for the primary lesion; radiotherapy for metastatic lesions in the brain, abdomen, and cervical lymph nodes; hepatic artery embolization for liver metastasis; and systemic chemotherapy.The patient died of progressive disease 17 months after the initial diagnosis.

Epstein-Barr virus--associated posttransplantation lymphoproliferative disorder with tacrolimus metabolism deterioration in infants after living-donor liver transplantation.

BACKGROUND: Posttransplantation lymphoproliferative disorder (PTLD) in infants after liver transplantation is strongly associated with tacrolimus (Tac) administration and primary Epstein-Barr virus (EBV) transmission. METHODS: From 1991 to 2012, 32 survivors younger than 2 years who had undergone living-donor liver transplantation using Tac for primary immunosuppression were retrospectively investigated for changes in Tac trough levels before and at the onset of posttransplantation viral infection episodes. RESULTS: Twenty-one recipients experienced 33 viral infection episodes associated with EBV-related PTLD (n = 5), symptomatic EBV infection without development of PTLD (n = 8), and other viral infections (n = 20). Although the average Tac trough levels during the 2 months before the onset of viral infection episodes were similar among the 33 episodes (9.0 ± 2.8 ng/mL), the Tac trough levels at the onset were significantly higher in the episodes with PTLD than in those with EBV infection without the development of PTLD and with other viral infections (19.2 ± 9.0 ng/mL vs. 9.3 ± 5.2 ng/mL and 10.6 ± 5.1 ng/mL, respectively) (P<0.05). Tacrolimus trough levels at the onset of PTLD were significantly higher during the 2 months before the onset (median, 1.83 times higher than average) compared with EBV infection (1.14 times higher) and other viral infections (1.06 times higher) (P<0.05). The Tac blood concentration-to-dose ratio at the onset of PTLD was more than twice as high as the average value during the 2 months before the onset. CONCLUSION: Deteriorated Tac metabolism accompanied by a positive change in the blood EBV DNA load may enable us to predict the development of PTLD in liver-transplanted infants with viral infection.

Hepatic venous reconstruction using the superficial femoral vein in a right-lobe living donor liver transplant patient with interrupted inferior vena cava.

Anatomical abnormalities in patients with BA often include polysplenia, preduodenal portal vein, interrupted retrohepatic IVC, cardiac abnormalities, and situs inversus. In LDLT patients who had congenital vascular anomalies, additional surgical modifications for the reconstruction of hepatic venous branches are sometimes necessary to prevent venous parenchymal congestion. We report a 12-yr-old female with post-Kasai BA with interrupted retrohepatic IVC who underwent right-lobe LDLT because the left liver graft volume was insufficient. The donor right liver graft had three major hepatic branches, including the RHV, IRHV, and MHV tributary (V8). We performed hepatic venous reconstruction by creating a large, wide triple orifice consisting of the RHV and two SFVs, which were anastomosed to the V8 and IRHV using the donor's SFV as an interposition graft. In conclusion, the reconstruction of venous orifices for right-lobe LDLT patients with the absent retrohepatic IVC is can be carried out using an SFV graft derived from the living donor or the recipient.

Solitary hepatic granuloma preoperatively diagnosed as intrahepatic cholangiocellular carcinoma: report of a case.

We herein report the case of a 67-year-old female with a solitary hepatic granuloma preoperatively diagnosed as a mass-forming type of intrahepatic cholangiocellular carcinoma. Magnetic resonance imaging using gadolinium-ethoxybenzyl-diethylenetriaminepentaacetic acid as a contrast medium is expected to be useful for making a differential diagnosis between hepatic granuloma and other hypovascular liver tumors, such as the mass-forming type of intrahepatic cholangiocellular carcinoma and metastatic liver tumors.

Post-transplantation lymphoproliferative disorder in living-donor liver transplantation: a single-center experience.

BACKGROUND: Post-transplantation lymphoproliferative disorder (PTLD) is a group of life-threatening complications of organ transplantation, which occurs most frequently in pediatric patients. This retrospective study evaluates a single-institution experience of five cases of PTLD after living-donor liver transplantation (LDLT). PATIENTS AND METHOD: We reviewed the records of 78 pediatric patients (<18 years old) and 54 adult patients, who underwent LDLT between July 1991 and December 2009. RESULT: PTLD was diagnosed in five pediatric patients, yielding an overall incidence of 3.8%. There were no significant differences between the pediatric patients with and those without PTLD in terms of their age, sex, reason for transplantation, calcineurin inhibitor, Epstein-Barr virus (EBV) serostatus, ABO compatibility, lymphocyte cross-matching, or episodes of biopsy proven rejection. Two patients with abdominal lymphadenopathy and one with gastrointestinal PTLD responded to a reduction in immunosuppression. Treatment with rituximab was necessary for another gastrointestinal PTLD patient. Diffuse large-B-cell lymphoma was diagnosed in one patient with mediastinal and lung masses. This patient was treated with chemotherapy and rituximab, followed by surgical resection. All patients survived and no evidence of recurrence has been found since. CONCLUSION: Although PTLD is potentially life-threatening, it can be managed by appropriate and prompt treatment, with a good outcome.

Contralateral glissonian pedicle occlusion in a case of portal vein tumor thrombosis.

To dissect portal vein branches directly and encircle them separately is a common procedure that is performed to control back flow bleeding during operations for hepatocellular carcinoma with portal vein tumor thrombosis. However, this technique has an increased risk of injuring contralateral portal branches and disseminating thrombosis fragments to the remnant liver. We present an alternative technique using right-sided glissonian pedicle occlusion for hepatocellular carcinoma with left portal vein tumor thrombosis due to complex anatomical vasculatures of the hepatic pedicle. This technique would be very useful for liver resection of hepatocellular carcinoma with the major type of portal vein tumor thrombosis.