Location in the ascending colon is a predictor of refractory colonic diverticular hemorrhage after endoscopic clipping.

BACKGROUND: Predictors of refractory colonic diverticular hemorrhage after endoscopic clipping (EC) remain unclear. OBJECTIVE: To elucidate the predictors of uncontrolled bleeding after EC. DESIGN: Retrospective study. SETTING: Two tertiary referral centers. PATIENTS: Eighty-nine patients with colonic diverticular hemorrhage who underwent EC as a first-line treatment were included. INTERVENTIONS: If bleeding remained uncontrolled after 1 or 2 EC sessions, other interventions (transcatheter arterial embolization, endoscopic band ligation, or surgery) were performed. Patients were divided into EC-controlled and EC-uncontrolled groups; the characteristics of each group were compared. MAIN OUTCOME MEASUREMENTS: Comorbidities, location of bleeding diverticula, and EC technique (direct vs indirect placement). RESULTS: Initial treatment with EC was successful in 87 patients. Early rebleeding (primary failure) occurred in 30 of 87 patients (34%). Secondary failure occurred in 6 of 22 patients treated with reclipping (27%). Cumulatively, 78 patients were successfully managed with EC. Non-EC treatments were required in 11 patients. Location in the right side of the colon, particularly in the ascending colon, was significantly more common in the EC-uncontrolled group than in the EC-controlled group (P = .017 and P = .0029, respectively). Although the difference was not significant, bleeding was successfully managed in all 13 patients treated with direct placement. Bleeding remained uncontrolled after EC in 11 of 52 ascending cases (21%) treated with indirect placement. Diverticular hemorrhage in other locations was managed regardless of EC technique. LIMITATIONS: Retrospective study. CONCLUSIONS: Location in the ascending colon is a significant predictor of refractory colonic diverticular hemorrhage after EC. Indirect placement of hemoclips in ascending lesions is ineffective.

Endoscopic band ligation for colonic diverticular hemorrhage.

BACKGROUND: The number of sample cases of colonic diverticular hemorrhage treated with endoscopic band ligation (EBL) has been small to date. OBJECTIVE: To elucidate the safety and efficacy of EBL for colonic diverticular hemorrhage. DESIGN: Retrospective study. SETTING: General hospital. PATIENTS: A total of 29 patients with 31 colonic diverticula with stigmata of recent hemorrhage (SRH). INTERVENTIONS: Urgent colonoscopy was performed after bowel preparation. When diverticula with SRH were identified, marking with hemoclips was done near the diverticula. The endoscope was removed and reinserted after a band-ligator device was attached to the tip of endoscope. At first, EBL was attempted. In patients who could not be treated with EBL, epinephrine injection or endoscopic clipping was performed. MAIN OUTCOME MEASUREMENTS: Procedure time, rate of hemostasis and rebleeding, complications. RESULTS: The mean procedure time was 47 ± 19 minutes. EBL was successfully completed in 27 colonic diverticula (87%); except in 3 diverticula with a small orifice and large dome and 1 diverticula in which the orifice was too large. Early rebleeding after EBL occurred in 3 of 27 cases (11%). Although 2 cases of sigmoid rebleeding could be managed by repeat EBL or conservatively, right hemicolectomy was performed in 1 ascending diverticulum, in which the bleeding source was not identified on repeat colonoscopy. Scar formation at previously banded diverticula was identified in 7 of 11 patients who underwent follow-up colonoscopy. There were no complications after EBL in any of the patients. LIMITATIONS: Retrospective study. CONCLUSIONS: EBL is a safe and effective treatment for colonic diverticular hemorrhage, and colonic diverticula resolve after EBL.

Endoscopic submucosal dissection (ESD) for gastrointestinal carcinoid tumors.

BACKGROUND: Gastrointestinal (GI) carcinoid tumors less than 10 mm in diameter and limited to the submucosal layer demonstrate a low frequency of lymph node and distant metastasis; endoscopic submucosal dissection (ESD) has been used to treat these tumors. However, the number of reported sample cases of rectal carcinoid tumors treated with ESD remains insufficient, and the safety and efficacy of ESD for gastric and duodenal carcinoid tumors have not been elucidated to date. METHODS: From January 2004 to March 2011, a series of 42 gastrointestinal carcinoid tumors (37 rectal, 2 gastric, and 3 duodenal) in 41 consecutive patients were treated with ESD. Therapeutic efficacy, complications, and follow-up results were retrospectively evaluated. RESULTS: Sessile type (type Is) was the most prevalent lesion. Mean procedural time was 41 ± 20 min. The mean sizes of tumors and resected specimens were 5 ± 3 mm and 19 ± 7, respectively. The overall rate of en bloc resection was 100% (42/42). Postoperative bleeding occurred in two rectal cases (5%), which were successfully managed with endoscopic clipping. Perforation occurred in two duodenal cases, which could be conservatively managed with medical treatment after endoscopic clipping, and neither laparoscopy nor emergent surgery was needed. No recurrence was observed during the mean follow-up period of 37 months. CONCLUSIONS: ESD was a safe and effective endoscopic treatment for rectal and gastric carcinoid tumors, although other treatment modalities were desirable for duodenal carcinoid tumors.

Risk for local recurrence of early gastric cancer treated with piecemeal endoscopic mucosal resection during a 10-year follow-up period.

BACKGROUND: Endoscopic mucosal resection (EMR) is a therapy for early gastric cancer (EGC) that can be provided relatively easily and safely in any institution. Identification of the resection margin is a problem in EMR, especially in cases of piecemeal EMR. Despite the long-standing widespread use of piecemeal EMR for EGC, its limitation and long-term outcomes in clinical practice have not been fully evaluated. This study aimed to determine the risk factors of piecemeal EMR, the local recurrence rates, and the mortality rate. METHODS: A cross-sectional, retrospective cohort study was performed to investigate the risks of piecemeal EMR for patients with the diagnosis of differentiated adenocarcinoma localized to the mucosa. Local recurrence of EGC was investigated by annual follow-up esophagogastroduodenoscopy (EGD) for 10 years. EMR was performed with snare electrocautery using a two-channel scope. When a resection margin was clearly positive for cancer, additional surgery was performed soon after the initial EMR. RESULTS: For the 149 EGC patients (mean age, 68.8 ± 9.8; male, 77%) who underwent EMR between 1995 and 2001, EMR was performed en bloc in 66 cases and piecemeal in 83 cases. The comorbid conditions existing in 34 of the 149 patients included other malignancies (n = 12), heart failure (n = 5), pulmonary disease (n = 7), liver cirrhosis (n = 4), and other illness (n = 6). However, EMR was completed without complication. The mean area (length × width) of the lesions was 404 ± 289 mm(2) in the piecemeal group and 250 ± 138 mm(2) in the en bloc groups. The en bloc and piecemeal EMR groups differed significantly in terms of unclear horizontal margins but not in terms of unclear vertical margins. Multiple logistic regression suggested that the adjusted odds ratio for maximum diameters exceeding 20 mm for piecemeal EMR was 2.71 (95% confidence interval [CI], 1.30-5.64). According to Kaplan-Meier estimates, the local recurrence rate was 30% (95% CI, 20-40%) at both 5 and 10 years. No recurrence was observed in the en bloc group. The adjusted hazard ratio of unclear horizontal margins for local recurrence was 1.63 (95% CI, 1.12-2.36). A total of 24 patients died after EMR because of comorbid conditions, including other malignancies (n = 11), cardiovascular disease (n = 6), pulmonary disease (n = 4), liver cirrhosis (n = 2), and traffic accident (n = 1). However, no patient died of gastric cancer during the 10-year follow-up period. CONCLUSIONS: An evaluation of horizontal margins in terms of local recurrence after piecemeal EMR is important, and en bloc resection is recommended. Close follow-up assessment is warranted, especially within 5 years in cases of unclear margin resection after piecemeal EMR. The use of EMR is safe even for patients with severe comorbid conditions.

Effects of carbon dioxide insufflation in esophageal endoscopic submucosal dissection.

BACKGROUND/AIMS: Although carbon dioxide (CO2) insufflation has successfully replaced air insufflation in a variety of procedures, the effects of CO2-insufflation in esophageal endoscopic submucosal dissection (ESD) have not been adequately investigated. This study was designed to evaluate the effects of CO2 insufflation in esophageal ESD. METHODOLOGY: From January 2009 to January 2011, 57 superficial esophageal neoplasias in 54 patients (51 men and 3 women) were treated under conscious sedation with midazolam and pethidine hydrochloride, using ESD technique with a combination of small-caliber-tip transparent hood and flex knife. They were divided into air-insufflation (39 lesions, 37 patients) and CO2-insufflation (18 lesions, 17 patients) groups and therapeutic efficacy and complications were retrospectively evaluated in each group. RESULTS: The rate of en bloc resection was 100% and there were no complications in each group. No significant differences were seen in procedural time, the amount of pethidine hydrochloride required, body temperature and white blood cell count on post-procedure day 1, and length of hospital stay after ESD. A difference in the amount of midazolam required between the air-insufflation group and the CO2-insufflation group was noted (6mg vs. 4mg, p=0.0017). CONCLUSIONS: CO2-insufflation could be considered useful for reducing patients' discomfort in esophageal ESD.

Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife is a safe and effective treatment for superficial esophageal neoplasias.

BACKGROUND: Superficial esophageal neoplasias resected in piecemeal manner with endoscopic mucosal resection (EMR) sometimes recur locally, and additional treatments need to be developed. Efficacy and safety of endoscopic submucosal dissection (ESD) for esophageal neoplasias are not sufficiently demonstrated, so we conducted a retrospective study to evaluate the efficacy and safety of ESD for superficial esophageal neoplasias. METHODS: Thirty-seven superficial esophageal neoplasias consisted of 34 squamous cell neoplasias and 3 columnar neoplasias in 35 patients were treated with ESD from May 2006 to July 2008. Patients were regularly followed up with endoscopy every 6 months, and with echoendoscope and computed tomography every year. Therapeutic efficacy, complications, and follow-up results were evaluated. RESULTS: The mean size of the resected neoplasias and that of the resected specimens were 22 mm (range 10-83 mm) and 41 mm (range 18-90 mm), respectively. The mean duration of the ESD procedures was 117 min (range 40-235 min). The overall rates of en bloc resection and of free margin resection were 100% (37/37) and 95% (35/37), respectively. The mean follow-up period of 19 months (range 7-32 months) revealed no local or distant recurrence. There were no complications such as bleeding or perforation in any case. In all nine cases, the strictures were successfully managed with prophylactic endoscopic balloon dilation. CONCLUSIONS: ESD with a combination of small-caliber-tip transparent hood and flex knife is a safe endoscopic treatment for superficial esophageal neoplasias and enables large en bloc resection.

Endoscopic submucosal dissection and preoperative assessment with endoscopic ultrasonography for the treatment of rectal carcinoid tumors.

BACKGROUND: Rectal carcinoid tumors 10 mm in diameter or smaller located within the submucosal layer can be cured by local excision including endoscopic treatment. But complete resection of these tumors with endoscopic polypectomy is difficult. This study aimed to evaluate the usefulness of endoscopic submucosal dissection (ESD) and endoscopic ultrasonography (EUS) for the treatment of rectal carcinoid tumors. METHODS: In this study, 22 rectal carcinoid tumors in 21 patients were evaluated with EUS and treated using ESD from January 2004 to December 2008. RESULTS: The mean size of the resected tumors was 6.1 mm (range, 2.0-10 mm) on histopathologic evaluations. When the sizes of the tumors shown by EUS and histopathologic evaluation were compared, the mean values were not significantly different. All the tumors were located within the submucosal layer, and the accuracy of the preoperative depth determination with EUS was 100% (22/22). The mean duration of the ESD procedure was 37 min (range, 20-71 min). The overall rate of en bloc resection with ESD was 100% (22/22). Although postoperative bleeding occurred in two cases (9%), both cases were successfully managed by endoscopic hemostasis. No perforation or recurrence was observed during the mean follow-up period of 30 months (range, 7-66 months). CONCLUSIONS: Endoscopic submucosal dissection and preoperative assessment with EUS are effective for treating rectal carcinoid tumors and enabling en bloc resection.

Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for large superficial colorectal neoplasias including ileocecal lesions.

BACKGROUND: Large superficial neoplasias of the ileocecal region pose an increased degree of complexity for endoscopic resection. This study aimed to evaluate the safety and efficacy of endoscopic submucosal dissection (ESD) for large superficial colorectal neoplasias including ileocecal lesions. METHODS: A total of 33 superficial colorectal neoplasias, including eight neoplasias in the ileocecal region, were treated with ESD from December 2005 to April 2009. Therapeutic efficacy, complications, and follow-up results were retrospectively evaluated among three groups: ileocecal region, colon, and rectum. RESULTS: The mean size of all resected neoplasias was 35 +/- 15 mm (range, 20-80 mm) and that of all resected specimens was 41 +/- 15 mm (range, 23-82 mm). The mean procedural time was 121 +/- 90 min (range, 22-420 min). The difference in mean values among the three groups was not significant. The overall rate of en bloc resection was 91% (30/33). Histopathologically, both the lateral and vertical margins in the specimens resected en bloc tested negative (30/30). The rate for en bloc resection in the ileocecal region did not differ significantly from that for the other two groups (p = 0.20 compared with the rate for the colon and p = 0.12 compared with the rate for the rectum). Complications such as perforation and postoperative bleeding did not occur in the ileocecal group. No recurrence was observed in any cases during the mean follow-up period of 20 +/- 12 months (range, 4-44 months). CONCLUSIONS: The ESD approach is safe and effective for treating large superficial neoplasias of the ileocecal region such as other colorectal neoplasias.

Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for superficial esophageal neoplasia. Is it safe for elderly patients?

BACKGROUND: Safety and efficacy of endoscopic submucosal dissection (ESD) for esophageal neoplasias have not been adequately investigated in elderly patients. This study was designed to evaluate the safety and efficacy of ESD for esophageal neoplasias in elderly patients. METHODS: Fifty-three superficial esophageal neoplasias treated with ESD using a combination of small-caliber-tip transparent hood and flex knife from May 2006 to June 2009 were divided into elderly group (aged 70 years or older: 25 lesions in 23 patients) and nonelderly group (younger than aged 70 years: 28 lesions in 25 patients). Therapeutic efficacy, complications, and follow-up results were evaluated retrospectively. RESULTS: The history of cerebral infarction or cardiopulmonary disease and the usage of antiplatelet agents or anticoagulants were significantly higher in elderly group (p 0.0050 and p 0.0013, respectively). Median procedural times in the elderly group and the nonelderly group were 93 ± 53 (range, 42-235) min and 95 ± 55 (range, 40-230) min (p 0.73), respectively. Median sizes of the neoplasias and the resected specimens were 14 ± 11 (range, 5-45) mm and 15 ± 17 (range, 5-83) mm (p 0.56), and 35 ± 12 (range, 18-60) mm and 38 ± 17 (range, 18-90) mm (p 0.38), respectively. En bloc resection rate was 100% in each group. Body temperature and white blood cell counts of the next day after ESD were significantly higher in the nonelderly group than in the elderly group (p 0.0087 and p 0.0043, respectively). There were no complications, such as postoperative bleeding or perforation, in each group. The median follow-up period of 23 ± 10 (range, 4-35) months in the elderly group revealed no local or distant metastasis. CONCLUSIONS: ESD with a combination of small-caliber-tip transparent hood and flex knife is a safe and effective treatment for superficial esophageal neoplasia in elderly and nonelderly patients.

Endoscopic resection after endoscopic hemostasis for hemorrhagic gastric cancer.

A 68 years old man was referred to our hospital with symptoms of hematemesis and melena. An emergent gastroscopy showed a gastric ulcerative lesion with an exposed vessel (Forrest IIa) protruding from its base, which was located at the posterior wall of the upper portion of the gastric body. Endoscopic hemostasis was performed with endoclips and antiulcer treatment was done. Although the ulcerative lesion was healed two months after endoscopic hemostasis, the histopathological examination of the biopsy specimens revealed well differentiated adenocarcinoma (0-IIc). The tumor could be resected en-bloc by endoscopic submucosal dissection (ESD) without any complications such as perforation or postoperative bleeding. The resected specimen showed that the resected tumor was well differentiated intramucosal adenocarcinoma (13 x 10 mm) with a clear lateral margin. There was no recurrence during 12 months follow-up after ESD treatment. Follow-up endoscopy with biopsies should be performed for accurate diagnosis of gastric ulcerative lesions and ESD after endoscopic hemostasis with endoclips was an effective method for early gastric cancer presenting with massive hemorrhage in our case.

Endoscopic band ligation with a water-jet scope for the treatment of colonic diverticular hemorrhage.

Although lower gastrointestinal bleeding generally has a less severe course and stops spontaneously in most cases without therapeutic intervention, some patients require endoscopic, surgical, or angiographic treatment depending on the nature of the bleeding. We applied endoscopic band ligation (EBL) with a water-jet scope to bleeding colonic diverticula and evaluated the efficacy and safety of EBL retrospectively. Five consecutive patients were diagnosed as having colonic diverticular hemorrhage, and were treated with EBL at St Luke's International Hospital in Tokyo from June 2009 to August 2009. Comorbid diseases, usage of anti-platelet agents, hemoglobin level on admission, procedural time, complications such as perforation and abscess formation, and rebleeding after EBL were retrospectively evaluated. In all cases, EBL achieved successful immediate hemostasis without any procedural complications. In four of five cases, bleeding colonic diverticula were everted after EBL. The mean length of hospital stay after EBL was 5 days (range 4-8 days). No patient exhibited clinical evidence of further bleeding during the mean follow-up period of 3 months (range 2-4 months), and no further intervention was needed after EBL. EBL with a water-jet scope is considered to be a safe and effective endoscopic treatment for colonic diverticular hemorrhage.

Annual change of primary resistance to clarithromycin among Helicobacter pylori isolates from 1996 through 2008 in Japan.

BACKGROUND: Recent studies have shown that the combination of proton pump inhibitor, amoxicillin and clarithromycin is one of the best choices for Helicobacter pylori eradication therapy. However, increasing number of cases of H. pylori infection showing resistance to clarithromycin therapy has been reported and this is currently the main cause of eradication failure. We investigated the annual changes of the antimicrobial susceptibility to clarithromycin, amoxicillin and minocycline during a period of 12 years in Japan. METHODS: This study comprised 3521 patients (mean age (SD), 55.4 (13.7) years-old, 2467 males and 1054 females) positive for H. pylori as assessed by microaerobic bacterial culture from 1996 through 2008. All patients were previously untreated for H. pylori and were enrolled in the study to assess primary resistance to the three antibiotics. RESULTS: The overall primary resistance to clarithromycin, amoxicillin and minocycline were 16.4%, (577/3521), 0.03% (1/3521) and 0.06% (2/3521), respectively. From 1996 through 2004, the resistance rate to clarithromycin increased gradually to approximately 30% and then it remained without marked fluctuation since 2004. Analysis by gender showed a significant increase (p < .0001) in resistance rate to clarithromycin among females (217/1057, 20.6%) compared to males (360/2467, 14.6%). Analysis by age, disclosed significantly (p < .0001) higher resistance rate to clarithromycin in patients of more than 65-years-old compared to the younger population. CONCLUSIONS: The resistance rate of H. pylori infection to clarithromycin in Japan has increased gradually to approximately 30% from 1996 through 2004, and remained unchanged since 2004. Elderly and females were at high risk of having resistance to clarithromycin. Our results suggested that the level of clarithromycin resistance in Japan has now risen to the point where it should no longer be used as empiric therapy.

[Effectiveness of endoscopic incision with an IT-knife for the treatment of severe postoperative stricture of GI tract].

BACKGROUND: Severe stenosis of gastrointestinal (GI) tract anastomosis often requires frequent treatment for restenosis. It can cause long-term poor quality of life. AIM: To investigate the effectiveness of the endoscopic incision method with an Insulation-Tipped (IT)-knife for cases of severe GI stenosis in which the condition of the area distal to the stricture is unknown. METHODS: Endoscopic incisions with an IT-knife were performed in 6 cases of postoperative stenosis who underwent gastrojejunostomy (n = 3), esophagogastrostomy (n = 2), and ileocolestomy (n = 1). The incisions were made in three or four directions. RESULT: In all cases, the incisions were successful, with no perforation. There was no severe complication excluding slight bleeding in one case. Because of sufficient incision, there was no restenosis for 20-40 weeks after treatment. CONCLUSION: Endoscopic incision with an IT-knife is useful for severe postoperative stenosis.

Prognosis of patients with hepatocellular carcinoma treated solely with transcatheter arterial chemoembolization: risk factors for one-year recurrence and two-year mortality (preliminary data).

OBJECTIVE: Transcatheter arterial chemoembolization (TACE) is an essential therapy for patients with hepatocellular carcinoma (HCC) in whom administering other treatments such as liver transplantation, resection or local therapy is not feasible. The purpose of our study was to determine the independent risk factors for one-year recurrence and two-year mortality in patients treated solely with TACE. METHODS: We conducted a retrospective cohort study of 34 consecutive patients (Group 1) with incident HCC who were treated solely with epirubicin-based TACE between April 2004 and March 2009. A subgroup analysis was performed among 24 patients (Group 2) who underwent complete TACE confirmed with abdominal computed tomography (CT) one month later. Tumor recurrence was evaluated using contrast CT every three months after the initial TACE. We calculated Kaplan-Meier estimates and performed a multiple regression analysis using a Cox-proportional hazard model. RESULTS: The patients in Group 1 (men, 59%), all of whom had liver cirrhosis, underwent TACE as the sole therapy for HCC. Kaplan-Meier estimates revealed a two-year survival rate [95% CI] of 70% [48-84%]. For the non-Child A patients, the adjusted hazard ratio (HR) [95% CI] for two-year survival was 7.1 [1.06-51.7]. In Group 2, the Kaplan-Meier estimate of the one-year recurrence rate [95% CI] was 61% [42-81%]. The adjusted HRs [95% CIs] for one-year recurrence for age and indocyanine green (ICG) 15-min >30% were 1.1 [1.0-1.26] and 7.87 [1.94-45.1], respectively. CONCLUSION: Non-Child A cirrhosis is an independent risk factor for two-year mortality in patients treated solely with TACE. For ICG 15-min >30%, careful monitoring for HCC recurrence at one year, even after complete TACE, is warranted.

Superficial tumors involving terminal ileum treated by endoscopic submucosal dissection.

It is recognized that superficial tumors of the ileocecal transition pose a higher degree of complexity for endoscopic resection and surgical treatment is sometimes required in cases of incomplete resection. We report some rare cases of superficial tumors involving the terminal ileum treated by endoscopic submucosal dissection (ESD). A 58-year-old woman was referred to our hospital for treatment of a superficial tumor involving the terminal ileum. Endoscopy showed a slightly elevated (type 0-IIa) tumor located at the ileocecal transition. The tumor could be resected en bloc by ESD with a combination of a small-caliber-tip transparent hood and a flex knife without any complications. A 61-year-old man was also referred to our hospital for treatment of a slightly elevated (type 0-IIa) tumor located at the ileocecal transition. The tumor could be resected en bloc. Both resected specimens showed intramucosal adenocarcinomas with clear lateral and vertical margins. By applying ESD with a combination of a flex knife and a small-caliber-tip transparent hood, the superficial tumors involving the terminal ileum were resected en bloc without any complications and the ileocecal valve was preserved in both cases.