Endoscopic submucosal dissection for gastric tube cancer after esophagectomy.

BACKGROUND: Recent improvements in the survival of patients after esophagectomy have led to an increasing occurrence of gastric tube cancer (GTC). Removal of the reconstructed gastric tube, however, can lead to high morbidity and mortality. OBJECTIVE: To assess the feasibility and effectiveness of endoscopic submucosal dissection (ESD) for GTC. DESIGN: Retrospective study. SETTING: National Cancer Center Hospital, Tokyo, Japan. PATIENTS: We investigated patients with GTC after esophagectomy undergoing ESD from 1998 to 2011. INTERVENTION ESD MAIN OUTCOME MEASUREMENTS: Patient characteristics, endoscopic findings, technical results, histopathology including curability and Helicobacter pylori gastritis, and long-term outcomes. RESULTS: There were 51 consecutive patients with 79 lesions including 38 lesions (48%) meeting the absolute indication, 31 (39%) satisfying the expanded indications, and 10 (13%) falling outside such indications. The median procedure time was 90 minutes. There were 73 en bloc resections (92%), 59 en bloc resections with tumor-free margins (R0 resections, 75%), and 51 curative resections (65%) based on the Japanese Gastric Cancer Association criteria. Fifty patients (98%) were assessed as H pylori gastritis positive. Adverse events included 3 perforations (3.8%) during ESD and 2 delayed perforations (2.5%) without any emergency surgery and 3 delayed bleeding (3.8%). Local recurrence was detected in 4 patients (7.8%), and metachronous GTCs were identified in 18 patients (35%). Five patients (10%) died of GTC including 3 metachronous lesions. The 5-year overall survival rate was 68.4%, and the disease-specific survival rate was 86.7% with 100% for curative and 72.7% for non-curative patients during a median follow-up period of 3.8 years (range, 0-12.1 years). LIMITATION: Single-center retrospective study. CONCLUSIONS: ESD for GTC was feasible and effective for curative patients; however, long-term outcomes for non-curative patients were less satisfactory.

Antithrombotic drugs are risk factors for delayed postoperative bleeding after endoscopic submucosal dissection for gastric neoplasms.

BACKGROUND: The discontinuation of antithrombotic drugs is recommended during endoscopic submucosal dissection (ESD) for gastric neoplasms; however, controversy remains as to whether antithrombotic drugs are risk factors for postoperative bleeding. OBJECTIVE: To determine the risk factors for post-ESD bleeding. DESIGN: Single-institution, retrospective review. SETTING: University hospital. PATIENTS: From June 2000 to December 2010, we treated 1192 gastric neoplasms in 1032 consecutive patients. INTERVENTION: The ESD procedures were performed by using the standard techniques. Antithrombotic drug therapy was principally interrupted preoperatively and was restarted when hemostasis was confirmed by second-look endoscopy. MAIN OUTCOME MEASUREMENTS: Risk factors for postoperative bleeding after ESD (early, delayed, and overall [combined] occurrence of bleeding during the first 5 postoperative days or thereafter) were analyzed by using logistic regression analysis. RESULTS: Among 1166 ESD-induced ulcer lesions, overall postoperative bleeding was evident in 62 lesions (5.3%); early and delayed bleeding occurred in 30 and 32 lesions (2.6% and 2.7%), respectively. Based on a multivariate analysis, a specimen size of >40 mm was the sole independent risk factor for overall bleeding. Moreover, oral antithrombotic drug therapy was selected as independent risk factor for delayed but not early bleeding, according to the multivariate analysis. The delayed bleeding rate in patients who had a specimen size of >40 mm and who used antithrombotic drugs was 11.6%. LIMITATIONS: Retrospective design and single-site data collection. CONCLUSION: Interruption of antithrombotic drug therapy may be adequate for preventing early post-ESD bleeding; however, reinitiating antithrombotic drug therapy is a significant independent risk factor for delayed post-ESD bleeding.

Endoscopic submucosal dissection with the combination of a scissor-type knife and novel traction method for colonic neoplasm involving a diverticulum.

Video 1A 35-mm laterally spreading tumor partially infiltrated the interior portion of the diverticular orifice in the ascending colon. Glycerol and hyaluronate solution were injected into the submucosa to maintain adequate mucosal elevation. Mucosal incision and submucosal dissection were performed using a DualKnife and insulation-tipped knife from the anal side; however, safe submucosal dissection was challenging with these knives because of severe fibrosis and abundant blood vessels in the diverticulum. Therefore, to improve the visibility of the submucosa, a scissor-type knife and a multiloop traction device was used to facilitate the submucosal dissection. Finally, en bloc resection was achieved in 117 minutes without adverse events. A part of the diverticular defect after endoscopic submucosal dissection was clipped to prevent delayed perforation.

Removal of a foreign body by rigid bronchoscope after virtual reality-aided presurgical planning: A case report.

Flexible bronchoscopy is becoming increasingly important for the removal of airway foreign bodies. However, in cases of risk of coughing during the procedure, rigid bronchoscopic intervention should be performed under general anesthesia. A 22-year-old man presented with history of several episodes of fever, for which he was administered antibiotics at a private clinic. In an annual chest X-ray and chest computed tomography examination, a foreign body, which appeared to be an orthodontic appliance, was discovered in the left main bronchus. It was deemed difficult to remove the foreign body using flexible bronchoscopy because of granulation tissue formation. Therefore, the patient was referred to our institution. We simulated the clinical situation using virtual reality, which indicated that the proximal and distal metallic parts of the appliance had grown into the bronchial mucosa. First, we inserted a rigid bronchoscope under general anesthesia and cut the granulation tissue using an insulation-tipped diathermic knife. Thereafter, we removed the appliance with grasping forceps under rigid bronchoscope guidance. In cases of risk of foreign body encroachment into the bronchial mucosa or granulation tissue development, rigid bronchoscopic intervention is effective. Furthermore, a VR-based intervention may be a useful option in such cases.