In performing endoscopic treatment in patients treated with antiplatelets or anticoagulants, the administration is suspended to prevent intraoperative and postoperative bleeding. However, suspension of the administration naturally increases the risk of thromboembolism, which may lead to serious complications. Therefore, in consideration of these two opposing risks, the Endoscopy Department established provisional rules concerning the administration of anti-platelets and anticoagulants during endoscopic treatment by obtaining cooperation from related departments in the hospital. Although these rules were determined without clear evidence in Japan, they are considered to be meaningful in that they were established through consultation with related departments.

View full abstract

Background : To subdivide patients with esophageal cancers penetrating to the muscularis mucosae (mm) and demonstrating lymph node metastases, we examined the predictive values of associated droplet infiltration (di) in invasive fronts. Methods : The study materials were from 27 cases of esophageal cancers undergone radical operations. From histological preparations, the droplet longitudinal diameter (di_s), the number of included cancer cells (di_n) and the distance from the main tumor (di_d) were determined and their predictive value was compared with that for vessel permeation (vp). Results : Histological findings of di_s ≤20μm, di_n≤4 and di_d≥200μm were related to lymph node metastasis (P=0.001, 0.006 and 0.43, respectively), Di_s≤20μm and di_n≤4 demonstrated equal or greater degrees of sensitivity and likelihood ratios (LR) than vp. However, di_d≥200μm had lower degrees of specificity and LR. Conclusions : Di_s≤20μm and di_n ≤4 are useful predictive factors for lymph node metastasis of mm cancers. They should facilitate decision making about treatment strategies for such lesions.

View full abstract

An elevating lesion was detected in a 46-year old man in the esophagus by G. I. series. Endoscopy revealed a soft bluish plateau lesion on the right wall of esophagus at 28 to 32 cm from incisor, compatible with hemangioma. Furthermore, an early esophageal carcinoma of 0-Jib type unstained by iodine was found on the hemangioma. Esophageal carcinoma developing on hemangioma had never been reported. Treatment was first performed for hemangioma by endoscopic injection sclerotherapy, followed by endoscopic mucosal resection for carcinoma. The complete resection of neoplasms was possible avoiding bleeding.

View full abstract

A 59 years-old man was admitted to our hospital because of severe epigastralgia. The patient had ingested loomL of 36% hydrochloric acid for the suicide purpose at home. Endoscopic examination on admission revealed the black mucosa of the esophagus and stom-ach. The grayish white mucosa with deep ulceration of the esophagus and the black mucosa with large ulceration of the stomach were found on 7th days. These finding suggested the necrosis of all layer of the esophageal and gastric wall. Although the patient was successfully treated with the antibiotic agent, proton pump inhibitor and intravenous hyperalimentation, swallowing disturbance was appeared during the clinical course. We treated the three portions of the esophageal stenose with balloon dilator but his symptom was not improved and he could not swallow the saliva. On the 77th hospital day, esophggo-gastrectomy and substernal bypass with descending colon interposition was performed. The resected specimen showed esophagus and stomach were severely constricted and inelastic and the microscopic finding revealed the severe inflammation and fibrosis of all the layers. Intensive care including the mental support and the surgical treatment was necessary to treat corrosive injuries of gastrointestinal tract. We experienced a case of corrosive injuries of gastrointestinal tract with hydrochloric acid ingestion and showing the typical endoscopic findings during the clinical course.

View full abstract

A case of metastatic carcinoma of the tongue at a percutaneous endoscopic gastrostomy (PEG) site is reported. A 61-year-old man with recurrent cancer of the tongue (rT4N2M0) underwent a PEG insertion using the "pull" technique. Four months later, the patient developed metastatic squamous cell carcinoma at the PEG site. A review of the literature revealed 29 cases of metastatic head and neck cancers to PEG site from western countries. Possible mechanisms of metastasis are direct implantation and hematogenous spread. This complication is rare and this case is the first report in Japan. However, this complication probably increase with the increase number of patients of PEG placement for head and neck cancers. Therefore, the selection of the methods of gastrostomy and the careful frequent medical examination after PEG placement should be important.

View full abstract

A 70-year-old woman was introduced to our hospital with severe vomiting Endoscopic examination showed duodenal carcinoma of the third portion. Simultaneously, the findings of abdominal computed tomography showed multiple metastatic liver tumor with much ascites after treatment for dehydration. The duodenal tumor was not thought to be curatively resectable. To relieve duodenal stenosis, an expandable metallic stent (EMS) was successfully and easily placed with longover tube of Ileus Aid System. The long over tube equipped with a balloon at the tip of the tube facilitated stent placement for sever duodenal stenosis and assisted the insertion by transporting the strength of pushing the tip of EMS because the balloon was fixed at the first portion of duodenum.

View full abstract

A 75-year-old man was admitted for the operation of his rectal cancer. Preoperative upper gastrointestinal endoscopy showed a tumor at the Vater's papilla. For this lesion, endoscopic snare papillectomy was carried out. The histological diagnosis of the resected specimen was tubulopapillary adenoma with moderate atypia and the resected margin was fully negative. One month after the papillectomy, upper abdominal pain and jaundice appeared. Endoscopic retrograde cholangiography confirmed the obstractive jaundice due to a cicatriceal stricture of the choledochus. Endoscopic sphincterotomy and biliary stenting were performed. The further clinical course was uneventful and no symptoms had appeared for 43 months. We must consider a cicatriceal stenosis of the papilla of Vater as the complication more than a month after endoscopic snare papillectomy.

View full abstract

Background Intraductal papillary-mucinous pancreatic tumor (IPMT) is an intraductal lesion formed by mucin-producing epithelium, which proliferates in a papillary pattern, and presents on a spectrum from hyperplasia to adenocarcinoma. The value of intraductal ultrasonography (IDUS) for excluding malignancy has not been assessed in a case series previously.Methods Intraductal ultrasonography was performed in 17 patients with IPMT (12 with adenocar-cinoma and five with adenoma) between November 1993 and June 2002. Intraductal ultrasono-graphy was used to determine the maximum height and maximum cross-sectional area of protruding lesions. Results were compared after dividing the tumors into three groups : a benign lesion group, nor-invasive cancer group, and an invasive cancer group. The resection line was located over 10 mm from edge of the protruding lesion visualized by intraductal ultrasonography.Results All adenocarcinomas had a height ≥5 mm and all benign lesions had≤3 mm, with this difference being significant (P=0.0034). The height of noninvasive and invasive cancer was similar. The maximum cross-sectional area of the protrusion was smaller for benign lesions (≤15 mm²) than for noninvasive cancers (≥34 mm², P=0.0034). The cross-sectional area of the protrusion was greater in patients with invasive cancer than in those with noninvasive cancer (P0.0367). All surgical margins have remained clear and no patient has suffered from a recurrence during 1 to 8 years of follow-up computed tomography and ultrasonography.Conclusions Intraductal ultrasonography can distinguish benign from malignant IPMT based on the height and maximum cross-sectional area of the protruding tumor.

View full abstract

Background: Accurate evaluation of the depth of tumor invasion, including the degree of submucosal invasion, is a prerequisite to selecting the treatment procedure for early colorectal cancer (CRC). The purpose of the present study was to evaluate the significance of endoscopic ultrasonography (EUS) for diagnosing the depth of invasion of early CRC and selecting the treatment procedure. We concurrently estimated the usefulness of three-dimensional EUS (3D =EUS) compared with that of conventional EUS. Methods: We studied 413 consecutive early CRC for which the depth of invasion was examined by EUS. They consisted of 239 lesions of mucosal cancers and 174 lesions of submucosal cancers (sm cancers). We divided sm cancers into two groups, sm-slight cancers (33 lesions) and sm-massive cancers (136 lesions), according to the degree of infiltration in the vertical direction in the submucosa. The diagnostic accuracy of the depth of cancerous invasion by EUS and the characteristics of tumors that were difficult to image by EUS were examined. For 59 lesions, the depth of invasion was concurrently evaluated by 3D-EUS to compare the clinical usefulness of this diagnostic tool with that of conventional EUS. Results: In 364 lesions (88%) of early CRC, we could diagnose the depth of invasion by EUS. Differentiation between mucosal or sm-slight cancers, which were generally treated by endos-copic resection or local excision, and sm-massive cancers, which were suitable for radical operation, was possible in 90%. A total of 49 lesions (12%) could not be imaged by EUS. Difficulty in imaging often occurred with lesions located proximally to the transverse colon and with protruded type lesions. The accuracy rate of 3D-EUS for differentiating between mucosal or sm-slight cancers and sm-massive cancers, including difficult-to-image lesions, was 36%. This figure was slightly, but not significantly higher, than the accuracy rate of 73% for conventional EUS (P=0.07). However, the concurrent application of 3D-EUS was considered useful in 31 of the 59 lesions (53%) evaluated by both techniques. Conclusions : EUS is useful for evaluating the depth of tumor invasion and selecting the treatment procedure for early CRC. The concurrent use of 3D-EUS may further improve diagnostic accuracy and decrease the number of difficult-to-image lesions.

View full abstract