Suturing is a basic and essential skill required in any type of surgery; however, in the field of flexible endoscopic surgery (FES), endoscopic suturing devices have not become available to date in Japan due to several technical difficulties in incorporating the suturing technology in flexible endoscopes. OverStitch and Incisionless Operating Platform are the two main endoscopic suturing devices that are currently commercially available in the United States (US). These devices have made complex surgical procedures amenable to endoscopic treatments, including endoscopic closure of large iatrogenic gastrointestinal (GI) perforations, endoscopic full-thickness resection, endoscopic closure of chronic GI fistula, esophageal stent fixation, and endoscopic treatment for bariatric patients. These suturing skills in endoscopic procedures are currently recognized as crucial, especially for advanced endoscopists in the US to be able to perform these procedures safely and effectively. In Japan, we have been seeing the limitations of endoscopic defect closure using the existing traditional endoscopic devices. Early approval by the Japanese government of those devices with known scientifically-proven efficacy is required to further expand the field of FES and ensure patientsʼ safety in Japan.
A 67-year-old female was found to have an elevated lesion of about 15mm in size at the gastric body by gastrointestinal endoscopy which had not been recognized one year previously. Magnifying endoscopy with narrow-band imaging showed outgrowth of capillaries from the lesion. However, the microvascular patterns were regular. Endoscopic imaging suggested that the lesion was most likely a plasmacytoma. Endoscopic submucosal dissection was performed to confirm the diagnosis. Pathological examination of the resected specimen revealed invasion of plasma cells expressing kappa chain and lambda chain. This lesion did not meet the criteria of plasmacytoma. The endoscopic image of this case resembled the image of plasmacytomas. This case demonstrates the limit of endoscopic diagnosis.
A 54-year-old man was admitted to our hospital for examination and treatment of a duodenal elevated lesion. Esophagogastroduodenoscopy revealed a submucosal tumor with a diameter of about 20mm located at the duodenal main papilla. Endoscopic ultrasonography showed a 20×17 mm, hypoechoic tumor that was located in the submucosa without any sign of invasion to adjacent structures. We observed no lymph node nor distant metastases in any images. Accordingly, we performed endoscopic snare papillectomy in this patient. After excision, pathological examination revealed that this tumor was a gangliocytic paraganglioma (GP) and that we had removed the tumor completely. Because of its benign nature, we should remove GP by a less invasive therapy such as endoscopic papillectomy for complete biopsy. To our knowledge, reports on GP excised endoscopically are rare; therefore, we report this case.
A 64-year-old woman visited our hospital for the purpose of colonoscopy for comprehensive medical examination. We detected a 5-mm lesion showing features of a submucosal tumor in the sigmoid colon. Most of the lesion was covered with normal mucosa, but there was a reddish depressed portion in the central part of the lesion, and a tubular or branched pit pattern was observed in the depressed portion. The same lesion was also detected 13 months previously; the lesion had become enlarged and the central depression had expanded within 13 months. Endoscopic mucosal resection was performed for therapeutic diagnosis. Pathologically, the lesion was diagnosed as a moderately differentiated tubular adenocarcinoma, and most of the tumor was located in the submucosal layer. The tumor invaded the submucosal layer in a flask shape. Colon cancer showing features of a submucosal tumor is relatively rare, and this lesion is valuable in that it followed the course of a small lesion.
An 80-year-old man with a history of chronic pancreatitis was admitted to our hospital because of abdominal pain and melena. Computed tomography revealed a cystic lesion of approximately 10 cm in diameter at the head of the pancreas. Esophagogastroduodenoscopy showed flowing hemorrhage from the ampulla of Vater. We diagnosed hemosuccus pancreaticus based on the presence of a hemorrhagic pancreatic cyst. Cystic drainage with a naso-pancreatic duct drainage tube was performed, and hemostasis and cyst reduction were achieved. Stenosis of the main pancreatic duct was found on the papilla side from the cyst region, and endoscopic pancreatic stenting was performed for prevention of recurrence. The stent was removed 1 year and 7 months later there was no recurrence of the disease. Endoscopic therapy is considered to be useful in cases of hemosuccus pancreaticus in which there are pseudocysts in the pancreatic head.
The Over-the-Scope Clip (OTSC) is a newly developed endoscopic suturing device designed for mechanical compression and tissue approximation that has been used for complicated cases of gastrointestinal bleeding, management of perforation and fistulae, and full-thickness resection of tumors. Some reports have suggested that use of OTSCs is an effective method of endoscopic hemostasis of colonic diverticular hemorrhage in other countries, but there has been no report in Japan so far. We report eight cases of colonic diverticular hemorrhage that were treated by the use of OTSCs. Hemostasis was successfully achieved in all eight cases without early-phase rebleeding nor adverse events. It is considered that use of OTSCs is an effective and safe method of endoscopic hemostasis of colonic diverticular hemorrhage.
This paper describes technical tips for performing endoscopic ultrasonography (EUS) for invasion depth diagnosis of colorectal T1 carcinomas. EUS is a unique diagnostic modality different from colonoscopy that enables observation of images of cancer invasion to the submucosal layer by obtaining cross-sectional images of the lesion. It is recommended that novice endoscopists perform EUS by using a high-frequency ultrasound probe (HFUP), which is inserted through a standard colonoscope. EUS has some disadvantages including not being able to obtain EUS images in about 10% of lesions and occasionally obtaining unsatisfactory images of lesions located in flexures of the colon or on the colonic haustra. The accuracy of invasion depth diagnosis can be improved with intensive scanning of the suspicious invasive portion of the lesion by colonoscopy and scanning while looking at only the EUS monitor and not the endoscopic monitor. In case of polypoid lesions with a height of 6mm or more, it is difficult to obtain good HFUP images of the deepest part of the lesion by deep attenuation. In such cases, additional use of low-frequency probes (12 or 7.5MHz) is helpful for obtaining satisfactory images. We performed a retrospective review of cases in which EUS was performed for invasion depth diagnosis of colonic lesions in our department between 2007 and 2017. The overall accuracy of invasion depth diagnosis for determining the choice of therapy (i.e., endoscopic resection or surgery) was not very high at 77.0% (211/274). The accuracy of invasion depth diagnosis was significantly higher in T1b carcinomas than in Tis･T1a carcinomas [87.3% (125/151) vs. 69.2% (86/123) respectively; p<0.01]. Moreover, the accuracy rate was significantly higher in flat and depressed-type T1b carcinomas than in polypoid-type T1b carcinomas [91.4% (53/58) vs. 83.3% (50/60), respectively; p<0.05]. We think that HFUP will be useful for invasion depth diagnosis of especially flat and depressed-type T1b carcinomas. Because the submucosal invasion distance measured by EUS images has a good correlation with that measured in histological specimens, EUS will become an essential diagnostic modality in oder to expand the indications for endoscopic resection of T1b carcinomas as total excisional biopsy. Therefore, it is strongly recommended that all endoscopists become familiar with EUS procedures.
Background and Aim: Salvage endoscopic resection (ER) is among the curative treatments for superficial local failure after chemoradiotherapy (CRT) for esophageal squamous cell carcinoma (ESCC). The present study aimed to clarify risk factors for recurrence after salvage ER.
Methods: This study enrolled consecutive ESCC patients treated with salvage ER for local failure after CRT between 1998 and 2013. Recurrences after salvage ER included locoregional recurrences and distant metastases. Multivariate analysis was carried out on clinicopathological parameters to identify risk factors for post-salvage ER recurrence.
Results: Of the 72 patients enrolled in this study, 37/8/23/4 patients had been staged before CRT as cT1/T2/T3/T4 and 44/28 patients as cN0/N1, respectively, and local failures detected before salvage ER were residual lesions after CRT in 19 and local recurrences in 53 patients. Resected specimens were classified as pT1a (M) in 45 and pT1b (SM) in 27 patients. During the median 45-month follow up (range, 3-175 months) after salvage ER, 27 (38%) patients developed recurrence with a 3- year recurrence-free survival rate of 48.9% (95% confidence interval [CI], 36.5-60.3). Multivariate analysis showed that residual lesions after CRT (HR, 2.55; 95% CI, 1.32-4.94) and lesions with a submucosal tumor (SMT)-like appearance before salvage ER (HR, 2.08; 95% CI, 1.04-4.18) were significantly associated with post-salvage ER recurrence.
Conclusions: Clinical findings (e.g. residual tumors found immediately after CRT and macroscopic SMT-like appearance before salvage ER) were shown to be significant risk factors for post-salvage ER recurrence.