Twelve judicial decisions that were made until the end of 2018, pertaining to endoscopy related to the biliary tract and pancreas in a Japanese legal database were analyzed. All cases were associated with adverse events leading to the patientsʼ death: severe acute pancreatitis (8 cases), intestinal perforation (3 cases), and sepsis (1 case). The hospital won in 5 cases, and lost in 7. The issues were as follows: (1) explanation (4 cases), (2) cleaning, sterilization, safekeeping, etc., of endoscopic instruments (1 case), (3) indication (1 case), (4) endoscopic technique (9 cases), and (5) treatment of adverse events (9 cases). In the cases in which perforation occurred due to contact of the endoscope during endoscopic retrograde cholangiopancreatography (ERCP), the hospital lost. In the cases in which diagnosis of (severe) acute pancreatitis was delayed or acute pancreatitis received insufficient treatment, the hospital lost. Endoscopists who carry out ERCP should have sufficient skills not to perforate the intestine, and treat patients who develop acute pancreatitis after ERCP carefully and properly, because acute pancreatitis may worsen to severe pancreatitis and rapidly lead to the patientʼs death.
A 73-year-old male visited our hospital for treatment of early esophageal cancer. The tumor was type 0-Ⅱb, 35 mm in diameter, and located on the posterior wall of the middle thoracic esophagus. The lesion was on a Rokitansky diverticulum. Endoscopic ultrasound examination revealed no thinness or defect of the muscularis propria in the diverticulum. Endoscopic submucosal dissection (ESD) was performed under general anesthesia, and showed that the submucosa at the bottom of the diverticulum was fibrotic and the muscularis propria was thinning. On resection, mediastinum tissue was observed through the thin muscularis propria and outer membrane. Also, X-ray revealed slight mediastinal and subcutaneous emphysema. The patient was treated with antibiotics and underwent drainage of the esophagus for mediastinitis. He was discharged on postoperative day 8.
Endoscopic resection is the standard therapy for early esophageal cancer in the epithelium and lamina propria, and ensures a high radical cure rate. However, ESD is difficult to perform when the lesion is located in an esophageal diverticulum. Esophageal diverticula are divided into three classes: Zenker, Rokitansky, and supradiaphragmatic. Zenker and supradiaphragmatic diverticula are pseudodiverticula; the muscularis propria has defects, and the location of these pseudodiverticula makes it difficult to perform ESD. Thus, ESD for tumors in these diverticula should not be attempted. On the other hand, the Rokitansky diverticulum is a true diverticulum. However, the muscularis propria is frequently thin or defective due to chronic inflammation. Therefore, ESD for Rokitansky diverticulum tumors poses a high risk for perforation. Examination of the muscularis propria is required to determine the safety of performing ESD. Thus, if thinness or defects of the muscularis propria are detected, surgery, chemoradiation therapy, or radiation therapy should be selected instead of ESD.
A 59-year-old male with a circumferential and superficial blackish brown lesion in the middle and lower thoracic esophagus that had been recognized at a health check-up, was diagnosed with malignant esophageal melanoma based on endoscopic biopsy.
The lesion was widespread Type 0-Ⅱb, and positron emission tomography (PET)/computed tomography (CT) showed no lymph node metastasis nor metastasis to other organs. Then, we determined that radical operation would be effective, and the patient underwent thoracoscopic subtotal esophagectomy in the prone position with three-field lymph node dissection. Microscopic findings of the resected specimen confirmed the presence of atypical cells with melanin deposition basally located in stratified squamous epithelium. Immunostaining revealed that atypical melanocytes had spread 16.4 centimeters in the longest diameter beyond the grossly visible blackish area. Dissected lymph nodes were negative for metastatic dissemination, and he was diagnosed with T1a-LPM N0M0; Stage 0.
No adjuvant chemotherapy was administered, and we continue to follow the patient carefully. At the one-year postoperative follow-up visit, no evidence of recurrence has been found. It is extremely rare that primary malignant esophageal melanoma is limited to the mucosa and resected at an early stage. Early detection of esophageal malignant melanoma with highly accurate endoscopic examination is important.
We report six cases of duodenal diverticular hemorrhage. In patients with upper gastrointestinal bleeding, we should suspect hemorrhage from a duodenal diverticulum if endoscopic examination does not detect the source of bleeding in the esophagus, stomach and first portion of the duodenum, or if an imaging study shows a duodenal diverticulum. Usage of a forward-viewing endoscope with a transparent hood makes it easier to observe inside of the duodenal diverticulum under good vision, and remove the blood clots and food residue in it. We consider that endoscopic clipping is a safe and useful method of hemostasis, because most duodenal diverticula are pseudodiverticula, and about half of the bleeding sources in bleeding diverticula are exposed vessels.
A 60-year-old male with tarry stools and shortness of breath was admitted to our hospital. Upper gastrointestinal endoscopy revealed a sub-pedunculated submucosal tumor with ulceration and blood clotting in the duodenal bulb. Endoscopic hemostatic clipping was unsuccessful due to mobility of the tumor, but hemostasis was achieved using a ligating device of endoscopic variceal ligation (EVL). Endoscopic ultrasonography showed an echogenic mass, supporting the diagnosis of a duodenal lipoma. Endoscopic resection of the tumor was performed to prevent further bleeding. The tumor was 25×16×18mm in size, and the pathological diagnosis was lipoma. EVL was useful for hemostasis of a hemorrhagic duodenal lipoma.
A 76-year-old man with abdominal pain underwent computed tomographic (CT) scan, which revealed bezoars in the stomach and ileus. The terminal ileum was obstructed by a mosaic mass with aerosol, which was suspected to be composed of bezoars that had migrated from the stomach. Because the obstruction was located in the terminal ileum, it could be reached by a colonoscope; the ileus was then released by removal of bezoars with a snare. Residual bezoars in the stomach were removed using a two-channel endoscope; the bezoars were crushed with a snare and forceps. Obstruction of the small intestine by migrated bezoars is generally an indication for surgical removal in many cases; however, by using a colonoscope to reach the location of the obstruction site and based on the appropriate imaging diagnosis, surgical removal was avoided in this case.
A 39-year-old woman visited our hospital for the purpose of careful examination due to a high carbohydrate antigen (CA) 19-9 level. Colonoscopy revealed a 40 mm, large, protruding lesion in the ascending colon with an unclear boundary. The surface exhibited a non-neoplastic pit pattern. On endoscopic ultrasonography, it was visualized as a tumor exhibiting low echoes in the 2nd to 4th layers. Laparoscopic ileocolic resection was performed. Histologically, nerve fibers and spindle-shaped cells proliferated diffusely from the lamina propria of the mucosa to the serosa, and large ganglion cells were found inside the tumor. The diagnosis of ganglioneuroma of the ascending colon was made. Colorectal ganglioneuroma that is not accompanied by neurofibromatosis-1 and multiple endocrine neoplasia syndrome is rare, and further accumulation of cases is necessary.
Percutaneous transesophageal gastro-tubing (PTEG) was developed in 1994 as an alternative method for patients in whom it would be difficult to perform percutaneous endoscopic gastrostomy. PTEG combines two existing procedures.
One is cervical esophagostomy under ultrasonic control with a rupture-free balloon, and the other is tube placement under fluoroscopic control. These non-vascular interventional radiological techniques for the gastrointestinal tract are safe and simple minimally invasive surgical procedures. PTEG is usually performed for enteral nutrition or for gastrointestinal decompression. We describe tips for PTEG implementation in this paper.
Percutaneous endoscopic gastrostomy (PEG) has become a common medical treatment, but sometimes unexpected events occur (e.g., mispuncture or inoperable puncture) due to interposition of the transverse colon or the mesentery. Computed tomographic (CT) scanning prior to PEG helps to detect such obstacles. Our routine CT scanning revealed that air injection into the stomach in the left-side down position is advisable to resolve those obstacles and to narrow down eligible candidates for colonoscopy-assisted PEG (C-PEG). If CT scanning shows the transverse colon or mesentery on the ventral side of the stomach, colonoscopy is feasible to relocate the colon that is laid over the stomach downward so that PEG can be performed (C-PEG). In our hospital, 426 cases underwent CT scanning prior to PEG during 2006-2017. The CT scanning procedure detected 38 cases who were eligible for C-PEG, and 37 (97.4%) of them underwent C-PEG successfully. There was no mispuncturing of the colon or the mesentery. Therefore, we consider that C-PEG is safe and useful for cases that have interposition of the transverse colon or the mesentery. Here we report our C-PEG strategy and practical methods including CT screening.
【Background and Objective】Laparoscopy endoscopy cooperative surgery (LECS) is performed in many institutions, but there are no literatures or reports about perioperative care. Therefore, we conducted a questionnaire survey on perioperative care for LECS.
【Methods】A questionnaire survey was distributed to the 59 institutions participating in the LECS research group.
【Results】Questionnaires were returned from 42 institutions (71.2%, 42/59). The medical staff at half (21/42) of the institutions followed the clinical pathway that had been developed at the respective institutions. Most of the institutions answered as follows: intake of normal diet on the day before surgery, intake of water 2～3 hours before anesthesia, use of epidural anesthesia, epidural analgesia for a few days after surgery, removal of foley catheter on postoperative day 1～2, start to drink water on postoperative day 1～2, and oral intake of food on postoperative day 2～3.
【Conclusion】We consider that the results of our survey can be used as a reference for introducing LECS and revising perioperative care in the future.
Background and Aim: Surveillance colonoscopy has been carried out for patients with long-standing ulcerative colitis who have an increased risk for colorectal cancer. The aim of the present study was to determine the incidence of and the risk factors for neoplasia.
Methods: We evaluated 289 ulcerative colitis patients who underwent surveillance colonoscopy between January1979 and December 2014. Cumulative incidence of neoplasia and its risk factors were investigated. Clinical stage and overall survival were compared between the surveillance and non-surveillance groups.
Results: Cumulative risk of dysplasia was 3.3%, 12.1%, 21.8%, and 29.1% at 10, 20, 30 and 40 years after the onset of ulcerative colitis, respectively. Cumulative risk of colorectal cancer was 0.7%, 3.2%, 5.2%, and 5.2% at 10, 20, 30 and 40 years from the onset of ulcerative colitis, respectively. Total colitis was a risk factor for neoplasia (P=0.015; hazard ratio, 2.96).
Conclusions: Our surveillance colonoscopy program revealed the incidence and risk factors of ulcerative colitis-associated neoplasias in the Japanese population. Total colitis is a risk factor for neoplasia.