In 2017, the Japan Gastroenterological Endoscopy Society (JGES) updated the guidelines for gastroenterological endoscopy in patients receiving antithrombotic treatments, considering the risk of thrombosis and gastrointestinal hemorrhage in patients who are receiving warfarin or one of the three newly available direct oral anticoagulants (DOACs). The guidelines recommend that among patients who are receiving anticoagulants, the endoscopic procedure is performed under continuous administration of warfarin or DOAC in patients who regularly receive the respective anticoagulant, or that the endoscopic procedure is performed under an alternative treatment of heparin or DOAC bridging therapy in patients who regularly receive warfarin. However, conventional heparin bridging therapy has the disadvantage of increasing the risk of gastrointestinal hemorrhage, and the disadvantage of DOAC is that there is no parameter to evaluate the pharmacological efficacy of the DOAC. Therefore, it is important to assess the utility of the guidelines and to establish a system that allows safe endoscopic procedures to be performed in patients who are receiving an anticoagulant such as warfarin or a DOAC.
A 72-year-old man visited our hospital to undergo esophagogastroduodenoscopy (EGD) for epigastric pain. Following EGD, he developed hoarseness, which persisted even after four days; therefore, we referred him to an otolaryngologist. Laryngoscopy revealed anterior dislocation of the left arytenoid cartilage, with a flaccid and shortened left vocal cord. Maximum phonation time was remarkably reduced to 3 seconds. Computed tomography findings were normal. Arytenoid dislocation caused by EGD was diagnosed. The patient underwent noninvasive reduction under general anesthesia.
An 80-year-old woman diagnosed as having metastatic breast cancer was initiated on combined bevacizumab＋paclitaxel therapy. After 7 courses of therapy, laboratory analysis showed leukocytosis and elevated serum C-reactive protein level. Abdominal computed tomography revealed a gastric wall abscess. Upper gastrointestinal endoscopy showed marked gastric mucosal swelling suggestive of phlegmonous gastritis. Percutaneous abscess drainage and antibiotic therapy proved to be effective treatments. Although not at a high frequency, gastrointestinal adverse events associated with bevacizumab treatment have been reported. We speculated that bevacizumab-induced mucosal damage led to the phlegmonous change and abscess formation in the stomach. Endoscopic or percutaneous drainage and administration of antibiotics have been reported to be effective treatments. Further accumulation of cases and relevant data are needed to clarify this clinical condition.
Post-polypectomy bleeding is the most common complication of colonoscopic polypectomy. Previous studies have reported that the interval between polypectomy and delayed bleeding is usually 3-7 days and up to 29 days following polypectomy. A 76-year-old man was referred to our hospital for a rectal polyp, which had been detected during a screening colonoscopy performed at a private clinic. The endoscopic image showed a type 0-Ⅰs polyp with a diameter of 6 mm in the lower rectum. We performed hot snare polypectomy for complete resection. There was no immediate bleeding. Results of the pathological examination showed a traditional serrated adenoma, and the lateral and vertical margins were clear. Thirty-six days after polypectomy, he presented to our hospital with hematochezia. Emergency colonoscopic examination showed a band-like structure at the original site of excision, and we observed oozing bleeding from the tip of the band-like structure. We performed hot snare polypectomy to remove the base of the band-like structure. Pathological findings of the band-like structure revealed fibrinous exudate and granulation tissue with small vessels and inflammatory cells. This is the first report of a patient with delayed bleeding of more than 30 days following colorectal polypectomy.
We have been facing the COVID-19 pandemic that has imposed significant stress on hospitals and health care providers since the end of 2019, when the SARS-CoV-2 was identified in Wuhan, China. According to the guidelines of the Japanese Society of Gastroenterological Endoscopy released in March 2020, we have taken measures such as postponing non-urgent endoscopies, preparing a vinyl sheet at the reception desk to protect both the patients and receptionists, and stratifying the patientʼs risk of being infected with COVID-19 before the procedure. In addition, we found that there is a shortage of personal protective equipment (PPE). In this paper, we introduce the current situation at our endoscopy unit and efforts including making an alternative long-sleeve plastic gown to deal with the shortage of PPE.
Unilateral or bilateral swelling from the parotid gland to the cervical region may occur after esophagogastroduodenoscopy (EGD). Of the seven cases we experienced, one case was bilateral and six were on the left side. In all cases, the onset of swelling occurred after peroral endoscopy, which had been performed without sedation in six patients and with sedation during double-balloon endoscopic retrograde cholangiopancreatography (DBERCP) in one patient. Two patients previously experienced similar swelling. Six patients felt no pain, and one patient felt slight pain at the swollen site. The swelling improved after about one hour in six patients, but disappeared after approximately 12 hours in one patient. Two patients underwent X-ray examination, but pooling of air could not be seen in either patient. One patient underwent computed tomography scan, and swelling of the parotid gland was diagnosed. Swelling from the parotid gland to the cervical region after EGD is not harmful and resolves spontaneously, but we believe that knowledge of the cases we report herein can be of importance to endoscopists.
Since superficial non-ampullary duodenal epithelial tumor (SNADET) is a rare disease, the chance of performing endoscopic resection of a SNADET is relatively low. Duodenal endoscopic submucosal dissection (ESD) is extremely challenging and risky due to poor maneuverability of the endoscope and the thin duodenal muscle layer. Therefore, the treatment strategy should be made after carefully checking characteristics of the lesions and maneuverability of the endoscope as well as skills of the operator. Although ESD is very difficult to perform in the duodenum due to difficulties in opening the submucosal space, the Water Pressure Method allows us to perform a steady procedure. Secure closure of the resection bed is mandatory to avoid serious complications, and the String Clip Suturing Method enables secure closure even for a large resection bed. In case of a difficult situation in suturing, external drainage by an endoscopic naso-biliary and pancreatic drainage (ENBPD) tube is known to be extremely useful. Duodenal ESD is a very challenging procedure; however, the number of large duodenal lesions that require ESD is limited. Therefore, duodenal ESD should be centralized to leading institutions to acquire a good clinical outcome.
Japanese guidelines for gastric cancer treatment were first published in 2001 for the purpose of showing the appropriate indication for each treatment method, thereby reducing differences in the therapeutic approach among institutions, and so on. With the accumulation of evidence and the development and prevalence of endoscopic submucosal dissection (ESD), the criteria for the indication and curability of endoscopic resection (ER) for early gastric cancer (EGC) have expanded. However, several problems still remain. Although a risk-scoring system (eCura system) for predicting lymph node metastasis (LNM) may help treatment decision in patients who do not meet the curative criteria for ER of EGC, which is referred to as eCura C-2 in the latest guidelines, additional gastrectomy with lymphadenectomy may be excessive for many patients, even those at high risk for LNM. Less-invasive function-preserving surgery, such as non-exposed endoscopic wall-inversion surgery with laparoscopic sentinel node sampling, may overcome this problem. In addition, further less-invasive treatment, such as ER with chemotherapy, should be established for patients who prefer not to undergo additional gastrectomy.