SUCCESSFUL ENDOSCOPIC CLOSURES OF COLONIC PERFORATIONS REQUIRING ABDOMINAL DECOMPRESSION AFTER ENDOSCOPIC MUCOSAL RESECTION AND ENDOSCOPIC SUBMUCOSAL DISSECTION FOR EARLY COLON CANCER

Endoscopic submucosal dissection (ESD) for colorectal cancer is not widely accepted because of its technical difficulty and the risk of perforation. In addition, the risk of peritonitis cannot be completely eliminated even if a perforation is closed successfully. Reported here are two cases of early colon cancer in which the patients sustained iatrogenic perforations of the ascending colon during conventional endoscopic mucosal resection and of the sigmoid colon during ESD, respectively, requiring abdominal decompression with an 18 G Medicut needle. Both of these perforations were successfully treated by endoscopic clipping. In conclusion, conservative medical management may be possible in patients who have undergone successful closure of colonic perforations using endoscopic clipping. In order to perform immediate endoscopic closure, abdominal decompression has been useful to decrease patient discomfort and colonic lumen collapse. Now, CO₂ insufflation is being used effectively for the prevention of pneumoperitoneum.     

TECHNIQUES AND PITFALLS OF ENDOSCOPIC SUBMUCOSAL DISSECTION FOR COLORECTAL TUMORS

Endoscopic submucosal dissection (ESD) for colorectal tumors is steadily being developed. Safety and standardization of ESD for colorectal tumors have not been yet established because of the technical difficulties and the unsuitable anatomical characteristics of the colon and rectum. The authors mainly use a Flex knife for mucosal incision and a Hook knife for submucosal dissection to perform ESD safely. Skillful colonoscopic control, selection of scope, distal attachment tip hood, adequate high‐frequency generator and correct approach strategy should all be considered for safe performance of ESD. However, the incidence of indicative lesions is rare because the majority of colorectal tumors are adenomatous large laterally spreading tumors, which can be cured by intentional endoscopic piecemeal resection. At present, ESD for colorectal tumors should be performed only at central facilities that have expert colonoscopists. With the development of new devices and associated techniques, technical standardization of ESD for colorectal tumors is expected in the near future.     

CURRENT STATUS OF DOUBLE BALLOON ENDOSCOPY

Yamamoto and colleagues have developed a novel insertion method of the endoscope, the ‘double balloon method’ for enteroscopy and, recently, a specialized system for the ‘double balloon method’ has been commercialized by Fujinon. The double balloon endoscopy enables visualization of the entire small bowel and also allows for interventional therapy in the small intestine. This method could be used either from the oral or anal approach. Observation of an affected area with controlled movement of the endoscope enables interventions, including biopsies, hemostasis, balloon dilatation, stent placement, polypectomy, and endoscopic mucosal resection. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.     

胆道癌ERCP诊断(附49例分析)

本文报道用ERCP诊断胆管癌24例、胆囊癌6例、壶腹癌19例、共49例,都经手术或病理证实,诊断符合率为85.7％。 文章描述了胆道癌ERCP的X线表现。依造影所见把胆管癌分为阻塞型、狭窄型和息肉型。狭窄型又分闭塞型、环型及弥漫型三个亚型。胆管癌以阻塞型和闭塞型狭窄多见。胆囊癌表现为胆囊内基底宽广固定不变的充盈缺损。壶腹癌为壶腹部边缘不整的占位病变,可阻塞胆管或胰管或同时阻塞胰胆管。肝内胆管的软藤状改变是胆道恶性肿瘤的特征性表现。     

达芬霖与肾上腺素在鼻内窥镜手术中应用的比较

目的探讨达芬霖与肾上腺素在鼻内窥镜手术中的应用价值。方法观察达芬霖、肾上腺素分别在鼻内窥镜手术应用中对患者血压、心率的影响,观察出现反跳性鼻腔黏膜充血肿胀的时间和例数,并进行对比讨论。结果在达芬霖应用前后,30例患者的血压、心率变化差异无显著性,在肾上腺素应用前后,30例患者的血压、心率变化差异也无显著性,60例手术均在1￣3h内完成,达芬霖组无1例出现反跳性鼻腔黏膜充血肿胀,肾上腺素组有6例出现轻微的反跳性鼻腔黏膜充血肿胀,达芬霖组平均出血量248mL,肾上腺素组平均出血量120mL,P<0.05。结论达芬霖、肾上腺素作为鼻黏膜血管减充血剂和麻醉辅助药,常规用于鼻内窥镜手术是安全、有效的,用肾上腺素优于用达芬霖。     

Is endoscopic one‐piece mucosal resection essential for early gastric cancer?

Background: Endoscopic mucosal resection (EMR) is widely accepted as a minimally invasive treatment for early gastric cancer (EGC) in Japan. However, the criteria for EMR must be strictly adhered to otherwise patients will miss the chance for additional therapy. We assess the important factor in expanding the indication of EMR. Methods: We investigated 1101 EGCs that had been resected by EMR at the National Cancer Center Hospital (NCCH), Tokyo, Japan, according to the indication recommended by Japanese Gastric Cancer Association (JGCA) and the expanded indication proposed by NCCH. Curability and local recurrence of the EMRs were assessed related to the applied indication and the number of resected specimens. Results: The recurrence rate of non‐evaluable resection was higher than that of evaluable resection (P < 0.0001). Eighty‐three lesions among 772 lesions in the JGCA group were non‐evaluable. Thirty‐seven leisons among 329 lesions in the NCCH group were non‐evaluable. There was no difference in the rate of non‐evaluable resection between JGCA and NCCH groups (P = 0.8329). However, the rate of curative resection was lower in the NCCH group than in the JGCA group (P = 0.0009). In piecemeal resection, there was no difference in the rate of non‐evaluable resection between JGCA and NCCH groups (P = 0.0527). In one‐piece resection, the rate of non‐evaluable resection was lower in the NCCH group than the JGCA group (P = 0.0137). Conclusion: Based on our series of cases, we propose one‐piece resection as a gold standard for EMR because it enables accurate histological evaluation, even in the EMR, according to the expanded indication.     

NASOGALLBLADDER DRAINAGE FOR MIRIZZI’S SYNDROME

The authors experienced a case of Mirizzi’s syndrome successfully treated with endoscopic nasogallbladder drainage (ENGBD). The patient was a 63‐year‐old man. He was admitted with abdominal pain and jaundice. Laboratory data indicated leukocytosis and elevation of serum bilirubin level. Abdominal ultrasound showed marked swelling of gallbladder and debris in the gallbladder, therefore, the authors strongly suspected Mirizzi’s syndrome. He had past history of acute myocardial infarction and treated with anticoagulation therapy. Then, the authors couldn’t perform surgical removal or percutaneous transhepatic drainage, and tried endoscopic transpapillary drainage. Endoscopic retrograde cholangiopancreatography revealed smooth stricture in the superior portion of common bile duct and occlusion of the cystic duct, and ENGBD was then performed. After ENGBD, his complaints, laboratory data, swelling of gallbladder and stricture of common bile duct were all remarkably improved.     

ENDOSCOPIC MANAGEMENT OF A DIEULAFOY‐LIKE LESION IN A DUODENAL DIVERTICULUM

We present a 70‐year‐old man who had two episodes of melena during the preceding 8‐year period. He had a Dieulafoy‐like lesion in a diverticulum in the third portion of the duodenum. While emergency endoscopy revealed neither apparent blood nor clots around the diverticular orifice, there was a non‐bleeding vessel in the fundus of the diverticulum. The vessel ceased bleeding after argon plasma coagulation and, since then, the patient has not experienced bleeding. In cases of gastrointestinal bleeding of obscure origin, duodenal diverticulum should be considered as a possible source of bleeding, even when endoscopy discloses no apparent bleeding.     

超声引导下经皮经肝胆管穿刺置管引流在梗阻性黄疸病人中的应用

目的　评价超声引导下经皮经肝穿刺胆管置管引流 (UPTBD)对梗阻性黄疸病人的治疗价值。方法　对 1995年 1月至 2 0 0 2年 7月期间的 4 17例梗阻性黄疸病人进行 4 97次UPTBD治疗 ,并回顾总结他们的临床资料。结果　接受PTBD治疗共有 4 17例 (5 1例病人进行了两个胆管枝的PTBD) ,穿刺成功率达 93.2 % (4 36 / 4 6 8) ,32例首次穿刺失败的病人有 2 9例进行了第二次穿刺置管 ,全部成功。发生胆汁漏 /胆汁性腹膜炎 9例 ,胆道出血 8例 ,感染性休克 1例 ,无腹腔出血、后腹膜血肿、气胸等其他并发症。对 6 4例置管引流患者进行肝功能检测 ,与穿刺前相比 ,引流后 1周和 3周检测病人血清胆红素、转氨酶均显著下降。结论　UPTBD是一项姑息性治疗梗阻性黄疸的快捷、安全、有效的方法     

微创经皮肾镜取石术治疗上尿路结石

目的 探讨微创经皮肾镜取石术治疗上尿路结石的有效性和安全性.方法上尿路结石患者368例,平均年龄57岁.其中输尿管上段结石116例,结石大小(2.1±0.8)cm;肾结石252例,结石大小(4.6±1.4)cm,其中非鹿角形结石190例,结石大小(3.2±1.1)cm,鹿角形结石62例,结石大小(7.6±1.6)cm.均采用微创经皮肾穿刺,输尿管镜下气压弹道或联合钬激光碎石治疗,对结石清除率和并发症等进行统计分析.结果 368例患者中单通道取石356例(96.7%),双通道12例(3.3%).一期取石344例(93.5%),二期取石24例(6.5%).总结石取净率为88.6%(326/368).平均手术时间73 min.一期取净结石者住院时间4～8 d,平均6 d.术后发热14例(3.8%);输血5例(1.4%);2例肾结石术后出血严重者经输血及超选择性肾动脉栓塞后治愈.结论 微创经皮肾镜取石术损伤小、住院时间短、术中出血及并发症少、结石清除率高、可重复取石,是治疗上尿路结石有效的微创手段.