ENDOSCOPICALLY RESECTED LIPOMA OF THE ESOPHAGUS: REPORT OF A CASE

Lipoma of the esophagus is rare. There are few reports of the endoscopic resection of esophageal lipoma. We present a 73‐year‐old woman with lipoma of the esophagus which was successfully extirpated using the technique of endoscopic mucosal resection. To determine the depth of tumor invasion, endoscopic ultrasonography was used. A total of 31 cases of esophageal lipoma have been reported in Japan. Of these, seven were successfully resected using endoscopic techniques. Lipomas of the esophagus can grow to become large pedunculated tumors which can obstruct the airway. The majority of these tumors occur in the cervical portion of the esophagus. Most patients have no symptoms. These tumors can be resected using minimally invasive surgery when they are small.     

Assessment of clinical impact of endoscopic ultrasound on esophageal cancer

BACKGROUND AND AIM: Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is the most accurate imaging modality for locoregional staging of esophageal cancer. It remains unclear whether this technology impacts on the outcome of patients with this malignancy. The aim of the present study was to assess the impact of EUS FNA by comparing the clinical outcomes of patients with esophageal cancer before and after the introduction of this staging modality in our institution. METHODS: Outcomes of patients with de novo non-metastatic esophageal cancer seen in 1998 without EUS FNA evaluation (non-EUS control group) were compared to patients evaluated in 2000 with EUS FNA (EUS group). RESULTS: Outcomes of 60 (non-EUS control group) and 107 (EUS group) patients with non-metastatic esophageal cancer were compared. Preoperative neoadjuvant therapy was administered to 35 patients in the EUS group, all of whom had advanced disease. Cox proportional hazards demonstrated EUS FNA to be associated with reduced recurrence risk (hazard ratio [HR]: 0.63; 95% confidence interval [CI]: 0.43-0.87), P = 0.004, and reduced mortality (HR: 0.66; 95% CI: 0.47-0.90), P = 0.008. CONCLUSIONS: The EUS staging of esophageal cancer leads to appropriate use of preoperative neoadjuvant therapy in patients with advanced disease. Use of EUS is associated with a recurrence-free survival advantage and overall survival advantage in patients, thus supporting its routine use in esophageal cancer staging.     

Endoscopic Clipping of Esophageal Varices

Abstract: A new method of endoscopic therapy for esophageal varices using a clipping apparatus was devised and applied prophylactically in nine patients with esophageal varices which were not bleeding. Eighty two ligations were placed in 21 separate treatment sessions in this study. All the esophageal varices were eradicated or reduced in size and length within 2 months following treatment. No major complications such as massive bleeding, the development of deep esophageal ulcers, esophageal perforation, esophageal stenosis and pleural effusion developed. The follow-up period ranged from 6 months to 18 months. Three patients (33%) were re-treated by the same method because of the regrowth of esophageal varices during this period, but no bleeding occured in these patients. It seems that this newly developed method is a safe, simple and effective technique for the treatment of esophageal varices.     

Nonoperative treatment of four esophageal perforations with hemostatic clips

Spontaneous or iatrogenic esophageal perforations are despite advances of modern surgery and intensive care medicine still potentially life-threatening events with a considerable mortality rate. Recently, encouraging results on the sealing of esophageal perforations by placement of endoluminal prostheses were reported. However, if the perforation is very proximal (close to the larynx) or very distal (involving the cardia), the situation is to our experience unsuitable for stent therapy. In these special cases non-operative treatment is still possible by application of hemostatic metal clips. We present four cases unsuitable for stent therapy where the perforation was sealed by endoscopic clip application. All patients had an uneventful recovery. Non-operative treatment of esophageal perforations with hemostatic metal clips is feasible and safe in cases not treatable with self-expanding metal stents.     

Endoscopic Injection Sclerotherapy for the Treatment of Recurrent Esophageal Varices after Esophageal Transection

Background: We examined the hemodynamic changes associated with recurrent esophageal varices after esophageal transection (ET) and evaluated the effectiveness of endoscopic injection sclerotherapy (EIS) as the treatment for these varices. Methods: Nineteen patients with recurrent esophageal varices after ET were treated by EIS. Endoscopic varicealography during injection sclerotherapy, following oral blockage of flow by a balloon, identified three patterns: (i) type 1: common type, continuous filling by the feeder vessel of the varix; (ii) type 2: retrograde‐disappearing type, confirmed hepatofugal flow; and (iii) type 3: immediate washout type, immediate washout of contrast medium. Results: Angiography revealed that the hepatofugal feeder vessel was the right gastric vein in all cases. Fourteen patients (73.7%) were classified as type 1, 4 patients (21.1%) as type 2, and 1 patient (5.3%) as type 3. Fewer treatment sessions were required in type 1 than in type 2 (P < 0.005). Recurrent varices were completely eradicated in all patients except the patient with type 3 disease. Cumulative re‐recurrence rates at 5 and 10 years were similar for types 1 and 2 (28.6 and 71.4%vs 25 and 25%, respectively). The cumulative survival rates after EIS at 5 and 10 years were also similar for types 1 and 2 (77.1 and 66.1%vs 66.7 and 66.7%). Conclusion: Endoscopic injection sclerotherapy is an effective treatment for recurrent esophageal varices after ET, except in type 3 disease. Our classification based on endoscopic varicealography during injection sclerotherapy provides knowledge of blood flow within the varices that helps to inform the treatment strategy.     

Clinical experience of esophageal perforation occurring with endoscopic submucosal dissection

Esophageal perforation occurring during or after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is a rare, but serious complication. However, reports of its characteristics, including endoscopic imaging and management, have not been fully detailed. To analyze and report the clinical presentation and management of esophageal perforations occurred during or after EMR/ESD. Four hundred seventy‐two esophageal neoplasms in 368 patients were treated (171 EMR; ESD 306) at Northern Yokohama Hospital from 2003 to 2012. Esophageal perforation occurred in a total of seven (1.9%) patients, all of whom were male and had undergone ESD. The etiology of perforation was: three (42.9%) intraoperative; three (42.9%) balloon dilatation for stricture prevention; one (14.2%) due to food bolus impaction. All cases were managed non‐operatively based on the comprehensive assessment of clinical severity, extent of the injury, and the time interval from perforation to treatment onset. Conservative management included (i) bed rest and continuous monitoring to determine the need for operative intervention; (ii) fasting and intravenous fluid infusion/ tube feeding; and (iii) intravenous antibiotics. All defects closed spontaneously, save one case where closure was achieved by endoscopic clipping. Surgery was not required. Conservative management for esophageal perforation during advanced endoscopic resection is may be possible when there is no delay in diagnosis or treatment. Decision‐making should be governed purely by multidisciplinary discussion.     

Successful endoscopic therapy of superficial esophageal cancer on varices in a patient with alcoholic liver cirrhosis

A case of successful endoscopic therapy of superficial esophageal cancer on varices in a patient with alcoholic liver cirrhosis is reported. A slightly depressed superficial cancer (type 0‐IIc) occupied half the inner surface of the middle esophagus. Endoscopic ultrasonography revealed esophageal varices and periesophageal collaterals, but no perforating veins connecting the varices and collaterals were observed where the cancer was located. The esophageal cancer could not be detected even with a 20 MHz microprobe. The tortuous esophageal varices in the lower esophagus were endoscopically ligated to reduce blood flow just below the cancer and 10 mL polidocanol solution was endoscopically injected to induce sclerosis of the varices. After these procedures, the mucosal cancer was endoscopically resected without any severe complications and residual cancer was eliminated by cauterization using a heater probe. Histopathological examination revealed that poorly differentiated squamous cell carcinoma invaded into the lamina propria mucosae but not into the vessels or the lymphatic system. Three years after treatment, the patient showed no signs of local recurrence of cancer. It is considered that the endoscopic techniques used in this patient constitute a valuable and minimally invasive treatment for superficial esophageal cancer on varices.     

Prognostic value and interobserver agreement of endoscopic ultrasonography for superficial squamous cell carcinoma of the esophagus: a prospective study

Background and Aims. Submucosal invasion of superficial esophageal cancer (SEC) is related to the prognosis. We prospectively analyzed outcomes of SEC in patients staged by endoscopic ultrasonography (EUS). Patients and Methods. We staged 31 endoscopically diagnosed SEC cases using a 20/15-MHz thin probe. The EUS tumor stage was classified as EUSM (limited within mucosa), EUS-SM (with submucosal invasion), or EUS-MP over (invading the muscularis propria or deeper). Lymph node metastasis and 2-yr survival were analyzed according to the EUS tumor stage in 29 squamous cell carcinoma cases. Interobserver agreement of the EUS stage was tested between the examiner and a blind reviewer. Results. Lymph node metastasis was significantly frequent in the EUS-SM group (8 of 18 cases [44.4%]) compared with the EUS-M group (1 of 10 cases [10%]) (p=0.03). Patient survival at 2 yr after initial therapy was 72.2% in the EUS-SM group and 90% in the EUS-M group. Death from cancer was noted only in the EUS-SM group (three cases). The accuracy rates of EUS tumor staging were 74.1% by the examiner and 66.7% by the blind reviewer, with moderate interobserver agreement (κ=0.46). Conclusions. Thin-probe EUS can classify SEC into two groups: the EUS-M group with excellent outcome and the EUS-SM group with a significant risk of lymph node metastasis.     

Endoscopic Ultrasonography for the Detection of Lymph Node Metastasis in Superficial Esophageal Carcinoma

Abstract: Preoperative diagnosis of lymph node metastasis is a very important factor in determining treatment for patients with superficial esophageal carcinoma (SEC), in terms of whether or not extensive lymphadenectomy is necessary. To evaluate the usefulness of endoscopic ultrasonography (EUS) for the diagnosis of lymph node metastasis, we compared preoperative EUS findings with postoperative histological findings of resected lymph nodes in 82 patients with SEC who underwent extensive lymphadenectomy. The regional lymph nodes of the esophagus were divided into seven areas, and the capability to diagnose the presence or absence of metastatic lymph nodes was evaluated for each area. The sensitivity of EUS in the detection of metastatic lymph nodes was 48.6% overall, which was less than satisfactory, and the positive predictive value was 72.0% overall. However, we obtained relatively good sensitivity (63.6%) in the upper mediastinal area, which had the highest frequency of metastasis (42% of cases with metastatic lymph nodes); the status of this area has a major influence on prognosis and the risk of postoperative complications. In conclusion, we should recognize that EUS findings suggesting the absence of positive nodes do not provide conclusive evidence and only allow the risk of remaining metastatic nodes to be reduced by approximately one half. Other factors, such as the depth of invasion, as well as the findings of percutanous echography and CT, must be comprehensively evaluated. On the other hand, in patients in whom positive nodes are suspected on EUS, the findings can be regarded as being fairly reliable; therefore, esophagectomy with lymph node dissection should be performed even in SEC. In such cases, EUS findings in the upper mediastinal area may be a good index of the suitability of minimally invasive surgery.     

ENDOSCOPIC SUBMUCOSAL DISSECTION FOR ESOPHAGEAL SQUAMOUS CELL NEOPLASMS

Endoscopic submucosal dissection (ESD) has gradually gained acceptance as one of the standard treatments for early esophageal cancer, as well as for early gastric cancer in Japan, but standardization of the knowledge is still incomplete. The final goal to perform ESD is not to resect the lesion in an en bloc fashion, but to save the patient from esophageal cancer‐related death. Thus, the indications should be considered based on the entire patient, not just the target lesion itself, and pre‐, peri‐ and postoperative management of the patient is also very important, as well as technical aspects of ESD. In terms of the techniques of ESD, owing to refinement of the procedural strategy, invention of the devices, and the learning curve, acceptable safety and favorable middle‐term efficacy have been obtained. We believe that ESD will become a standard treatment for early esophageal cancer not only in Japan but also worldwide in the near future.     

Endoscopic diagnosis of early squamous neoplasia of the esophagus with iodine staining: high-grade intra-epithelial neoplasia turns pink within a few minutes

Background and Aim: The ability to detect early squamous neoplasia of the esophagus can be enhanced considerably by iodine staining during endoscopic examination; however, there has been no study on distinguishing high‐grade intra‐epithelial squamous neoplasia from low‐grade dysplasia by endoscopic examination. We assumed that high‐grade intra‐epithelial neoplasia could be identified as iodine‐unstained areas more distinct and reddish than low‐grade dysplasia after the brown color of iodine solution has faded, because there is almost no remaining glycogen‐containing epithelium in high‐grade intra‐epithelial neoplasia. Methods: Seventy‐nine patients who were found to have demarcated iodine‐unstained areas (0.5 cm to 1.5 cm at widest part, 121 lesions in total) were studied. After a target lesion was found, the lesion was observed for about 3 min and its discoloration was evaluated. If a light‐pink part appeared in the iodine‐unstained area, the lesion was regarded as being positive for pink color. If no light‐pink part was observed in the lesion within 3 min, the lesion was regarded as being negative for pink color. Results: Thirty‐four (87.2%) of the 39 lesions diagnosed as pink‐color positive were histologically confirmed to be high‐grade intra‐epithelial squamous neoplasia or squamous cell carcinoma, whereas only three (3.7%) of the 82 lesions diagnosed as negative for pink color were histologically confirmed to be high‐grade intra‐epithelial squamous neoplasia (P < 0.0001). Using the pink‐color sign as a diagnostic index for high‐grade intra‐epithelial squamous neoplasia and squamous cell carcinoma, sensitivity was 91.9% and specificity was 94.0%. Conclusion: By using the pink‐color sign for endoscopic diagnosis, accurate diagnosis without endoscopic biopsy for iodine‐unstained areas was possible.     

EFFECT OF ENDOSCOPIC VARICEAL LIGATION FOR ESOPHAGEAL VARICES: VASCULAR STRUCTURE IMAGES BY MINIATURE ULTRASOUND PROBE

Background: The effect of eradication of esophageal varices on the collateral veins beside the esophagogastric junction in portal hypertensive patients remains unclear. Methods: The intramural and extramural vascular structures of the cardia and lower esophagus of 35 patients with portal hypertension were examined by endoscopic ultrasonography (EUS) before and after treatment of esophageal varices with endoscopic variceal ligation (EVL), in which ligations were repeatedly performed until complete obliteration of the varices. The vascular structures were classified into the gastric, palisade/perforating (p/p), and truncal zones, and were quantitatively evaluated. Results: No esophageal varices remained in the p/p nor in the truncal zones after EVL. EVL significantly reduced the total cross‐sectional area (CSA) of the submucosal vessels and number of perforating veins in the gastric zone (P < 0.01, P < 0.01), and the total CSA of the peri‐esophageal collateral veins (peri‐ECV) and number of perforating veins in the p/p zone (P < 0.001, P < 0.001). Furthermore, the total CSA of the peri‐ECV was larger among patients with perforating veins in the p/p zone than among those without, both before and after EVL. Conclusions: EVL obliterated esophageal varices, and indirectly influenced the intramural and extramural vascularities in the region of the esophagogastric junction, which may contribute to prevention of variceal recurrence.     

Endoscopic ultrasound for esophageal and gastroesophageal junction cancer: Impact of increased use of primary neoadjuvant therapy on preoperative locoregional staging accuracy

Initial treatment of locally advanced esophageal and gastroesophageal junction (GEJ) malignancies for selected patients at some institutions has recently changed from surgical resection to neoadjuvant therapy. The aim of this study is to evaluate the impact of this change in treatment strategy on both the overall disease profile and locoregional endoscopic ultrasound (EUS) staging accuracy for a cohort of patients managed with primary surgical resection over a 10-year period at our institution. All subjects at our institution who underwent primary esophagectomy from 1993 to 2002 following preoperative EUS for known or suspected esophageal and/or GEJ cancers were identified. Patients with dysplasia alone, prior upper gastrointestinal tract surgery, preoperative neoadjuvant therapy, cancer of the gastric cardia or recurrent malignancy were excluded. EUS findings and staging results were compared to surgical pathology following resection. The impact of the gradually increased use of primary chemoradiation during the second half of the study was assessed. Of the 286 operations performed, 184 subjects were excluded. The remaining 102 underwent primary surgical resection a median of 18 days following EUS staging for adenocarcinoma (88%) or squamous cell carcinoma (12%) of the esophagus (69%) or GEJ (31%). Overall EUS locoregional T and N staging accuracy was 72% and 75% respectively; accuracy for T1, T2, T3 and T4 cancer was 42%, 50%, 88% and 50% respectively. Despite an increased frequency of pathologically confirmed T1 and T2 cancers (P = 0.005) and an insignificant trend toward increased N0 malignancy (P = 0.05) during the second half of the study period, no statistically significant changes in T (P = 0.07) or N (P = 0.82) staging accuracies for EUS or disease characteristics were noted between the first and second half of the study period. Despite both inaccurate radial EUS staging and increased relative use of primary surgery for early cancers, recent increased use of primary neoadjuvant therapy did not change overall disease characteristics and accuracy of locoregional EUS staging of esophageal and GEJ cancers managed with primary surgical resection.     

Three Cases of Esophageal Granular Cell Tumor

Abstract: Although it has long been thought that granular cell tumor (GCT) is relatively uncommon in the esophagus, in recent years, reports of this disease have increased due to advances in endoscopic examination and endoscopic therapy. The authors recently experienced three cases of esophageal GCT, all of whom underwent endoscopic polypectomy. Endoscopic findings were consistent with Yamada's type I or II, the surface of the lesions being smooth and the color white or whitish-yellow. These three cases were treated by endoscopic polypectomy. In case 1, the resection was made possible by raising the tumor with forceps under a 2-channel-scope. In case 2, the tumor was resectable following submucosal injection of physiological saline. In case 3, the tumor was resected via strangulation with a snare. The lesions described herein were diagnosed as benign and completely resected by polypectomy, though some showed differences in nuclear size or dyskaryosis. As numerous points remain to be clarified regarding the clinical characteristics of this tumor, and some tumors have been diagnosed as malignant despite being small, it appears that endoscopic polypectomy should be performed for the purpose of diagnosis as well as complete resection.     

食管乳头状瘤内镜下套扎的疗效观察

[目的]观察内镜下套扎治疗食管乳头状瘤的临床效果。[方法]分析31例食管乳头状瘤患者的临床及内镜特点,并行内镜下套扎治疗,术后口服抑酸药物治疗,定期复查电子胃镜。[结果]31例患者内镜下套扎治疗均成功;其中术后1例出现胸骨后疼痛,1例表现为轻度吞咽困难,治疗3~5d后症状缓解。[结论]内镜下套扎治疗是一种安全有效的治疗食管乳头状瘤的方法,值得临床推广应用。     

Endoscopic Resection Using a Ligating Device for Esophageal Granular Cell Tumors: A Report of Two Cases

Many esophageal granular cell tumors (GCT) diagnosed incidentally during endoscopic examinations are less than 10 mm in diameter and can be treated endoscopically for histological examination of the entire lesion. However, it is difficult to remove them with sufficient surgical margins by conventional endoscopic methods because GCT, even if small in diameter, lie in the submucosal layer and lesions in the esophagus make it difficult to manipulate cutting devices. To overcome these drawbacks we tried using a ligating device that has recently been employed for endoscopic resection of early gastrointestinal carcinoma. Two patients diagnosed with GCT by biopsy, and with lesions confirmed to be in the submucosal layer by endoscopic ultrasonography, were treated easily and completely by this method without any complications. The tumors measured 5 × 5 mm and 8 × 6 mm. Endoscopic resection with the ligating device is thought to be the simplest and most effective endoscopic treatment for GCT.     

Advantages of endoscopic submucosal dissection versus endoscopic oblique aspiration mucosectomy for superficial esophageal tumors

Background and Aim: In the treatment of superficial esophageal tumors (SET), en bloc histologically‐complete resection reduces the risk of local recurrence. Endoscopic oblique aspiration mucosectomy (EOAM) and endoscopic submucosal dissection (ESD) have been applied to resect SET. The aim of this study was to retrospectively determine whether ESD is more advantageous than EOAM for SET. Methods: In the present study, there was a total of 122 patients in whom 162 SET were resected endoscopically at Hiroshima University Hospital. EOAM (83 lesions/63 patients) or ESD (79 lesions/59 patients) was performed. En bloc histologically‐complete resection rates, operation time, complications, and the local recurrence rate were studied. Results: In SET > 20 mm, the en bloc histologically‐complete resection rate was significantly higher with ESD than with EOAM (94% vs 42%, P < 0.001). In SET of 16–20 mm, the rate tended to be higher with ESD than with EOAM (100% vs 81%, P = 0.08). In SET < 15 mm, the rates did not differ significantly between groups. The average operation time was significantly longer for ESD than for EOAM, regardless of tumor size (49.7 ± 33.0 min vs 19.1 ± 6.1 min, P < 0.001). Complication rates did not differ significantly between groups. The local recurrence rate was significantly lower with ESD than with EOAM (0%, mean observation period: 18.9 months vs 9%, mean observation period: 30.7 months, P = 0.03). Conclusion: Although increased operation time with ESD remains problematic, SET >15 mm should be treated with ESD to reduce local recurrence. In lesions ≤15 mm, EOAM might be preferable, especially in high‐risk patients.