CLINICAL USEFULNESS OF COLONOSCOPIC INSERTION OF A DECOMPRESSION TUBE FOR OBSTRUCTIVE COLORECTAL CANCER

We evaluated the clinical usefulness of colonoscopic insertion of a decompression tube (decompression method) for the treatment of ileus associated with left‐sided colorectal cancer. Decompression method was done in 48 patients with colorectal cancer (38 primary cancer, 10 metastatic cancer). A decompression tube was successfully inserted in all but 10 patients who had primary cancer with severe strictures. The overall insertion rate was 79%. Decompression method improved obstructive symptoms and decreased intestinal gas as evaluated on plain X‐ray films of the abdomen. Emergency operation was unnecessary in 96% of the patients with primary cancers, in whom the decompression tube was successfully inserted. We conclude that decompression method can improve abdominal symptoms caused by obstructive colorectal cancer and reduce the need for emergency operation.     

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.     

LONG INTESTINAL TUBE INSERTION WITH THE ROPEWAY METHOD FACILITATED BY A GUIDEWIRE PLACED BY TRANSNASAL ULTRATHIN ENDOSCOPY FOR BOWEL OBSTRUCTION

Aim: For patients with bowel obstruction, intestinal decompression by a long tube is recommended. We assessed the usefulness of a new technique for insertion of a long tube with a guidewire placed by transnasal ultrathin endoscopy. Methods: Nineteen patients who had been diagnosed as suffering from bowel obstruction underwent long‐tube insertion with the ropeway technique using a guidewire placed by transnasal endoscopy. Thirty‐three patients who had undergone conventional insertion of a long tube were included as controls. The success rate of intubation of the small bowel and the time required for the procedure were compared between the subjects and controls. Results: The success rate of intubation was 94.7% (18/19) in subjects and 84.8% (28/33) in controls (P = 0.53). The time required for insertion in the subjects and controls was 24.1 ± 8.1 min and 48.7 ± 25.3 min, respectively, with a statistically significant difference (P < 0.001). No complications relevant to the procedure were encountered in either of the groups. Conclusion: Long‐tube insertion facilitated by transnasal endoscopy reduces the time required for insertion in comparison with the conventional technique without endoscopy. Endoscopy‐assisted long‐tube insertion with the ropeway method is a safe and useful procedure for decompression in patients with bowel obstruction.     

COMMUNITY‐BASED MASS SCREENING FOR COLORECTAL CANCER BY A COMBINATION OF FECAL OCCULT BLOOD TESTING AND FLEXIBLE SIGMOIDOSCOPY

Background: There have only been a few large‐scale community‐based reports on the combination of immunological fecal occult blood testing (IFOBT) and flexible sigmoidoscopy (FS). Based on the results of mass screening at our hospital, we investigated the utility of combining IFOBT with FS to detect colorectal cancer (CRC) and analyzed the detection rates of CRC. Subjects and methods: The subjects comprised examinees during mass screening for CRC from 1992 to 2002. Only examinees that underwent the 2‐day IFOBT method were enrolled. During the 11 years, 117 644 subjects had negative 2‐day IFOBT and underwent FS. Cancers that were directly found by FS or by work‐up examinations with negative 2‐day IFOBT were designated as IFOBT‐FS‐detected cancers. Results: The detection rate of CRC was 0.16% (mucosal cancer, 0.13%; invasive cancer, 0.03%) by negative 2‐day IFOBT and FS. It was 0.27% (mucosal cancer, 0.22%; invasive cancer, 0.05%) in first‐time examinees. The detection rate was significantly higher in males than in females, and rates increased with age in both genders. Adverse events included eight cases of ischemic colitis that occurred after FS (incidence rate, 0.0068%). There were no cases of perforation, hemorrhage or infection after endoscopy. Conclusion: Although there are problems in introducing FS into mass screening for CRC, such as cost‐effectiveness, speed of examinations and lack of manpower, FS is expected to prevail because preparation is easier, and it is a shorter and safer procedure than colonoscopy. In particular, a combination of IFOBT with FS is effective and recommended in first‐time examinees and for individuals 50 years and older. Mass screening using the combination of IFOBT and FS provides limited benefit in those who are below 50 years of age.     

MID‐TERM PROGNOSIS AFTER ENDOSCOPIC RESECTION FOR SUBMUCOSAL COLORECTAL CARCINOMA: SUMMARY OF A MULTICENTER QUESTIONNAIRE SURVEY CONDUCTED BY THE COLORECTAL ENDOSCOPIC RESECTION STANDARDIZATION IMPLEMENTATION WORKING GROUP IN JAPANESE SOCIETY FOR CANCER OF THE COLON AND RECTUM

We carried out a retrospective questionnaire survey of 792 submucosal colorectal carcinoma (CRC) cases from 15 institutions affiliated with the Colorectal Endoscopic Resection Standardization Implementation Working Group in Japanese Society for Cancer of the Colon and Rectum. In these cases, endoscopic resection (ER) and surveillance was carried out without additional surgical resection. Local recurrence or metastasis was observed in 18 cases. Local submucosal recurrence was observed in 11 cases, and metastatic recurrence was observed in 13 cases. Among the 15 cases in which the depth of submucosal invasion was measured, two cases showed depth less than 1000 µm, which has other risk factors for metastasis. Metastatic recurrence was observed in the lung, liver, lymph node, bone, adrenal glands, and the brain; in some cases, metastatic recurrence was observed in multiple organs. Death due to primary disease was observed in six cases. The average interval between ER and recurrence was 19.7 ± 9.2 months. In 16 cases, recurrence was observed within 3 years after ER. Thus, validity of ER without additional surgical resection for cases with the conditions that the depth of submucosal invasion is less than 1000 µm and the histological grade is well or moderately differentiated adenocarcinoma with no lymphatic and venous involvement was proven.     

NEW METHOD OF COVERED WALLSTENTS FOR DISTAL MALIGNANT BILIARY OBSTRUCTION TO REDUCE EARLY STENT‐RELATED COMPLICATIONS BASED ON CHARACTERISTICS

Aim: We previously reported a low occlusion rate with covered Wallstents for malignant biliary obstruction, but stent‐related complications other than occlusion posed a problem. A modified covered Wallstent insertion method based on stent characteristics was evaluated to reduce stent‐related complications. Methods: A total of 138 patients with distal malignant biliary obstruction received covered Wallstent placement. From October 2001 to October 2003, 69 patients received covered Wallstent placement (Group 1). Thereafter, we modified our stent insertion method and 69 patients received stent placement using this modified method from November 2003 to January 2007 (Group 2). The modified insertion method consists of endoscopic sphincterotomy carried out in patients without pancreatic duct invasion and longer stent placement with the center of the stent located in the center of the biliary stricture to prevent pancreatitis, kinking of the bile duct, and stent dislocation. A comparative analysis was carried out using prospectively collected data in these two cohorts. Results: Tumor ingrowth was not observed, and stent occlusion rate was 18.8% in Group 1 and 23.2% in Group 2. The overall rates of stent‐related complications did not differ (39.1% in Group 1 and 30.4% in Group 2), but stent‐related complications within 3 months decreased from 22 episodes in Group 1 to 13 episodes in Group 2. Median event‐free survival was prolonged by modified stent insertion method (125 days in Group 1 and 268 days in Group 2, P = 0.020), although cumulative survival and stent patency were not significantly different. Conclusions: Our modified method of covered Wallstent placement showed improved event‐free survival.     

介绍一种新的气管内插管最佳深度的定位方法(附200例分析)

以往气管内插管的定位方法虽多,但都不够确切和全面,有一定的盲目性,因此插管过深或过浅时有发生。本文介绍一种新定位方法:以手指在胸骨上窝触摸气管,当插管尖端通过时可清楚触及,如掌握得当则可获得插管的最佳深度。本文通过200例测量与观察发现,此定位方法有一定规律性,如气管中点位于胸骨上窝,插管最佳深度与身高有很好的相关性,并总结推导出简便计算公式。