Endoscopic full-thickness resection of a lateral spreading rectal tumor after unplanned injection of dilute hyaluronic acid into the subserosal layer (with video)

A 74-year-old woman underwent colonoscopy for investigation of a liver tumor. A lateral spreading tumor of the non-granular type (LST-NG), 25?mm in diameter, was detected at the rectosigmoid junction. As magnifying image-enhanced colonoscopy suggested a tubulovillous adenoma, endoscopic mucosal resection (EMR) was chosen for removal of the LST-NG. The lesion was effectively and evenly lifted after injection of 0.4% hyaluronic acid diluted with glycerol in the ratio of 1:1. A small amount of indigo-carmine dye was also added for coloration of the plane of resection. The lesion was completely removed en bloc. Although a blue-colored layer was identified in the resection defect, a small amount of a whitish layer was detected above the blue layer. The muscle layer was clearly located on the underside of the resected polyp. A total of 14 endoclips were used to close the defect completely. The patient was successfully treated conservatively without surgery. Histology of the resected specimen showed that it contained a tubulovillous adenoma with the submucosal layer and both layers of the muscularis propria. The surgical margin was free of neoplastic change horizontally and vertically. To the best of our knowledge, this is the first case report of full-thickness resection associated with EMR after unplanned injection of dilute hyaluronic acid into the subserosal layer rather than the intended submucosal layer. We describe how to promptly recognize this complication during colonoscopy, in order to achieve immediate closure of the defect, with the identification of a "mirror target sign" on the colonic wall.     

Potential benefits of early continuous positive pressure ventilation in patients with rapidly progressive interstitial pneumonia

Background and objective: Rapidly progressive interstitial pneumonia (RPIP), including acute exacerbations of interstitial pneumonia, is associated with high rates of mortality. The present study was performed to examine the effects of respiratory management using non‐invasive ventilation (NIV) in patients with RPIP and to assess the prognostic factors for survival. Methods: BiPAP Vision was used for NIV. Clinical data and information on NIV were retrospectively obtained from patient records. Survival at 30 days was evaluated, and biomarkers were measured after initiation of NIV. Results: Thirty‐eight patients who had been admitted with RPIP and treated by NIV were included in the study. The ratio of PaO₂ to fraction of inspired oxygen at initiation of NIV was higher in survivors than in non‐survivors (P = 0.0054). The mean duration to initiation of NIV after admission was significantly shorter in survivors than in non‐survivors (P = 0.0006). Serum Krebs von den Lungen‐6 (KL‐6) and LDH levels at the start of NIV were higher in non‐survivors than in survivors (KL‐6, P = 0.022; LDH, P = 0.044). Bivariate logistic regression analysis showed that early intervention with NIV was a significant predictor of survival at 30 days. In addition, the ratio of PaO₂ to fraction of inspired oxygen and both LDH and KL‐6 levels at initiation of NIV were significant predictors of survival. Conclusions: Early intervention with NIV, mainly continuous positive pressure ventilation, is beneficial for the management of patients with RPIP. A randomized controlled study in a large population is needed to confirm the value of early NIV.     

Spontaneously hypertensive rats develop pronounced hepatic steatosis induced by choline-deficient diet: Evidence for hypertension as a potential enhancer in non-alcoholic steatohepatitis

Aim: Patients with non‐alcoholic steatohepatitis (NASH) frequently have many co‐morbidities including essential hypertension, which is reported to increase vascular production of reactive oxygen species (ROS) and alter the hepatic anti‐oxidant defense system. Since ROS play a role in the pathogenesis of NASH, it is hypothesized that hypertension modulates the hepatic oxidative status and influences the development of NASH. The aim of this study was to investigate the potential effects of hypertension on the progression of NASH. Methods: Spontaneously hypertensive rats (SHR) and Wistar‐Kyoto (WKY) rats as normotensive controls were fed choline‐deficient (CD) diet for 5 weeks. Histological changes, messenger RNA (mRNA) expression and thiobarbituric acid reactive substances (TBARS) levels in the liver were assessed in each group. Results: Choline‐deficient diet led to pronounced hepatic steatosis in SHR with an 8‐fold increase of the hepatic triglyceride content, while there was no significant increase in WKY. These changes in SHR were associated with significant reduction in the expression of mRNA for peroxisome proliferator activated receptor α, acyl‐CoA oxidase, microsomal triglyceride transfer protein, and apolipoprotein B100. Consistent with the significant reduction of hepatic superoxide dismutase activity and marked downregulation of the gene expression of hepatic antioxidant enzymes, the hepatic TBARS level and the plasma level of alanine aminotransferase were only increased in SHR on CD diet. Conclusions: Spontaneously hypertensive rats receiving CD diet showed severe hepatic steatosis associated with reduction of hepatic anti‐oxidant capacity, leading to increased hepatic oxidative stress and tissue damage. Accordingly, hypertension might have a potential effect on the progression of NASH.     

Influence of oxygen inhibition on the surface free energy and enamel bond strength of self-etch adhesives

We compared the surface free energies and enamel bond strengths of single-step self-etch adhesives with and without an oxygen-inhibited layer. The adhesives were applied to the enamel surfaces of bovine incisors, light irradiated, and the oxygen-inhibited layer was either retained or removed with ethanol. The surface free energies and their components (γ(S)(LW), γ(S)(+), and γ(S)(-)) were determined by measuring the contact angles of three test liquids placed on the cured adhesives. The enamel bond strengths of specimens with and without the oxygen-inhibited layer were measured. For all surfaces, the value of the estimated surface tension component γ(S)(LW) was relatively constant. The value of the γ(S)(+) component increased slightly when the oxygen-inhibited layer was removed, whereas that of the γ(S)(-) component decreased significantly. The enamel bond strengths of the self-etch adhesives were significantly lower in the specimens without an oxygen-inhibited layer. The oxygen-inhibited layer therefore appeared to promote higher enamel bond strength.     

Chemoradiotherapy for patients with recurrent lymph-node metastasis or local recurrence of gastric cancer after curative gastrectomy

Objectives

Whether chemoradiotherapy (CRT) is clinically beneficial for the management of postoperative recurrence of advanced gastric cancer remains unclear. We retrospectively studied treatment outcomes in patients who had unresectable localized recurrence after surgery for advanced gastric cancer and evaluated the safety and efficacy of CRT.

Methods

The study group comprised 21 patients who received concurrent CRT for unresectable localized recurrence after undergoing R0 resection for stage II/III advanced gastric cancer. Localized recurrence was defined as a few or limited recurrent lesions.

Results

The recurrence pattern was anastomotic recurrence in 7 patients, abdominal lymph-node recurrence in 12, and anastomotic recurrence plus abdominal lymph-node recurrence in 2. The median total dose of radiotherapy was 48.6 Gy (range 39.6–56.0), and the CRT completion rate was 100 % (21 of 21 patients). CRT-related grade 3 or higher toxicity comprised neutropenia in 33.3 % of patients and anorexia in 9.5 %. The response rate was 61.9 % (complete response 38.1 %, partial response 23.8 %). The median overall survival was 35.0 months.

Conclusions

We conclude that CRT may become one treatment strategy for the management of unresectable localized recurrence after curative resection of advanced gastric cancer.