Endoscopic submucosal dissection and preoperative assessment with endoscopic ultrasonography for the treatment of rectal carcinoid tumors

Background

Rectal carcinoid tumors 10 mm in diameter or smaller located within the submucosal layer can be cured by local excision including endoscopic treatment. But complete resection of these tumors with endoscopic polypectomy is difficult. This study aimed to evaluate the usefulness of endoscopic submucosal dissection (ESD) and endoscopic ultrasonography (EUS) for the treatment of rectal carcinoid tumors.

Methods

In this study, 22 rectal carcinoid tumors in 21 patients were evaluated with EUS and treated using ESD from January 2004 to December 2008.

Results

The mean size of the resected tumors was 6.1 mm (range, 2.0–10 mm) on histopathologic evaluations. When the sizes of the tumors shown by EUS and histopathologic evaluation were compared, the mean values were not significantly different. All the tumors were located within the submucosal layer, and the accuracy of the preoperative depth determination with EUS was 100% (22/22). The mean duration of the ESD procedure was 37 min (range, 20–71 min). The overall rate of en bloc resection with ESD was 100% (22/22). Although postoperative bleeding occurred in two cases (9%), both cases were successfully managed by endoscopic hemostasis. No perforation or recurrence was observed during the mean follow-up period of 30 months (range, 7–66 months).

Conclusions

Endoscopic submucosal dissection and preoperative assessment with EUS are effective for treating rectal carcinoid tumors and enabling en bloc resection.     

Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for large superficial colorectal neoplasias including ileocecal lesions

Background

Large superficial neoplasias of the ileocecal region pose an increased degree of complexity for endoscopic resection. This study aimed to evaluate the safety and efficacy of endoscopic submucosal dissection (ESD) for large superficial colorectal neoplasias including ileocecal lesions.

Methods

A total of 33 superficial colorectal neoplasias, including eight neoplasias in the ileocecal region, were treated with ESD from December 2005 to April 2009. Therapeutic efficacy, complications, and follow-up results were retrospectively evaluated among three groups: ileocecal region, colon, and rectum.

Results

The mean size of all resected neoplasias was 35 ± 15 mm (range, 20–80 mm) and that of all resected specimens was 41 ± 15 mm (range, 23–82 mm). The mean procedural time was 121 ± 90 min (range, 22–420 min). The difference in mean values among the three groups was not significant. The overall rate of en bloc resection was 91% (30/33). Histopathologically, both the lateral and vertical margins in the specimens resected en bloc tested negative (30/30). The rate for en bloc resection in the ileocecal region did not differ significantly from that for the other two groups (p = 0.20 compared with the rate for the colon and p = 0.12 compared with the rate for the rectum). Complications such as perforation and postoperative bleeding did not occur in the ileocecal group. No recurrence was observed in any cases during the mean follow-up period of 20 ± 12 months (range, 4–44 months).

Conclusions

The ESD approach is safe and effective for treating large superficial neoplasias of the ileocecal region such as other colorectal neoplasias.     

Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for superficial esophageal neoplasia. Is it safe for elderly patients?

Background

Safety and efficacy of endoscopic submucosal dissection (ESD) for esophageal neoplasias have not been adequately investigated in elderly patients. This study was designed to evaluate the safety and efficacy of ESD for esophageal neoplasias in elderly patients.

Methods

Fifty-three superficial esophageal neoplasias treated with ESD using a combination of small-caliber-tip transparent hood and flex knife from May 2006 to June 2009 were divided into elderly group (aged 70 years or older: 25 lesions in 23 patients) and nonelderly group (younger than aged 70 years: 28 lesions in 25 patients). Therapeutic efficacy, complications, and follow-up results were evaluated retrospectively.

Results

The history of cerebral infarction or cardiopulmonary disease and the usage of antiplatelet agents or anticoagulants were significantly higher in elderly group (p 0.0050 and p 0.0013, respectively). Median procedural times in the elderly group and the nonelderly group were 93 ± 53 (range, 42–235) min and 95 ± 55 (range, 40–230) min (p 0.73), respectively. Median sizes of the neoplasias and the resected specimens were 14 ± 11 (range, 5–45) mm and 15 ± 17 (range, 5–83) mm (p 0.56), and 35 ± 12 (range, 18–60) mm and 38 ± 17 (range, 18–90) mm (p 0.38), respectively. En bloc resection rate was 100% in each group. Body temperature and white blood cell counts of the next day after ESD were significantly higher in the nonelderly group than in the elderly group (p 0.0087 and p 0.0043, respectively). There were no complications, such as postoperative bleeding or perforation, in each group. The median follow-up period of 23 ± 10 (range, 4–35) months in the elderly group revealed no local or distant metastasis.

Conclusions

ESD with a combination of small-caliber-tip transparent hood and flex knife is a safe and effective treatment for superficial esophageal neoplasia in elderly and nonelderly patients.     

Application of Polyethylene Glycolic Acid Felt with Fibrin Sealant to Prevent Postoperative Pancreatic Fistula in Pancreatic Surgery

Objective

The purpose of this nonrandomized retrospective study was to report our new procedures using polyethylene glycolic acid (PGA) felt with fibrin sealant to prevent severe pancreatic fistula in patients undergoing pancreatic surgery.

Methods

From 2000 to 2008, 54 and 63 patients underwent pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), respectively. Of those patients, we applied PGA felt with fibrin sealant to 18 PD patients and 26 DP patients. In PD patients, the PGA felt was wrapped around the pancreatic suture site, while in DP patients, the PGA felt was wrapped around the predictive division site. The pancreaticojejunostomy site in PD patients and the cut stump in DP patients were coated with fibrin sealant. We compared the occurrence rates for severe postoperative pancreatic fistula (POPF) that occurred after PD or DP both with and without our new procedures.

Results

Before introduction of our procedures, severe POPF developed in 14 of 36 PD patients (39%) and 10 of 37 DP patients (27%). In contrast, after introduction of our procedures, the incidence of POPF was only one in both of 18 PD (6%; P?=?0.016) and 26 DP (4%; P?=?0.017) patients.

Conclusion

In summary, our procedure using PGA felt with fibrin sealant may reduce the risk of severe POPF.     

Sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery: A case report

We report a case of sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery. A 38-year old asymptomatic woman was referred to our hospital for evaluation of a submucosal tumor of the stomach. Endoscopic examination showed a solitary submucosal tumor without ulceration or central depression on the posterior wall of the antrum and biopsy specimens were not sufficient to determine the diagnosis. Endoscopic ultrasound revealed a tumor nearly 2 cm in diameter arising from the muscle layer and a computed tomography scan showed the tumor enhanced in the arterial phase. Laparoscopic wedge resection was performed for definitive diagnosis. Pathologically, the tumor was shown to be gastric carcinoid infiltrating the muscle layer which indicated the probability of lymph node metastasis. Serum gastrin levels were normal. As a radical treatment, laparoscopy-assisted distal gastrectomy with regional lymphadenectomy was performed 3 wk after the initial surgery. Finally, pathological examination revealed no lymph node metastasis.     

Specific Antibiotic Prophylaxis Based on Bile Cultures Is Required to Prevent Postoperative Infectious Complications in Pancreatoduodenectomy Patients Who Have Undergone Preoperative Biliary Drainage

Background Preoperative biliary drainage (PBD) is associated with bacterial contamination of bile, but the effects of PBD on morbidity after pancreatoduodenectomy remain controversial. The aim of this study was to characterize bile contamination to develop successful specific antibiotic prophylactic strategies for pancreatoduodenectomy. Methods Ninety-one consecutive patients who underwent pancreatoduodenectomy for periampullary tumor were prospectively evaluated. Prophylactic antibiotics were selected based on preoperative bile cultures. Bile cultures and postoperative complications were compared in 46 patients who underwent PBD (drainage group) versus 45 patients who did not (nondrainage group). Results The incidence of positive bile cultures was higher in the drainage group (78%) than in the nondrainage group (36%) (P < 0.001). In the drainage group, positive bile cultures were frequently polymicrobial (61%) and demonstrated resistance to several antibiotics, including cefazolin (83%), cefmetazole (72%), and cefpirome (64%). Overall morbidity (30% and 22%) and infectious morbidity (13% and 11%) did not differ significantly between the drainage and nondrainage groups, respectively. Conclusions PBD had a notable influence on bile microbial contamination, including a higher rate of antibiotic resistance. Therefore, specific antibiotic prophylaxis based on bile culture is required for preventing infectious complications in pancreatoduodenectomy patients who undergo PBD.     

Multiple Inflammatory Pseudotumor of the Liver,Mimicking Cholangiocarcinoma with Tumor Embolus in the Hepatic Vein: Report of a Case

A 68-year-old Japanese woman complaining of general fatigue and intermittent high fever was admitted to our hospital. Abdominal ultrasonography showed two tumors in the lateral segment of the liver, with soft tissue in the left hepatic vein that was considered to be a tumor embolus. A diagnosis of cholangiocarcinoma was made based on various radiological and laboratory examinations and therefore a surgical resection was performed. Microscopically, the tumor consisted of inflammatory cells, which had aggressively invaded the hepatic vein and Arantius' duct. The pathological diagnosis was inflammatory pseudotumor (IPT) that had invaded the hepatic vein. Although many cases of hepatic IPT have been previously reported, cases of hepatic IPT massively invading the hepatic vein are very rare as far as we could determine, based on a literature search. We herein report this case and discuss the diagnosis and treatment regarding hepatic IPT with massive venous invasion.     

Ruptured aneurysm at an anastomotic artery extending from the vertebral artery to the posterior inferior cerebellar artery: a case report

A 51-year-old hypertensive man presented with subarachnoid haemorrhage. He had a past history of cerebellar infarction due to occlusion of the right posterior inferior cerebellar artery (PICA) 4 years earlier. Digital subtraction angiography showed a saccular aneurysm above an arterial loop extending from the vertebral artery to the distal part of the PICA, reminiscent of peripheral PICA branches. We performed aneurysmal neck clipping with excellent outcome. Aneurysms at anastomotic arteries are extremely rare and can result from increased haemodynamic stress. We report the first case of a ruptured aneurysm at an anastomotic artery in the posterior circulation territory.     

Efficacy of motor cortex stimulation for intractable central neuropathic pain: comparison of stimulation parameters between post-stroke pain and other central pain

Motor cortex stimulation (MCS) has now become the preferred option for neurosurgical management of intractable central neuropathic pain such as post-stroke pain and trigeminal neuropathic pain. However, the efficacy of MCS for other central neuropathic pain such as pain resulting from spinal cord or brainstem lesions is unclear. We retrospectively reviewed 11 consecutive patients with intractable central neuropathic pain who underwent MCS in our institution. Eight patients had poststroke pain caused by thalamic hemorrhage (n = 5) or infarction (n = 3) (thalamic group). Two patients had postoperative neuropathic pain caused by spinal cord lesions, and one patient had facial pain caused by a brainstem lesion associated with multiple sclerosis (brainstem-spinal group). Visual analog scale and stimulation parameters were evaluated at 1 and 6 months postoperatively. MCS was effective for six of eight patients in the thalamic group, and all three patients in the brainstem-spinal group. These efficacies continued for 6 months after surgery without significant change in the stimulation parameters compared with the parameters at 1 month in both groups. The mean amplitude at 1 month and frequency at 6 months after surgery were significantly higher in the brainstem-spinal group than the thalamic group, although the patient number was small. MCS is effective for other central neuropathic pain, but higher intensity stimulation parameters may be necessary to gain adequate pain reduction.     

A large-sized bubbling appearance of the glomerular basement membrane in a patient with pulmonary limited AL amyloidosis and a past history of lupus nephritis

We report an unusual pathological finding, a large-sized bubbling appearance of the glomerular basement membrane (GBM), in a patient with pulmonary limited AL amyloidosis and a past history of lupus nephritis. The first renal biopsy specimen from 10 years ago, when systemic lupus erythematosus was diagnosed, demonstrated mild mesangial proliferation and subepithelial deposits (WHO classification: III + V). Light microscopy of the current biopsy using periodic acid methenamine silver (PAMS) stain demonstrated a large-sized bubbling appearance of the GBM; however, very weak immunoglobulin and complement deposition was observed in immunofluorescence studies. Routine electron microscopy demonstrated partial subendothelial expansion with electron-lucent materials, but no electron-dense deposits or amyloid fibrils. Electron microscopy with PAMS stain revealed electron-lucent endothelial scalloping, including some cellular components and microspheres in the GBM; however, it is not clear if these materials are derived from endothelial cells. One possibility is that these unique findings represent a recovery phase of lupus membranous nephritis; another is that these findings correspond to a new disease entity.