Distribución Topográfica y Manejo de Tumores Neuroendocrinos del Tubo Digestivo / Topographic Distribution and Management of Neuroendocrine Tumors of the Digestive Tube

Introducción: Los tumores neuroendocrinos (TNE) son un grupo de neoplasias que se originan a partir de células enterocromafínicas, especialmente ubicadas en el tubo digestivo. El objetivo del presente estudio es escribir la distribución topográfica, el manejo multidisciplinario y diagnóstico patológico según la OMS de los tumores neuroendocrinos del tubo digestivo. Métodos: El presente es un estudio descriptivo, retrospectivo de los casos con diagnóstico anatomopatológico confirmado de tumor neuroendocrino localizados en el tubo digestivo entre enero del 2011 a diciembre del 2018 en el Instituto Oncológico Nacional del Ecuador- SOLCA de Guayaquil. Se describe topografía y tipo de tratamiento establecido con frecuencias y porcentajes. Resultados: Ingresaron al estudio 21 casos. La localización más frecuente fue el apéndice cecal n = 8 (38 %), en estómago n=4 (19 %), intestino delgado n=3 (14 %). El diagnóstico patológico en estadio G1 (65 %); G2 (24%) y G3 (12%). La primera línea de tratamiento fue la cirugía con intención curativa n=19 (90.5 %) y tratamiento endoscópico n=2 (9.5 %). Los pacientes sometidos a cirugía, n=16/19; (84 %) obtuvieron niveles de resección 0 (R0) y permanecieron en observación clínica, los demás sujetos en el estudio recibieron tratamiento adyuvante con somatostatina sola n=1 (4.8 %) o combinación de somatostatina y radioterapia n=2 (9.5 %). Conclusión: El diagnóstico de tumor neuroendocrino de tubo digestivo es una etiología oncológica poco frecuente. El tratamiento quirúrgico en esta serie de casos está enfocada en una acción curativa de tipo quirúrgico.

Introduction: Neuroendocrine tumors (NETs) are a group of neoplasms that originate from enterochromaffin cells, especially located in the digestive tract. The objective of the present study is to write the topographic distribution, the multidisciplinary management and pathological diagnosis according to the WHO of the neuroendocrine tumors of the digestive tract. Methods: This is a descriptive, retrospective study of the cases with a confirmed anatomopathological diagnosis of neuroendocrine tumor located in the digestive tract between January 2011 to December 2018 at the National Oncology Institute of Ecuador- SOLCA of Guayaquil. The topography and type of treatment established with frequencies and percentages are described. Results: 21 cases were entered into the study. The most frequent location was the cecal appendix n = 8 (38%), stomach n = 4 (19%), small intestine n = 3 (14%). The pathological diagnosis in stage G1 (65%); G2 (24%) and G3 (12%). The first line of treatment was surgery with curative intent n = 19 (90.5%) and endoscopic treatment n = 2 (9.5%). Patients undergoing surgery, n = 16/19; (84%) obtained resection levels 0 (R0) and remained under clinical observation, the other subjects in the study received adjuvant treatment with somatostatin alone n = 1 (4.8%) or combination of somatostatin and radiotherapy n = 2 (9.5%). Conclusion: The diagnosis of neuroendocrine tumor of the digestive tract is a rare oncological etiology. The surgical treatment in this series of cases is focused on a surgical action of a surgical type.

The Colonoscopic Characteristics and Clinical Manifestations Associated with Lower Gastrointestinal Tract Bleeding in Patients with Chronic Kidney Disease / 대한내과학회지

BACKGROUND/AIMS: Patients with chronic kidney disease (CKD) have a high risk of gastrointestinal tract bleeding because of platelet dysfunction attributable to uremia, a poor blood supply, and frequent use of anticoagulant agents. We describe the colonoscopic characteristics of lower gastrointestinal tract bleeding (LGIB) in patients with CKD. METHODS: A total of 230 hospitalized patients with CKD who underwent colonoscopy because of suspected LGIB between January 2003 and August 2016 were reviewed retrospectively. We categorized CKD into five stages according to the estimated glomerular filtration rate and compared the colonoscopic findings and clinical manifestations among these five subgroups. RESULTS: Of the 230 patients with CKD suspected of LGIB, 73 (31.7%, 103 cases) were colonoscopically confirmed to exhibit LGIB. Their mean age was 65.7 ± 12.8 years, and 52.1% were female (n = 38). The most common causes of LGIB were hemorrhoidal bleeding (32 cases, 43.8%), followed by bleeding of colorectal ulcers (21 cases, 28.8%), diverticular bleeding (12 cases, 16.4%), colitis-related bleeding (12 cases, 16.4%), and angiodysplastic bleeding (12 cases, 16.4%). As the CKD stage progressed, the incidence of LGIB increased (p = 0.043). On multivariate logistic regression analysis, LGIB was more common in CKD patients with hemorrhoids (odds ratio [OR]: 4.349, 95% confidence interval [CI]: 2.043–9.256, p < 0.001) or colorectal ulcers (OR: 20.001, 95% CI: 4.780–83.686, p ℃ 0.001) and in those on hemodialysis (OR: 6.863, 95% CI: 1.140–41.308, p = 0.035). CONCLUSIONS: In CKD patients, the risk of LGIB is significantly increased by hemorrhoids, colorectal ulcers, and a positive hemodialysis status.

Primary malignant melanoma without melanosis of the colon

Primary malignant melanoma (PMM) of the gastrointestinal tract is rare. Reported cases of PMM of the lower gastrointestinal tract typically describe anal and rectal involvement rather than colonic lesions. This report describes a rare case of a 50-year-old woman with PMM originating in the colon. The patient presented to Inje University Busan Paik Hospital with a 3-day history of blood-tinged stools. She underwent colonoscopy for a diagnosis of hematochezia. The colonoscopic examination revealed a large-sized semi-pedunculated sigmoid colon polyp with a reddish-colored mucosal surface. Endoscopic mucosal resection was performed, and the final histopathological findings were consistent with a diagnosis of malignant melanoma. Systemic work-up was performed for assessment of metastasis and to identify the primary tumor considering the high metastatic rate of gastrointestinal malignant melanoma; however, no other malignant lesion was detected. Thus, she was diagnosed with colonic PMM. She underwent laparoscopic low anterior resection and lymph node dissection and has been recurrence-free for > 2 years.

Efficacy and Safety of Robotic Procedures Performed Using the da Vinci Robotic Surgical System at a Single Institute in Korea: Experience with 10000 Cases

PURPOSE: To evaluate the efficacy and safety of robotic procedures performed using the da Vinci Robotic Surgical System at a single institute. MATERIALS AND METHODS: We analyzed all robotic procedures performed at Severance Hospital, Yonsei University Health System (Seoul, Korea). Reliability and mortality rates of the robotic surgeries were also investigated. RESULTS: From July 2005 to December 2013, 10267 da Vinci robotic procedures were performed in seven different departments by 47 surgeons at our institute. There were 5641 cases (54.9%) of general surgery, including endocrine (38.0%), upper (7.7%) and lower gastrointestinal tract (7.5%), hepato-biliary and pancreatic (1.2%), and pediatric (0.6%) surgeries. Urologic surgery (33.0%) was the second most common, followed by otorhinolaryngologic (7.0%), obstetric and gynecologic (3.2%), thoracic (1.5%), cardiac (0.3%), and neurosurgery (0.1%). Thyroid (40.8%) and prostate (27.4%) procedures accounted for more than half of all surgeries, followed by stomach (7.6%), colorectal (7.5%), kidney and ureter (5.1%), head and neck (4.0%), uterus (3.2%), thoracic (1.5%), and other (2.9%) surgeries. Most surgeries (94.5%) were performed for malignancies. General and urologic surgeries rapidly increased after 2005, whereas others increased slowly. Thyroid and prostate surgeries increased rapidly after 2007. Surgeries for benign conditions accounted for a small portion of all procedures, although the numbers thereof have been steadily increasing. System malfunctions and failures were reported in 185 (1.8%) cases. Mortality related to robotic surgery was observed for 12 (0.12%) cases. CONCLUSION: Robotic surgeries have increased steadily at our institution. The da Vinci Robotic Surgical System is effective and safe for use during surgery.

Pediatric Colonoscopy: The Changing Patterns and Single Institutional Experience Over a Decade

The safety and effectiveness of pediatric colonoscopy for lower gastrointestinal tract diseases have been established in Korea for about 30 years. Both diagnostic and therapeutic colonoscopies have had many advances in terms of operator skill and experience and are now being performed by most pediatric gastroenterologists. Pediatric colonoscopy is different in many aspects from that of adults, such as expected diagnoses, patient management, bowel preparation, selection criteria for sedation, and instrument selection. In this review, the author presents practical information on pediatric colonoscopy, the author's experiences, and the changes in colonoscopy practices over a decade in a tertiary hospital in Korea.

Is glue embolization safe and effective for gastrointestinal bleeding?

Transcatheter arterial embolization using N-butyl-2-cyanoacrylate (NBCA) for gastrointestinal arterial bleeding enables higher cessation rate and lower recurrent bleeding rate compared with conventional embolic materials including gelatin sponge, metallic coil, and polyvinyl alcohol (PVA) particle. Glue embolization is particularly effective in patients with coagulopathy. Even in the lower gastrointestinal tract, ischemic bowel complications by glue embolization are comparable to other agents. Glue embolization is also effective for arterial esophageal bleeding without any serious ischemic complications although the anatomy of the esophageal artery is complex and varied. For bleeding after abdominal surgery such as pancreaticoduodenectomy or hepatic lobectomy, interventional radiologists should be careful with indicating glue embolization because the presence of fewer collateral vessels can easily result in serious ischemic complications. Modified glue such as Glubran 2 (NBCA associated with methacryloxyfulfolane) can reduce the risk of ischemic complication due to its less thermal reaction, but the outcomes seem unsatisfactory.

[Lower gastrointestinal bleeding; a case report]

A 40-year-old woman was referred to our health center with a bulky rectorrhagia. The patient was treated with meropenem and vancomycin for an enterococcal meningitis one week earlier. A colonoscopy was performed at a different center, which was unsuccessful due to high blood volume in the colon and poor vision. The patient underwent angiography of the superior and inferior mesenteric arteries and the rectum artery, but the origin of the bleeding was not known. A polypoid mass with ulcer and bleeding from the site was seen in repeated colonoscopy of the left colon reagion. Due to the severity of the bleeding, the patient was transferred to the operating room and a large uterine mass that had transmitted to the lobes of the sigmoid colon was observed. Due to the diagnosis of uterine tumor, hysterectomy and oophorectomy were performed, and the descending colon was removed as a colostomy from the abdominal wall. In the pathological examination, diffuse endometriosis was found, which had involved the left ovary, the left fallopian tube, and both parametrium and sigmoid to the submucosal layer. On the 26th day, the patient was discharged with a good general condition and full vigilance

Heterotopía Gástrica Rectal. Reporte de un Caso / Rectal Gastric Heterotopia. A Case Report

La mucosa gástrica heterotópica es una alteración caracterizada por la presencia de mucosa gástrica fuera del estómago siendo la ubicación más frecuente en esófago. La heterotopía gástrica del recto es un hallazgo infrecuente, con sólo 50 casos reportados hasta el momento, descripta por primera vez en 1939. A continuación, describimos un caso de heterotopía gástrica en recto haciendo una breve actualización de las manifestaciones, posibles etiologías y opciones terapéuticas.

Heterotopic gastric mucosa is an anomaly that is characterized by the appearance of gastric mucosa out of the stomach, usually in the esophagus. The gastric heterotopia in rectum is a rare finding -of which only 50 cases reported so far- that was first described in 1939. Below, we describe a case of gastric heterotopia in rectum briefly updating the manifestations, possible causes and therapeutic options.

Therapeutic Modulation of Gut Microbiota in Functional Bowel Disorders

Functional bowel disorders (FBDs) are functional gastrointestinal disorders with symptoms attributable to the middle or lower gastrointestinal tract. These include irritable bowel syndrome, functional bloating, functional constipation, functional diarrhea, and unspecified FBD. Increasing evidence has emerged of late that intestinal microbiota is involved in the pathogenesis of FBDs. In this review, the therapeutic benefits and future perspectives of the currently available strategies for modifying the gut microbiota in FBDs are described, focusing primarily on irritable bowel syndrome and functional constipation.

Metachronous metastatic renal cell carcinoma to the jejunum presenting with massive lower gastrointestinal bleeding

Metastatic renal cell carcinoma [MRCC] is a rare cause of massive lower gastrointestinal bleeding [LGIB]. We report a 51-year man who underwent left nephrectomy for renal cell carcinoma [RCC] 6 years ago. presenting with massive LGIB. Preoperative abdominal computed tomography [CT] revealed small bowel mass. Exploration of the abdomen revealed jejunal mass. Resection of the mass along with the jejunal segment with end-to-end anastomosis was performed. Histopathology of the jejunal mass confirmed MRCC. MRCC should be expected as a source of massive LGIB in a patient with history of RCC. Surgical intervention should not be delayed in a hemodynamically unstable patient and persistent bleeding

Expression of P53, HER2 and Ki67 proteins in rats subjected to bladder augmentation with stomach, colon and ileum

PURPOSE: To study the expression of HER2, p53 and Ki67 proteins in cystoplasties. METHODS: Sixty rats were distributed randomly into three groups of 20 animals. Bladder augmentation was held to increase with ileum (Group I), colon (Group II) and stomach (Group III). Tissue samples of neobladder was collected from each rat to its own control. The animals were sacrificed after 12 weeks. The neobladder was withdrawn for immunohistochemitry analysis of p53, HER2 and Ki67 expression. Wilcoxon and Mann-Whitney tests were used for statistical study. RESULTS: There were no significant changes in the expression of p53 and HER2 proteins. It was observed significant increase (p<0.0001) in Ki67 expression in all groups, when compared with their respective controls. When the study groups were compared with each other, there was increase of cell proliferation in the largest gastrocystoplasties in respect of ileocystoplasties (p=0.004) and colocystoplasties (p=0.003). CONCLUSION: We observed significant increase of cell proliferation characterized by Ki67 protein in the digestive tract of the ileocystoplasties, the colocystoplasties and the gastrocystoplasties and this increase was significantly greater in gastrocystoplasties.

Nonsteroidal Anti-inflammatory Drug and Aspirin-induced Peptic Ulcer Disease / 대한소화기학회지

Despite decreasing Helicobacter pylori prevalence, the prevalence of peptic ulcer disease is increasing in the aged population, mainly due to increasing use of NSAIDs to manage pain and inflammation. In addition, low dose aspirin is employed as an anti-coagulant for those who have suffered or are at high risk of ischemic stroke and cardiovascular disease. However, NSAIDs and aspirin are injurious to mucosa of stomach and duodenum. NSAID-induced inhibition of mucosal prostaglandin synthesis is thought to be a major mechanism of gastrointestinal mucosal injury. The proportion of elderly has increased rapidly in Korea, with the proportion over 65 years old expected to be 24.3% in 2030. In this higher-risk population, the strategy to reduce the incidence of NSAID-related peptic ulcers and complications such as bleeding, obstruction and perforation is very important. Proton pump inhibitors (PPIs) with cyclooxygenase-2 inhibitor can be used for reducing the risk of NSAID-related ulcers and upper gastrointestinal (GI) complications. However, continuous use of PPI has several problems. In addition, NSAID-related problems in the lower GI tract have increased, in contrast to the decrease of NSAID-related upper GI disease. The aim of this review is to provide an evidence-based knowledge regarding the mechanism, complications of treatment, and prevention strategies for NSAID- or aspirin-related peptic ulcer disease in Korea.

Hematochezia due to Angiodysplasia of the Appendix

Common causes of lower gastrointestinal bleeding include diverticular disease, vascular disease, inflammatory bowel disease, neoplasms, and hemorrhoids. Lower gastrointestinal bleeding of appendiceal origin is extremely rare. We report a case of lower gastrointestinal bleeding due to angiodysplasia of the appendix. A 72-year-old man presented with hematochezia. Colonoscopy showed active bleeding from the orifice of the appendix. We performed a laparoscopic appendectomy. Microscopically, dilated veins were found at the submucosal layer of the appendix. The patient was discharged uneventfully. Although lower gastrointestinal bleeding of appendiceal origin is very rare, clinicians should consider it during differential diagnosis.

Splenic Injury after Colonoscopy in Patient on Anti-Platelet Agents : A Case Study / 계명의대학술지

Colonoscopy is frequently used for lower GI tract screening tests. Although rare, splenic injury may develop in the high-risk patients on anticoagulants or antiplatelet agents. A 78-year-old female visited our hospital complaining of chest pain. She had taken antihyperlipidemic and antiplatelet agent with hyperlipidemia and 20%-stenosis in the left anterior descending artery. She was taken polypectomy after colonoscopy 4 years ago. The next day, after a follow-up colonoscopy for polypectomy, she complained epigastric and left upper abdominal discomfort. Pain intensity was not high, but next day, epigastric pain was increased, so coronary angiography was performed 2 days later using anticoagulants. Coronary angiography showed 40~50%-stenosis in the left anterior descending artery. Another antiplatelet agent was added. After 72 hours on colonoscopy, her pain was localized upper left abdominal area. Abdominal CT showed intracapsular bleeding in the spleen with a small amount of hemoperitoneum in the pelvis. Since her vital signs were stable, she was treated with conservative management. Her pain improved and discharged. One month later, she was taken Abdominal CT. CT showed the size of intracapsular fluid collection in the spleen was increased, but the whole fluid collection was liquidized. 2 weeks later, follow-up sonography showed the size of fluid collection conspicuously was reduced. The case reported herein is a splenic Injury after Colonoscopy in patient on antiplatelet agents.

Highlights from the 52nd Seminar of the Korean Society of Gastrointestinal Endoscopy

In this July issue of Clinical Endoscopy, state-of-the-art articles selected from the lectures delivered during the 52nd Seminar of the Korean Society of Gastrointestinal Endoscopy (KSGE) on March 29, 2015 are covered, focusing on highlighted educational contents relevant to either diagnostic or therapeutic gastrointestinal (GI) endoscopy. Our society, the KSGE, has continued to host this opportunity for annual seminars twice a year over the last 26 years and it has become a large-scale prestigious seminar accommodating over 4,000 participants. Definitely, the KSGE seminar is considered as one of the premier state-of-the-art seminars dealing with GI endoscopy, appealing to both the beginner and advanced experts. Lectures, live demonstrations, hands-on courses, as well as an editor school, which was an important consensus meeting on how to upgrade our society journal, Clinical Endoscopy, to a Science Citation Index (Expanded) designation were included in this seminar. The 52nd KSGE seminar consisted of more than 20 sessions, including special lectures, concurrent sessions for GI endoscopy nurses, and sessions exploring new technologies. This is a very special omnibus article to highlight the core contents divided into four sessions: upper GI tract, lower GI tract, pancreatobiliary system, and other specialized sessions.

Highlights from the 50th Seminar of the Korean Society of Gastrointestinal Endoscopy

The July issue of Clinical Endoscopy deals with selected articles covering the state-of-the-art lectures delivered during the 50th seminar of the Korean Society of Gastrointestinal Endoscopy (KSGE) on March 30, 2014, highlighting educational contents pertaining to either diagnostic or therapeutic gastrointestinal (GI) endoscopy, which contain fundamental and essential points in GI endoscopy. KSGE is very proud of its seminar, which has been presented twice a year for the last 25 years, and hosted more than 3,500 participants at the current meeting. KSGE seminar is positioned as one of premier state-of-the-art seminars for endoscopy, covering topics for novice endoscopists and advanced experts, as well as diagnostic and therapeutic endoscopy. The 50th KSGE seminar consists of more than 20 sessions, including a single special lecture, concurrent sessions for GI endoscopy nurses, and sessions exploring new technologies. Nine articles were selected from these prestigious lectures, and invited for publication in this special issue. This introductory review, prepared by the editors of Clinical Endoscopy, highlights core contents divided into four sessions: upper GI tract, lower GI tract, pancreatobiliary system, and other specialized topic sessions, including live demonstrations and hands-on courses.

Regression of Colonic Adenomas After Treatment With Sulindac in Familial Adenomatous Polyposis: A Case With a 2-Year Follow-up Without a Prophylactic Colectomy

Familial adenomatous polyposis (FAP) is an autosomal dominant disorder characterized by hundreds of colorectal adenomatous polyps that progress to colorectal cancer. Management of patients with FAP is with a total colectomy. Chemopreventive strategies have been studied in FAP patients in an effort to delay the development of adenomas in the upper and the lower gastrointestinal tract and to prevent recurrence of adenomas in the retained rectum of patients after prophylactic surgery. Sulindac, a nonsteroidal anti-inflammatory drug, causes regression of colorectal adenomas in the retained rectal segment of FAP patients. However, evidence regarding long-term use of this therapy and its effect on the intact colon has been insufficient. We report a case in which the long-term use of sulindac was effective in reducing the size and the number of colonic polyps in patients with FAP without a prophylactic colectomy and polypectomy; we also present a review of the literature.

A Case of Pericolonic Metastasis in Recurrent Signet-Ring-Cell Adenocarcinoma Diagnosed by Endoscopic Ultrasound-Guided Fine-Needle Aspiration Using a Forward-Viewing Echoendoscope / 대한내과학회지

Endoscopic ultrasound-guided fine-needle aspiration is used for the diagnosis and evaluation of rectal and pelvic lesions in lower gastrointestinal tract disease. However, it is not used widely in proximal and transverse colon disease because of the limited visual field and technical problems related to an oblique-viewing echoendoscope. Here, we report a case of recurrent signet-ring-cell gastric adenocarcinoma involving the transverse colon not diagnosed by repeated colonoscopic biopsies that was eventually diagnosed using a forward-viewing echoendoscope with fine-needle aspiration biopsy.

A Case of Pericolonic Metastasis in Recurrent Signet-Ring-Cell Adenocarcinoma Diagnosed by Endoscopic Ultrasound-Guided Fine-Needle Aspiration Using a Forward-Viewing Echoendoscope / 대한내과학회지

Endoscopic ultrasound-guided fine-needle aspiration is used for the diagnosis and evaluation of rectal and pelvic lesions in lower gastrointestinal tract disease. However, it is not used widely in proximal and transverse colon disease because of the limited visual field and technical problems related to an oblique-viewing echoendoscope. Here, we report a case of recurrent signet-ring-cell gastric adenocarcinoma involving the transverse colon not diagnosed by repeated colonoscopic biopsies that was eventually diagnosed using a forward-viewing echoendoscope with fine-needle aspiration biopsy.