[Learning experiences of colorectal ESD in a community general hospital].

Learning how to perform colorectal endoscopic submucosal dissection (ESD) is considered difficult because of different factors including the thin colorectal wall, poor fixation, numerous folds and flexures, and changing conditions over time. A surgeon with experience in performing 25 gastric ESDs began to perform colorectal ESD after fully communicating and consulting with the Department of Surgery and obtaining adequate informed consent. Herein, we examined the results of colorectal ESD performed for 57 lesions between July 2012 and September 2013. Moreover, we selected the first 10 cases (early-phase) and the last 10 cases (late-phase) from 33 colorectal ESD cases to compare the results between the early-phase and late-phase groups. For sites where it was difficult to perform colorectal ESD, it was possible to perform ESD by changing the detachment device, tip attachment, body position, and endoscope. As the surgeon gained experience in performing gastric ESD, the colorectal procedure in the late phase group could be performed with greater speed, and a rising learning curve was observed. An incidental event of delayed perforation occurred in 1 case, for which laparoscopic partial colectomy was performed immediately after the definitive diagnosis had been made.

Central nervous system relapse of Whipple's disease.

A 50-year-old man presented with a 12 kg weight loss in 8 months. Upper gastrointestinal endoscopy findings showed strong erosion and diffuse bleeding in the duodenum. Histopathological findings showed PAS staining-positive macrophages consistent with Whipple's disease. He was treated with trimethoprim-sulfamethoxazole. His condition initially improved. However, during his 6-year course of treatment he developed a central nervous system relapse. Tropheryma whipplei DNA was detected by a polymerase chain reaction in his cerebrospinal fluid. This relapse was successfully treated with ceftriaxone sodium (CTRX). We considered that as initial therapy for Whipple's disease, it would be important to administer CTRX for at least a few months, due to its high translatability to CSF.

[Pneumatosis cystoides intestinalis in a patient with lung cancer].

We report a case of pneumatosis cystoides intestinalis (PCI) in a patient with lung cancer. A 60-year-old woman was admitted with multiple lung tumors and multiple brain tumors. She was given steroid hormones to reduce her brain edema. Total resection of a brain tumor yielded a pathological diagnosis of metastatic squamous cell carcinoma. During treatment, X-ray and CT images revealed intestinal pneumatosis and free air in the abdominal cavity, but a physical examination revealed no abnormal findings. She was given a diagnosis of PCI, and received conservative treatment. Her intestinal gas cysts and intra-abdominal free air disappeared spontaneously. PCI is an uncommon but important condition in which gas is found in a linear or cystic form in the submucosa or subserosa of the bowel wall. It is important to consider PCI as a possible complication in lung cancer patients who are given steroid hormones and systemic chemotherapy in the long-term.