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.

[Craniopharyngioma with malignant transformation--a report of two cases].

Two cases of a craniopharyngioma with malignant transformation are reported. Case 1 involved a 3-year-old male who had received a partial resection and radiotherapy for a suprasellar tumor. Histologically, a biopsy specimen showed craniopharyngioma. Eight years later, the child died of an intracerebral and nasopharyngeal invasion of the recurrent tumor. Case 2 involved a 9-year-old male who initially had been diagnosed as having a craniopharyngioma in the suprasellar region. Five years after the first operation, he died from growth of the tumor in spite of radiotherapy and a partial resection. The pathological examinations of these two cases showed an apparent transition of the craniopharyngioma into a squamous cell carcinoma.

A non-alcoholic Japanese patient with Wernicke's encephalopathy and Marchiafava-Bignami disease.

In Japan Wernicke's encephalopathy is not rare, but only one case of Marchiafava-Bignami disease has been reported. In our case, Wernicke lesions were found in the mamillary bodies, septal nuclei, and periventricular regions. Involvement of the septal nuclei is rare in this encephalopathy. A characteristic Marchiafava-Bignami lesion was observed only in the anterior part of the corpus callosum. From the clinicopathologic viewpoint, Wernicke's encephalopathy might have preceded Marchiafava-Bignami disease in our case. To our knowledge, only two cases without a history of alcoholism and both suffering from Wernicke's encephalopathy and Marchiafava-Bignami disease have been documented. However, in both cases Wernicke lesions were atypical, since characteristic lesions were absent in the mamillary bodies and in the regions surrounding the third ventricle and the aqueduct. Ours appears to be the first report on a non-alcoholic patient with typical lesions of both diseases.

An abnormal pancreatico-choledocho-ductal junction in cases of biliary tract carcinoma.

A histopathologic study on how the common bile duct and main pancreatic duct open into the duodenum was performed on 72 autopsied cases of biliary tract carcinoma. Type IIIb which was considered to be an abnormal pancreatico-choledocho-ductal junction was identified in 8 of 34 cases in common bile duct carcinoma and in 4 of 24 cases in gallbladder carcinoma, while none of the control cases belonging to Type IIIb. In cases of Type IIIb, reflux of pancreatic juice may occur into the bile duct and produce the repeated inflammation on the biliary tract. Therefore, the abnormal pancreatico-choledocho-ductal junction was suggested to be one of the pathogenic factors which cause biliary tract carcinoma.