Early Esophageal Adenocarcinoma with Non-Barrett's Columnar Epithelium Origin: Two Case Reports and a Literature Review.

We herein report two cases of early esophageal adenocarcinoma derived from non-Barrett's columnar epithelium. Both patients, a 65-year-old woman and 60-year-old man, had elevated lesions on white-light imaging. Magnifying endoscopy revealed slightly irregular surface and vessel patterns, and both patients were successfully treated with endoscopic submucosal dissection. Histopathologically, both lesions comprised of well-differentiated gastric mucin phenotype adenocarcinoma. One lesion was accompanied by ectopic gastric mucosa, but the other was speculated to be ectopic gastric mucosa according to the tumor locus at the upper thoracic esophagus. Despite its rarity, endoscopists should consider the existence of adenocarcinoma derived from non-Barrett's columnar epithelium.

Efficacy of the pocket-creation method with a traction device in endoscopic submucosal dissection for residual or recurrent colorectal lesions.

BACKGROUND/AIMS: Endoscopic submucosal dissection (ESD) for residual or recurrent colorectal lesions after incomplete resection is challenging because of severe fibrosis. This study aimed to compare the efficacy of the pocket-creation method (PCM) with a traction device (TD) with that of conventional ESD for residual or recurrent colorectal lesions. METHODS: We retrospectively studied 72 patients with residual or recurrent colorectal lesions resected using ESD. Overall, 31 and 41 lesions were resected using PCM with TD and conventional ESD methods, respectively. We compared patient background and treatment outcomes between the PCM with TD and conventional ESD groups, respectively. The primary endpoints were en bloc resection and R0 resection rates. The secondary endpoints were the dissection speed and incidence of adverse events. RESULTS: En bloc resection was feasible in all cases with PCM with TD, but failed in 22% of cases of conventional ESD. The R0 resection rates for PCM with TD and conventional ESD were 97% and 66%, respectively. Dissection was significantly faster in the PCM with TD group (13.0 vs. 7.9 mm2/min). Perforation and postoperative bleeding were observed in one patient in each group. CONCLUSION: PCM with TD is an effective method for treating residual or recurrent colorectal lesions after incomplete resection.

Risk factors for lymph node metastasis and indication of local resection in duodenal neuroendocrine tumors.

Background and Aim: The risk factors for lymph node metastasis (LNM) of duodenal neuroendocrine tumors (DNETs) are not well identified, and a definitive standard of treatment for DNETs has not been established. In this study, we aimed to identify the risk factors for LNM and establish the indication of local resection for DNETs. Methods: We retrospectively reviewed 55 patients with 60 non-ampullary and nonfunctional DNETs. We evaluated the risk factors for LNM and compared the outcomes between endoscopic resection (ER) for DNETs <5 mm and laparoscopy and endoscopy cooperative surgery (LECS) for DNETs ≥5 mm. Results: LNM was present in four (8.7%) patients. Univariate analysis revealed that tumor size ≥10 mm, positive lymphovascular invasion (LVI), and 0-Is morphology were significantly associated with LNM (P = 0.008, P = 0.037, and P = 0.045, respectively). ER and LECS were performed for 18 and 11 DNETs, respectively. All lesions treated with ER or LECS were confined to the submucosal layer. The median tumor size was 3 mm in ER and 6 mm in LECS. Although there was no significant difference in the R0 (no residual tumor) resection rate, R0 resection was completely achieved in the LECS. No significant differences were observed in terms of complication rates. No recurrence was observed in any of the groups. Conclusions: Tumor size ≥10 mm, positive LVI, and 0-Is morphology were significant risk factors for LNM. We demonstrated that ER is feasible and could be safely applied for DNETs <5 mm, and LECS could be applied for DNETs 5-10 mm in size.

A case of percutaneous transhepatic portal vein stent placement and endoscopic injection sclerotherapy for duodenal variceal rupture occurring during chemotherapy for unresectable perihilar cholangiocarcinoma.

Duodenal varices are ectopic varices that are rare but can involve any site along the digestive tract outside the gastroesophageal region. Ectopic variceal bleeding is generally massive and life threatening; the mortality rate is approximately 40%. Up to 17% of ectopic varices occur in the duodenum. However, duodenal varices pose a significant therapeutic challenge due to the lack of standard treatment guidelines. We report a case of duodenal variceal bleeding secondary to portal vein stenosis in a 77-year-old woman receiving chemotherapy for unresectable perihilar cholangiocarcinoma. The patient presented with melena, nausea, vomiting and unstable vital signs suggestive of hemorrhagic shock. Emergency esophagogastroduodenoscopy revealed large nodular varices with a ruptured erosion on top in the superior duodenal angle, and variceal bleeding had stopped by the time of the procedure. Subsequent computed tomography showed the development of portosystemic collaterals; therefore, we performed percutaneous portal vein stent placement to reduce portal vein pressure. Since persistent bleeding was suspected, we also performed endoscopic injection sclerotherapy and achieved successful hemostasis with an improvement in liver function. This case revealed that a combination of portal vein stent placement and endoscopic injection sclerotherapy might be an effective therapy for duodenal variceal bleeding caused by portal vein stenosis.

Usefulness of "Nelaton Attachment" for endoscopic submucosal dissection of colorectal neoplasms.

Background and study aims Although colorectal endoscopic submucosal dissection (ESD) has enabled high en bloc resection rates regardless of tumor size, colorectal ESD is still a challenging procedure. We developed a novel device called the Nelaton Attachment, which allows endoscopists to manipulate the ESD knives using two fingers of their left hand while holding the endoscope with their right hand. We retrospectively investigated the efficacy and safety of the Nelaton Attachment for colorectal ESD. We compared efficacy and safety between Nelaton Attachment and non-Nelaton Attachment groups, and also conducted an ex vivo experiment to evaluate the effect of the Nelaton Attachment. Patients and methods We retrospectively reviewed 36 consecutive patients with 37 colorectal tumors who had undergone ESD at Kishiwada Tokushukai Hospital and Naritatomisato Tokushukai Hospital between April 2016 and September 2018. The Nelaton Attachment was used for 22 of the 37 colorectal ESDs. In the ex vivo experiment, endoscopists inserted and withdrew an ESD knife 2 cm using two fingers of their left hand with and without the Nelaton Attachment. Results Median procedure time was significantly shorter in the Nelaton Attachment group (38 min [range 6 - 195 min]) compared to the non-Nelaton Attachment group (75 min [range 17 - 198 min]; P  = 0.030). Median time to complete the ex vivo experiment five times was significantly faster with the Nelaton Attachment than without the Nelaton Attachment ( P  = 0.001). Conclusions Use of the Nelaton Attachment for colorectal ESD is feasible and safe, and may facilitate colorectal ESD procedures.

Implantation of esophageal cancer onto post-dissection ulcer after gastric endoscopic submucosal dissection.

A case in which implantation of esophageal squamous cell carcinoma onto a post-dissection gastric ulcer was strongly suspected is presented. A 72-year-old man with alcoholic liver cirrhosis underwent esophagogastroduodenoscopy (EGD). Esophageal cancer (EC) (Mt, 20 mm, 0-Is) and gastric cancer (GC) (antrum, 15 mm, 0-IIc) were identified. Biopsy specimens revealed moderately differentiated squamous cell carcinoma (SCC) and differentiated adenocarcinoma, respectively. The GC was resected by endoscopic submucosal dissection (ESD) [14 mm × 9 mm, type 0-IIc, tub1, pT1a(M), ly0, v0, HM(-), VM(-)]. Two months after ESD, radiation therapy was started for the EC, and an almost complete response was obtained. Nine months after the ESD, a follow-up EGD showed a submucosal tumor-like lesion with ulceration, located immediately under the post-ESD scar, and biopsy specimens showed moderately differentiated SCC. There were no similar lesions suggesting hematogenous or lymphatic metastasis in the stomach.

Water immersion colonoscopy facilitates straight passage of the colonoscope through the sigmoid colon without loop formation: randomized controlled trial.

BACKGROUND AND AIM: One of the major causes of pain during colonoscopy is looping of the instrument during insertion through the sigmoid colon, which causes discomfort by stretching the mesentery. There are many studies in colonoscope techniques, but they have not been assessed objectively with respect to colonoscope passage through the sigmoid colon without loop formation. The aim of the present study was to determine whether cap-fitted colonoscopy and water immersion increase the success rate of insertion through the sigmoid without loop formation. METHODS: A total of 1005 patients were randomized to standard colonoscopy, cap-fitted colonoscopy or water immersion technique. All examinations were carried out under a magnetic endoscope imaging device. Main outcome was the success rate of insertion without loop formation. RESULTS: Success rate of insertion without loop formation was 37.5%, 40.0%, and 53.8% in the standard, cap, and water groups, respectively (standard vs water P = 0.00014, cap vs water P = 0.00186). There were no significant differences among the groups regarding cecal intubation rate, cecal intubation time and number of polyps ≥5 mm per patient. CONCLUSIONS: Water immersion increases the success rate of insertion through the sigmoid colon without loop formation. This practical technique, requiring only preparation of a cap and water, is useful without compromising cecal intubation rate, cecal intubation time, or polyp detection rate.