Lowering the setting value of the esophageal endoscopic submucosal dissection device enabled tissue damage control in vitro porcine model.

One of the complications of esophageal endoscopic submucosal dissection (ESD) is postoperative stricture formation. Stenosis formation is associated with inflammation and fibrosis in the healing process. We hypothesized that the degree of thermal damage caused by the device is related to stricture formation. We aimed to reveal the relationship between thermal damage and setting value of the device. We energized a resected porcine esophagus using the ESD device (Flush Knife 1.5). We performed 10 energization points for 1 s, 3 s, and 5 s at four setting values of the device. We measured the amount of current flowing to the conducted points and the temperature and evaluated the effects of thermal damage pathologically. As results, the mean highest temperatures for 1 s were I (SWIFT Effect3 Wat20): 61.19 °C, II (SWIFT Effect3 Wat30): 77.28 °C, III (SWIFT Effect4 Wat20): 94.50 °C, and IV (SWIFT Effect4 Wat30): 94.29 °C. The mean heat denaturation areas were I: 0.84 mm2, II: 1.00 mm2, III: 1.91 mm2, and IV: 1.54 mm2. The mean highest temperature and mean heat denaturation area were significantly correlated (P < 0.001). In conclusion, Low-current ESD can suppress the actual temperature and thermal damage in the ESD wound.

A double-scope technique enabled a patient with an esophageal plastic fork foreign body to avoid surgery: a case report and review of the literature.

Foreign body ingestion is a common problem, and endoscopic removal is often performed with ancillary equipment. However, long, sharp foreign bodies are much more difficult to remove endoscopically than other objects and require emergent surgery. A 68-year-old man with a history of distal gastrectomy accidentally swallowed a plastic fork. He complained of chest pain at the visit. The plastic fork was located between the thoracic esophagus and remnant stomach. Endoscopic removal of the plastic fork was considered difficult, and surgery was deemed necessary. However, we were able to avoid surgery to remove the object using two endoscopes with hoods and a polypectomy snare. The first endoscope covered the sharp edge with a hood, and the snare grasped the neck of the plastic fork. The second endoscope covered the remaining sharp tip. A single operator held the two endoscopes and the snare and pulled them out together. This new double-scope technique is simple and useful for removing long, sharp foreign bodies, such as forks, from the esophagus.

Does thoracoscopic esophagectomy really reduce post-operative pneumonia in all cases?

It has been said that "thoracoscopy suppresses the occurrence of pneumonia in comparison to thoracotomy", but does it reflect real clinical practice? To resolve this clinical question, we compared the results of randomized controlled trials (RCTs) and retrospective cohort studies from limited institutes (CLIs) in which a large number of high-volume centers were the main participants to those of retrospective cohort studies based on nationwide databases (CNDs) in which both high-volume centers and low-volume hospitals participated. A systematic review and meta-analysis were conducted to compare the short-term outcomes of thoracoscopic to open esophagectomy for esophageal cancer in the three above-mentioned research formats. In total, 43 studies with 21,057 patients, which included 1 RCT with 115 patients, 38 CLIs with 6,126 patients and 4 CNDs with 14,816 patients, were selected. Pneumonia was one of the most important complications. Although significant superiority in thoracoscopic esophagectomy was observed in RCTs (p = 0.005) and CLIs (p = 0.003), no such difference was seen in findings using nationwide databases (p = 0.69). In conclusion, unlike RCTs and CLIs, CNDs did not show the superiority of thoracoscopic surgery in terms of post-operative pneumonia. RCTs and CLIs were predominantly performed by high-volume hospitals, while CNDs were often performed by low-volume hospitals. In actual clinical practice including various types of hospitals, the superiority of thoracoscopic over open esophagectomy regarding the incidence of pneumonia may, therefore, decrease.

Predictor of respiratory disturbances during gastric endoscopic submucosal dissection under deep sedation.

BACKGROUND: Sedation is commonly performed for the endoscopic submucosal dissection (ESD) of early gastric cancer. Severe hypoxemia occasionally occurs due to the respiratory depression during sedation. AIM: To establish predictive models for respiratory depression during sedation for ESD. METHODS: Thirty-five adult patients undergoing sedation using propofol and pentazocine for gastric ESDs participated in this prospective observational study. Preoperatively, a portable sleep monitor and STOP questionnaires, which are the established screening tools for sleep apnea syndrome, were utilized. Respiration during sedation was assessed by a standard polysomnography technique including the pulse oximeter, nasal pressure sensor, nasal thermistor sensor, and chest and abdominal respiratory motion sensors. The apnea-hypopnea index (AHI) was obtained using a preoperative portable sleep monitor and polysomnography during ESD. A predictive model for the AHI during sedation was developed using either the preoperative AHI or STOP questionnaire score. RESULTS: All ESDs were completed successfully and without complications. Seventeen patients (49%) had a preoperative AHI greater than 5/h. The intraoperative AHI was significantly greater than the preoperative AHI (12.8 ± 7.6 events/h vs 9.35 ± 11.0 events/h, P = 0.049). Among the potential predictive variables, age, body mass index, STOP questionnaire score, and preoperative AHI were significantly correlated with AHI during sedation. Multiple linear regression analysis determined either STOP questionnaire score or preoperative AHI as independent predictors for intraoperative AHI ≥ 30/h (area under the curve [AUC]: 0.707 and 0.833, respectively) and AHI between 15 and 30/h (AUC: 0.761 and 0.778, respectively). CONCLUSION: The cost-effective STOP questionnaire shows performance for predicting abnormal breathing during sedation for ESD that was equivalent to that of preoperative portable sleep monitoring.

[A Case of Rapidly Growing Breast Spindle Cell Carcinoma].

We report a case of rapidly growing breast spindle cell carcinoma. The case was a 69-year-old female. Her chief complaint was right breast pain. She was being followed after surgery for left breast cancer but was seen because of right breast pain. In the right mammary gland CD area, a 27×27 mm large unclear mass lesion was observed, which had not been seen half a year prior. Right mastectomy and axillary dissection were performed following a preoperative diagnosis of pT2N1M0, pStage ⅡB ductal carcinoma. Currently, 2 years and 2 months have passed since the operation, and recurrence has not been observed. Case reports of rapidly growing breast spindle cell carcinoma are occasionally found, but no literature specifically defines acute growth. Here, we defined rapid growth using the tumor doubling time(DT)proposed by Gerstenberg et al. Of all the reported cases of breast spindle cell carcinoma, the DT was fewer than 90 days in most cases. Breast spindle cell carcinoma demonstrates rapid grown compared to normal breast cancer.

Occurrence of Cortical Arousal at Recovery from Respiratory Disturbances during Deep Propofol Sedation.

Abstract: Recent evidences suggest that non-arousal mechanisms can restore and stabilize breathing in sleeping patients with obstructive sleep apnea. This possibility can be examined under deep sedation which increases the cortical arousal threshold. We examined incidences of cortical arousal at termination of apneas and hypopneas in elderly patients receiving propofol sedation which increases the cortical arousal threshold. Ten elderly patients undergoing advanced endoscopic procedures under propofol-sedation were recruited. Standard polysomnographic measurements were performed to assess nature of breathing, consciousness, and occurrence of arousal at recovery from apneas and hypopneas. A total of 245 periodic apneas and hypopneas were identified during propofol-induced sleep state. Cortical arousal only occurred in 55 apneas and hypopneas (22.5%), and apneas and hypopneas without arousal and desaturation were most commonly observed (65.7%) regardless of the types of disordered breathing. Chi-square test indicated that incidence of no cortical arousal was significantly associated with occurrence of no desaturation. Higher dose of propofol was associated with a higher apnea hypopnea index (r = 0.673, p = 0.033). In conclusion, even under deep propofol sedation, apneas and hypopneas can be terminated without cortical arousal. However, extensive suppression of the arousal threshold can lead to critical hypoxemia suggesting careful respiratory monitoring.

Polysomnographic assessment of respiratory disturbance during deep propofol sedation for endoscopic submucosal dissection of gastric tumors.

AIM: To investigate that polysomnographic monitoring can accurately evaluate respiratory disturbance incidence during sedation for gastrointestinal endoscopy compare to pulse oximetry alone. METHODS: This prospective observational study included 10 elderly patients with early gastric cancer undergoing endoscopic submucosal dissection (ESD) under propofol sedation. Apart from routine cardiorespiratory monitoring, polysomnography measurements were acquired. The primary hypothesis was tested by comparing the apnea hypopnea index (AHI), defined as the number of apnea and hypopnea instances per hour during sedation, with and without hypoxemia; hypoxemia was defined as the reduction in oxygen saturation by ≥ 3% from baseline. RESULTS: Polysomnography (PSG) detected 207 respiratory disturbances in the 10 patients. PSG yielded a significantly greater AHI (10.44 ± 5.68/h) compared with pulse oximetry (1.54 ± 1.81/h, P < 0.001), thus supporting our hypothesis. Obstructive AHI (9.26 ± 5.44/h) was significantly greater than central AHI (1.19 ± 0.90/h, P < 0.001). Compared with pulse oximetry, PSG detected the 25 instances of respiratory disturbances with hypoxemia 107.4 s earlier on average. CONCLUSION: Compared with pulse oximetry, PSG can better detect respiratory irregularities and thus provide superior AHI values, leading to avoidance of fatal respiratory complications during ESD under propofol-induced sedation.

[A Case of Gallbladder Jejunal Anastomosis and Duodenal Jejunal Anastomosis to Maintain QOL for an Elderly Patient with Pancreatic Cancer].

An 87-year-oldwoman was admittedto our hospital with abdominal pain andfever. Computedtomography showeda 25 mm tumor mass in the pancreatic headandshowedd ilatation of the pancreatic duct andcommon bile duct. She was diagnosed with obstructive cholangitis due to pancreatic head cancer. An endoscopic naso-biliary drainage(EUS)tube was inserted, and an endoscopic ultrasound(ENBD)examination was performed. At this time, duodenal perforation occurred, and an emergency operation was performed. During the laparotomy, perforation was found in the anterior wall of the duodenum. The contamination in the abdominal cavity and the degree of tissue damage in the duodenum were mild. Gall bladder jejunal andd uodenal jejunal anastomoses were performedfor biliary bypass andto close the perforation andbypass the gastrointestinal tract, respectively. She hadno postoperative complications andwas discharged 13 days postoperatively. Oral intake was possible after discharge, andthe patient returnedhome without complications. She died 5 months postoperatively. In this case, we performedbile duct andgastrointestinal bypass surgery prophylactically. Although this surgery will not be effective for all patients, we thought that it wouldbe useful for predicting the patient's future condition and for increasing the procedural options, even in case of emergency surgery.

[Long-Term Survival of a Rectal Cancer Patient with Virchow Lymph Node Metastasis, Liver Metastasis, and Para-Aortic Lymph Node Metastasis].

A 67-year-old female was diagnosed with Stage Ⅳ rectal cancer with paraaortic lymph node metastasis. The patient underwent Hartmann's operation with D3 lymph node and paraaortic lymph node dissection. Postoperative chemotherapy with FOLFIRI was then administered for 1 year. However, liver metastasis developed, for which partial hepatectomy was performed. Postoperative chemotherapy with S-1(20 courses)was then administered. Three years and 11 months following the first operation, lymph node metastases developed and resection of lymph nodes(No. 12p, No. 16b1int)was performed. Postoperative chemotherapy with capecitabine(Cape)(8 courses)was then administered. Five years and 7 months following the first operation, Virchow lymph node metastasis developed. Despite chemotherapy with Cape and bevacizumab (Bmab), Virchow lymph node swelling recurred, and resection was performed. Nine years and 4 months following the first operation, lymph node metastases developed, and resection of lymph nodes(Virchow, No. 16b1int)was performed. Postoperative chemotherapy with S-1(8 courses)was then administered. At present, 11 years and 4 months after the first operation, the patient, whose chemotherapy has been discontinued, is alive without recurrence.

[Pulmonary Metastasis Resection Twice after Curative Resection of Esophageal Cancer-A Long-Term Survival Case].

The prognosis of patients with esophageal cancer recurrence is poor, and surgical treatment is rarely performed. Here, we report on a patient with long-term survival who underwent pulmonary metastasis resection twice after curative resection of esophageal cancer. A 62-year-old male underwent curative resection of esophageal cancer after preoperative chemoradiotherapy. The histopathological diagnosis was poorly differentiated squamous cell carcinoma(pT2N1M0, fStage Ⅱ). Five months after the operation, right lung metastasis(right-S2)was detected. Accordingly, pulmonary metastasis resection was performed. Fourteen months after the initial operation, left lung metastases(left-S3/S6)were detected. The patient underwent resection again for the pulmonary metastases. The patient died of pneumonia without recurrence 8 years 3 months after the initial operation. In selected cases, surgical resection seems effective for treating distant esophageal cancer metastasis, suggesting that surgery should be an option in cases of accumulation of numerous distant metastases in esophageal cancer.

[A Case of Colon Metastasis from Invasive Lobular Carcinoma of the Breast].

The patient was a 48-year-old woman. She consulted our hospital with a chief complaint of vomiting. Colonoscopy showed stenosis and edematous mucosa, and biopsy was performed. Histological examination demonstrated the lesion to be colonic metastasis of breast cancer, invasive lobular carcinoma. Although colorectal metastasis of breast cancer has a poor prognosis and chemotherapy is considered as the main treatment modality, hormone therapy is also a treatment option depending on the condition.

[A Case of HER2 Positive Locally Advanced Breast Cancer Successfully Treated with a Combination Therapy of Eribulin, Trastuzumab and Pertuzumab].

The patient was an 82-year-oldwoman. She consultedour hospital with a chief complaint of left breast mass. MRI showed enhancedtumor with skin andextensive pectoral muscle invasion, so it was unresectable. Immunohistopathological analysis revealeda HER2-positive lesion. We administerederibulin, trastuzumab andpertuzumab, after which the tumor became resectable. Histological examination revealedremarkable response. Combination therapy of eribulin, trastuzumab andpertuzumab was well toleratedandconsid eredto be effective.

[A Comparison of the Treatment Methods for Obstructive Colorectal Cancer].

PURPOSE: Emergency surgery for obstructive colorectal cancer is considered to be associated with a high degree of risk, and surgery may after decompression is considered to be safer. In cases of obstructive colorectal cancer, decompression can be achieved with surgery, an ileus tube, or a stent, depending on the disease condition. We herein compare the treatment methods for obstructive colorectal cancer. METHODS: Forty-two patients with obstructive colorectal cancer underwent emergency treatment between January 2012 and December 2016. RESULTS: Among the patients with obstructive colorectal cancer, 18 receiveda stent, 10 receiveda nasal ileus tube, 6 receiveda transanal ileus tube, 5 underwent stoma construction, and 3 underwent emergency surgery without decompression. The stent group showed the highest laparoscopic operation rate. There was no significant difference in the overall survival of the treatment groups. One patient in the stent group developed duplicated cancer. CONCLUSION: Stent placement can be considered to be a viable option in the emergency treatment for obstructive colorectal cancer because laparoscopic surgery anda preoperative examination can be performed.

Drill needle aspiration biopsy for submucosal tumors in an experimental study.

BACKGROUND AND AIMS: EUS-guided FNA biopsy has been widely performed to aid in the diagnosis of submucosal tumors (SMTs). However, in cases of small tumors, the diagnostic yield of EUS-FNA is poor. Therefore, it is necessary to develop a new needle for the diagnosis. We developed a device with a new mechanism that we refer to as a drill needle aspiration biopsy (DNAB). The aim of this study was to evaluate the use of DNAB in resected gastric SMT specimens. METHODS: A drill needle with a sharp tip and wide ditch was inserted into a catheter for angiography. Continuous suction is enabled through the catheter at the tip. DNAB was performed with one pass and one stroke in 13 gastric SMTs resected by operation. Similarly, FNA was performed by one pass and ten strokes. These gastric tumors included nine diagnosed gastrointestinal stromal tumors and four undiagnosed SMTs by preoperative examinations. The tissue quantity between DNAB and FNA was macroscopically and microscopically examined. RESULTS: All 13 drill biopsy specimens were obtained. Additionally, all 13 gastric SMTs, including 4 undiagnosed tumors, could be diagnosed by DNAB. The quantity of each specimen obtained by DNAB was macroscopically and microscopically much greater than that by FNA. In particular, for tumors <25 mm in the longer axis, the ratio of microscopic diagnosable cases was 100 % (7/7) for DNAB and 42.9 % (3/7) for FNA. CONCLUSIONS: DNAB is a novel method that can obtain more tissue than FNA for small gastric SMT.

Lymphoepithelioma-like esophageal carcinoma with macroscopic reduction.

Esophageal lymphoepithelioma-like carcinoma (LELC) is extremely rare. We report the first case of esophageal LELC showing macroscopic reduction. A 67-year-old male presented with dysphagia and, by endoscopic examination, was found to have a significantly raised tumor of 10 mm in diameter in the thoracic esophagus. The biopsied material showed esophageal cancer. We performed endoscopic submucosal dissection. However, the tumor became flattened, similar to a scar, in only 2 mo. Histologically, the carcinoma cells had infiltrated the submucosal layer. Prominent infiltration of T lymphoid cells that stained positive for CD8 was observed around the carcinoma cells. Therefore, this lesion was considered to be an LELC with poorly differentiated squamous cells. Because the margin was positive, an esophagectomy was performed. Carcinoma cells were detected in the neck in one lymph node. The staging was T1N0M1b. However, the patient has been well, without adjuvant therapy or recurrence, for more than 5 years.