Colonic Endoscopic Submucosal Dissection for a Granular Cell Tumor with Insufficient Endoscopic Manipulation in the Hepatic Flexure.

This report describes a granular cell tumor (GCT) with insufficient endoscopic manipulation in the hepatic flexure (HF) of the colon, which was treated by endoscopic submucosal dissection (ESD) using a splinting tube and the spring S-O clip traction method. A 44-year-old man presented with a 10 mm subepithelial tumor in the HF near the ascending colon on colonoscopy. The lesion had a smooth surface without erosion. The histology of biopsied specimen from the lesion was suspected as a GCT. Most GCTs are considered low-grade malignant, but ESD was chosen to treat the lesion due to the patient's insistence on endoscopic treatment. Because the lesion was located in the HF, it was assumed that the scope manipulation during ESD would be difficult. During ESD, a splinting tube was utilized to stabilize endoscopic manipulation and the spring S-O clip traction method to keep clear visualization of the submucosa, and the procedure was completed without adverse events. An 8 × 7 mm lesion with negative margins was removed by ESD. Hematoxylin and eosin staining showed atypical cells with round-to-oval nuclei and acidophilic vesicles, and immunohistochemical staining for S-100 protein was strongly positive with a Ki-67 labeling index of 5%. The lesion was pathologically confirmed as a GCT. This case showed the usefulness and safety of ESD for GCT with insufficient endoscopic manipulation in the HF.

Efficacy of a novel large-cell Niti-S stent with a slim delivery system for hilar biliary obstruction: a preliminary study.

OBJECTIVES: The large-cell Niti-S stent is useful for multiple stenting in patients with malignant hilar biliary obstruction (MHBO). Recently, a novel uncovered self-expandable metallic stent (USEMS) (a Niti-S large-cell SR slim delivery system) was developed. In this study, we aimed to evaluate the efficacy of this USEMS slim delivery system in MHBO patients. MATERIALS AND METHODS: Outcomes related to USEMS placement, the clinical course, and the period to recurrent biliary obstruction (RBO) were evaluated in MHBO patients who received multiple USEMSs with the Niti-S large-cell SR slim delivery system. RESULTS: Twenty-two MHBO patients underwent the placement of multiple USEMSs, including the novel slim-delivery stent. Six patients had a past history of upper gastrointestinal reconstruction (Billroth I: 1, Billroth II: 4, Roux-en-Y: 1). The number of USEMSs placed in each patient was 2-6. Three procedures were reinterventions. The new slim delivery system was placed as the first stent in ten patients and as an additional stent in the remaining patients. Seven patients were drained using only Niti-S large-cell SR slim delivery stents. The technical and clinical success rates were both 100%. CONCLUSIONS: Placing multiple USEMSs in patients with a past history of abdominal surgery or in reintervention is difficult. Although difficult cases were included in this study, stent-in-stent placement with the novel Niti-S large-cell SR slim delivery system was useful in treating MHBO patients. In addition, this novel stent might be the first choice for MHBO patients.KEY MESSAGESEndoscopic multistenting for MHBO is challenging. In addition, reintervention or multistenting for MHBO patients with a past history of abdominal surgery becomes more difficult.The novel Niti-S large-cell SR slim delivery USEMS is useful as an additional stent because the delivery system is thin and suitable for a 0.025 guidewire. In addition, the novel stent is of the braided type and has a large mesh. Therefore, the novel stent is expected to have strong radial force and can be used as the first SEMS.The Niti-S large-cell SR slim delivery stent is long enough to be used in patients with upper gastrointestinal reconstruction. Although this study included patients with reintervention or a past history of upper gastrointestinal reconstruction, the technical success rate of multiple stenting for MHBO patients was 100%. The slim-delivery stent might overcome several difficulties of endoscopic multistenting.

Trichuris trichiura Incidentally Detected by Colonoscopy and Identified by a Genetic Analysis.

Although trichuriasis, a zoonotic disease, has recently become rare in Japan due to improved environmental hygiene, we herein report a 79-year-old man in whom a worm was incidentally found in the ascending colon during colonoscopy for positive fecal occult blood and was endoscopically removed. A genetic analysis identified the worm as Trichuris trichiura possessing mixed sequences from non-human primate and human origins. Despite controversy regarding Trichuris trichiura infection originating from Japanese macaques, according to some studies, it originates primarily from humans. This report suggests the efficacy of a genetic analysis for identifying infection sources.

Spontaneous disappearance of common bile duct stones following the insertion of a new dumbbell-shaped, covered self-expandable metallic stent in a patient with benign biliary stricture.

The new dumbbell-shaped, covered self-expanding metallic stent can efficiently remove the choledocholiths in cases with common bile duct (CBD) strictures; moreover, it may potentially prevent a positional displacement and contribute to the better improvement of the CBD stricture.

A case of stricture-type ischemic colitis from excessive alcohol consumption, with follow-up to rule out colon cancer.

A 69-year-old man was admitted to Hanawa Kousei Hospital with acute hepatitis attributed to alcohol consumption. His condition improved with conservative treatment. Computed tomography (CT) showed localized thickening of the colonic wall at the splenic flexure;carcinoembryonic antigen level was slightly elevated to 9.7 ng/mL. Colonoscopy (CS) showed an ulcerative lesion in the colonic splenic flexure. Ischemic colitis (IC) and type 4 colon cancer were suspected, but biopsy was not confirmatory. Malignancy could not be ruled out by contrast-enhanced CT;repeat CS showed circumferential stenosis of the colonic splenic flexure. Ischemic colitis was suspected based on changes between the first and second CS. Biopsy histopathology led us to diagnose stricture-type IC. Constipation, but not intestinal obstruction, occurred. Conservative treatment improved the stenosis. Excessive alcohol consumption may lead to IC;imaging studies may be useful to distinguish IC from colon cancer. Since most cases of ischemic colitis can be improved with conservative treatment, patients with stricture-type ischemic colitis may also be treated without surgery early on, with follow-up that includes careful, periodic imaging.