The short-term outcomes of laparoscopic-endoscopic cooperative surgery for colorectal tumors (LECS-CR) in cases involving endoscopically unresectable colorectal tumors.

PURPOSE: Laparoscopic and endoscopic cooperative colorectal surgery (LECS) is widely used for the removal of endoscopically unresectable colonic polyps. We evaluated the invasiveness of LECS in comparison to conventional laparoscopic surgery (CLS) for endoscopically unresectable colorectal tumors. METHOD: We retrospectively analyzed the data of patients with colorectal adenoma or mucosal cancer and submucosal tumors who underwent either LECS or CLS at a single, high-volume center in Japan between 2004 and 2017. The short-term and oncological outcomes were compared between groups. RESULTS: Of the 83 eligible patients, 15 underwent LECS and 68 underwent CLS. There was no conversion to open surgery in either group. En bloc resection was achieved in all cases in both groups. The median time to solid diet intake was the same in both groups (2 days, p = 0.39). The median duration of hospital stay after surgery was 6 days (range 4-12 days) in the LECS group and 10 days (range 5-68 days) in the CLS group (p = 0.01). Clavien-Dindo grade ≥ 3 postoperative complications only occurred in the CLS group (two cases, p = 0.37). CONCLUSION: Our results indicated that LECS is a safe and feasible technique that results in high-quality colorectal polyp resection with quicker recovery and favorable 30-days postoperative outcomes.

Laparoscopic and endoscopic cooperative surgery (LECS) to overcome the limitations of endoscopic resection for colorectal tumors.

Background and study aims We developed a laparoscopy endoscopy cooperative surgery (LECS) to overcome the limitations of endoscopic resection for colorectal tumors. The aim of this study was to evaluate the feasibility of LECS, which combines endoscopic submucosal dissection (ESD) and laparoscopic partial colectomy. Patients and methods We performed LECS for 17 colorectal tumors in 17 patients (male:female 10:7; mean age, 66.5 years). The clinicopathological outcomes of these 17 cases and the feasibility of LECS were evaluated retrospectively. Indications for LECS were as follows: 1) intramucosal cancer and adenoma accompanied by wide and severe fibrosis; 2) intramucosal cancer and adenoma involving the diverticulum or appendix; and 3) submucosal tumors. Results We successfully performed LECS procedures in 17 cases (intramucosal cancer [n = 6], adenoma [n = 9], schwannoma [n = 1], and gastro-intestinal stromal tumour [GIST] [n = 1]. Mean tumor diameter was 22.4 mm (range, 8 - 41 mm). LECS was successfully performed in all 17 cases without conversion to open surgery; the R0 rate was 100 %. LECS was applied to the following situations: involving the appendix (n = 6), tumor accompanied by severe fibrosis (n = 5), involving the diverticulum (n = 3), submucosal tumor (n = 2), and poor endoscopic operability (n = 1). We experienced no adverse events (e. g., leakage or anastomotic stricture) and the median hospital stay was 6.4 dayus (range, 4 to 12). All 17 patients who were followed for ≥ 3 months (median, 30.8 months; range, 3 - 72 months) showed no residual/local recurrence. Conclusion LECS was a safe, feasible, minimally invasive procedure that achieved full-thickness resection of colorectal tumors and showed excellent clinical outcomes.

Efficacy of hyperbaric oxygen therapy in patients with radiation-induced rectal ulcers: Report of five cases.

For decades, hyperbaric oxygen therapy has been considered a treatment option in patients with chronic radiation-induced proctitis after pelvic radiation therapy. Refractory cases of chronic radiation-induced proctitis include ulceration, stenosis, and intestinal fistulas with perforation. Appropriate treatment needs to be given. In the present study, we assessed the efficacy of hyperbaric oxygen therapy in five patients with radiation-induced rectal ulcers. Significant improvement and complete ulcer resolution were observed in all treated patients; no side-effects were reported. Hyperbaric oxygen therapy has a low toxicity profile and appears to be highly effective in patients with radiation-induced rectal ulcers. However, hyperbaric oxygen therapy alone failed to improve telangiectasia and easy bleeding in four of the five patients; these patients were further treated with argon plasma coagulation (APC). Although hyperbaric oxygen therapy may be effective in healing patients with ulcers, it seems inadequate in cases with easy bleeding. Altogether, these data suggest that combination therapy with hyperbaric oxygen therapy and APC may be an effective and safe treatment strategy in patients with radiation-induced rectal ulcers.

Advantages of magnifying narrow-band imaging for diagnosing colorectal cancer coexisting with sessile serrated adenoma/polyp.

BACKGROUND AND AIM: In the present study, we investigated the advantages of narrow-band imaging (NBI) for efficient diagnosis of sessile serrated adenoma/polyp (SSA/P). The main objective of this study was to analyze the characteristic features of cancer coexisting with serrated lesion by carrying out NBI. METHODS: We evaluated 264 non-malignant serrated lesions by using three modalities (conventional white light colonoscopy, magnifying chromoendoscopy, and magnifying NBI). Of the evaluated cancer cases with serrated lesions, 37 fulfilled the inclusion criteria. RESULTS: In diagnosing non-malignant SSA/P, an expanded crypt opening (ECO) under magnifying NBI is a useful sign. One hundred and twenty-five lesions (87%) of observed ECO were, at the same time, detected to have type II open pit pattern, which is known to be a valuable indicator when using magnifying chromoendoscopy. ECO had high sensitivity of 80% for identifying SSA/P, with 62% specificity and 83% positive predictive value (PPV). In detecting the cancer with SSA/P, irregular vessels under magnifying NBI were frequently observed with 100% sensitivity and 99% specificity, 86% PPV and 100% negative predictive value. CONCLUSIONS: A focus on irregular vessels in serrated lesions might be useful for identification of cancer with SSA/P. This is an advantage of carrying out magnifying NBI in addition to being used simultaneously with other modalities by switching, and observations can be made by using wash-in water alone. We can carry out advanced examinations for selected lesions with irregular vessels. To confirm cancerous demarcation and invasion depth, a combination of all three aforementioned modalities should be done.

Endoscopic evaluation of clinical response after preoperative chemoradiotherapy for lower rectal cancer: the significance of endoscopic complete response.

PURPOSE: The management of rectal cancer is a significant oncologic challenge because rectal cancer has a poor prognosis among the various types of colorectal cancer. There have been several recent reports on a nonoperative approach for advanced lower rectal cancer, and this may be best for local disease control. However, objective evaluation of tumor response after preoperative chemoradiotherapy has not been standardized. The purpose of this study is to evaluate our method of endoscopic evaluation of complete response. METHODS: This is a retrospective chart review. All patients received a long course of preoperative chemoradiotherapy (5-fluorouracil-based chemotherapy and 45-50.4 Gy) followed by radical surgical resection from May 2005 to March 2012 in The Cancer Institute Hospital of Japanese Foundation for Cancer Research. One hundred fifty-seven patients were reviewed consecutively. Criteria for endoscopic complete response were defined with a focus on the degree of ulcer healing and pit pattern without magnification. RESULTS: Endoscopic CR (E-CR) evaluation with our definitions reflected histopathologic response evaluation with an accuracy of 91.7 %, sensitivity of 27.8 %, specificity of 100 %, positive predictive value (PPV) of 100 %, and negative predictive value (NPV) of 91.4 % (p < 0.001). Our criteria of E-CR led all cases of y-clinical CR (ycCR) to pathological CR. CONCLUSIONS: Endoscopic evaluation focused on the degree of ulcer healing, and pit pattern without magnification is useful for judging ycCR.

Successful use of endoscopic argon plasma coagulation for hemorrhagic radiation cystitis: a case report.

Hemorrhagic radiation cystitis is an example of a typical radiotherapy-induced adverse event. However, the optimal treatment for hemorrhagic radiation cystitis is not known. There are limited data regarding the use of argon plasma coagulation for hemorrhagic radiation cystitis. Here, we present the use of argon plasma coagulation using a gastrointestinal endoscope to treat hemorrhagic radiation cystitis. The patient was a 75-year-old male patient with hemorrhagic radiation cystitis due to external beam irradiation for prostate adenocarcinoma. Six years after radiotherapy, the patient presented with macroscopic hematuria over the preceding 4 months, and laboratory investigations revealed a low hemoglobin level. The hematuria was not controlled with 2 days of bladder irrigation using normal saline. Thus, argon plasma coagulation using an upper gastrointestinal endoscope was considered for treatment of the hemorrhagic radiation cystitis. The cystoscopic examination revealed diffuse radiation cystitis with oozing telangiectasia and coagula. All of the bleeding sites and telangiectasia were coagulated using argon plasma coagulation. Following treatment, the patient's clinical symptoms improved and did not recur. The hemoglobin level also recovered. No complications associated with the treatment were observed during the 6-month follow-up period. Thus, argon plasma coagulation using a gastrointestinal endoscope is a safe and effective treatment for hemorrhagic radiation cystitis.

Risk factors for bleeding after endoscopic submucosal dissection of colorectal neoplasms.

AIM: To investigate the risk factors for delayed bleeding following endoscopic submucosal dissection (ESD) treatment for colorectal neoplasms. METHODS: We retrospectively reviewed the medical records of 317 consecutive patients with 325 lesions who underwent ESD for superficial colorectal neoplasms at our hospital from January 2009 to June 2013. Delayed post-ESD bleeding was defined as bleeding that resulted in overt hematochezia 6 h to 30 d after ESD and the observation of bleeding spots as confirmed by repeat colonoscopy or a required blood transfusion. We analyzed the relationship between risk factors for delayed bleeding following ESD and the following factors using univariate and multivariate analyses: age, gender, presence of comorbidities, use of antithrombotic drugs, use of intravenous heparin, resected specimen size, lesion size, lesion location, lesion morphology, lesion histology, the device used, procedure time, and the presence of significant bleeding during ESD. RESULTS: Delayed post-ESD bleeding was found in 14 lesions from 14 patients (4.3% of all specimens, 4.4% patients). Patients with episodes of delayed post-ESD bleeding had a mean hemoglobin decrease of 2.35 g/dL. All episodes were treated successfully using endoscopic hemostatic clips. Emergency surgery was not required in any of the cases. Blood transfusion was needed in 1 patient (0.3%). Univariate analysis revealed that lesions located in the cecum (P = 0.012) and the presence of significant bleeding during ESD (P = 0.024) were significantly associated with delayed post-ESD bleeding. The risk of delayed bleeding was higher for larger lesion sizes, but this trend was not statistically significant. Multivariate analysis revealed that lesions located in the cecum (OR = 7.26, 95%CI: 1.99-26.55, P = 0.003) and the presence of significant bleeding during ESD (OR = 16.41, 95%CI: 2.60-103.68, P = 0.003) were independent risk factors for delayed post-ESD bleeding. CONCLUSION: Location in the cecum and significant bleeding during ESD predispose patients to delayed post-procedural bleeding. Therefore, careful and additional management is recommended for these patients.

New technique of en bloc resection of colorectal tumor using laparoscopy and endoscopy cooperatively (laparoscopy and endoscopy cooperative surgery - colorectal).

BACKGROUND AND AIM: Various factors make complete en bloc resection by endoscopic techniques alone of some laterally spreading colorectal tumors difficult or unsafe. Drawing on recent radical developments in endoscopic and laparoscopic techniques for managing colorectal lesions, we aimed to develop a safe resection procedure by using a combination of laparoscopy and endoscopy. We have named this procedure laparoscopic endoscopic cooperative colorectal surgery. PATIENTS: We have performed this procedure on 3patients who had laterally spreading colorectal tumors. The factors contraindicating endoscopic submucosal dissection were submucosal fibrosis because of previous endoscopic mucosal resection in 1 patient and multiple surrounding diverticula in 2 patients. TECHNIQUE: The patient is placed under general anesthesia and 5 ports are inserted. Following confirmation of the tumor location by endoscopy and laparoscopy, the colon wall at this site is exposed. First, a mucosa-to-submucosa dissection circumferential to the lesion with an appropriate safety margin is performed endoscopically. Complete full-thickness dissection and excision is then performed by using ultrasonic activating scissors, endoscopy, and laparoscopy cooperatively. The excised lesion is withdrawn intraluminally with endoscopic forceps. The opened colon is then closed with laparoscopic linear staplers. RESULTS: The mean operating time and blood loss in this series were 205 minutes and 13 mL. There were no intraoperative or postoperative complications. Histological examination revealed tubular adenomas with severe dysplasia and adequate surgical margins in all cases. CONCLUSION: Laparoscopic endoscopic cooperative colorectal surgery involves removal of a minimal length of colon and is a feasible procedure for en bloc resection of some colonic lateral spreading tumors that would be difficult to resect endoscopically.

Diagnosis of laterally spreading tumors (LST) in the rectum and selection of treatment: characteristics of each of the subclassifications of LST in the rectum.

BACKGROUND: In recent years, endoscopic submucosal dissection (ESD) has often been used for the treatment of laterally spreading tumors (LST) of the rectum. The present study was carried out with the aim of clarifying the characteristics of each of the subtypes of LST in the rectum that are often treated by ESD. PATIENTS AND METHODS: This study involved 141 rectal LST that were initially treated at our hospital between March 2005 and December 2010 and whose endoscopic images and histopathological specimens could be re-examined. The LST were divided into LST-G-H (homogeneous type), LST-G-MIX (nodular mixed type), LST-NG-F (flat type) and LST-NG-PD (pseudo-depressed type) type lesions, and tumor diameter and depth of invasion of each of these tumor types were investigated. RESULTS: Regarding the depth of invasion, the proportion of submucosa-massive (SM-m) lesions was high in the LST-NG-PDtumors, even among tumors measuring <20 mm in diameter; both the rate of cancer and proportion of SM-m lesions were significantly higher in the LST-NG-PD tumors than in the LST-NG-F tumors (P < 0.05). In both LST-NG-MIX and LST-NG-PD tumors, the proportion of SM-m lesions was significantly higher in the lower rectum than in the upper rectum (P < 0.05). CONCLUSION: For LST of the rectum (particularly of the lower rectum), it is necessary to carefully select the treatment considering LST subclass and tumor diameter from the standpoint of the presence of malignancy, quality of life, and prognosis of patients.

Multicenter questionnaire survey on the current situation of colorectal endoscopic submucosal dissection in Japan.

In order to understand the current use of endoscopic submucosal dissection (ESD) for the treatment of colorectal tumors in Japan, we administered a questionnaire survey to 1356 institutions all over the country. The subject of the survey was colorectal ESD performed from January 2000 to September 2008. Among the 1356 institutions, 391 (28.8%) responded to the questionnaire, and colorectal ESD was currently being performed in 194 institutions. The 194 institutions were almost equally distributed in Japan, that is, colorectal ESD has been performed all over the country. Among these 194 institutions, the procedure had been performed in 100 or more cases in 22 (11.3%) institutions and in 50-99 cases in 18 institutions (9.3%). The knives used in colorectal ESD were the Hook knife, Flush knife, and Flex knife. The average time required for colorectal ESD was 92.2 min, the rate of complete en bloc resection was 83.8%, the perforation rate was 4.8%, and no case of death from complications was reported.

[Two cases of cancer in the reconstructed gastric tube after resection of esophageal cancer -An analysis of 7 cases in our hospital-].

We review 7 cases of cancer in the reconstructed gastric tube after resection for esophageal cancer in our hospital. From this experience, we report 2 cases which were resected curatively by endoscopic or open surgery. Case 1, a 61-year-old man received a subtotal esophagectomy reconstructed by a gastric tube, retromediastinally. 85 months after operation, cancer in the gastric tube was detected endoscopically, and partial resection was performed. Case 2, a 75-year-old man received subtotal esophagectomy reconstructed by a gastric tube via a retro-mediastinal route. After 104 months, early cancer in the gastric tube was diagnosed and we performed endoscopic mucosal dissection (ESD). Long-term follow-up by regular endoscopy is necessary in patients after esophageal surgery to screen for cancer in the reconstructed gastric tube.

Pneumoconiosis associated with an esophageal ulcer and uptake revealed in FDGPET.

A 76-year-old man with a past history of pneumoconiosis visited the Department of Gastroenterology in our hospital suffering from dysphagia. Gastroscopy revealed an esophageal ulcer on the top of a torus lesion. Chest computed tomography (CT) revealed it was caused by a swollen lymph node in the mediastinum. Squamous cell carcinoma related antigen (SCC) was elevated to 1.8 ng/ml. To rule out malignancy, we performed fluorine-18 deoxyglucose positron emission tomography (FDGPET) which revealed a significantly increased uptake in a nodular lesion in the right upper lobe and mediastinal lymph nodes. Biopsy and cytology of the nodular lesion revealed only pneumoconiosis. We must be careful when we interpret the findings of FDGPET in pneumoconiosis patients.

Relation of E-cadherin and beta-catenin expression to pit pattern in colorectal cancer.

To investigate the usefulness of pit pattern to estimate depth of submucosal invasion and the mechanism of change in pit pattern by tumor character in colorectal cancer, we investigated the relation between pit pattern and immuno-histochemical E-cadherin and beta-catenin expression. Fifty-seven colorectal tumors including 37 submucosal invasive carcinomas, 10 high-grade adenomas and 10 cases of advanced carcinomas invading into the muscularis propria were divided into a non-VN and VN group according to a modification of the Kudo classification system. In addition, distance between the invasive front and muscularis mucosae was measured, and histological and immunohistochemical expression of E-cadherin and beta-catenin in the superficial portion and invasive portion were examined. Many tumors with deep invasion were classified in the VN group. Among the submucosal invasive carcinomas in the VN group, there was a significantly higher number with deep invasion than with slight invasion. All submucosal invasive cancers with lymphatic invasion also had deep submucosal invasion. Immunohistochemical analysis revealed significant loss of normal membrano-cytoplasmic beta-catenin expression in the superficial area of cancers in the VN group. Submucosal carcinoma with deep invasion also had significant loss of membrano-cytoplasmic expression of beta-catenin in the superficial area. Pit pattern is useful not only to predict tumor character but also to estimate depth of invasion. Change in pit pattern may be associated with abnormality of beta-catenin expression.

Effectiveness of immunochemotherapy with PSK, a protein-bound polysaccharide, in colorectal cancer and changes of tumor marker.

In the present study, curatively resected patients of colorectal cancer at pTNM stages II and III were selected. Patients receiving postoperative combined PSK, a protein-bound polysaccharide, and fluoropyrimidine therapy (PSK + chemotherapy group) were compared with patients receiving postoperative chemotherapy alone (chemotherapy group) during the same period of study. Three-year disease-free survival rates were evaluated and the postoperative changes of serum type IV collagen level were investigated. The results confirmed a significant improvement of the three-year disease-free survival rate in the PSK + chemotherapy group compared to the chemotherapy group, suggesting that PSK is useful as postoperative prognosis control including relapse prevention for colorectal cancers at pTNM stage II and III. Analysis of the postoperative changes of serum type IV collagen level showed significantly higher levels in the chemotherapy group than in the PSK + chemotherapy group, and this tendency was sustained for 12 months after surgery. This observation is speculated to be caused by inhibition of vascular basement membrane destruction by PSK, leading to inhibition of release of type IV collagen into the blood. These results indicated a possibility that combined PSK and chemotherapy inhibited metastasis, thereby reducing the risk of relapse and leading to improvement of the three-year disease-free survival rate.