Piecemeal endoscopic aspiration mucosectomy for large superficial intramucosal tumors of the stomach.

BACKGROUND AND STUDY AIMS: As endoscopic techniques continue to develop, endoscopic mucosal resection is increasingly being used in the treatment of intramucosal gastric tumors. The aim of this study was to explore the feasibility of piecemeal endoscopic aspiration mucosectomy for large superficial intramucosal tumors of the stomach. PATIENTS AND METHODS: The study group consisted of five consecutive patients with large superficial intramucosal tumors of the stomach, 4 cm or more in diameter. Piecemeal endoscopic aspiration mucosectomy using a cap-fitted panendoscope was carried out. The initial resection was undertaken at the oral side of the lesion. Subsequent resections were carried out along the anal margin of the previous resection site, until the marks around the boundary of the tumor completely disappeared. RESULTS: The shape of the tumors was slightly elevated in four cases and slightly depressed in one. The mean diameter of the tumors was 4.8 cm. The diameters of the resected specimens ranged from approximately 1.0 cm to 2.3 cm. The numbers of piecemeal resection procedures needed per lesion ranged from five to 18 (mean 11). The visual field was well ensured by the cap, and the tumors were macroscopically completely resected without any complications in all patients. The final histological diagnoses in the specimens were adenoma in one case and mucosal carcinoma in adenoma in four. One patient had residual or recurrent tumor, and received full treatment with additional endoscopic procedures. CONCLUSIONS: Piecemeal endoscopic aspiration mucosectomy is a simple and very useful technique for treating large superficial intramucosal tumors of the stomach.

Efficacy of a distal attachment in endoscopic resection of colorectal polyps situated behind semilunar folds.

BACKGROUND AND STUDY AIMS: It is difficult, dangerous, and time consuming to resect colorectal polyps situated behind the semilunar folds. The aim of this study was to examine the efficacy of a distal attachment in the endoscopic resection of these polyps. PATIENTS AND METHODS: The study group consisted of 11 patients, each with a colorectal polyp situated behind a semilunar fold, and of which the base was invisible without the use of a distal attachment. With the attachment fitted to the distal end of the endoscope, we pressed the semilunar fold situated at the anal side of the polyp so that the polyp, including its base, could be brought within the visual field. Maintaing the optimal position, we snared, ligated, and resected all polyps by electrocautery. RESULTS: The polyps were of sessile type in eight patients and pendunculated type in three, with a diameter ranging from 7 to 18 mm (mean 11 mm). Although the base of the polyp was invisible under conventional observation, pressing the fold brought good visualization. The optimal position for snaring the polyp was secured by fine endoscopic adjustment, and the polyps were easily resected in all patients. CONCLUSION: We conclude that the distal attachment is a simple but very valuable tool in the endoscopic resection of colorectal polyps situated behind the semilunar folds, and recommend its routine use in both diagnostic and therapeutic colonoscopy.

Feasibility study on endoscopic suture with the combination of a distal attachment and a rotatable clip for complications of endoscopic resection in the large intestine.

BACKGROUND AND STUDY AIMS: Endoscopic resection has been more frequently performed for increasingly larger intramucosal tumors of the large intestine in recent years. It is reasonable to expect that the larger the resected mucosal surface, the greater is the likelihood of complications such as bleeding or perforation. The aim of this study was to explore the feasibility of endoscopic suture with a distal attachment and a rotatable clip-fixing device for complications of endoscopic resection in the large intestine. PATIENTS AND METHODS: The study population consisted of 15 patients who underwent endoscopic clipping therapy following endoscopic resection for intramucosal tumors of the large intestine. With a distal attachment fitted to the distal end of the endoscope, the optimal position for clipping was ensured by pressing the intestinal wall and deflating the intraluminal air little by little. With a rotatable clip-fixing device, the resection site was endoscopically sutured clip by clip. RESULTS: Tumors were of the laterally spreading tumor type in six patients, small sessile polyps in three, and pedunculated polyps in six. The complications consisted of bleeding in 12 patients, overt perforation in one, and latent perforation in two; 14 of the 15 patients underwent successful suturing by this method. The number of clips used ranged from two to seven (mean 4.4). No patients had further complications after the treatment. CONCLUSION: We conclude that endoscopic suture with the combination of a distal attachment and a rotatable clip-fixing device is very useful for complications of endoscopic resection in the large intestine.

A case of eosinophilic peritonitis in which ascites interleukin 5 presented at a high level.

A 17-year-old girl was admitted to Handa City Hospital presenting with nausea, vomiting, diarrhea, and abdominal pain. Cytological examination of the ascites and the increased eosinophil count in the peripheral blood led to the diagnosis of eosinophilic peritonitis. Serum concentrations of interleukin 5 and interleukin 3 were normal, while only interleukin 5 level in the ascites presented at a high level; interleukin 5 at the affected part may be specifically related to the intestinal recruitment of eosinophils in this disease.

Disseminated intravascular coagulation in an ulcerative colitis case not associated with surgery.

We describe a case of disseminated intravascular coagulation in an ulcerative colitis case. This is the first reported case not associated with surgery, and was successfully treated with conservative therapy. The combined use of heparin and gabexate mesilate was considered to be very effective for improving this condition, although a slight increase in rectal bleeding was recognized for a short time.

Gastric hyperplastic polyp occurring at the resection site of gastric adenoma.

Endoscopic mucosal resection was carried out in a 70-year-old man with a gastric adenoma. Endoscopy 1 year later revealed a subpedunculated polyp about 1 cm in diameter at the resection site. Pathological examination of the resected specimen showed hyperplasia of the regenerative epithelium. The mechanism of occurrence of hyperplastic polyp at the resection site is discussed.

Endoscopic resection of laterally spreading tumours of the large intestine using a distal attachment.

BACKGROUND AND STUDY AIMS: Among colorectal neoplasms, laterally spreading tumors (LSTs) are lesions over 10 mm in diameter that are low in height and grow superficially. As most LSTs are adenomas or mucosal carcinomas, endoscopic resection is desirable, but this has been not easy because of their flat and wide shape. The aim of this study was to explore the usefulness of a distal attachment to the endoscope in the endoscopic resection of LSTs. PATIENTS AND METHODS: The study population consisted of 23 patients with an LST of the large intestine. Using a distal attachment fitted to the distal end of the endoscope, saline solution with a low concentration of epinephrine was injected underneath the lesion. The lesion was snared and drawn into the cap using the suction function of the endoscope, and then ligated and resected using electrocautery. RESULTS: The size of the lesions ranged from 1 cm to 5cm. Endoscopic resection was completed in 22 of 23 patients. Resection in one segment was successful in 15 of 22 patients; in the remaining seven patients, piece-meal resection was done. Pathological investigation showed hyperplasia in one patient, adenoma in 20 (with mild atypia 1, moderate atypia 11, severe atypia 8), and mucosal carcinoma in one patient. Complications occurred in two patients, with one instance of perforation and another of bleeding. Both were successfully treated with endoscopic clipping. Recurrent adenoma was detected in one patient. CONCLUSION: We conclude that the distal attachment was very useful for endoscopically resecting LSTs of the large intestine.

Endoscopic resection of small duodenal carcinoid tumors with strip biopsy technique.

BACKGROUND: Most cases of duodenal carcinoid have conventionally been treated by surgical resection. The aim of our study was to explore the feasibility of endoscopic resection in small duodenal carcinoids. METHODS: The study population consisted of seven patients with small duodenal carcinoids. The diagnosis was confirmed by preoperative biopsies. The depth of tumor invasion was evaluated by endosonography. RESULTS: The carcinoid was detected by endosonography in all cases. Size ranged ultrasonographically from 1.5 mm to 7 mm. Tumor invasion was confined to the submucosa in all patients. Endoscopic resection was performed with the strip biopsy technique using a two-channel endoscope. In six patients, the specimens were resected without severe complications. Five of them were confirmed histologically to be typical carcinoids. In one patient, carcinoid was not detected histologically in the specimen. In the remaining patient, a perforation occurred. However, the huge ulcer was managed conservatively. Follow-up endoscopy revealed no evidence of recurrent or residual tumor in any patient. CONCLUSION: Small duodenal carcinoids confined to the submucosa can be resected endoscopically and preoperative endosonography is necessary for the determination of endoscopic resectability.

Multiple early bile duct carcinoma associated with congenital choledochal cyst.

Emergency ultrasonography showed a protruding tumor in the markedly dilated common bile duct of a 33-year-old Japanese woman. Magnetic resonance cholangiopancreatography also demonstrated the tumor clearly, almost as clearly as did percutaneous transhepatic cholangiography. With a diagnosis of common bile duct carcinoma associated with congenital choledochal cyst, pancreaticoduodenectomy was performed. In the resected specimen, as well as the protruding tumor, there was also a small slightly elevated lesion. Pathology examination showed adenocarcinoma limited to the fibromuscular layer in the protruding tumor, and adenocarcinoma limited to the mucosa in the elevated lesion. Prophylactic total excision of the choledochal cyst before the occurrence of malignant change is strongly recommended in patients with congenital choledochal cyst. However, in those who are reluctant to undergo the operation, periodic follow-up with ultrasonography and magnetic resonance cholangiopancreatography would be ideal to achieve early detection of malignant change.

Familial occurrence of gastric carcinoid tumors associated with type A chronic atrophic gastritis.

We present here familial occurrence of two patients with gastric carcinoid. Both patients, a sister and older sister, had type A chronic atrophic gastritis with hypergastrinemia. This is the first case report of familial occurrence of gastric carcinoid associated with type A chronic atrophic gastritis in the world literature. The possible mechanism of familial occurrence in the patients is discussed.

Regression of superficial gastric MALT lymphoma with unsuccessful eradication therapy for Helicobacter pylori infection.

A 51-year-old man had a reddish flat granular lesion in the stomach on endoscopic examination. Histology of biopsied specimen confirmed the diagnosis of low-grade B-cell gastric lymphoma of mucosa-associated lymphoid tissue (gastric MALT lymphoma) and simultaneous infection with Helicobacter pylori. He was given antibiotic treatment. Five weeks later, endoscopy and histology of biopsied specimen showed eradication of H. pylori, and the tumor had regressed. Six months later, H. pylori reemerged, but the tumor had not recurred. After the second antibiotic therapy, H. pylori has been eradicated. The lymphoma has been in remission for 14 months.

Evaluation of handling methods in the histological diagnosis of Helicobacter pylori: the effect of filter paper.

OBJECTIVES: Few studies have evaluated the handling methods used in the histological diagnosis of Helicobacter pylori. Filter paper has conventionally been used as a receptacle for the biopsy specimen before fixation. The aim of this study was to determine the presence of any effect caused by the use of filter paper. METHODS: The study population consisted of 104 consecutive patients undergoing endoscopic examination. Two antral biopsy specimens from the same area were obtained from each patient. One specimen was put onto a piece of filter paper, and the other into a plastic case. The specimens were fixed overnight in buffered formalin, embedded in paraffin, sectioned, and stained with hematoxylin and eosin and Giemsa. A direct smear was also prepared from 77 patients by vigorously rubbing the filter paper on a glass slide and staining it with Giemsa. RESULTS: The detection rate of H. pylori was 47.1% (49 of 104) for the filter paper method, 56.7% (59 of 104) for the plastic case method, and 57.7% (60 of 104) for either of the two methods. Of the 60 positive patients, 11 filter paper specimens were negative, whereas only one plastic case specimen was negative. Statistical analysis revealed a significant difference between the two groups (p < 0.01). On the amount of H. pylori, the filter paper method showed a significantly lower grade than the plastic case method (p < 0.05). In the Giemsa-stained smears, H. pylori was identified in 17 (22.1%) of the 77 patients studied. CONCLUSIONS: Use of filter paper may decrease the sensitivity for detection of H. pylori infection. We recommend not using filter paper in the histological diagnosis of H. pylori.