Efficacy and safety of over-the-scope clip: Including complications after endoscopic submucosal dissection

AIM: To retrospectively review the results of over-thescope clip (OTSC) use in our hospital and to examine the feasibility of using the OTSC to treat perforations after endoscopic submucosal dissection (ESD). METHODS: We enrolled 23 patients who presented with gastrointestinal (GI) bleeding, fistulae and perforations and were treated with OTSCs (Ovesco Endoscopy GmbH, Tuebingen, Germany) between November 2011 and September 2012. Maximum lesion size was defined as lesion diameter. The number of OTSCs to be used per patient was not decided until the lesion was completely closed. We used a twin grasper (Ovesco Endoscopy GmbH, Tuebingen, Germany) as a grasping device for all the patients. A 9 mm OTSC was chosen for use in the esophagus and colon, and a 10 mm device was used for the stomach, duodenum and rectum. The overall success rate and complications were evaluated, with a particular emphasis on patients who had undergone ESD due to adenocarcinoma. In technical successful cases we included not only complete closing by using OTSCs, but also partial closing where complete closure with OTSCs is almost difficult. In overall clinical successful cases we included only complete closing by using only OTSCs perfectly. All the OTSCs were placed by 2 experienced endoscopists. The sites closed after ESD included not only the perforation site but also all defective ulcers sites.RESULTS: A total of 23 patients [mean age 77 years (range 64-98 years)] underwent OTSC placement during the study period. The indications for OTSC placement were GI bleeding (n = 9), perforation (n = 10), fistula (n = 4) and the prevention of post-ESD duodenal artificial ulcer perforation (n = 1). One patient had a perforation caused by a glycerin enema, after which a fistula formed. Lesion closure using the OTSC alone was successful in 19 out of 23 patients, and overall success rate was 82.6%. A large lesion size (greater than 20 mm) and a delayed diagnosis (more than 1 wk) were the major contributing factors for the overall unsuccessful clinical cases. The location of the unsuccessful lesion was in the stomach. The median operation time in the successful cases was 18 min, and the average observation time was 67 d. During the observation period, none of the patients experienced any complications associated with OTSC placement. In addition, we successfully used the OTSC to close the perforation site after ESD in 6 patients. This was a single-center, retrospective study with a small sample size. CONCLUSION: The OTSC is effective for treating GI bleeding, fistulae as well as perforations, and the OTSC technique proofed effective treatment for perforation after ESD.

Management of a large mucosal defect after duodenal endoscopic resection

Duodenal endoscopic resection is the most difficult type of endoscopic treatment in the gastrointestinal tract(GI) and is technically challenging because of anatomical specificities. In addition to these technical difficulties, this procedure is associated with a significantly higher rate of complication than endoscopic treatment in other parts of the GI tract. Postoperative delayed perforation and bleeding are hazardous complications, and emergency surgical intervention is sometimes required. Therefore, it is urgently necessary to establish a management protocol for preventing serious complications. For instance, the prophylactic closure of large mucosal defects after endoscopic resection may reduce the risk of hazardous complications. However, the size of mucosal defects after endoscopic submucosal dissection(ESD) is relatively large compared with the size after endoscopic mucosal resection, making it impossible to achieve complete closure using only conventional clips. The over-the-scope clip and polyglycolic acid sheets with fibrin gel make it possible to close large mucosal defects after duodenal ESD. In addition to the combination of laparoscopic surgery and endoscopic resection, endoscopic full-thickness resection holds therapeutic potential for difficult duodenal lesions and may overcome the disadvantages of endoscopic resection in the near future. This review aims to summarize the complications and closure techniques of large mucosal defects and to highlight some directions for management after duodenal endoscopic treatment.

A rare case of hyaline-type Castleman disease in the liver

Castleman disease often develops in the neck, mediastinum and pulmonary hilum. Its onset in the peritoneal cavity is very rare. The patient, a woman in her 70s, was referred to our department for a detailed examination of an abdominal mass. On abdominal ultrasonography, computed tomography scan, magnetic resonance imaging and positron emission tomography, a mass approximately 15 mm in diameter was noted in the hepatic S6. We attempted radical treatment and conducted a laparoscope-assisted right lobectomy. On the basis of histopathological findings, the patient was diagnosed as having hyaline type Castleman disease in the liver, a very rare condition.

Reduction effect of bacterial counts by preoperative saline lavage of the stomach in performing laparoscopic and endoscopic cooperative surgery

AIM: To investigate the effects of gastric lavage with 2000 mL of saline in laparoscopic and endoscopic cooperative surgery.

Two rare gastric hamartomatous inverted polyp cases suggest the pathogenesis of growth

Gastric hamartomatous inverted polyps(GHIP)are difficult to diagnose accurately because of inversion into the submucosal layer.GHIP are diagnosed using the pathological characteristics of the tumor,including the fibroblast cells,smooth muscle,nerve components,glandular hyperplasia,and cystic gland dilatation.Although Peutz-Jeghers syndrome,juvenile polyposis,and Cowden disease are hereditary,it is rare to encounter 2 cases of monostotic and asymptomatic gastric hamartomas.The pathogeneses of hamartomatous inverted polyps and inverted hyperplastic polyps remain controversial because of the paucity of reported cases.There are 3 hypotheses regarding the pathogenesis of complete gastric inverted polyps.Based on our experience with 2 successive,rare GHIP cases,we affirm the hypothesis that after a hamartomatous change occurs in the submucosal layer,some of these components are exposed to the gastric mucosa and,consequently,form a hypertrophic lesion.In Case 1,our hypothesis explains why a tiny hypertrophic change was first detected on the top of the submucosal tumor using a detailed narrow band imaging-magnified endoscopy.There was no confirmation that the milky white mucous and calcification structures were exuding directly from the biopsy site like Case 1,and in Case 2 the presence of this mucous was indirectly confirmed during an endoscopic submucosal dissection(ESD).Regarding the pathogenesis of GHIP,a submucosal hamartomatous change may occur prior to the growth of hypertrophic portions.An en bloc resection using ESD is recommended for treatment.

Bleeding duodenal hemangioma: Morphological changes and endoscopic mucosal resection

Recently, the development of endoscopic procedures has increased the availability of minimally invasive treatments; however, there have been few case reports of duodenal hemangioma treated by endoscopic mucosal resection. The present report describes a case of duodenal hemangioma that showed various endoscopic changes over time and was treated by endoscopic mucosal resection. An 80-year-old woman presented with tarry stools and a loss of appetite. An examination of her blood revealed severe anemia, and her hemoglobin level was 4.2 g/dL. An emergency upper gastrointestinal endoscopy was performed. A red, protrusive, semipedunculated tumor (approximately 20 mm in diameter) with spontaneous bleeding on its surface was found in the superior duodenal angle. Given the semipedunculated appearance of the tumor, it was suspected to be an epithelial tumor with a differential diagnosis of hyperplastic polyp. The biopsy results suggested a telangiectatic hemangioma. Because this lesion was considered to be responsible for her anemia, endoscopic mucosal resection was performed for diagnostic and treatment purposes after informed consent was obtained. A histopathological examination of the resected specimen revealed dilated and proliferated capillary lumens of various sizes, which confirmed the final diagnosis of duodenal hemangioma. Neither anemia nor tumor recurrence has been observed since the endoscopic mucosal resection (approximately 1 year). Duodenal hemangiomas can be treated endoscopically provided that sufficient consideration is given to all of the possible treatment strategies. Interestingly, duodenal hemangiomas show morphological changes that are influenced by various factors, such as mechanical stimuli.

Rectal perforations and fistulae secondary to a glycerin enema:Closure by over-the-scope-clip

Rectal perforations due to glycerin enemas(GE) typically occur when the patient is in a seated or lordotic standing position.Once the perforation occurs and peritonitis results,death is usually inevitable.We describe two cases of rectal perforation and fistula caused by a GE.An 88-year-old woman presented with a large rectal perforation and a fistula just after receiving a GE.Her case was further complicated by an abscess in the right rectal wall.The second patient was a 78-year-old woman who suffered from a rectovesical fistula after a GE.In both cases,we performed direct endoscopic abscess lavage with a saline solution and closed the fistula using an over-the-scope-clip(OTSC) procedure.These procedures resulted in dramatic improvement in both patients.Direct endoscopic lavage and OTSC closure are very useful for pararectal abscess lavage and fistula closure,respectively,in elderly patients who are in poor general condition.Our two cases are the first reports of the successful endoscopic closure of fistulae using double OTSCs after endoscopic lavage of the debris and an abscess of the rectum secondary to a GE.

Case of pediatric traditional serrated adenoma resected via endoscopic submucosal dissection

Traditional serrated adenoma(TSA)is a type of serrated polyp of the colorectum and is thought to be a precancerous lesion.There are three types of serrated polyps,namely,hyperplastic polyps,sessile serrated adenomas/polyps,and TSAs.TSA is the least common of the three types and accounts for about 5% of serrated polyps.Here we report a pediatric case of TSA that was successfully resected by endoscopic submucosal dissection(ESD).This rare case report describes a pediatric patient with no family history of colonic polyp who was admitted to our hospital with hematochezia.On colonoscopy,we found a polypoid lesion measuring 10 mm in diameter in the lower rectum.We selected ESD as a surgical option for en bloc resection,and histopathological examination revealed TSA.The findings in this case suggest that TSA with precancerous potential can occur in children,and that ESD is useful for treating this lesion.

Outcomes of gastrointestinal defect closure with an overthe-scope clip system in a multicenter experience: An analysis of a successful suction method

To demonstrate the clinical outcomes of a multicenter experience and to suggest guidelines for choosing a suction method.METHODSThis retrospective study at 5 medical centers involved 58 consecutive patients undergoing over-the-scope clips (OTSCs) placement. The overall rates of technical success (TSR), clinical success (CSR), complications, and procedure time were analyzed as major outcomes. Subsequently, 56 patients, excluding two cases that used the Anchor device, were divided into two groups: 14 cases of simple suction (SS-group) and 42 cases using the Twin Grasper (TG-group). Secondary evaluation was performed to clarify the predictors of OTSC success.RESULTSThe TSR, CSR, complication rate, and median procedure time were 89.7%, 84.5%, 1.8%, and 8 (range 1-36) min, respectively, demonstrating good outcomes. However, significant differences were observed between the two groups in terms of the mean procedure time (5.9 min vs 14.1 min). The CSR of the SS- and TG-groups among cases with a maximum defect size ≤ 10 mm and immediate or acute refractory bleeding was 100%, which suggests that SS is a better method than TG in terms of time efficacy. The CSR in the SS-group (78.6%), despite the technical success of the SS method (TSR, 100%), tended to decrease due to delayed leakage compared to that in the TG-group (TSR, CSR; 88.1%), indicating that TG may be desirable for leaks and fistulae with defects of the entire layer.CONCLUSIONOTSC system is a safe and effective therapeutic option for gastrointestinal defects. Individualized selection of the suction method based on particular clinical conditions may contribute to the improvement of OTSC success.

Endoscopic management of a rare granulation polyp in a colonic diverticulum

There are many case reports on colon diverticula that cause irritable bowel syndrome,constipation,bleeding,diverticulitis,stricture due to multiple recurrences of diverticulitis,and perforation.However,few articles have examined neoplasms that arise from a diverticulum,such as adenoma and adenocarcinoma,and there have been no reports of granulation polyps that arise from a colon diverticulum after recurrent diverticulitis.We observed a rare granulation polyp that arose from a diverticulum as a result of repeated episodes of local diverticulitis.Narrow band imaging magnified colonoscopy was very useful to diagnose the polyp as a granulation polyp because of the absence of a pit pattern on the surface of the polyp.We successfully resected the polyp using endoscopic mucosal resection.We inverted the diverticulum,and the resected stalk of the polyp was used to close the diverticulum with an over-thescope clip.If a granulomatous polyp could arise from a diverticulum,differential diagnosis between a colon neoplasm and a granulomatous polyp would not only be difficult but also necessary for suitable endoscopic treatment.

Novel method to prevent gastric antral strictures after endoscopic submucosal dissection: Using triamcinolone

Endoscopic submucosal dissection(ESD) of large gastric lesions often leads to severe gastric strictures, especially in cases of large ESD in the antrum of the stomach. It has recently been reported that balloon dilation, mucosal incision, and local steroid injections can successfully treat gastric strictures. However, there are some complications with existing methods and decreasing the quality of life. We have developed a novel method to prevent severe gastric strictures that does not involve balloon dilation, mucosal incision, or steroid injections after circumferential ESD. Our original method involves the submucosal injection of a mixed solution composed of triamcinolone acetonide and a general solution of glycerol, hyaluronic acid, and a small amount of indigo carmine and epinephrine dur-ing the ESD procedure; this mixture is called a mixed solution of triamcinolone(MST). According to standard ESD procedures, several milliliters of MST are injected into the submucosal layer for the purpose of elevating the submucosa during ESD resulting in prevention of severe strictures. Our method using MST take several advantages such as MST method suppress inflammation in ulcer from initial phase, prevention of stricture without obstructive symptoms, and does not require several ballooning. Therefore, MST method is safe and gentle, shorten the hospitalization duration. Here, we described two cases in which we prevented severe strictures of the gastric antrum after completing a circumferential ESD using MST without any complications.

Difficulty in differentiating two cases of sigmoid stenosis by diverticulitis from cancer

The incidence of colonic diverticulosis with or without diverticulitis has increased in the Japanese population due to the modernization of food and aging. The rate of diverticulitis in colon diverticulosis ranges from 8.1% to 9.6%. However, few cases of stenosis due to diverticulitis have been reported. These reports suggest that the differentiation between sigmoid diverticulitis and colon cancer is difficult. This report describes two cases of colon stenosis due to diverticulitis that were difficult to differentiate from colon cancer. Case i was a 70-year-old woman with narrowed stools for 1 month who underwent colonofiberscopy （CFS）. CFS revealed a diverticulum and circumferential stenosis in the sigmoid colon. Barium enema revealed a marked, hourglass- shaped, 2-cm circumferential stenosis in the sigmoid colon. Fluorodeoxyglucose （FDG）-positron emission tomography computed tomography （CT） revealed an increased FDG uptake at the affected portion of the sigmoid colon. Sigmoid colon cancer was suspected,and laparoscopic sigmoidectomy was performed. Patho- logical examination demonstrated active inflammation with no evidence of malignancy. Case 2 was a 50-year- old man who presented to a nearby clinic with reduced stool output despite the urge to defecate. CFS detected severe stenosis in the sigmoid colon approximately 25 cm from the dentate line. Contrast-enhanced abdomi- nal CT revealed multiple diverticula, wall thickening, and swelling of the lymph nodes around the peritoneal aorta and the inferior mesenteric artery. A partial sig- moidectomy was performed. Pathological examination of the resected specimen revealed no changes in the mucosal epithelial surface, but a marked infiltration of inflammatory cells was observed.

Accurate hemostasis with a new endoscopic overtube for emergency endoscopy

Endoscopic hemostasis performed in the emergency room is difficult due to the presence of blood clots and food residue that makes obtaining a clear view of the bleeding vessel difficult. We experienced the efficacy of a newly developed inverted overtube to shorten the hemostatic time and obtain a clear endoscopic view with upper gastrointestinal bleeding patient who were transferred by ambulance car and required emergency endoscopy. The technique improved the endoscopic views and enabled us to perform the hemostatic procedures from the conventional standing position while freely and easily changing the patient's position. The presence of blood clots and food residue in the gastric fornix or upper gastric body makes identifying a bleeding exposed vessel impossible. This set-up significantly shortened the procedure time. The inverted overtube helped us obtain a clear view in patients who were laid in the right lateral position. Rapid identification of ex-posed vessels resulted in success of hemostasis.

Influence of percutaneous local therapy for hepatocellular carcinoma on gastric function

AIM:To investigate the influence of percutaneous local therapy on gastric myoelectrical activity in patients with hepatocellular carcinomas.METHODS:Forty-four patients with hepatocellular carcinoma(HCC) [27 males and 17 females,ranging in age from 49 to 81 years old(69.7 ± 8.01 years)] who were admitted for percutaneous local therapy were enrolled in this study.We examined clinical abdominal symptoms using the Gastrointestinal Symptom Rating Scale(GSRS) before and 3 d after percutaneous local therapy.We also measured cutaneous fasting and postprandial electrogastrography(EGG) recordings before and 3 d after percutaneous local therapy.RESULTS:We found that the percentage of normogastria in the fasting period was lower in the Child B group than in the Child A group(66.8% ± 8.6% vs 84.0% ± 3.8%).After percutaneous local therapy for HCC,the percentages of normogastria in the fasting period were significantly decreased(81.6% ± 3.5% vs 75.2% ± 4.5%).None of the postprandial EGG parameters changed significantly after percutaneous local therapy for HCC.Percutaneous local therapy for HCC reduced the power ratio(PR).In particular,the PR of tachygastria was significantly decreased after therapy(P < 0.01).However,no significant differences were found in the postprandial EGG parameters.Likewise,no significant differences were found in the calculated GSRS scores obtained from the questionnaire before and after therapy.CONCLUSION:Gastric slow-wave dysrhythmias were induced by percutaneous local therapy in HCC patients,even though the GSRS scores obtained from the questionnaire did not change significantly.

Suitable closure for post-duodenal endoscopic resection taking medical costs into consideration

AIM:To compare closure methods,closure times and medical costs between two groups of patients who had post-endoscopic resection(ER) artificial ulcer floor closures.METHODS:Nineteen patients with duodenal adenoma,early duodenal cancer,and subepithelial tumors that received ER between September 2009 and September 2014 at Kagawa University Hospital and Ehime Rosai Hospital,an affiliated hospital of Kagawa University,were included in the study.We retrospectively compared two groups of patients who received postER artificial ulcer floor closure:the conventional clip group vs the over-the-scope clip(OTSC) group.Delayed bleeding,procedure time of closure,delayed perforation,total number of conventional clips and OTSCs and medical costs were analyzed.RESULTS:Although we observed delayed bleeding in three patients in the conventional clip group,we observed no delayed bleeding in the OTSC group(P = 0.049).We did not observe perforation in either group.The mean procedure times for ulcer closure were 33.26 ± 12.57 min and 9.71 ± 2.92 min,respectively(P = 0.0001).The resection diameters were 18.8 ± 1.30 mm and 22.9 ± 1.21 mm for the conventional clip group and the OTSC group,respectively,with significant difference(P = 0.039).As for medical costs,the costs of all conventional clips were USD $1257 and the costs of OTSCs were $7850(P = 0.005).If the post-ER ulcer is under 20 mm in diameter,a conventional clip closure may be more suitable with regard to the prevention of delayed perforation and to medical costs.CONCLUSION:If the post-ER ulcer is over 20 mm,the OTSC closure should be selected with regard to safety and reliable closure even if there are high medical costs.

Oval mucosal opening bloc biopsy after incision and widening by ring thread traction for submucosal tumor

Gastric submucosal tumors(SMTs) less than 2 cm are generally considered benign neoplasms, and endoscopic observation is recommended, but SMTs over 2 cm, 40% of which are gastrointestinal stromal tumors(GISTs), have malignant potential. Although the Japanese Guidelines for GIST recommend partial surgical resection for GIST over 2 cm with malignant potential as well as en bloc large tissue sample to obtain appropriate and large specimens of SMTs, several reports have been published on tissue sampling of SMTs, such as with endoscopic ultrasound sound fine needle aspiration, submucosal tunneling bloc biopsy, and the combination of bite biopsy and endoscopic mucosal resection. Because a simpler, more accurate method is needed for appropriate treatment, we developed oval mucosal opening bloc biopsy after incision and widening by ring thread traction for submucosal tumor(OMOB) approach. OMOB was simple and enabled us to obtain large samples under direct procedure view as well as allowed us to restore to original mucosa.

Novel and safer endoscopic cholecystectomy using only a flexible endoscope via single port

AIM: To apply the laparoscopic and endoscopic cooperative surgery concept, we investigated whether endoscopic cholecystectomy could be performed more safely and rapidly via only 1 port or not.METHODS: Two dogs(11 and 13-mo-old female Beagle) were used in this study. Only 1 blunt port was created, and a flexible endoscope with a tip attachment was inserted between the fundus of gallbladder and liver. After local injection of saline to the gallbladder bed, resection of the gallbladder bed from the liver was performed. After complete resection of the gallbladder bed, the gallbladder was pulled up to resect its neck using the Ring-shaped thread technique. The neck of the gallbladder was cut using scissor forceps. Resected gallbladder was retrieved using endoscopic net forceps via a port. RESULTS: The operation times from general anesthetizing with sevoflurane to finishing the closure of the blunt port site were about 50 min and 60 min respectively. The resection times of gallbladder bed were about 15 min and 13 min respectively without liver injury and bleeding at all. Feed were given just after next day of operation, and they had a good appetite. Two dogs are in good health now and no complications for 1 mo after endoscopic cholecystectomy using only a flexible endoscope via one port.CONCLUSION: We are sure of great feasibility of endoscopic cholecystectomy via single port for human.

Cytomegalovirus-associated gastric ulcer:A side effect of steroid injections for pyloric stenosis

The local injection of triamcinolone acetonide(TA) is effective in preventing pyloric stenosis and deformity following large endoscopic submucosal dissection(ESD).However,because of its long-acting nature,TA can induce long-term local immunosuppression and subsequent adverse events.We report a case of a cytomegalovirus(CMV) ulcer that formed only at the TA local injection site.A 68-year-old man underwent ESD to treat early gastric cancer that formed over the pylorus.The lesion extended to the duodenum,and an artificial ulcer covered more than two-thirds of the circumference of the pylorus.To prevent pyloric stenosis,TA was locally injected into the ulcer floor.On day 12,a deeper ulcer 10 mm in diameter was discovered in the center of the post-ESD ulcer.Biopsies revealed large cells with intranuclear inclusion bodies,which stained positive for the anti-CMV antibody.Local TA injections are useful,however,CMV ulcer might occur as adverse events.

Radical excision of Barrett's esophagus and complete recovery of normal squamous epithelium

To treat Barrett's esophagus(BE),radiofrequency ablation or cryotherapy are effective treatments for eradicating BE with dysplasia and intestinal metaplasia,and reduce the rates of Barrett's esophageal adenocarcinoma(BAC).However,patients with BE and dysplasia or early cancer who achieved complete eradication of intestinal metaplasia,BE recurred in 5% within a year,requiring expensive endoscopic surveillances.We performed endoscopic submucosal dissection as complete radically curable treatment procedure for BE with dysplasia,intestinal metaplasia and BAC.

Novel concept of endoscopic device delivery station system for rapid and tight attachment of polyglycolic acid sheet

AIM To evaluate appropriate and rapid polyglycolic acid sheet(PGAs) covering time using device delivery station system(DDSS).METHODS This pilot basic study was conducted to evaluate the potential of accurate and rapid PGAs delivery using DDSS. Three 11-month-old female Beagle dogs were used in this study. Two endoscopic submucosal dissections(ESDs) 4 cm in diameter were performed in lesser curvature of middle gastric body and greater curvature of antrum(total 6 ESDs performed). DDSS(3 cm length, 12 mm in outer diameter) has 2 chambers which 16 cm^2 large 2 PGAs were stored, and DDSS was attached post ESD ulcers, respectively. Beriplast P?(CSL Behring K.K., Tokyo, Japan)(combination of fibringlue and thrombin) was applied equally to the artificial ulcer, and tight attachment of 2 PGAs with DDSS were completed. The evaluation items were covering times, post ESD bleeding and perforation during ESD.RESULTS The covering time of PGAs(defined as the duration from the beginning of endoscope insertion into the mouth to the end of the fibrin glue coating process) was 6.07(4.86-8.29) min. There was no postESD bleeding(1-7 d after ESD), and there was no perforation during ESD.CONCLUSION DDSS was very useful for rapid delivering and tight attachment of PGAs, and has potentials of multipurpose delivery station system.