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.

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.

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.

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.

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.