Effectiveness of clip-and-snare method using pre-looping technique for gastric endoscopic submucosal dissection

AIM:To evaluate efficacy and safety of clip-and-snare method using pre-looping technique(CSM-PLT)for gastric endoscopic submucosal dissection(ESD).METHODS:In the CSM-PLT method,a clip attached to the lesion side was strangulated with a snare,followed by application of an appropriate tension to the lesion independent of an endoscope.Twenty consecutive lesions were resected by ESD using CSM-PLT(CSM-PLT group)and compared with a control group,including20 lesions that were resected by conventional ESD.The control group was matched based on the size and location of the lesion,presence of pathologic fibrosis,and experience of endoscopists.Total procedure time of ESD,proportion of en bloc resection,and complications were analyzed.RESULTS:The total procedure time for the CSM-PLT group was significantly shorter than that for the control group(38.5 min vs 59.5 min,P=0.023);all lesions were resected en bloc by ESD.There was no significant difference in complications between the two groups.Moreover,there was no complication in the CSM-PLT group.In one large lesion(size:74 mm)that underwentextensive CSM-PLT during ESD,we used an additional CSM-PLT on another edge of the lesion after achieving submucosal resection to the maximum extent possible during initial CSM-PLT.In two lesions,the snare came off the lesion together with the clip after a sudden pull;nevertheless,ESD was successful in all lesions.CONCLUSION:CSM-PLT was an effective and safe method for gastric ESD.

Pseudolymphoma of the liver associated with primary biliary cirrhosis:A case report and review of literature

We report a case of two pseudolymphomas of the liver in a 63-year-old Japanese woman with primary biliary cirrhosis.One of the lesions was found incidentally during a medical examination,presenting as a 10 mm hypodense nodule that revealed hyperdensity in the early phase and hypodensity in the late phase in computed tomography(CT)after injection of contrast medium.Retrospectively,the 10 mm nodule had first been discovered as a 4 mm nodule during CT 4 years previously.Superparamagnetic iron oxide-enhanced MRI revealed another 4 mm hyperintense nodule in segment 6 in addition to the 10 mm hyperintense nodule in segment 7.CT during arterial portography revealed two hypointense nodules.Findings with other imaging modalities such as ultrasonography,magnetic resonance imaging,and hepatic angiography were consistent with hepatocellular carcinoma.A right posterior segmentectomy was performed,and the lesions were microscopically diagnosed as pseudolymphoma.To the best of our knowledge,only 31 other cases of this disease have ever been reported,with a highly asymmetrical male:female ratio of 1:9.7.Although we could find only one case of transformation of hepaticpseudolymphoma into lymphoma in the liver,the exact nature of development from benign pseudolymphoma to malignant lymphoma is still not fully understood and cases of hepatic lymphoma need to be followed carefully.

Preoperative endoscopic diagnosis of superficial non-ampullary duodenal epithelial tumors, including magnifying endoscopy

Superficial non-ampullary duodenal epithelial tumor(SNADET) is defined as a sporadic tumor that is confined to the mucosa or submucosa that does not arise from Vater's papilla, and it includes adenoma a n d a d e n o c a r c i n o m a. R e c e n t d e v e l o p m e n t s i n endoscopic technology, such as high-resolution endoscopy and image-enhanced endoscopy, may increase the chances of detecting SNADET lesions. However, because SNADET is rare, little is known about its preoperative endoscopic diagnosis. The use of endoscopic resection for SNADET, which has no risk of metastasis, is increasing, but the incidence of complications, such as perforation, is significantly higher than in any other part of the digestive tract. A preoperative diagnosis is required to distinguish between lesions that should be followed up and those that require treatment. Retrospective studies have revealed certain endoscopic findings that suggest malignancy. In recent years, several new imaging modalities have been developed and explored for realtime diagnosis of these lesion types. Establishing an endoscopic diagnostic tool to differentiate between adenoma and adenocarcinoma in SNADET lesions is required to select the most appropriate treatment. This review describes the current state of knowledge about preoperative endoscopic diagnosis of SNADETs, such as duodenal adenoma and duodenal adenocarcinoma. Newer endoscopic techniques, including magnifying endoscopy, may help to guide these diagnostics, but their additional advantages remain unclear, and further studies are required to clarify these issues.