Assessment of the validity of the clinical pathway for colon endoscopic submucosal dissection

AIM: To determine the effective hospitalization period as the clinical pathway to prepare patients for endoscopic submucosal dissection (ESD). METHODS: This is a retrospective observational study which included 189 patients consecutively treated by ESD at the National Cancer Center Hospital from May 2007 to March 2009. Patients were divided into 2 groups; patients in group A were discharged in 5 d and patients in group B included those who stayed longer than 5 d. The following data were collected for both groups: mean hospitalization period, tumor site, median tumor size, post-ESD rectal bleeding requiring urgent endoscopy, perforation during or after ESD, abdominal pain, fever above 38 ℃, and blood test results positive for inflammatory markers before and after ESD. Each parameter was compared after data collection. RESULTS: A total of 83% (156/189) of all patients could be discharged from the hospital on day 3 postESD. Complications were observed in 12.1% (23/189) of patients. Perforation occurred in 3.7% (7/189) of patients. All the perforations occurred during the ESD procedure and they were managed with endoscopic clipping. The incidence of post-operative bleeding was 2.6% (5/189); all the cases involved rectal bleeding. We divided the subjects into 2 groups: tumor diameter ≥ 4 cm and < 4 cm; there was no significant difference between the 2 groups (P = 0.93, χ 2 test with Yates correction). The incidence of abdominal pain was 3.7% (7/189). All the cases occurred on the day of the procedure or the next day. The median white blood cell count was 6800 ± 2280 (cells/μL; ± SD) for group A, and 7700 ± 2775 (cells/μL; ± SD) for group B, showing a statistically significant difference (P = 0.023, t-test). The mean C-reactive protein values the day after ESD were 0.4 ± 1.3 mg/dL and 0.5 ± 1.3 mg/dL for groups A and B, respectively, with no significant difference between the 2 groups (P = 0.54, t -test). CONCLUSION: One-day admission is sufficient in the absence of complications during ESD or early postoperative bleeding.

Condyloma acuminatum of the anal canal,treated with endoscopic submucosal dissection

Condyloma acuminatum(CA) is a common sexually transmitted disease caused by human papilloma virus infection. Not all individuals develop persistent, progressive disease, but careful follow up is required with moderate-to-severe dysplasia to prevent progression to malignancy. Standard therapies include surgical treatments(trans-anal resection and transanal endoscopic microsurgery) and immunotherapeutic and topical methods(topical imiquimod); however, local recurrence remains a considerable problem. Here, we report a case with superficial CA of the anal canal, treated with endoscopic submucosal dissection(ESD). A 28-year-old man presented with a chief complaint of hematochezia. Digital exam did not detect a tumor. Screening colonoscopy revealed 10-mm long, whitish condyles extending from the anal canal to the lower rectum. The lesion covered almost the whole circumference, and only a small amount of normal mucosa remained. Magnifying endoscopy with narrow band imaging showed brownish hairpin-shaped, coiled capillaries. Although histopathological diagnosis by biopsy revealed CA, accurate histological differentiation between CA, papilloma, and squamous cell carcinoma can be difficult with a small specimen. Therefore, weperformed diagnostic ESD, which provides a complete specimen for precise histopathological evaluation. The pathological diagnosis was CA, with moderate dysplasia(anal intraepithelial neoplasia 2). There was no recurrence at 16 mo after the initial ESD. Compared to surgical treatment, endoscopic diagnosis and resection could be performed simultaneously and the tumor margin observed clearly with a magnifying chromocolonoscopy, resulting in less recurrence. These findings suggest that endoscopic resection may be an alternative method for CA that prevents recurrence.

Endoscopic submucosal dissection for colorectal neoplasms:A review

The introduction of colorectal endoscopic submucosal dissection(ESD)has expanded the application of endoscopic treatment,which can be used for lesions with a low metastatic potential regardless of their size.ESD has the advantage of achieving en bloc resection with a lower local recurrence rate compared with that of piecemeal endoscopic mucosal resection.Moreover,in the past,surgery was indicated in patients with large lesions spreading to almost the entire circumference of the rectum,regardless of the depth of invasion,as endoscopic resection of these lesions was technically difficult.Therefore,a prime benefit of ESD is significant improvement in the quality of life for patients who have large rectal lesions.On the other hand,ESD is not as widely applied in the treatment of colorectal neoplasms as it is in gastric cancers owing to the associated technical difficulty,longer procedural duration,and increased risk of perforation.To diversify the available endoscopic treatment strategies for superficial colorectal neoplasms,endoscopists performing ESD need torecognize its indications,the technical issues involved in its application,and the associated complications.This review outlines the methods and type of devices used for colorectal ESD,and the training required by endoscopists to perform this procedure.

Endoscopic submucosal dissection for large laterally spreading tumors involving the ileocecal valve and terminal ileum

Endoscopic submucosal dissection is a challenging technique that enables en-bloc resection for large colorectal tumors, as laterally spreading tumors, particularly difficult, if the ileocecal valve and terminal ileum is involved. Herein, we report on one of 4 cases. The procedures, using a bipolar needle knife (B-Knife) to reduce the perforation risk and carbon dioxide instead of conventional air insufflation for patient comfort, achieved curative resections without any complications.

Evolving roles of magnifying endoscopy and endoscopic resection for neoplasia in inflammatory bowel diseases

Magnifying endoscopy is a useful technique to differentiate neoplasia from non-neoplastic lesions. Data regarding the clinical utility of magnifying endoscopy for neoplasia in patients with inflammatory bowel disease(IBD) has been emerging.While Kudo’s pit pattern types Ⅲ-Ⅴ are findings suggestive of neoplasia in non-IBD patients, these pit patterns are predictive of IBD-associated neoplasia as well.However, active chronic inflammatory processes, particularly regenerative changes, can mimic neoplastic pit patterns and may affect a meticulous evaluation of pit pattern diagnosis in patients with IBD. The clinical evidence regarding the utility of magnifying endoscopy with narrow band imaging or endocytoscopy has also been evolving in regard to the diagnosis of IBD-associated neoplasia. These advanced endoscopic techniques are promising for multiple reasons;not only for making an accurate diagnosis of neoplasia, but also in determining if endoscopic resection is appropriate for such lesions in patients with IBD. In this review, we discuss the diagnostic accuracy and limitations of magnifying endoscopy in assessing IBD-associated neoplasia and examine the feasibility and outcomes of endoscopic resection for these lesions.

Successful endoscopic closure of a colonic perforation one day after endoscopic mucosal resection of a lesion in the transverse colon

A 73-year-old man underwent endoscopic mucosal resection(EMR) of a 20-mm flat elevated lesion on the transverse colon. The morning after the procedure, he started to have severe right upper quadrant pain after his first meal. A computed tomography scan revealed free air and a stomach filled with food. He was diagnosed to have delayed post-EMR intestinal perforation. He underwent emergent colonoscopy and clipping of the perforated site. He was discharged 8 d after the endoscopic closure without the need for surgical intervention. The meal was not the cause of the colon transversum perforation.

Endoscopic reduction of colocolonic intussusception due to metastatic malignant melanoma:A case report

BACKGROUND Intussusception rarely causes intestinal obstruction in adults.Metastatic malignant melanoma is the main cause of intussusception of the small intestine among adults.However,malignant melanoma rarely causes intussusception of the colorectum.Moreover,emergent surgery is usually performed for such cases.Here,we report a case of a patient with colocolonic intussusception caused by a malignant melanoma,for which endoscopic reduction and elective surgery were performed.CASE SUMMARY The patient was a 64-year-old woman who underwent multiple surgeries and received chemotherapy and immunotherapy for a malignant melanoma.During immunotherapy,she had abdominal pain,diarrhea,and bloody stool.Physical examination and laboratory studies did not reveal any findings that warranted emergent surgery.Computed tomography revealed intussusception in the descending colon without intestinal necrosis and perforation.Intussusception was reduced endoscopically,and elective surgery was performed.CONCLUSION This report suggests that endoscopic reduction and elective surgery constitute a treatment option for colocolonic intussusception of metastatic malignant melanomas.