Risk factors for intraoperative perforation during endoscopic submucosal dissection of superficial esophageal squamous cell carcinoma

AIM To identify the risk factors and clarify the subsequent clinical courses.METHODS This study retrospectively analyzed consecutive patients with esophageal squamous cell carcinoma( ESCC) treated using endoscopic submucosal dissection(ESD) between April 2008 and October 2012. We divided the ESCC lesions into perforation cases and non-perforation cases, and compared characteristics and endoscopic findings between the two groups. "Intraoperative perforation" was defined as the detection of a perforation site during ESD and the presence of mediastinal emphysema.RESULTS In total, 147 patients with 156 ESCC lesions were treated by ESD. Intraoperative perforation was recorded for nine lesions(5.8%) from nine patients. Multivariate analysis identified mucosal deficiency larger than 75% of the circumference of the esophagus as an independent risk factor for intraoperative perforation(OR = 7.37, 95%CI: 1.45-37.4, P = 0.016). The predominant site of perforation was the left wall [6/9(67%)]. Six of nine perforation sites were successfully closed by clips during the procedures. Two of nine cases required drainage for pleural effusions; however, all nine cases recovered with conservative treatment and without surgical intervention. At the median follow up of 42 mo after ESD, no cases of local recurrence or distant organ metastasis had been observed.CONCLUSION This study suggests that mucosal deficiency larger than 75% of the luminal circumference is a risk factor for intraoperative perforation during ESD for ESCC.

Unexpected endoscopic full-thickness resection of a duodenal neuroendocrine tumor

A 57-year-old man underwent endoscopy for investigation of a duodenal polyp. Endoscopy revealed a hemispheric submucosal tumor, about 5 mm in diameter, in the anterior wall of the duodenal bulb. Endoscopic biopsy disclosed a neuroendocrine tumor histologically, therefore endoscopic mucosal resection was conducted. The tumor was effectively and evenly elevated after injection of a mixture of 0.2% hyaluronic acid and glycerol at a ratio of 1:1 into the submucosal layer. A small amount of indigo-carmine dye was also added for coloration of injection fluid. The lesion was completely resected en bloc with a snare after submucosal fluid injection. Immediately, muscle-fiber-like tissues were identified in the marginal area of the resected defect above the blue-colored layer, which suggested perforation. The defect was completely closed with a total of 9 endoclips, and no symptoms associated with peritonitis appeared thereafter. Histologically, the horizontal and vertical margins of the resected specimen were free of tumor and muscularis propria was also seen in the resected specimen. Generally, endoscopic mucosal resection is considered to be theoretically successful if the mucosal defect is colored blue. The blue layer in this case, however, had been created by unplanned injection into the subserosal rather than the submucosal layer.

Small undifferentiated intramucosal gastric cancer with lymph-node metastasis:Case report

It has been reported recently that small undifferentiated intramucosal early gastric cancer(EGC) < 20 mm in size without any lymphovascular involvement or ulcerative findings had virtually no risk of lymph-node(LN) metastasis.Consequently,the indications for endoscopic resection were expanded to include such undifferentiated EGC lesions.We describe herein a case of a small undifferentiated intramucosal EGC < 20 mm in size without lymphovascular involvement or ulcerative findings that involved lymph-node metastasis.A 57-year-old female underwent pylorus preserving gastrectomy as standard treatment for an undifferentiated EGC 15 mm in size without any ulcerative finding.The surgical specimen revealed a signet-ring cell carcinoma with a moderately to poorly differentiated adenocarcinoma limited to the mucosa that was 15 mm in size with no lymphovascular involvement or ulcerative findings.This case involved LN metastasis,however,and the lesion was diagnosed as pathological stage ⅡA(T1N2M0) according to the Japanese Classification of Gastric Carcinoma.