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.

Treatment outcomes of chemotherapy between unresectable and recurrent biliary tract cancer

AIM: To evaluate the differences in the treatment outcomes between the unresectable and recurrent biliary tract cancer patients who received chemotherapy.

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.

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.

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.

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.

Diabetes mellitus and metformin in hepatocellular carcinoma

Hepatocellular carcinoma(HCC) is the leading cause of cancer-related death worldwide. Diabetes mellitus, a risk factor for cancer, is also globally endemic. The clinical link between these two diseases has been the subject of investigation for a century, and diabetes mellitus has been established as a risk factor for HCC. Accordingly, metformin, a first-line oral anti-diabetic, was first proposed as a candidate anti-cancer agent in 2005 in a cohort study in Scotland. Several subsequent large cohort studies and randomized controlled trials have not demonstrated significant efficacy for metformin in suppressing HCC incidence and mortality in diabetic patients; however, two recent randomized controlled trials have reported positive data for the tumor-preventive potential of metformin in non-diabetic subjects. The search for biological links between cancer and diabetes has revealed intracellular pathways that are shared by cancer and diabetes. The signal transduction mechanisms by which metformin suppresses carcinogenesis in cell lines or xenograft tissues and improves chemoresistance in cancer stem cells have also been elucidated. This review addresses the clinical and biological links between HCC and diabetes mellitus and the anti-cancer activity of metformin in clinical studies and basic experiments.

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.

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.