Grasping forceps assisted endoscopic resection of large pedunculated GI polypoid lesions

BACKGROUND

Endoscopic resection of pedunculated polyps with heads 1 cm or greater in diameter is technically complex. To facilitate removal of such polyps, we developed grasping forceps assisted endoscopic resection in which we use a detachable snare to prevent polypectomy-related bleeding and evaluated the usefulness and safety of the procedure.

METHODS

Ten patients with pedunculated polyps with heads 1 cm or greater in diameter were treated with this technique. A two-channel endoscope, grasping forceps, electrosurgical snare, and detachable snare are needed for the procedure.

RESULTS

All lesions were easily and safely resected. During this procedure, a two-channel endoscope with grasping forceps proved to be satisfactory for handling the detachable snare and the electrosurgical snare and for accurate recognition of the stalk under good visual control. No hemorrhage, perforation, or other complication occurred as a result of use of this new technique.

CONCLUSIONS

Grasping forceps assisted endoscopic resection of polyps with a detachable snare is an effective method for the prevention of polypectomy-associated bleeding. This technique makes it technically easier to resect large pedunculated polypoid lesions of the GI tract.

Transanal endoscopic microsurgery for T1 rectal cancer in patients with synchronous colorectal cancer

We treated T1 rectal cancer in three patients with synchronous colorectal cancer by transanal endoscopic microsurgery (TEM) before performing a radical operation for the second lesion. On pathological examination, all rectal specimens resected by TEM showed cancer invasion within the submucosal layer, while the margins of the specimen were completely free of cancerous tissue. Few complications were encountered with either the TEM for the rectal lesions or the succeeding radical operation for the second lesions. When patients present with synchronous colorectal cancer, including T1 rectal cancer, local excision of the rectal lesion via TEM can help to improve the patient's quality of life without affecting the curability of the disease.

Pre-operative staging of ampullary tumours by endoscopic ultrasound

Ampullary carcinomas have a significantly higher resectability rate and better prognosis than other periampullary carcinomas, although the prognosis is poor with advanced disease. Accurate tumour staging is therefore important in surgical planning. Our objective was to evaluate the usefulness of, and problems associated with, endoscopic ultrasound (EUS) in the pre-operative staging of ampullary tumours. 35 patients with ampullary tumours were pre-operatively examined with EUS. The imaging results were compared with histopathological findings of the resected specimen according to the TNM staging classification. The overall accuracy of tumour (T) staging was 74% (26/35) for all tumours, and 67% (6/9), 71% (10/14) and 83% (10/12) respectively for T1, T2 and T3 tumours. The overall accuracy of nodal (N) staging was 63%. In diagnosing pancreatic invasion, EUS had an accuracy of 86% (30/35), a sensitivity of 83% (10/12), and a specificity of 87% (20/23). In conclusion, EUS provides an accurate method of evaluating the stage of ampullary tumours, especially infiltration into the pancreas. This modality is useful to surgeons in deciding on an appropriate therapeutic approach and in giving a prognosis.

Complete response of early gastric cancer to uracil and tegafur

A 74-year-old Japanese woman with early gastric cancer was successfully treated with uracil and tegafur (UFT). She was diagnosed by endoscopy (including endoscopic biopsy and endosonography) with an early gastric cancer, type IIa + IIc, on the greater curvature of the angulus. Surgical procedures or endoscopic therapy could not be performed because the patient had severe ischemic heart disease. Therefore, chemotherapy with UFT was administered at 300 mg/day for 15 months. Follow-up endoscopy, endosonography, and biopsy showed disappearance of the gastric cancer. To our knowledge, this is the first case report of the complete response of an early gastric cancer to UFT in the English-language literature.

Pretreatment staging of endoscopically early gastric cancer with a 15 MHz ultrasound catheter probe

BACKGROUND

The usefulness of and problems associated with an ultrasound catheter probe in the pretreatment staging of endoscopically early gastric cancer remain unexplored.

METHODS

Endoscopic ultrasonography using a 15 MHz catheter probe of 2.6 mm diameter was performed in a prospective study to determine the pretherapy staging of endoscopically early gastric cancer in 78 patients. The results of the ultrasound images were compared with the histologic findings of the specimens obtained by endoscopic mucosal resection or surgical resection.

RESULTS

The accuracy of the catheter probe for depth of invasion of endoscopically early gastric cancers was 67% (52 of 78 patients). The accuracy in determining depth of invasion in relation to endoscopic type was significantly higher for the elevated type (91%) than for the depressed type of early cancer (56%) (p < 0.01). The staging accuracy classified by histologic type was significantly higher for differentiated (86%) than for undifferentiated (18%) cancer (p < 0.01). Staging accuracy decreased as tumor size increased. The accuracy, sensitivity, and specificity for nodal staging were 80%, 17%, and 90%, respectively.

CONCLUSIONS

A 15 MHz ultrasound catheter probe is most useful for determining depth of invasion when the tumor is histologically differentiated and endoscopically of the small elevated type early gastric cancer, but it is unreliable in the diagnosis of metastatic lymph nodes.

Diagnosis and staging of pancreatic cancer by endoscopic ultrasound

The aim of this study was to evaluate the usefulness of and problems associated with endoscopic ultrasonography (EUS) in the diagnosis and pre-operative staging of pancreatic cancer. 96 patients suspected of having pancreatic cancer were pre-operatively examined with EUS. 37 of these 96 patients had pancreatic cancer. Results of the EUS imaging were compared with findings of histology and/or surgery, and the patient's clinical course. The sensitivity and specificity of EUS for diagnosing pancreatic cancer were 89% and 97%, respectively. EUS had excellent sensitivity regardless of tumour size or location. EUS was accurate (90%) in determining tumour size in pancreatic cancers less than 3 cm in maximum diameter, but not for tumours greater than 3 cm (30%). The accuracy of tumour (T) and nodal (N) staging were 64% and 50%, respectively. EUS is a promising method for the early diagnosis and pre-operative staging of pancreatic cancers, but requires further refinement.

Diagnosis and staging of pancreatic cancer by endoscopic ultrasound

The aim of this study was to evaluate the usefulness of and problems associated with endoscopic ultrasonography (EUS) in the diagnosis and pre-operative staging of pancreatic cancer. 96 patients suspected of having pancreatic cancer were pre-operatively examined with EUS. 37 of these 96 patients had pancreatic cancer. Results of the EUS imaging were compared with findings of histology and/or surgery, and the patient's clinical course. The sensitivity and specificity of EUS for diagnosing pancreatic cancer were 89% and 97%, respectively. EUS had excellent sensitivity regardless of tumour size or location. EUS was accurate (90%) in determining tumour size in pancreatic cancers less than 3 cm in maximum diameter, but not for tumours greater than 3 cm (30%). The accuracy of tumour (T) and nodal (N) staging were 64% and 50%, respectively. EUS is a promising method for the early diagnosis and pre-operative staging of pancreatic cancers, but requires further refinement.

Preoperative staging of colorectal cancer by a 15 MHz ultrasound miniprobe

BACKGROUND

Our objective was to examine the accuracy of a 15 MHz ultrasound miniprobe in the pre-operative staging of colorectal cancer by assessing the depth of tumor infiltration and involvement of pericolonic lymph nodes.

METHODS

Thirty-three patients with colorectal cancer who underwent ultrasonography with a miniprobe were studied prospectively. The results of this imaging were compared with the histologic findings of the resected specimens.

RESULTS

The accuracy of the miniprobe for depth of invasion (T category) was 82% (27 of 33) for all tumors, 76% (13 of 17) in pT1 cases, and 88% (14 of 16) in pT2 to pT4 cases. The accuracy of the miniprobe for nodal staging (N category) was 87% (26 of 30) overall. The sensitivity was 63% (5 of 8), the specificity was 95% (21 of 22), the positive predictive value was 83% (5 of 6), and the negative predictive value was 88% (21 of 24).

CONCLUSIONS

The miniprobe is an accurate method for the preoperative TN staging of colorectal cancer. We recommend its preoperative use because the results may influence the surgical approach.

Endoscopic ultrasonography: a promising method for assessing the prospects of endoscopic mucosal resection in early gastric cancer

BACKGROUND AND STUDY AIMS

A recent challenge that is increasingly being faced in endoscopy is the use of endoscopic mucosal resection (EMR) to treat differentiated intramucosal gastric cancers smaller than 2 cm. The usefulness of pretherapeutic endoscopic ultrasonography (EUS) in assessing whether this form of treatment is possible remains controversial.

PATIENTS AND METHODS

We retrospectively investigated the value of pretherapeutic EUS evaluation in 58 patients with macroscopically early gastric cancer that was histologically differentiated and less than 2 cm in diameter. The patients were classified as negative for endoscopic mucosal resection if EUS showed modifications of the third layer, and as positive if such modifications were not seen. All patients underwent radical surgery and the preoperative EUS findings were compared with the histological findings.

RESULTS

The prevalence of metastatic adenopathy was 3% (two of 58). In the lymph-node staging, endosonography had a sensitivity of 0% (neither of two cases), and a specificity of 93% (52 of 56). In assessing the indication for EMR, EUS had a sensitivity of 93% (27 of 29), and a specificity of 86% (25 of 29).

CONCLUSIONS

These results suggest that EUS is a promising method of evaluating the indication for endoscopic mucosal resection in early gastric cancer. EUS may improve pretherapeutic prediction of tumor curability by EMR, and may reduce the need for standard gastrectomy.

Relationship between histological type and endosonographic detection of regional lymph node metastases in gastric cancer

The aim of the study was to compare the ability of endoscopic ultrasonography (EUS) in detecting lymph node metastases in differentiated and undifferentiated gastric adenocarcinoma. EUS was performed in 149 patients with differentiated or undifferentiated gastric cancer. Histopathological findings were compared with pre-operative EUS findings in a total of 2961 resected lymph nodes. The EUS detection rates of metastasis to individual nodes in relation to node size, the ratio of the metastasized area to the cross-sectional area of the node and to the depth of primary tumour invasion, were also investigated. The accuracy and negative predictive values of EUS for detecting metastatic lymphadenopathy in each patient were significantly higher for differentiated (87%, 94%) than for undifferentiated (71%, 71%) tumours. The detection rate of individual node metastasis was higher for differentiated (31%) than for undifferentiated (21%) tumours. For differentiated lesions, EUS detected more small nodal metastases (< 5 mm in diameter) (p < 0.01) and more nodes involved with a relatively small proportion of the metastasized area to the cross-sectional area of the node (< 1/3 involvement) (p < 0.05). In relatively superficial lesions, such as pT1 and pT2, the pre-operative EUS detection rate of metastatic nodes was higher for differentiated than for undifferentiated tumours. In conclusion, the ability of EUS to detect nodal metastases is related to the histological type of gastric cancer.

Pre-operative TN staging of gastric cancer using a 15 MHz ultrasound miniprobe

The aim of the study was to evaluate the usefulness of and problems associated with a new endoscopically guided ultrasound miniprobe, used for pre-operative staging of gastric cancers. 59 cases of gastric cancer were prospectively examined with a 15 MHz ultrasound miniprobe. The results of the ultrasound imaging were compared with the histological findings of the resected specimens. The accuracy of the miniprobe for depth of invasion (T category) was 61% for all tumours, and 72% and 40%, respectively, for T1 and T2 to T4 lesions. If indeterminate cases due to ultrasound attenuation were excluded, the accuracy was improved to 82% for T1 and 57% for T2 to T4 tumours, respectively. The accuracy of the miniprobe for nodal staging (N category) was 69% overall, and 86%, 25% and 14% for stages N0, N1 and N2, respectively. In tumours classified on the basis of endoscopic types, the miniprobe staged early type gastric cancers (T category = 73%, N category = 80%) significantly (p < 0.01) more accurately than advanced ones (T category = 21%, N category = 36%). This study suggests that the miniprobe is indicated for pre-operative TN staging when endoscopy reveals an early gastric cancer.

Metastatic large-cell lung carcinoma presenting as gastrointestinal hemorrhage

A rare case of severe small bowel hemorrhage due to jejunal metastases from a large-cell type carcinoma of the lung is reported. A 69-yr-old Japanese woman presented with complaints of mild abdominal pain and liquid tarry stools 6 months following surgery for lung carcinoma. Gastroduodenoscopy and barium enema yielded unremarkable findings, although a subsequent small bowel enema revealed a large, 15-cm ulcerated mass in the jejunum. This tumor was resected and histology confirmed to be consistent with a metastasis from the primary undifferentiated large-cell carcinoma of the lung. The patient had an uneventful postoperative course and survived for 9 months. There have been only two prior case reports of major intestinal hemorrhage secondary to pulmonary carcinoma metastases in the English literature. Previous reports of such metastases of the small bowel have bowel have documented a very poor prognosis and our patient demonstrated the longest survival period to date. The clinical course of this patient suggests that the early diagnosis and palliative surgery for this complication provide a more favourable outcome.

Diagnostic value of endoscopic ultrasonography in an unusual case of gastric cyst

Using endoscopic ultrasonography, we diagnosed a gastric antral submucosal cyst with a papillous protrusion in a 71-yr-old woman, apparently the first such case to be detected by this method. Endoscopic ultrasonography demonstrated a well-marginated hypoechoic area with papillary tumor in the submucosal layer that did not extend to the muscularis propria. The lesion was diagnosed as a gastric submucosal cyst. CT and transabdominal ultrasound each failed to detect the intracystic papillary tumor. Follow-up endoscopic ultrasonography performed 6 months later revealed an increase in the diameter of the cyst and the papillary tumor. The patient then underwent a partial gastrectomy for a suspected malignancy. The resected specimen showed a cystic lesion with papillary tumor. Although no malignancy was present, examination of cross-sections of the resected specimen gave results consistent with the endoscopic ultrasonographic findings. Endoscopic ultrasonography is thus useful in assessing the nature of a submucosal gastric cyst in detail and in monitoring patients with this lesion.

Desensitization for sulfasalazine-induced skin rash in a patient with ulcerative colitis

A patient with ulcerative colitis developed a sulfasalazine-induced skin allergy manifested by a urticaria rash. The patient underwent drug desensitization. The first desensitization, done according to Holdsworth's protocol, resulted in eruption with itching at a dose of 800 mg. The second desensitization, with Das's protocol, failed to reintroduce the drug because of urticarial eruptions. The third challenge, with a more gradual increase in sulfasalazine dose than that used in Holdsworth's protocol, successfully desensitized the patient. The relationship between the drug and various adverse reactions is reviewed and the desensitization to sulfasalazine is discussed.

A case of combined primary biliary cirrhosis, ulcerative colitis and chronic myelocytic leukemia

A rare case of primary biliary cirrhosis, ulcerative colitis and chronic myelocytic leukemia is described in a 49-year-old Japanese diabetic woman. Primary biliary cirrhosis was diagnosed by characteristic liver histology and positive serum mitochondrial antibody test. Ulcerative colitis was diagnosed by typical findings of barium enema and colonoscopy, negative fecal test for pathogens and compatible rectal histology. Chronic myelocytic leukemia was determined by representative hematologic findings and positive result for Ph1 chromosome. This is the first case with combination of primary biliary cirrhosis, ulcerative colitis and chronic myelocytic leukemia.

Regional lymph node metastasis in gastric cancer: evaluation with endoscopic US

Endoscopic ultrasound (EUS) was performed in 83 patients with gastric cancer to evaluate regional lymph node metastasis. Histopathologic findings were compared with preoperative EUS findings in a total of 1,519 resected lymph nodes. In lymph node staging, the prevalence of metastatic adenopathy was 31.3% (26 of 83 patients); EUS had an accuracy of 83.1% (69 of 83 patients), sensitivity of 53.8% (14 of 26 patients), specificity of 96.5% (55 of 57 patients), positive predictive value of 87.5% (14 of 16 patients), and negative predictive value of 82.1% (55 of 67 patients). The greater the maximum diameter of the node with metastasis, or the larger the ratio of the metastatic area to the cross-sectional area of the node, the higher the detection rate. In tumors classified on the basis of depth of invasion according to the 1987 TNM system, the rate of detection of metastasis in individual nodes was 0% in pT1 tumors (none of five nodes), 20% in pT2 tumors (17 of 85 nodes), 29% in pT3 tumors (20 of 70 nodes), and 10% in pT4 tumors (three of 31 nodes). It is concluded that the most important use of EUS will be in diagnosis of regional lymph node metastasis.

Scirrhous carcinoma of the stomach versus hypertrophic gastritis: findings at endoscopic US

To differentiate scirrhous carcinoma from hypertrophic gastritis, 16 patients with scirrhous carcinoma of the stomach and seven patients with hypertrophic gastritis were examined with endoscopic ultrasonography (US) between August 1987 and October 1990. US images of the normal gastric walls of 16 patients with gastric ulcers served as controls. Characteristic features of scirrhous carcinoma included an irregular hypoechoic enlargement of the third (submucosa) and fourth (muscularis propria) layers. The mean thickness of the third and fourth layers was increased sixfold and threefold, respectively, compared with thickness in healthy subjects. In the patients with scirrhous carcinoma, the mucosal layer remained normal in appearance at US, and it was possible to distinguish the five-layer structure of the gastric wall. These findings were prospectively correlated with histopathologic findings in the resected specimens. In contrast, only the mucosal layer was thickened in cases of hypertrophic gastritis. Recognition of these patterns at US can aid in the differential diagnosis of scirrhous carcinoma and such benign diseases as hypertrophic gastritis with a thickened gastric wall.