Early Esophageal Adenocarcinoma with Non-Barrett's Columnar Epithelium Origin: Two Case Reports and a Literature Review

We herein report two cases of early esophageal adenocarcinoma derived from non-Barrett's columnar epithelium. Both patients, a 65-year-old woman and 60-year-old man, had elevated lesions on white-light imaging. Magnifying endoscopy revealed slightly irregular surface and vessel patterns, and both patients were successfully treated with endoscopic submucosal dissection. Histopathologically, both lesions comprised of well-differentiated gastric mucin phenotype adenocarcinoma. One lesion was accompanied by ectopic gastric mucosa, but the other was speculated to be ectopic gastric mucosa according to the tumor locus at the upper thoracic esophagus. Despite its rarity, endoscopists should consider the existence of adenocarcinoma derived from non-Barrett's columnar epithelium.

Prophylactic hemostasis for postpolypectomy mucosal defect using endoclip under infrared imaging endoscopy

The efficacy of prophylactic hemostasis with endoclips after polypectomy is still controversial. The purpose of this study is to evaluate the efficacy of prophylactic hemostasis for postpolypectomy mucosal defects using endoclips under infrared imaging. Patients with colon polyps who were endoscopically treated at Jikei University Aoto Hospital were retrospectively reviewed to compare the delayed bleeding rate in the infrared imaging group with the conventional imaging group. A total of 813 colon polyps in 416 patients were endoscopically treated from July 2003 to November 2006. The overall postpolypectomy bleeding rate in the infrared imaging group was shown to be significantly lower than in the conventional imaging group. The postpolypectomy bleeding from the endoclip site was also significantly lower in the infrared imaging group than in the conventional imaging group. Even the number of applied endoclips was significantly fewer in the infrared group than the conventional group. The prophylactic use of endoclips with infrared imaging effectively reduced the postpolypectomy bleeding with fewer clip applications.

Tailoring treatment for early gastric cancer after endoscopic resection using sentinel node navigation with infrared ray electronic endoscopy combined with indocyanine green injection

BACKGROUND

This study evaluated the efficacy of sentinel node navigation surgery using infrared ray electronic endoscopy (IREE) combined with indocyanine green in patients after endoscopic treatments of early gastric cancer.

METHODS

14 patients with early gastric cancer after endoscopic treatments were included. Each patient underwent sentinel node navigation surgery using IREE. Sentinel node detection rate, accuracy of sentinel node metastases and clinical efficacy including the presence or absence of recurrence were evaluated.

RESULTS

The intraoperative sentinel node detection rate was 100% (14/14), and accuracy for sentinel node metastases was 93% (13/14). Based on the results of sentinel node mapping, 2 patients received standard gastrectomy with D2 lymphadenectomy, and the remaining 12 patients underwent limited surgery with lymphatic basin dissection. After median follow-up of 32 months, no patients had tumor recurrence.

CONCLUSION

The validity of limited surgery based on sentinel node navigation for early gastric cancer remains unclear because the results of a well-designed multicenter clinical trial of sentinel node mapping for gastric cancer have not yet been reported. However, this study suggests that sentinel node navigation surgery using IREE combined with indocyanine green is useful for early gastric cancer after endoscopic resection.

Infrared ray electronic endoscopy combined with indocyanine green injection for detection of sentinel nodes of patients with gastric cancer

BACKGROUND

To avoid unnecessary lymphadenectomy in patients with cancer accurate diagnosis of the sentinel lymph node (SLN) is important.

METHODS

This report examined the initial clinical use of infrared ray electronic endoscopy (IREE) combined with indocyanine green (ICG) injection for SLN detection in 84 patients with gastric cancer not invading the subserosa (75 T1 N0 M0 and nine T2 N0 M0 tumours, according to tumour node metastasis classification).

RESULTS

There were no adverse events after injection of ICG. At least one SLN was detected in all but one patient by both ICG injection alone and by IREE with ICG. Eleven of the 84 patients had lymph node metastasis. SLNs detected by ICG injection alone did not include metastases in four of 11 patients, whereas IREE with ICG detected SLNs containing lymph node metastases in all 11 patients. Moreover, SLNs illuminated by IREE with ICG included all metastases among the 105 regional lymph nodes in the 11 patients; no metastatic lymph nodes were identified among 154 non-SLNs.

CONCLUSION

IREE combined with ICG injection may efficiently detect SLNs that contain metastases in patients with gastric cancer.

The effectiveness of a new multibending scope for endoscopic mucosal resection

BACKGROUND AND STUDY AIMS

Each year at our institution we have been performing over 100 endoscopic mucosal resections (EMRs) for gastric tumor. However, there are some tumor locations where it is difficult to carry out this procedure, such as the lesser curvature or posterior wall of the gastric body, the cardia, and the lesser curvature of the antrum. To facilitate EMR of tumors in these locations, a multibending scope (the "M-scope", Olympus GIF-2T240M; Olympus Optical, Tokyo, Japan) has been developed, which has two independently curving segments. The aim of this study was to evaluate the effectiveness of this new multibending scope for EMR of gastric tumors.

PATIENTS AND METHODS

Using the M-scope, we carried out EMR in 59 patients at the Jikei University Hospital. The lesions were located in the cardia in seven patients, in the gastric body in 30 patients, and in the antrum in 22 patients. The effectiveness of the M-scope was evaluated by experienced endoscopists; a score of 1 was given for very good effectiveness, and a score of 0 was given when there was no notable difference in effectiveness from the conventional scope. Evaluation was done according to the location of the lesions, the method used for EMR, and the tumor diameter. When the score for each item was equivalent to the average overall score for all the procedures or higher, the M-scope was defined as being effective.

RESULTS

The overall score for all the procedures was 0.7 +/- 0.4 (average +/- SD) (very good in 43 procedures; no notable difference in 16 procedures). When assessed according to the location of the lesion, the mean effectiveness scores of the M-scope for lesions at the following locations were higher than the average overall score: the lesser curvature of the antrum (0.8 +/- 0.5); the posterior wall of the gastric body (1.0 +/- 0.0); the greater curvature of the gastric body (1.0 +/- 0.0); and the lesser curvature of the gastric body (0.9 +/- 0.4). The results suggested that the M-scope was effective for EMR of gastric tumors at these traditionally difficult locations. With regard to the scores assessed according to the method of EMR, the mean scores were 0.8 +/- 0.4 for the two-channel scope method and 0.9 +/- 0.4 for EMR using an insulated-tip diathermic knife (IT-EMR), again suggesting that the M-scope was effective for EMR by these methods. When evaluated according to tumor size, the score was 0.8 +/- 0.4 when the tumor was 11 mm or greater in diameter, indicating that the M-scope was effective for EMR of large tumors.

CONCLUSION

The results of the study suggest that the M-scope is effective for EMR of tumors in the lesser curvature of the antrum, and in the posterior wall, lesser curvature, or greater curvature of the gastric body. With regard to the method of EMR, the M-scope is effective for both the two-channel scope method and IT-EMR. In relation to tumor size, the M-scope is effective for the resection of large tumors.

Protective effect of a vasopressin-1 selective antagonist, OPC-21268, against ethanol-induced damage of the rat gastric wall

Since endogenous vasopressin has been reported to be an aggressor in the gastric mucosa and a vasoconstrictor in the gastric circulation, we investigated the gastric cytoprotective effects of OPC-21268, a newly developed, nonpeptide, orally active vasopressin-1 receptor antagonist, on ethanol-induced gastric injury in rats. The rats were treated with OPC-21268 or placebo 2 hr before ethanol administration, and the gastric mucosa was evaluated macroscopically for ulcer damage, and histologically for gastric mucosal injury. Gastric mucosal blood flow, erythrocyte volume, and erythrocyte velocity were also measured in groups given saline, ethanol alone, and ethanol after OPC-21268. To investigate the role of systemic or locally secreted vasopressin, we measured plasma and tissue (gastric mucosa) vasopressin concentrations after ethanol or vehicle administration. Prophylactic OPC-21268 treatment improved the gastric ulcer score in a dose-dependent manner, and histological examination demonstrated that the drug significantly ameliorated the gastric injury induced by ethanol. The hemodynamic values obtained in the OPC-21268-treated and ethanol-treated group were similar to those in the saline control group, but values were significantly (P < 0.05) higher for gastric mucosal blood flow and erythrocyte velocity and lower for erythrocyte volume compared to the group given ethanol alone. Plasma vasopressin concentrations were not significantly different in the control group and at 15, 30, and 60 min after administration of ethanol. However, ethanol administration caused a threefold increase in gastric tissue vasopressin level (P < 0.05) compared to the control group. These results suggested that OPC-21268 relieved congestive hyperemia in the gastric mucosa and ameliorated the mucosal injury caused by ethanol, probably as a result of inhibition of vasopressin-mediated actions on the stomach. The vasopressin involved was probably generated locally in the gastric mucosa after ethanol administration.

[Forms of an in vivo polymerization product, n-butyl-2-cyanoacrylate, within the gastric wall]

The in vivo morphology of sclerosants, n-butyl-2-cyanoacrylate (Histoacryl; referred hereinafter to briefly as HA) polymer formed within the gastric wall was investigated in an animal experiment. The results indicate that HA polymer formed after local injection of HA into the stomach wall with deliberate avoidance of contact with blood got scattered in an arboroid pattern, suggesting thus that when HA is injected into the gastric mucosa at an extravascular site, the resulting polymer is likely to get scattered and miss the target site. Polymerization products that were formed after injection of HA alone were deep purple, dense, firm, rounded in shape and lesser in adverse histologic influence upon the walls of stomach. On the other hand, those formed by injection of HA with Lipiodol were large-sized, light brown and oval-shaped ones with more irregular margins and less distinct boundaries as compared to those seen after injection of HA alone. These results of the study led us to conclude that at the present time it would seem wise to limit the use of HA for this particular therapeutic purpose only to those cases of bleeding gastric varices.

[A study on endoscopic hemostasis from the viewpoint of morphologic traits of Dieulafoy ulcer--an attempt at endoscopic hemostasis by local injection of aethoxysklerol and ethanol]

Characteristics of the vascular course of ruptured vessels in the submucosal layer of Dieulafoy ulcer were studied, and endoscopic hemostatic treatment was performed using Aethoxysklerol and ethanol. 1) Observations of vessel courses in serial sections revealed that ruptured vessels in Dieulafoy ulcer exhibit rhexis in the lateral portions of the vessel and long courses over the ulcer margin in the submucous layer. 2) More dependable hemostasis seemed to be provided by thrombosis not only at the source of bleeding. i.e., at the site of vessel rupture, but also in the region of the whole ruptured vessel in the submucous layer. 3) Hemostatic treatment by local injection of Aethoxysklerol and ethanol was performed in 4 patients with Dieulafoy ulcer, and complete hemostasis was achieved in all 4 patients.