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Gastric adenocarcinoma with enteroblastic differentiation (GAED) is a very rare variant of alpha-fetoprotein-producing gastric cancer (AFPGC). GAED is histologically characterized by cuboidal or columnar cells, which resemble those found in the primitive gut and have clear cytoplasm. In previously reported cases, GAED exhibit more aggressive behavior, as well as AFPGC, than conventional gastric cancer, such as marked lymphovascular invasion, lymph node metastasis, and liver metastasis. And also GAED was usually located in a deep mucosal layer and was covered by a conventional adenocarcinoma (CA) component. Based on these findings, GAED is considered to develop from CA during the process of tumor invasion and proliferation. We present a very rare case of early-stage GAED achieved curatively resected via endoscopic submucosal dissection, in which the lesion was composed of a pure enteroblastic differentiation component without a CA component.

Suitable lesions for endoscopic treatment include not only early colorectal carcinomas but also several types of precarcinomatous adenomas. It is important to establish practical guidelines wherein preoperative diagnosis of colorectal neoplasia and selection of endoscopic treatment procedures are appropriately outlined and to ensure that actual endoscopic treatment is useful and safe in general hospitals when carried out in accordance with guidelines. In cooperation with the Japanese Society for Cancer of the Colon and Rectum, the Japanese Society of Coloproctology, and the Japanese Society of Gastroenterology, the Japan Gastroenterological Endoscopy Society compiled colorectal endoscopic submucosal dissection/endoscopic mucosal resection guidelines by using evidence-based methods in 2014. The first edition of these guidelines was published 5 years ago. Accordingly, we have published the second edition of these guidelines based on recent new knowledge and evidence., (© 2019 Japan Gastroenterological Endoscopy Society.)

Objectives: A Japanese multicenter prospective cohort study examining endoscopic resection (ER) for early gastric cancer (EGC) has been conducted using a Web registry developed to determine the short-term and long-term outcomes based on absolute and expanded indications. We hereby present the short-term outcomes of this study., Methods: All consecutive patients with EGC or suspected EGC undergoing ER at 41 participating institutions between July 2010 and June 2012 were enrolled and prospectively registered into the Web registry. The baseline characteristics were entered before ER, and the short-term outcomes were collected at 6 months following ER., Results: Nine thousand six hundred and sixteen patients with 10 821 lesions underwent ER (endoscopic submucosal dissection [ESD]: 99.4%). The median procedure time was 76 min, and R0 resections were achieved for 91.6% of the lesions. Postoperative bleeding and intraoperative perforation occurred in 4.4% and 2.3% of the patients, respectively. Significant independent factors correlated with a longer procedure time (120 min or longer) were as follows: tumor size >20 mm, upper-third location, middle-third location, local recurrent lesion, ulcer findings, gastric tube, male gender, and submucosa. Histopathologically, 10 031 lesions were identified as common-type gastric cancers. The median tumor size was 15 mm. Noncurative resections were diagnosed for 18.3% of the lesions. Additional surgery was performed for 48.6% (824 lesions) of the 1695 noncurative ER lesions with a possible risk of lymph node (LN) metastasis. Among them, 64 (7.8%) exhibited LN metastasis., Conclusions: This multicenter prospective study showed favorable short-term outcomes for gastric ESD., (© 2018 Japan Gastroenterological Endoscopy Society.)

Background and Study Aims: Endoscopic submucosal dissection (ESD) is a reliable method that can replace surgery under certain conditions. However, limited information is available on the clinical course of T1b colorectal cancer (CRC) after ESD. The aim of the study was to clarify the feasibility of ESD for T1b CRC., Patients and Methods: Three hundred and two patients with 312 T1 CRC were identified in this retrospective cohort study. All patients were treated with ESD, other endoscopic treatments, or surgery. In this study, we (I) investigated the en bloc resection rate of ESD and (II) compared the overall survival (OS) rate for patients who underwent ESD with additional surgery (Group A) and surgery without upfront endoscopic resection (Group B) for T1b CRC., Results: No significant differences were observed in the en bloc resection rates between T1b and T1a CRC (100 vs. 98.7%), but the en bloc R0 resection rate was significantly lower in T1b CRC than in T1a CRC (64.7 vs. 97.4%). Regarding complications, perforations occurred in 2.9% of patients with T1b CRC, which was not significantly different from the rate of 5.3% in patients with T1a CRC. No significant differences were observed in the OS or recurrence-free survival (RFS) curves between Groups A and B (OS rates at 5 years: 92.3 vs. 88.9%, RFS rates at 5 years: 81.4 vs. 85.3%). Similarly, the 5-year disease-specific survival (DSS) rate of Group A was identical to that of Group B (both 100%)., Conclusions: ESD for T1b CRC before surgery is a possible strategy because of the low rate of complications and favorable long-term outcomes.

Aim: To evaluate the feasibility and safety of endoscopic submucosal dissection (ESD) for lower rectal lesions with hemorrhoids., Methods: The outcome of ESD for 23 lesions with hemorrhoids (hemorrhoid group) was compared with that of 48 lesions without hemorrhoids extending to the dentate line (non-hemorrhoid group) during the same study period., Results: Median operation times (ranges) in the hemorrhoid and non-hemorrhoid groups were 121 (51-390) and 130 (28-540) min. The en bloc resection rate and the curative resection rate in the hemorrhoid group were 96% and 83%, and they were 100% and 90% in the non-hemorrhoid group, respectively. In terms of adverse events, perforation and postoperative bleeding did not occur in both groups. In terms of the clinical course of hemorrhoids after ESD, the rate of complete recovery of hemorrhoids after ESD in lesions with resection of more than 90% was significantly higher than that in lesions with resection of less than 90%., Conclusion: ESD on lower rectal lesions with hemorrhoids could be performed safely, similarly to that on rectal lesions extending to the dentate line without hemorrhoids. In addition, all hemorrhoids after ESD improved to various degrees, depending on the resection range.

A 75-year-old female underwent esophagogastroduodenoscopy, revealing a widely spreading tumor occupying the anterior wall, lesser curvature, and posterior wall of the antrum and lower body. Endoscopic submucosal dissection was performed and resulted in more than five-sixths circumferential antral mucosal resection. One month later, she complained of nausea, vomiting, and abdominal distention. Endoscopy showed residual food in the stomach and deformation of the antrum with traction toward the contracted scar in the lesser curvature. The pyloric ring could not be seen from the antrum although the endoscope was able to pass easily beyond the area of deformation and the pyloric ring was intact. Despite repeated endoscopic balloon dilations, the patient's symptoms remained refractory. The problem was speculated to be not due to any potential stricture but to antrum deformation resulting from the traction force toward the healing ulcer. We hypothesized that an additional countertraction force opposite the previous ESD site might resolve the problem, and ESD of approximately 2.5 cm size was performed in the greater curvature of the antrum. Along with development of a scar, traction toward the greater curvature was added, and the pyloric ring could be observed on repeat esophagogastroduodenoscopy. The symptoms were also gradually ameliorated. Afterwards, the endoscopic findings have now been unchanged during 7 years of follow-up.

Background and Study Aims: Improvements in the endoscopic submucosal dissection (ESD) technique have made circumferential ESD in the rectum possible. However, little is known about the clinical course after extensive ESD in the rectum. The aim of this study was to determine the stricture risk in the rectum after total or subtotal circumferential ESD., Patients and Methods: A total of 69 patients with 69 rectal tumors that required ≥ 75 % circumferential resection were identified at Kobe University Hospital and an affiliated hospital between April 2005 and May 2014. Among the patients, 61 were available for evaluation of stricture development, either by follow-up colonoscopy or by surgical specimens. The rate and possible risk factors of post-ESD strictures were investigated., Results: Post-ESD rectal strictures developed in 12 patients (19.7 %). Patients who underwent total circumferential ESD developed a stricture (5/7, 71.4 %) more frequently than those with subtotal (≥ 90 %) ESD (7/16, 43.8 %). Patients undergoing an ESD procedure that involved < 90 % of the circumference did not develop strictures. The strictures were membranous or < 10 mm long in all cases. Of the patients with stricture, 11 received endoscopic balloon dilation and one received bougie with short-caliber-tip transparent hood; all strictures improved following dilation therapy. Statistical analysis revealed that ≥ 90 % circumferential resection was an independent risk factor for stricture, whereas morphology and size were not., Conclusions: Patients who underwent total or subtotal circumferential ESD of a rectal tumor had a high risk of stricture formation. Dilation helped to alleviate the stenosis.Study registered at University Hospital Medical Information Network (UMIN 000016559)., (© Georg Thieme Verlag KG Stuttgart · New York.)

A 66-year-old woman presented to us with malaise, anorexia and rectal mucous discharge, and her laboratory data showed severe hyponatremia, hypokalemia, hypochloremia and renal failure. Computed tomography revealed massive occupation of the rectum by a large tumor. Colonoscopy revealed a mucus-rich villous tumor in the rectum. As there were no other factors that could cause an electrolyte disorder, she was diagnosed with McKittrick-Wheelock syndrome (MWS). The current standard treatment for MWS is partial surgical colectomy. However, surgeries are invasive and postoperative complications sometimes become an issue. After confirming no signs of submucosal invasion of the tumor by magnifying chromoendoscopic examination, endoscopic submucosal dissection (ESD) was indicated. The tumor was completely removed en bloc without adverse events. The histology showed a mucosal adenocarcinoma containing a villous component, 24.5 x 17.0 cm in size. This removal dramatically improved the patient's symptoms and the electrolyte abnormalities without medication. Although several sessions of endoscopic balloon dilation were required to treat postoperative stricture, she has been symptom-free and had no recurrence for 4 years after treatment. We experienced a case of MWS treated by ESD instead of surgery. ESD should be feasible and beneficial for the treatment of MWS.

Background: Detection of early gastric cancer (EGC) in the remnant stomach is increasing because of follow-up endoscopic surveillance programs. Endoscopic treatment appears to be desirable for EGC in the remnant stomach because it is less invasive than surgical resection., Methods: In this retrospective study, to evaluate the feasibility of endoscopic submucosal dissection (ESD) for EGC in an anastomotic site, treatment results of ESD for EGC in an anastomotic site and in remnant stomach not involving an anastomotic site were compared. In total, 11 EGC lesions of anastomotic sites in 11 patients and 22 EGC lesions of remnant stomach not involving an anastomotic site in 21 patients were treated by ESD., Results: All lesions were successfully treated by en bloc resection. There were three patients with perforations in the anastomotic site group. Although resected specimen size and tumor size were larger in the anastomotic site group than in the non-anastomotic site group (P < 0.01), the procedure duration was far longer in the anastomotic site group than in the non-anastomotic site group (P < 0.01). The speed of the procedure was faster in the non-anastomotic site group than in the anastomotic site group (P < 0.05)., Conclusions: Although ESD for EGC in an anastomotic site is a time-consuming procedure and requires advanced techniques compared with ESD for EGC not involving an anastomotic site, a high en bloc resection rate was achieved. ESD by endoscopists with sufficient experience appears to be a feasible treatment for EGC in an anastomotic site.

Conventionally, long-segment Barrett's esophagus (LSBE) has been considered a high-risk background for the occurrence of Barrett's adenocarcinoma in Western countries, and random biopsy has been proposed for surveillance, aiming to detect early cancer. However, accurate detection of a lesion and diagnosis of the expansion are difficult by this blind method. Herein, we report a case of early Barrett's adenocarcinoma derived from LSBE that was successfully detected by narrow-band imaging with magnifying endoscopy., (© 2013 The Authors. Digestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society.)

Endoscopic diagnosis of gastric cancer is very often made by conventional white light endoscopy and/or by indigo carmine chromoendoscopy. However, with this method it is difficult to detect and demarcate a small lesion affected by inflammation or a biopsy procedure. We considered it is useful for diagnosis of such small cancers to observe a lesion with a magnifying endoscope combined with a narrow band imaging system., (© 2011 The Authors. Digestive Endoscopy © 2011 Japan Gastroenterological Endoscopy Society.)

Aim: Although the treatment of early gastric cancer with endoscopic submucosal dissection (ESD) has been widely carried out, a standardized method of sedation for ESD has not been established. The purpose of the present study was to evaluate the efficacy and safety of sedation with dexmedetomidine (DEX)., Methods: We conducted a randomized study involving 90 patients with gastric tumors who were intended to be treated with ESD. The patients were sedated either with DEX (i.v. infusion of 3.0 µg/kg per h over 5 min followed by continuous infusion at 0.4 µg/kg per h [n = 30]), propofol (PF [n = 30]), or midazolam (MDZ [n = 30]). In all groups, 1 mg MDZ was added i.v. as needed., Results: En bloc resection of the gastric tumor was achieved in 88 (98%) patients. None of the DEX-sedated patients showed a significant reduction of the oxygen saturation level. The percentage of patients who showed body movement in the DEX group was significantly lower than those in the PF and MDZ groups, and the mean dose of additional MDZ in the DEX group was significantly smaller than that in the MDZ group. The rate of effective sedation was significantly higher in the DEX group compared with the MDZ or PF group. The mean length of ESD in the DEX group was 65 min, which was significantly shorter than in the other two groups. No DEX-sedated patient developed major surgical complications., Conclusions: Sedation with DEX is effective and safe for patients with gastric tumors who are undergoing ESD., (© 2010 The Authors. Digestive Endoscopy © 2010 Japan Gastroenterological Endoscopy Society.)