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Background A delayed perforation can often occur after endoscopic treatment for duodenal neoplasms and may be fatal due to leakage of pancreatic and bile juices. We aimed to evaluate the feasibility and safety of laparoscopic and endoscopic cooperative surgery for duodenal neoplasms (D-LECS) in a multicenter, retrospective study. Methods The clinical characteristics and surgical outcomes of 206 patients with duodenal neoplasms in whom D-LECS had initially been attempted at one of 14 institutions were reviewed retrospectively. Results Of the 206 patients, 63 (30.6 %), 128 (62.1 %), and 15 patients (7.3 %) had lesions at the bulb, second portion, and third portion of the duodenum, respectively. The rates of en bloc and R0 resections during D-LECS were 96.1 % and 95.1 %, respectively. Intraoperative and delayed perforations occurred in 10 (4.9 %) and 5 patients (2.4 %), respectively. No cases of recurrence were observed. Surgical duration of ≥ 180 minutes was an independent risk factor for postoperative complications. Conclusions The results revealed that D-LECS was performed with oncological safety and technical feasibility.

Background and study aims Although colorectal endoscopic submucosal dissection (ESD) has enabled high en bloc resection rates regardless of tumor size, colorectal ESD is still a challenging procedure. We developed a novel device called the Nelaton Attachment, which allows endoscopists to manipulate the ESD knives using two fingers of their left hand while holding the endoscope with their right hand. We retrospectively investigated the efficacy and safety of the Nelaton Attachment for colorectal ESD. We compared efficacy and safety between Nelaton Attachment and non-Nelaton Attachment groups, and also conducted an ex vivo experiment to evaluate the effect of the Nelaton Attachment. Patients and methods We retrospectively reviewed 36 consecutive patients with 37 colorectal tumors who had undergone ESD at Kishiwada Tokushukai Hospital and Naritatomisato Tokushukai Hospital between April 2016 and September 2018. The Nelaton Attachment was used for 22 of the 37 colorectal ESDs. In the ex vivo experiment, endoscopists inserted and withdrew an ESD knife 2 cm using two fingers of their left hand with and without the Nelaton Attachment. Results Median procedure time was significantly shorter in the Nelaton Attachment group (38 min [range 6 – 195 min]) compared to the non-Nelaton Attachment group (75 min [range 17 – 198 min]; P = 0.030). Median time to complete the ex vivo experiment five times was significantly faster with the Nelaton Attachment than without the Nelaton Attachment (P = 0.001). Conclusions Use of the Nelaton Attachment for colorectal ESD is feasible and safe, and may facilitate colorectal ESD procedures.

Background/Aims: The anastomotic site after distal gastrectomy is the area most affected by duodenogastric reflux. Different reconstruction methods may affect the lesion characteristics and treatment outcomes of remnant gastric cancers at the anastomotic site. We retrospectively investigated the clinicopathologic and endoscopic submucosal dissection outcomes of remnant gastric cancers at the anastomotic site.Methods: We recruited 34 consecutive patients who underwent endoscopic submucosal dissection for remnant gastric cancer at the anastomotic site after distal gastrectomy. Clinicopathology and treatment outcomes were compared between the Billroth II and non-Billroth II groups.Results: The tumor size in the Billroth II group was significantly larger than that in the non-Billroth II group (22 vs. 19 mm; p=0.048). More severe gastritis was detected endoscopically in the Billroth II group (2 vs. 1.33; p=0.0075). Moreover, operation time was longer (238 vs. 121 min; p=0.004) and the frequency of bleeding episodes was higher (7.5 vs. 3.1; p=0.014) in the Billroth II group.Conclusions: Compared to remnant gastric cancers in non-Billroth II patients, those in the Billroth II group had larger lesions with a background of severe remnant gastritis. Endoscopic submucosal dissection for remnant gastric cancers in Billroth II patients involved longer operative times and more frequent bleeding episodes than that in patients without Billroth II.

Objectives: Recently, several studies have demonstrated the usefulness of endoscopic submucosal dissection (ESD) for residual or locally recurrent colorectal lesions after endoscopic treatment. However, the feasibility of ESD for recurrent rectal lesions after transanal endoscopic microsurgery (TEM) has not been fully investigated. In this study, we evaluated the feasibility and safety of ESD for recurrent rectal lesions after TEM. Methods: The treatment outcomes of 10 lesions in 9 patients, who underwent ESD between January 2006 and March 2018 for recurrent rectal lesions after transanal endoscopic microsurgery, were evaluated. Results: All lesions were successfully resected en bloc, and the R0 resection rate was 90%. The median size of the resected specimens and lesions (range) was 44 mm (21–70) and 27.5 mm (5–60), respectively. The pathological diagnoses included 4 adenomas and 6 cancerous lesions. The cancerous lesions included 5 cases of mucosal cancer and 1 case of superficial submucosal invasive cancer (depth of submucosal invasion Conclusions: ESD for recurrent rectal lesions after TEM by expert’s hands appears to be safe and feasible.

Phlegmonous gastritis is a rare, suppurative disease characterized by full-thickness exudative changes, infiltration of inflammatory cells, and edema primarily in the submucosal layer. A 76-year-old woman with type 2 diabetes and myelodysplastic syndrome underwent endoscopic submucosal dissection (ESD) for early gastric cancer. Postoperatively, she developed persistent fever and computed tomography displayed full-circumference thickening of the gastric wall and increased levels of fat stranding. Endoscopy showed post-ESD ulcer floor expansion, formation of a false lumen between the ulcer floor and surrounding folds, and adhesion of purulent matter. Klebsiella pneumoniae, Pseudomonas aeruginosa, and Candida albicans were detected from pus culture and Klebsiella pneumoniae from blood culture, leading to a diagnosis of phlegmonous gastritis. Contrast examination showed no leakage outside the gastric wall; therefore, the patient fasted and was given antibiotics. She was successfully treated with medical therapy, as demonstrated by repeat endoscopy. Based on our experience, we recommend antibiotics before and after ESD in patients thought to be at high risk of infection, as well as careful postoperative management including postoperative endoscopy.