Clin J Gastroenterol (2010) 3:226–229 DOI 10.1007/s12328-010-0167-8
CASE REPORT
Superficial tumors involving terminal ileum treated by endoscopic submucosal dissection Naoki Ishii • Takeshi Setoyama • Michitaka Matsuda Shoko Suzuki • Masayo Uemura • Yusuke Iizuka • Katsuyuki Fukuda • Koyu Suzuki • Yoshiyuki Fujita
•
Received: 11 June 2010 / Accepted: 8 July 2010 / Published online: 29 July 2010 Ó Springer 2010
Abstract It is recognized that superficial tumors of the ileocecal transition pose a higher degree of complexity for endoscopic resection and surgical treatment is sometimes required in cases of incomplete resection. We report some rare cases of superficial tumors involving the terminal ileum treated by endoscopic submucosal dissection (ESD). A 58-year-old woman was referred to our hospital for treatment of a superficial tumor involving the terminal ileum. Endoscopy showed a slightly elevated (type 0-IIa) tumor located at the ileocecal transition. The tumor could be resected en bloc by ESD with a combination of a smallcaliber-tip transparent hood and a flex knife without any complications. A 61-year-old man was also referred to our hospital for treatment of a slightly elevated (type 0-IIa) tumor located at the ileocecal transition. The tumor could be resected en bloc. Both resected specimens showed intramucosal adenocarcinomas with clear lateral and vertical margins. By applying ESD with a combination of a flex knife and a small-caliber-tip transparent hood, the superficial tumors involving the terminal ileum were resected en bloc without any complications and the ileocecal valve was preserved in both cases. Keywords Endoscopic submucosal dissection Terminal ileum Colonic tumor
N. Ishii (&) T. Setoyama M. Matsuda S. Suzuki M. Uemura Y. Iizuka K. Fukuda Y. Fujita Department of Gastroenterology, St. Luke’s International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo 104-8560, Japan e-mail: [email protected] K. Suzuki Department of Pathology, St. Luke’s International Hospital, Tokyo, Japan
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Introduction It is recognized that large superficial tumors of the ileocecal transition pose an increased degree of complexity for endoscopic resection and surgical treatment is sometimes required in cases of incomplete resection. Recently, endoscopic submucosal dissection (ESD) has been applied to colorectal tumors because it provides a higher en bloc resection rate and is less invasive than surgical resection [1–6]; however, this technique has disadvantages such as a longer operative time and a higher complication rate. We report on two cases of superficial tumors involving the terminal ileum treated by ESD.
Case report 1 A 58-year-old woman was referred to our hospital for treatment of a superficial tumor involving the terminal ileum. Endoscopy showed a slightly elevated (type 0-IIa) tumor located at the transition between the cecum and the ascending colon. Because the tumor was extending into the terminal ileum, an overall view of the lesion could not be obtained (Fig. 1). ESD with a combination of a smallcaliber-tip transparent hood (DH-15GR; Fujinon-Toshiba, Saitama, Japan) and a flex knife (Flex KnifeTM; KD-630L, Olympus, Optical Co., Ltd, Tokyo, Japan) was planned [6, 7]. An electrosurgical current generator (VIO300D; ERBE, Tubimugen, Germany) was used for the ESD treatment. Because the margin of the lesions could be identified clearly with 0.4% indigo carmine dye spraying, marking dots for mucosal incision were not performed. After 0.4% sodium hyaluronate solution (MucoUpTM, Johnson and Johnson Medical Co., Tokyo, Japan) was injected into the oral side of the tumor to pull out the tumor
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Fig. 1 Chromoendoscopy with 0.4% indigo carmine dye spraying, showing a slightly elevated (type IIa) tumor involving the terminal ileum. An overall view of the lesion could not be obtained
sufficiently towards the colonic lumen, a mucosal incision was made with the flex knife. For this procedure, the electrosurgical generator output was set at duration 2 and interval 3 of endocut I, effect 1 in VIO300D. After the mucosal incision, the submucosal layer was dissected with the same knife. Using a small-caliber-tip transparent hood, the dissected submucosal layer could be directly visualized during submucosal dissection. After an additional injection beneath the lesion to separate it sufficiently from the muscularis propria, the submucosal layer was dissected directly using the flex knife set to about 1 mm in length, with the electrosurgical generator output set at 20 W of swift coagulation mode, effect 3 in VIO300D. The hemostatic forceps (SDB2422; Pentax Co, Tokyo, Japan) were used to control bleeding during the ESD treatment. The output of the electrosurgical generator was set at 60 W of soft coagulation mode, effect 5 in VIO300D. The tumor was resected en bloc by ESD without any complications in 155 min (Fig. 2). Pathologically, the tumor was diagnosed as a well-differentiated intramucosal adenocarcinoma with clear lateral and vertical margins according to the Vienna classification of epithelial neoplasia of the gastrointestinal tract (Fig. 3) [8].
Fig. 2 a Region after ESD. Post-ESD ulcer of the terminal ileum was observed. b Macroscopic view of the resected specimen (61 9 47 mm)
Case report 2 A 61-year-old man was referred to our hospital for treatment of a slightly elevated (type 0-IIa) tumor located in the terminal ileum (Fig. 4). The tumor was resected en bloc by ESD with a combination of a small-caliber-tip transparent hood and a flex knife, as in case report 1, in 30 min
Fig. 3 Pathologically, the tumor was diagnosed as a well-differentiated intramucosal adenocarcinoma
(Fig. 5). Pathologically, the tumor was diagnosed as a welldifferentiated intramucosal adenocarcinoma with clear lateral and vertical margins (Fig. 6). Carbon dioxide
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Fig. 6 Pathologically, the tumor was diagnosed as a well-differentiated intramucosal adenocarcinoma Fig. 4 Chromoendoscopy with 0.4% indigo carmine dye spraying, showing a slightly elevated (type 0-IIa) tumor located at the ileocecal transition
insufflation during ESD was not used in either case. Neither stenosis nor recurrence was observed in either case during the follow-up periods of 20 months and 8 months, respectively.
Discussion
Fig. 5 a Region after ESD. b Macroscopic view of the resected specimen (20 9 17 mm)
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Endoscopic mucosal resection (EMR) is indicated for the treatment of early-stage gastrointestinal tumors which show a low frequency of lymph nodes and distant metastases. There are some reports of tumors located in the terminal ileum which were treated by EMR [9, 10]; however, local recurrence is frequently observed because EMR is inadequate for en bloc resection of large superficial colorectal tumors (diameter [20 mm) and tumors with submucosal infiltration or fibrosis caused by prior EMR [3, 11]. Although ESD provides a higher en bloc resection rate and is less invasive than surgical resection, it has disadvantages such as a longer operative time and a higher complication rate, and safer procedures are required to complete colorectal ESD. We applied a combination of a flex knife and a small-caliber-tip transparent hood to ESD for superficial tumors involving terminal ileum as in previous reports [6, 7]. The flex knife has special features [2]. It is easy to handle in any direction—vertically, horizontally, or diagonally. It is soft and has a unique loop shape to minimize the possibility of tissue perforation. The length of the knife tip is adjustable so that distance and depth of the mucosal incision and the submucosal dissection can be controlled precisely. By using a small-caliber-tip transparent hood, the knife was set in the center of the lumen so that it was easier to handle in any direction during both mucosal incision and submucosal dissection without rotating the endoscope [1]. While performing submucosal
Clin J Gastroenterol (2010) 3:226–229
dissection, we could obtain a clear view of the submucosal tissue and control bleeding easily by using a small-calibertip transparent hood. Thus, severe complications such as perforation and intolerable bleeding during ESD treatment can be prevented even in the ileocecal region. The ileocecal valve has two functions: to prevent regurgitation of material from the cecum into the ileum and to delay passage of ileal contents into the cecum, allowing more time for digestion and absorption of foodstuffs to occur in the ileum [12, 13]. Bile acids absorbed in the terminal ileum are essential to an intact enterohepatic cycle and lipid digestion. Therefore, malabsorption and diarrhea sometimes occur, causing the quality of life for patients to decrease after ileocecal resection. By applying ESD with a combination of a flex knife and a small-caliber-tip transparent hood, the superficial tumors involving the terminal ileum were resected en bloc without any complications and the ileocecal valve was preserved in both cases. ESD with a combination of a small-caliber-tip transparent hood and a flex knife was a safe and effective endoscopic treatment for superficial tumors involving the terminal ileum. Acknowledgments The authors have no commercial associations that may cause a conflict of interest in relation to the article and report that there are no disclosures relevant to this publication.
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References 1. Yamamoto H, Kawata H, Sunada K, Sasaki A, Nakazawa K, Miyata T, et al. Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood. Endoscopy. 2003;35:690–4. 2. Yahagi N, Fujishiro M, Imagawa A, Kakushima N, Iguchi M, Omata M. Endoscopic submucosal dissection for the reliable en
12.
13.
bloc resection of colorectal mucosal tumors. Dig Endosc. 2004;16:89–92. Tanaka S, Oka S, Kaneko I, Hirata M, Mouri R, Kanao H, et al. Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc. 2007;66:100–7. Saito Y, Uraoka T, Matsuda T, Emura F, Ikehara H, Mashimo Y, Kikuchi T, et al. Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections (with video). Gastrointest Endosc. 2007;66:966–73. Fujishiro M, Yahagi N, Kakushima N, Kodashima S, Muraki Y, Ono S, et al. Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases. Clin Gastroenterol Hepatol. 2007;5:678–83. Ishii N, Itoh T, Horiki N, Matsuda M, Setoyama T, Suzuki S, et al. Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for large superficial colorectal neoplasias including ileocecal lesions. Surg Endosc. 2010;24:1941–7. Ishii N, Horiki N, Itoh T, Uemura M, Maruyama M, Suzuki S, et al. Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife is a safe and effective treatment for superficial esophageal neoplasias. Surg Endosc. 2010;24:335–42. Stolte M. The new Vienna classification of epithelia neoplasia of gastrointestinal tract: advantages and disadvantages. Virchows Arch. 2003;442:99–106. Tsuchida K, Joh T, Okayama N, Yokoyama Y, Senoo K, Okumura F, et al. Ileal adenoma with high-grade dysplasia involving the ileocecal valve treated by endoscopic mucosal resection: a case report. Gastrointest Endosc. 2002;55:125–8. Tsuchida K, Okayama N, Yokoyama Y, Joh T, Seno K, Ohara H, et al. EMR of ileal adenoma: report of two cases. Gastrointest Endosc. 2004;59:443–6. Walsh RM, Ackroyd FW, Shellito PC. Endoscopic resection of large sessile colorectal polyps. Gastrointest Endosc. 1992;38: 303–9. Cosnes J, Gendre JP. Le Quintrec Role of the ileocecal valve and site of intestinal resection in malabsorption after extensive small bowel resection. Digestion. 1978;18:329–36. Mitchell JE, Breuer RI, Zuckerman L, Berlin J, Schilli R, Dunn JK. The colon influences ileal resection diarrhea. Dig Dis Sci. 1980;25:33–41.
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CASE REPORT
Superficial tumors involving terminal ileum treated by endoscopic submucosal dissection Naoki Ishii • Takeshi Setoyama • Michitaka Matsuda Shoko Suzuki • Masayo Uemura • Yusuke Iizuka • Katsuyuki Fukuda • Koyu Suzuki • Yoshiyuki Fujita
•
Received: 11 June 2010 / Accepted: 8 July 2010 / Published online: 29 July 2010 Ó Springer 2010
Abstract It is recognized that superficial tumors of the ileocecal transition pose a higher degree of complexity for endoscopic resection and surgical treatment is sometimes required in cases of incomplete resection. We report some rare cases of superficial tumors involving the terminal ileum treated by endoscopic submucosal dissection (ESD). A 58-year-old woman was referred to our hospital for treatment of a superficial tumor involving the terminal ileum. Endoscopy showed a slightly elevated (type 0-IIa) tumor located at the ileocecal transition. The tumor could be resected en bloc by ESD with a combination of a smallcaliber-tip transparent hood and a flex knife without any complications. A 61-year-old man was also referred to our hospital for treatment of a slightly elevated (type 0-IIa) tumor located at the ileocecal transition. The tumor could be resected en bloc. Both resected specimens showed intramucosal adenocarcinomas with clear lateral and vertical margins. By applying ESD with a combination of a flex knife and a small-caliber-tip transparent hood, the superficial tumors involving the terminal ileum were resected en bloc without any complications and the ileocecal valve was preserved in both cases. Keywords Endoscopic submucosal dissection Terminal ileum Colonic tumor
N. Ishii (&) T. Setoyama M. Matsuda S. Suzuki M. Uemura Y. Iizuka K. Fukuda Y. Fujita Department of Gastroenterology, St. Luke’s International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo 104-8560, Japan e-mail: [email protected] K. Suzuki Department of Pathology, St. Luke’s International Hospital, Tokyo, Japan
123
Introduction It is recognized that large superficial tumors of the ileocecal transition pose an increased degree of complexity for endoscopic resection and surgical treatment is sometimes required in cases of incomplete resection. Recently, endoscopic submucosal dissection (ESD) has been applied to colorectal tumors because it provides a higher en bloc resection rate and is less invasive than surgical resection [1–6]; however, this technique has disadvantages such as a longer operative time and a higher complication rate. We report on two cases of superficial tumors involving the terminal ileum treated by ESD.
Case report 1 A 58-year-old woman was referred to our hospital for treatment of a superficial tumor involving the terminal ileum. Endoscopy showed a slightly elevated (type 0-IIa) tumor located at the transition between the cecum and the ascending colon. Because the tumor was extending into the terminal ileum, an overall view of the lesion could not be obtained (Fig. 1). ESD with a combination of a smallcaliber-tip transparent hood (DH-15GR; Fujinon-Toshiba, Saitama, Japan) and a flex knife (Flex KnifeTM; KD-630L, Olympus, Optical Co., Ltd, Tokyo, Japan) was planned [6, 7]. An electrosurgical current generator (VIO300D; ERBE, Tubimugen, Germany) was used for the ESD treatment. Because the margin of the lesions could be identified clearly with 0.4% indigo carmine dye spraying, marking dots for mucosal incision were not performed. After 0.4% sodium hyaluronate solution (MucoUpTM, Johnson and Johnson Medical Co., Tokyo, Japan) was injected into the oral side of the tumor to pull out the tumor
Clin J Gastroenterol (2010) 3:226–229
227
Fig. 1 Chromoendoscopy with 0.4% indigo carmine dye spraying, showing a slightly elevated (type IIa) tumor involving the terminal ileum. An overall view of the lesion could not be obtained
sufficiently towards the colonic lumen, a mucosal incision was made with the flex knife. For this procedure, the electrosurgical generator output was set at duration 2 and interval 3 of endocut I, effect 1 in VIO300D. After the mucosal incision, the submucosal layer was dissected with the same knife. Using a small-caliber-tip transparent hood, the dissected submucosal layer could be directly visualized during submucosal dissection. After an additional injection beneath the lesion to separate it sufficiently from the muscularis propria, the submucosal layer was dissected directly using the flex knife set to about 1 mm in length, with the electrosurgical generator output set at 20 W of swift coagulation mode, effect 3 in VIO300D. The hemostatic forceps (SDB2422; Pentax Co, Tokyo, Japan) were used to control bleeding during the ESD treatment. The output of the electrosurgical generator was set at 60 W of soft coagulation mode, effect 5 in VIO300D. The tumor was resected en bloc by ESD without any complications in 155 min (Fig. 2). Pathologically, the tumor was diagnosed as a well-differentiated intramucosal adenocarcinoma with clear lateral and vertical margins according to the Vienna classification of epithelial neoplasia of the gastrointestinal tract (Fig. 3) [8].
Fig. 2 a Region after ESD. Post-ESD ulcer of the terminal ileum was observed. b Macroscopic view of the resected specimen (61 9 47 mm)
Case report 2 A 61-year-old man was referred to our hospital for treatment of a slightly elevated (type 0-IIa) tumor located in the terminal ileum (Fig. 4). The tumor was resected en bloc by ESD with a combination of a small-caliber-tip transparent hood and a flex knife, as in case report 1, in 30 min
Fig. 3 Pathologically, the tumor was diagnosed as a well-differentiated intramucosal adenocarcinoma
(Fig. 5). Pathologically, the tumor was diagnosed as a welldifferentiated intramucosal adenocarcinoma with clear lateral and vertical margins (Fig. 6). Carbon dioxide
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Fig. 6 Pathologically, the tumor was diagnosed as a well-differentiated intramucosal adenocarcinoma Fig. 4 Chromoendoscopy with 0.4% indigo carmine dye spraying, showing a slightly elevated (type 0-IIa) tumor located at the ileocecal transition
insufflation during ESD was not used in either case. Neither stenosis nor recurrence was observed in either case during the follow-up periods of 20 months and 8 months, respectively.
Discussion
Fig. 5 a Region after ESD. b Macroscopic view of the resected specimen (20 9 17 mm)
123
Endoscopic mucosal resection (EMR) is indicated for the treatment of early-stage gastrointestinal tumors which show a low frequency of lymph nodes and distant metastases. There are some reports of tumors located in the terminal ileum which were treated by EMR [9, 10]; however, local recurrence is frequently observed because EMR is inadequate for en bloc resection of large superficial colorectal tumors (diameter [20 mm) and tumors with submucosal infiltration or fibrosis caused by prior EMR [3, 11]. Although ESD provides a higher en bloc resection rate and is less invasive than surgical resection, it has disadvantages such as a longer operative time and a higher complication rate, and safer procedures are required to complete colorectal ESD. We applied a combination of a flex knife and a small-caliber-tip transparent hood to ESD for superficial tumors involving terminal ileum as in previous reports [6, 7]. The flex knife has special features [2]. It is easy to handle in any direction—vertically, horizontally, or diagonally. It is soft and has a unique loop shape to minimize the possibility of tissue perforation. The length of the knife tip is adjustable so that distance and depth of the mucosal incision and the submucosal dissection can be controlled precisely. By using a small-caliber-tip transparent hood, the knife was set in the center of the lumen so that it was easier to handle in any direction during both mucosal incision and submucosal dissection without rotating the endoscope [1]. While performing submucosal
Clin J Gastroenterol (2010) 3:226–229
dissection, we could obtain a clear view of the submucosal tissue and control bleeding easily by using a small-calibertip transparent hood. Thus, severe complications such as perforation and intolerable bleeding during ESD treatment can be prevented even in the ileocecal region. The ileocecal valve has two functions: to prevent regurgitation of material from the cecum into the ileum and to delay passage of ileal contents into the cecum, allowing more time for digestion and absorption of foodstuffs to occur in the ileum [12, 13]. Bile acids absorbed in the terminal ileum are essential to an intact enterohepatic cycle and lipid digestion. Therefore, malabsorption and diarrhea sometimes occur, causing the quality of life for patients to decrease after ileocecal resection. By applying ESD with a combination of a flex knife and a small-caliber-tip transparent hood, the superficial tumors involving the terminal ileum were resected en bloc without any complications and the ileocecal valve was preserved in both cases. ESD with a combination of a small-caliber-tip transparent hood and a flex knife was a safe and effective endoscopic treatment for superficial tumors involving the terminal ileum. Acknowledgments The authors have no commercial associations that may cause a conflict of interest in relation to the article and report that there are no disclosures relevant to this publication.
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References 1. Yamamoto H, Kawata H, Sunada K, Sasaki A, Nakazawa K, Miyata T, et al. Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood. Endoscopy. 2003;35:690–4. 2. Yahagi N, Fujishiro M, Imagawa A, Kakushima N, Iguchi M, Omata M. Endoscopic submucosal dissection for the reliable en
12.
13.
bloc resection of colorectal mucosal tumors. Dig Endosc. 2004;16:89–92. Tanaka S, Oka S, Kaneko I, Hirata M, Mouri R, Kanao H, et al. Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc. 2007;66:100–7. Saito Y, Uraoka T, Matsuda T, Emura F, Ikehara H, Mashimo Y, Kikuchi T, et al. Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections (with video). Gastrointest Endosc. 2007;66:966–73. Fujishiro M, Yahagi N, Kakushima N, Kodashima S, Muraki Y, Ono S, et al. Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases. Clin Gastroenterol Hepatol. 2007;5:678–83. Ishii N, Itoh T, Horiki N, Matsuda M, Setoyama T, Suzuki S, et al. Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife for large superficial colorectal neoplasias including ileocecal lesions. Surg Endosc. 2010;24:1941–7. Ishii N, Horiki N, Itoh T, Uemura M, Maruyama M, Suzuki S, et al. Endoscopic submucosal dissection with a combination of small-caliber-tip transparent hood and flex knife is a safe and effective treatment for superficial esophageal neoplasias. Surg Endosc. 2010;24:335–42. Stolte M. The new Vienna classification of epithelia neoplasia of gastrointestinal tract: advantages and disadvantages. Virchows Arch. 2003;442:99–106. Tsuchida K, Joh T, Okayama N, Yokoyama Y, Senoo K, Okumura F, et al. Ileal adenoma with high-grade dysplasia involving the ileocecal valve treated by endoscopic mucosal resection: a case report. Gastrointest Endosc. 2002;55:125–8. Tsuchida K, Okayama N, Yokoyama Y, Joh T, Seno K, Ohara H, et al. EMR of ileal adenoma: report of two cases. Gastrointest Endosc. 2004;59:443–6. Walsh RM, Ackroyd FW, Shellito PC. Endoscopic resection of large sessile colorectal polyps. Gastrointest Endosc. 1992;38: 303–9. Cosnes J, Gendre JP. Le Quintrec Role of the ileocecal valve and site of intestinal resection in malabsorption after extensive small bowel resection. Digestion. 1978;18:329–36. Mitchell JE, Breuer RI, Zuckerman L, Berlin J, Schilli R, Dunn JK. The colon influences ileal resection diarrhea. Dig Dis Sci. 1980;25:33–41.
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