Endoscopic submucosal dissection (ESD) has emerged as a novel technique for achieving en bloc resection for superficial neoplasms limited to the mucosa. ESD was originally developed in Japan as a method of endoscopic resection of superficial gastric cancers. In our hospital, ESD has been used concurrently in other parts of the gastrointestinal tract, including the esophagus and colorectum from the beginning of its development. However, ESD in the duodenum is considered more challenging than other parts. From August 2005 to March 2008, a total of 15 superficial duodenal neoplastic lesions in 14 patients were treated with endoscopic resection. Of these, nine underwent ESD. We report our experience with duodenal ESD with a combination of ST hood and hook knife.

Our results indicate that higher stages are found in patients with GC using the OLGA staging system and that the high risk of GC can be recognized. It is simple to use and useful for the assessment of the severity of atrophic gastritis.

No abstract

The transnasal FICE system enables clear visualization of palisade vessels and provides better contrasting images of the demarcation between the BE mucosa and the gastric mucosa, and thus contributes to easier diagnosis of endoscopic BE.

No abstract

The demarcation line between the cancerous lesion and the surrounding area could be easily recognized with flexible spectral imaging color enhancement (FICE) system compared with conventional white light images. The characteristic finding of depressed-type early gastric cancer (EGC) in most cases was revealed as reddish lesions distinct from the surrounding yellowish noncancerous area without magnification. Conventional endoscopic images provide little information regarding depressed lesions located in the tangential line, but FICE produces higher color contrast of such cancers. Histological findings in depressed area with reddish color changes show a high density of glandular structure and an apparently irregular microvessel in intervening parts between crypts, resulting in the higher color contrast of FICE image between cancer and surrounding area. Some depressed cancers are shown as whitish lesion by conventional endoscopy. FICE also can produce higher color contrast between whitish cancerous lesions and surrounding atrophic mucosa. For nearly flat cancer, FICE can produce an irregular structural pattern of cancer distinct from that of the surrounding mucosa, leading to a clear demarcation. Most elevatedtype EGCs are detected easily as yellowish lesions with clearly contrasting demarcation. In some cases, a partially reddish change is accompanied on the tumor surface similar to depressed type cancer. In addition, the FICE system is quite useful for the detection of minute gastric cancer, even without magnification. These new contrasting images with the FICE system may have the potential to increase the rate of detection of gastric cancers and screen for them more effectively as well as to determine the extent of EGC.

A 74-year-old man with diabetic nephropathy developed epigastric pain and high fever after endoscopic submucosal dissection (ESD) for early gastric cancer. Gastroscopy, endoscopic ultrasonography and computed tomography showed ulceration with a purulent lake, thickened entire gastric mucosal layers suggesting focal abscess formation, leading to the diagnosis of phlegmonous gastritis. He underwent total gastrectomy as an emergency. Histological findings of the resected specimen showed severe inflammatory cell infiltration and multiple focal abscess formation spreading to the entire gastric wall. In patients with poorer general conditions, phlegmonous gastritis should be considered as a serious complication after ESD, indicating a requirement of antibiotic prophylaxis.

Small-caliber endoscopy with the FICE system provides better color contrast of depressed-type early gastric cancers than conventional small-caliber endoscopy, and the FICE system may facilitate the diagnosis of this type of cancer as a new endoscopic modality.