Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a two-channel colonoscope

CASE REPORTS Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a two-channel colonoscope Takahisa Matsuda, MD, Takahiro Fujii, MD, PhD, Fabian Emura, MD, PhD, Takahiro Kozu, MD, Yutaka Saito, MD, PhD, Hiroaki Ikematsu, MD, Daizo Saito, MD, PhD

EMR is indicated for the treatment of superficial, early stage colorectal cancer.1 The indications for EMR have expanded to include large tumors that spread laterally and circumferentially but that have a low risk of submucosal invasion, the so-called laterally spreading tumor (LST).2 However, massive submucosal invasion can occur with LSTs, and factors such as an uneven-nodular surface, large nodules, large size, and aggressive histopathologic type necessitate further evaluation.3 EMR has been performed as first-line treatment for LSTs based on these criteria and the pit pattern as determined by magnifying chromoendoscopy.4,5 Bleeding is the most common complication of EMR.6 It occurs in as many as 22% of cases; the risk is increased for lesions over 2 cm in size.7 To reduce the risk of complications, a new technique for immediate and complete closure of large mucosal defects was developed and is described by the following case report. CASE REPORT A 64-year-old man with a positive fecal occult blood test underwent colonoscopy, at which a protruded Is + IIa (LST-granular type) lesion, 40 3 40 mm in size, with uneven surface texture was detected in the lower rectum. It was slightly elevated and had a reddish surface. Chromoendoscopy with a high-magnification colonoscope (CF240ZI; Olympus Optical Co., Ltd., Tokyo, Japan) and indigo carmine (0.2%) dye demonstrated the surface character and margin of the lesion (Fig. 1). Staining with crystal violet (0.05%) revealed a Kudo type IV pit pattern8 and a noninvasive Fujii crypt pattern,4,9 thereby indicatCurrent affiliations: Gastrointestinal Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan, Takahiro Fujii Clinic, Tokyo, Japan. This report was an oral presentation at Digestive Diseases Week, May 7-22, 2003, Orlando, Florida (Gastrointest Endosc 2003; 57:SP165). Reprint requests: Takahisa Matsuda, MD, National Cancer Center Hospital, Gastrointestinal Endoscopy Division, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)02033-4 836

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Figure 1. Chromoendoscopic view (indigo carmine) showing uneven, 40 3 40 mm, flat-elevated lesion (Is + IIa) (LST, granular type) in distal rectum.

Figure 2. Endoscopic view after piecemeal resection, showing large defect (approximately 50 3 50 mm). ing the lesion to be suitable for endoscopic piecemeal resection. It was elevated by submucosal injection of approximately 20 mL of Glyceol (Chugai, Tokyo, Japan) and resected piecemeal with an electrosurgical snare. The margin of the defect was sprayed again with indigo carmine, and no residual tumor was evident. The post-resection defect was approximately 5 cm in diameter (Fig. 2) and was closed immediately by using the endoloop snare/metallic clip suture method and a twochannel colonoscope, (XCF-2TQ240Z; Olympus), which allowed simultaneous insertion of the endoloop (MAJ254; Olympus) and hemoclip applicator device (HX-5QR-1/ HX-600-090; Olympus). The endoloop snare was anchored with a clip to normal mucosa within 5 mm of the proximal resection margin. This maneuver was repeated to anchor the same endoloop snare at the distal resection margin (Fig. 3). The endoloop was tightened slightly, which approximated the borders of the defect. Two more endoloops were required to bring the margins together, and 3 more clips were placed to obtain complete closure (Fig. 4). There was no bleeding, and the patient experienced no discomfort during the procedure. He was discharged the following day without complication. VOLUME 60, NO. 5, 2004

Closure of a large defect after EMR of a colorectal tumor

Figure 3. Endoscopic view showing anchoring of endoloop snare at proximal and distal resection margins with metallic clips.

T Matsuda, T Fujii, F Emura, et al.

Figure 4. Endoscopic view showing complete closure of defect after application of 3 loop snare-endoclip sutures and placement of individual clips.

Figure 5. Schematic diagram of technique for complete closure of large mucosal defect when using two-channel colonoscope. A, Placement of clip and endoloop snare at proximal edge of defect. B, Endoloop snare anchored by endoclips at proximal and distal edges of defect. C, Approximation of borders of defect by tightening endoloop snare. D, Placement of individual endoclips to achieve complete closure.

Histopathologic evaluation of the resection specimen disclosed well-differentiated adenocarcinoma without lymphovascular involvement or submucosal invasion. All margins were free of tumor. Colonoscopy 6 months later revealed a healed scar and no tumor recurrence.

DISCUSSION Complications of EMR, such as bleeding, perforation, pain, and stricture formation, are more common with large lesions. Post-EMR bleeding may be immediate and/or delayed.6 Hemoclip application can be used to control post-polypectomy bleeding. VOLUME 60, NO. 5, 2004

However, accurate prediction of delayed bleeding remains difficult,10,11 and the risk of such bleeding is not fully known, especially for large mucosa defects that occur as a result of piecemeal EMR. Hemoclips have been used for endoscopic closure of EMR defects,10,12,13 although the diameter of the defect must be less than the width of the open clip. For this reason, it usually is impossible to close a defect caused by EMR of an LST with hemoclips. Thus, the endoloop/metallic clip method, which mimics a surgical suture, was developed (Fig. 5) for approximation of the borders and closure of large defects. GASTROINTESTINAL ENDOSCOPY

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M Hartel, M Wente, F Bergmann, et al.

Hurlstone and Lobo14 also described an endoscope technique for closure of large mucosal defects. However, their method requires two colonoscopes and, therefore, two colonoscopists, which makes it relatively impractical. Other techniques are not suitable for closure of large defects.15 The endoloop/metallic clip method is performed with a single two-channel colonoscope by a single operator and can be used to close large defects immediately after EMR. It technically was easy to close the large defect in the distal rectum in the present case, but further experience with its use in other segments of the GI tract is needed to demonstrate the general applicability of the method. Moreover, it has not been proven that the endoloop snare/metallic clip method decreases the frequency of hemorrhage caused by EMR. However, it is our belief that closure of the EMR-induced defect by approximation of the mucosa promotes rapid wound healing and shields the submucosal vessels from mechanical trauma, thereby reducing the potential for delayed bleeding. REFERENCES 1. Soetikno RM, Gotoda T, Nakanishi Y, Soehendra N. Endoscopic mucosal resection. Gastrointest Endosc 2003;57: 567-79. 2. Kudo S. Endoscopic mucosal resection of flat and depressed types of early colorectal cancer. Endoscopy 1993;25:455-61. 3. Saito Y, Fujii T, Kondo H, Mukai T, Yokota T, Kozu T, et al. Endoscopic treatment for laterally spreading tumors in the colon. Endoscopy 2001;33:682-6. 4. Fujii T, Hasegawa R, Saitoh Y, Fleisher D, Saito Y, Sano Y, et al. Chromoscopy during colonoscopy. Endoscopy 2001;33: 1036-41.

Large-cell neuroendocrine carcinoma of the major duodenal papilla: case report Mark Hartel, MD, Moritz N. Wente, MD, Frank Bergmann, MD, Jan Schmidt, MD, Markus W. Bu¨chler, MD, Helmut Friess, MD

For many years, neoplasms of the disseminated neuroendocrine cell system of the GI tract have been subsumed as ‘‘carcinoids.’’ However, because these tumors have a broad morphologic and biologic spectrum, this is no longer adequate.1 Instead, the Current affiliations: Department of General Surgery, Institute of Pathology, University of Heidelberg, Heidelberg, Germany. Reprint requests: Helmut Friess, MD, Department of General Surgery, University of Heidelberg, Im Neuenheimer Feld 110, D69120 Heidelberg, Germany. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)02034-6 838

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Large-cell neuroendocrine carcinoma of the major duodenal ampulla

5. Hurlstone DP, Fujii T, Lobo AJ. Early detection of colorectal cancer using high-magnification chromoscopic colonoscopy. Br J Surg 2000;89:272-82. 6. Parra-Blanco A, Kaminaga N, Kojima T, Endo Y, Uragami N, Okawa N, et al. Hemoclipping for postpolypectomy and postbiopsy colonic bleeding. Gastrointest Endosc 2000;51: 37-41. 7. Ahmad NA, Kochman ML, Long WB, Furth EE, Ginsberg GG. Efficacy, safety, and clinical outcomes of endoscopic mucosal resection: a study of 101 cases. Gastrointest Endosc 2002; 55:390-6. 8. Kudo S, Hirota S, Nakajima T, Hosobe S, Kusaka H, Kobayashi T, et al. Colorectal tumours and pit pattern. J Clin Pathol 1994;47:880-5. 9. Kato S, Fujii T, Koba I, Sano Y, Fu KI, Parra-Blanco A, et al. Assessment of colorectal lesions using magnifying colonoscopy and mucosal dye spraying: can significant lesions be distinguished? Endoscopy 2001;33:306-10. 10. Shioji K, Suzuki Y, Kobayashi M, Nakamura A, Azumaya M, Takeuchi M, et al. Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy. Gastrointest Endosc 2003;57:691-4. 11. Nguyen M, Soetikno R. Prophylactic clip application [letter]. Gastrointest Endosc 2003;58:941. 12. Kaneko T, Akamatsu T, Shimodaira K, Ueno T, Gotoh A, Mukawa K, et al. Nonsurgical treatment of duodenal perforation by endoscopic repair using a clipping device. Gastrointest Endosc 1999;50:410-3. 13. Tsunada S, Ogata S, Ohyama T, Ootani H, Oda K, Kikkawa A, et al. Endoscopic closure of perforations caused by EMR in the stomach by application of metallic clips. Gastrointest Endosc 2003;57:948-51. 14. Hurlstone DP, Lobo AJ. A new technique for endoscopic resection of large lateral spreading tumors of the colon: dual intubation colonoscopy with endoclip-assisted ‘‘loop suturing’’ method. Am J Gastroenterol 2002;97:2931-2. 15. Suzuki H, Ikeda K. Endoscopic mucosal resection and full thickness resection with complete defect closure for early gastrointestinal malignancies. Endoscopy 2001;33: 437-9.

latest World Health Organization (WHO) classification (2000) recommends that these tumors be differentiated into 3 types: (1) well-differentiated endocrine tumor (carcinoid), (2) well-differentiated endocrine carcinoma (malignant carcinoid), and (3) poorly differentiated endocrine carcinoma (small-cell carcinoma).2 Large-cell neuroendocrine carcinoma (LCNEC) arising at the major duodenal papilla is extremely rare, and differential diagnosis with respect to other neuroendocrine tumors is difficult.3,4 A case is presented that illustrates the difficulty of preoperative diagnosis, different possibilities for treatment and follow-up, and, especially, pitfalls. CASE REPORT A 44-year-old woman presented with painless jaundice, pruritus, and dark urine of 4 weeks’ duration. The medical history and the examination were unremarkable; there was no weight loss, sweating, or fever. Laboratory test results included: total bilirubin, 3.9 mg/dL VOLUME 60, NO. 5, 2004