A Multicenter Prospective Validation Study on Selective Endoscopic Resection of Sessile Serrated Lesions Using Magnifying Colonoscopy in Clinical Practice

INTRODUCTION

Sessile serrated lesions (SSLs) have malignant potential for colorectal cancer in the serrated pathway. Selective endoscopic resection of SSLs would reduce medical costs and procedure-related accidents, but the accurate endoscopic differentiation of SSLs from hyperplastic polyps (HPs) is challenging. To explore the differential diagnostic performance of magnifying colonoscopy in distinguishing SSLs from HPs, we conducted a multicenter prospective validation study in clinical practice.

METHODS

Considering the rarity of diminutive SSLs, all lesions ≥6 mm that were detected during colonoscopy and diagnosed as type 1 based on the Japan narrow-band imaging expert team (JNET) classification were included in this study. Twenty expert endoscopists were asked to differentiate between SSLs and HPs with high or low confidence level after conventional and magnifying NBI observation. To examine the validity of selective endoscopic resection of SSLs using magnifying colonoscopy in clinical practice, we calculated the sensitivity of endoscopic diagnosis of SSLs with histopathological findings as comparable reference.

RESULTS

A total of 217 JNET type 1 lesions from 162 patients were analyzed, and 114 lesions were diagnosed with high confidence. The sensitivity of magnifying colonoscopy in detecting SSLs was 79.8% (95% confidence interval [CI]: 74.7-84.4%) overall, and 82.4% (95% CI: 76.1-87.7%) in the high-confidence group. These results showed that the sensitivity of this study was not high enough, even limited in the high-confidence group.

CONCLUSIONS

Accurate differential diagnosis of SSLs and HPs using magnifying colonoscopy was challenging even for experts. JNET type 1 lesions ≥6 mm are recommended to be resected because selective endoscopic resection has a disadvantage of leaving approximately 20% of SSLs on site.

Efficacy of international web-based educational intervention in the detection of high-risk flat and depressed colorectal lesions higher (CATCH project) with a video: Randomized trial

OBJECTIVES

Three subcategories of high-risk flat and depressed lesions (FDLs), laterally spreading tumors non-granular type (LST-NG), depressed lesions, and large sessile serrated lesions (SSLs), are highly attributable to post-colonoscopy colorectal cancer (CRC). Efficient and organized educational programs on detecting high-risk FDLs are lacking. We aimed to explore whether a web-based educational intervention with training on FIND clues (fold deformation, intensive stool/mucus attachment, no vessel visibility, and demarcated reddish area) may improve the ability to detect high-risk FDLs.

METHODS

This was an international web-based randomized control trial that enrolled non-expert endoscopists in 13 Asian countries. The participants were randomized into either education or non-education group. All participants took the pre-test and post-test to read 60 endoscopic images (40 high-risk FDLs, five polypoid, 15 no lesions) and answered whether there was a lesion. Only the education group received a self-education program (video and training questions and answers) between the tests. The primary outcome was a detection rate of high-risk FDLs.

RESULTS

In total, 284 participants were randomized. After excluding non-responders, the final data analyses were based on 139 participants in the education group and 130 in the non-education group. The detection rate of high-risk FDLs in the education group significantly improved by 14.7% (66.6-81.3%) compared with -0.8% (70.8-70.0%) in the non-education group. Similarly, the detection rate of LST-NG, depressed lesions, and large SSLs significantly increased only in the education group by 12.7%, 12.0%, and 21.6%, respectively.

CONCLUSION

Short self-education focusing on detecting high-risk FDLs was effective for Asian non-expert endoscopists. (UMIN000042348).

Sporadic fundic gland polyps with dysplasia or carcinoma: Clinical and endoscopic characteristics

Fundic gland polyps (FGPs) are the most common gastric polyps and have been regarded as benign lesions with little malignant potential, except in the setting of familial adenomatous polyposis. However, in recent years, the prevalence of FGPs has been increasing along with the widespread and frequent use of proton pump inhibitors (PPIs). To date, several cases of FGPs with dysplasia or carcinoma (FGPD/CAs) have been reported. In this review, we evaluated the clinical and endoscopic characteristics of sporadic FGPD/CAs. Majority of the patients with sporadic FGPD/CAs were middle-aged women receiving PPI therapy and without Helicobacter pylori (H. pylori) infection. Majority of the sporadic FGPD/ CAs occurred in the body of the stomach and were sessile and small with a mean size of 5.4 mm. The sporadic FGPs with carcinoma showed redness, irregular surface structure, depression, or erosion during white light observation and irregular microvessels on the lesion surface during magnifying narrow-band imaging. In addition, sporadic FGPs, even with dysplasia, are likely to progress to cancer slowly. Therefore, frequent endoscopy is not required for patients with sporadic FGPs. However, histopathological evaluation is necessary if endoscopic findings different from ordinary FGPs are observed, regardless of their size. In the future, the prevalence of FGPs is expected to further increase along with the widespread and frequent use of PPIs and decreasing infection rate of H. pylori. Currently, it is unclear whether FGPD/CAs will also increase in the same way as FGPs. However, the trends of these lesions warrant further attention in the future.

Serrated polyps of the colon and rectum: Remove or not?

In recent years, the serrated neoplasia pathway where serrated polyps arise as a colorectal cancer has gained considerable attention as a new carcinogenic pathway. Colorectal serrated polyps are histopathologically classified into hyperplastic polyps (HPs), sessile serrated lesions, and traditional serrated adenomas; in the serrated neoplasia pathway, the latter two are considered to be premalignant. In western countries, all colorectal polyps, including serrated polyps, apart from diminutive rectosigmoid HPs are removed. However, in Asian countries, the treatment strategy for colorectal serrated polyps has remained unestablished. Therefore, in this review, we described the clinicopathological features of colorectal serrated polyps and proposed to remove HPs and sessile serrated lesions ≥ 6 mm in size, and traditional serrated adenomas of any size.

Clinical importance of cold polypectomy during the insertion phase in the left side of the colon and rectum: a multicenter randomized controlled trial (PRESECT study)

BACKGROUND AND AIMS

Colorectal polyps are often detected during the insertion phase of colonoscopy but are commonly removed during the withdrawal phase. We aimed to investigate the clinical advantages of instant removal of colorectal polyps during the insertion phase to determine the appropriate strategy for polyps detected on insertion.

METHODS

This prospective, multicenter, randomized trial targeted patients with at least 1 left-sided polyp <10 mm in size detected unintentionally on endoscope insertion from April 2018 to March 2019. Patients were allocated to the following 2 groups: study group, consisting of patients who had polyp removal instantly on insertion, and control group, comprising patients who had the endoscope inserted to the cecum first and polyps removed subsequently on withdrawal. Carbon dioxide gas insufflation and cold polypectomy were applied to minimize the influences of polypectomy on endoscope insertion. Twenty advanced endoscopists from 7 community-based institutions participated in this trial.

RESULTS

Of 1451 patients enrolled, 220 patients were eligible for full assessment. Mean total procedure time was significantly shorter in the study group (18.9 vs 22.3 minutes, P < .001). Mean pure cecal intubation time and number of polyps per patient were similar between the 2 groups. In the control group, among 107 polyps found during insertion, 48 (45.8%) required reinspection and 7 (6.5%) were completely missed, with an average reinspection time of approximately 3 minutes.

CONCLUSIONS

Polypectomy during the insertion phase in the colon and rectum significantly shortens the total procedure time and eliminates all missed polyps without experiencing any disadvantages.

[A Case of Histological Complete Remission after Chemotherapy for Paraaortic Lymph Node Recurrence after Colon Cancer Surgery]

In September 2013, a 50-year-old woman presented to our hospital with right abdominal pain as the main complaint. Careful examinations led to the diagnosis of ascending colon cancer. In October 2013, resection of the right half colon and removal of the D3 lymph nodes were performed. As postoperative adjunctive chemotherapy, 6 courses of CAPOX therapy were initiated. PET-CT conducted 17 months after the surgery revealed an enlarged right para-aoric lymph nodes and abnormal FDG accumulation. Lymph node recurrence was diagnosed. In April 2015, 10 courses of CAPOX plus BEV therapy, followed by 12courses of capecitabine single agent, were initiated. PET-CT revealed complete remission of the right para-aoric lymph nodes. However, abnormal FDG accumulation was detected in the right ovary and uterine corpus. After careful examinations in March 2017, we performed expanded total hysterectomy, bilateral resection of the appendicular organs, resection of body reticular region, and removal of the lymph nodes and those at the right side of the aorta for the ovarian and uterine cancer. Pathologically, intimal cancer in the right ovary and uterine corpus was diagnosed. Examination of the right para-aoric lymph nodes resected at the same time showed complete remission on images, although histological complete remission was found with scarring. Currently, 63 months after the initial surgery, the patient is alive without recurrence.

[Two Cases of Locally Advanced Rectal Cancer and Lower Rectal Cancer Resected Successfully That Enabled Anus Preservation after Preoperative Chemotherapy]

We reported 2 cases of colorectal cancer receiving neoadjuvant chemotherapy(NAC)with the aim of curative resection or anal preservation. Case 1: A 50-year-old man was diagnosed with locally advanced rectal cancer with sacral invasion. Because of the sacral invasion, we performed preoperative chemotherapy. He was treated with 12 courses of CapeOX plus Bmab and 3 courses of capecitabine plus radiation therapy(45 Gy in total). After chemoradiation therapy, a lower anterior resection was performed. The pathological finding was pT3pN0pM0, pStage Ⅱ. Case 2: A 69-year-old man was diagnosed with lower rectal cancer. Colonoscopy revealed a tumor near the dentate line. Because the patient desired anal preservation, we performed preoperative chemotherapy. He was treated with IRIS plus Bmab. After 3 courses of chemotherapy, the tumor had reduced in size. The pathological findings were no residual tumor cell, pN0. In our hospital, we have preserved the anus in 2 patients after NAC. Including the above 2 cases, we have performed curative resection in 7 cases. The mean observation period after surgery was 30 months; 1 case died from cancer recurrence(41 months after resection)and other 6 cases lived without cancer relapse.

Clinical and endoscopic evaluations of sessile serrated adenoma/polyps with cytological dysplasia

BACKGROUND AND AIM

Although sessile serrated adenoma/polyps (SSA/Ps) are considered to be premalignant lesions and rapidly progress to carcinomas after they develop cytological dysplasia (CD), a treatment strategy for SSA/Ps in Asian countries is still being debated and has not yet been established. The present study aimed to propose a treatment strategy for SSA/Ps.

METHODS

Histopathological data of patients, who underwent colonoscopy at our center between January 2011 and December 2016, were reviewed. Data of patients with ≥ 1 SSA/P were retrieved, and clinicopathological characteristics were retrospectively analyzed.

RESULTS

A total of 281 patients with 326 SSA/Ps, including 258 patients who had 300 SSA/Ps without CD (SSA/Ps-CD[-]) and 23 patients who had 26 SSA/Ps with CD (SSA/Ps-CD[+]), were evaluated in this study. Although SSA/Ps-CD(+) were often found in older female patients and in the proximal colon, there were no significant differences between SSA/Ps-CD(-) and SSA/Ps-CD(+). Endoscopic morphological findings, such as large or small nodules on the surface and partial protrusion of the lesions, were significantly more common in SSA/Ps-CD(+) than in SSA/Ps-CD(-). Although the diagnostic ability of nodule/protrusion in lesions to predict CD within SSA/Ps was very high with an accuracy of 93.9% and a negative predictive value of 95.4%, sensitivity was low at 46.2%. SSA/Ps-CD(+) were significantly larger than SSA/Ps-CD(-), and the rate of CD within SSA/Ps significantly increased with lesion size (≤ 5 mm, 0%; 6-9 mm, 6.0%; ≥ 10 mm, 13.6%).

CONCLUSION

The study proposes removing all SSA/Ps ≥ 6 mm in order to remove high-risk SSA/Ps-CD(+), with high sensitivity.

Prospective real-time evaluation of diagnostic performance using endocytoscopy in differentiating neoplasia from non-neoplasia for colorectal diminutive polyps (≤ 5 mm)

AIM

To clarify the diagnostic performance of endocytoscopy for differentiation between neoplastic and non-neoplastic colorectal diminutive polyps.

METHODS

Patients who underwent endocytoscopy between October and December 2016 at Sano Hospital were prospectively recruited. When diminutive polyps (≤ 5 mm) were detected, the lesions were evaluated by endocytoscopy after being stained with 0.05% crystal violet and 1% methylene blue. The diminutive polyps were classified into five categories (EC 1a, 1b, 2, 3a, and 3b). Endoscopists were asked to take a biopsy from any lesion diagnosed as EC1b (indicator of hyperplastic polyp) or EC2 (indicator of adenoma). We have assessed the diagnostic performance of endocytoscopy for EC2 and EC1b lesions by comparison with the histopathology of the biopsy specimen.

RESULTS

A total of 39 patients with 63 diminutive polyps were analyzed. All polyps were evaluated by endocytoscopy. The mean polyp size was 3.3 ± 0.9 mm. Among the 63 diminutive polyps, 60 were flat and 3 were pedunculated. The mean time required for EC observation, including the time for staining with crystal violet and methylene blue, was 3.0 ± 1.9 min. Histopathologic evaluation showed that 13 polyps were hyperplastic and 50 were adenomas. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of EC2 for adenoma compared with EC1b for hyperplastic polyp were 98.0%, 92.3%, 96.8%, 98.0% and 92.3%, respectively. There were only two cases of disagreement between the endoscopic diagnosis made by endocytoscopy and the corresponding histopathological diagnosis.

CONCLUSION

Endocytoscopy showed a high diagnostic performance for differentiating between neoplastic and non-neoplastic colorectal diminutive polyps, and therefore has the potential to be used for “real-time histopathology”.

Additional chromoendoscopy for colorectal lesions initially diagnosed with low confidence by magnifying narrow-band imaging: Can it improve diagnostic accuracy?

BACKGROUND AND AIM

Magnifying chromoendoscopy has been one of the most reliable diagnostic methods for distinguishing neoplastic from non-neoplastic lesions. The aim of this prospective study was to clarify the clinical usefulness of magnifying chromoendoscopy for colorectal polyps initially diagnosed with low confidence (LC) by magnifying narrow-band imaging (NBI).

METHODS

Consecutive adult patients who underwent total colonoscopic examination with magnifying NBI between July and December 2016 at Sano Hospital were prospectively recruited. Endoscopists were asked to carry out additional magnifying chromoendoscopy for cases that had been initially diagnosed as Japan NBI Expert Team (JNET) Type 1 or 2A with LC by magnifying NBI. We investigated the diagnostic performance of magnifying NBI for polyps diagnosed as JNET Type 1 or 2A with LC (first phase) and that of subsequent magnifying chromoendoscopy (second phase) in differentiating neoplasia from non-neoplasia.

RESULTS

In 50 patients, we analyzed 53 polyps classified as JNET Type 1 or 2A with LC prediction. Accuracy and negative predictive value of magnifying NBI (first phase) were 58.5% (95% CI, 44.1-71.9%) and 66.0% (95% CI, 36.6-77.9%), and those of magnifying chromoendoscopy (second phase) were 66.0% (95% CI, 51.7-78.5%) and 61.1% (95% CI, 43.5-76.9%), respectively.

CONCLUSION

Regardless of the findings of additional chromoendoscopy, all polyps should be resected and submitted for histopathological examination when the confidence level in differentiating adenomatous from hyperplastic polyps by magnifying NBI is low.

Post-colonoscopy colorectal cancer rate in the era of high-definition colonoscopy

AIM

To investigate the post-colonoscopy colorectal cancer (PCCRC) rate for high-definition (HD) colonoscopy compared with that for standard-definition colonoscopy reported previously.

METHODS

Using medical records at Sano Hospital (SH) and Dokkyo Medical University Koshigaya Hospital (DMUKH), we retrospectively obtained data on consecutive patients diagnosed as having CRC between January 2010 and December 2015. The definition of PCCRC was diagnosis of CRC between 7 and 36 mo after initial high-definition colonoscopy that had detected no cancer, and patients were divided into a PCCRC group and a non-PCCRC group. The primary outcome was the rate of PCCRC for HD colonoscopy. The secondary outcomes were factors associated with PCCRC and possible reason for occurrence of early and advanced PCCRC.

RESULTS

Among 892 CRC patients, 11 were diagnosed as having PCCRC and 881 had non-PCCRC. The PCCRC rate was 1.7% (8/471) at SH and 0.7% (3/421) at DMUKH. In comparison with the non-PCCRC group, the PCCRC group had a significantly higher preponderance of smaller tumors (39 mm vs 19 mm, P = 0.002), a shallower invasion depth (T1 rate, 25.4% vs 63.6%, P = 0.01), a non-polypoid macroscopic appearance (39.0% vs 85.7%, P = 0.02) and an earlier stage (59.7% vs 90.9%, P = 0.03). Possible reasons for PCCRC were “missed or new” in 9 patients (82%), “incomplete resection” in 1 (9%), and “inadequate examination’” in 1 (9%). Among 9 “missed or new” PCCRC, the leading cause was non-polypoid shape for early PCCRC and blinded location for advanced PCCRC.

CONCLUSION

The PCCRC rate for HD colonoscopy was 0.7%-1.7%, being lower than that for standard-definition colonoscopy (1.8%-9.0%) reported previously employing the same methodology.

Nonempirical Calculation of Superconducting Transition Temperatures in Light-Element Superconductors

Recent progress in the fully nonempirical calculation of the superconducting transition temperature (T_c ) is reviewed. Especially, this study focuses on three representative light-element high-T_c superconductors, i.e., elemental Li, sulfur hydrides, and alkali-doped fullerides. Here, it is discussed how crucial it is to develop the beyond Migdal-Eliashberg (ME) methods. For Li, a scheme of superconducting density functional theory for the plasmon mechanism is formulated and it is found that T_c is dramatically enhanced by considering the frequency dependence of the screened Coulomb interaction. For sulfur hydrides, it is essential to go beyond not only the static approximation for the screened Coulomb interaction, but also the constant density-of-states approximation for electrons, the harmonic approximation for phonons, and the Migdal approximation for the electron-phonon vertex, all of which have been employed in the standard ME calculation. It is also shown that the feedback effect in the self-consistent calculation of the self-energy and the zero point motion considerably affect the calculation of T_c . For alkali-doped fullerides, the interplay between electron-phonon coupling and electron correlations becomes more nontrivial. It has been demonstrated that the combination of density functional theory and dynamical mean field theory with the ab initio downfolding scheme for electron-phonon coupled systems works successfully. This study not only reproduces the experimental phase diagram but also obtains a unified view of the high-T_c superconductivity and the Mott-Hubbard transition in the fullerides. The results for these high-T_c superconductors will provide a firm ground for future materials design of new superconductors.

Possible "Magnéli" Phases and Self-Alloying in the Superconducting Sulfur Hydride

We theoretically give an infinite number of metastable crystal structures for the superconducting sulfur hydride H_{x}S under pressure. Previously predicted crystalline phases of H_{2}S and H_{3}S have been thought to have important roles for experimentally observed low and high T_{c}, respectively. The newly found structures are long-period modulated crystals where slablike H_{2}S and H_{3}S regions intergrow on a microscopic scale. The extremely small formation enthalpy for the H_{2}S-H_{3}S boundary indicated by first-principles calculations suggests possible alloying of these phases through the formation of local H_{3}S regions. The modulated structures and gradual alloying transformations between them not only explain the peculiar pressure dependence of T_{c} in sulfur hydride observed experimentally, but also could prevail in the experimental samples under various compression schemes.

Postherpetic pseudohernia: delayed onset of paresis of abdominal muscles due to herpes zoster causing an ipsilateral abdominal bulge

Postherpetic pseudohernia causes an abdominal bulge as well as an abdominal wall herniation. This disease is one of the neurological complications of herpes zoster and essentially consists of paresis of ipsilateral abdominal muscles. Postherpetic pseudohernia may be mistaken for abdominal wall herniation because it is not well known. We describe two cases presenting an abdominal bulge. The ipsilateral abdominal bulge appeared after recovery from abdominal zoster. Abdominal CT showed no evidence of a herniation or mass. We diagnosed a postherpetic pseudohernia. One of the patients recovered spontaneously 4 months after the onset, and the other partially recovered after 2 months. This disease can be expected to disappear spontaneously, unlike abdominal herniation requiring surgery. It has been reported that 79.3% of patients eventually recovered spontaneously. For surgeons and general practitioners, it is beneficial to keep this disease in mind when examining a patient presenting an abdominal bulge.

Colorectal cancer screening of the general population in East Asia

In recent years, the incidence of colorectal cancer (CRC) has been increasing, and CRC has been becoming the major cause of cancer deaths in Asian countries. Therefore, an organized screening program to reduce CRC incidence and mortality is currently implemented in each country. In the present review, we summarize the current status and future perspectives of CRC screening of the general population in East Asian and South-East Asian countries. The fecal occult blood test is widely used for CRC screening in these countries, and its effectiveness in reducing CRC incidence and mortality has been demonstrated; however, the low participation rate in CRC screening programs is a problem to be solved in every country. Improvement in the public awareness of CRC and promotion of CRC screening by physicians will help to raise the participation rate and reduce the number of deaths caused by CRC. Regarding screening colonoscopy, several studies have recently demonstrated its effectiveness in reducing CRC incidence and mortality. However, at present, CRC screening colonoscopy is not adopted as a primary population-based screening tool because of staffing constraints in relation to large population sizes, increased medical costs, and potential adverse events (e.g., perforation and drug-induced anaphylaxis). Further study is required to consider colonoscopy as CRC screening that is established in Western countries.

Polyp Detection, Characterization, and Management Using Narrow-Band Imaging with/without Magnification

Narrow-band imaging (NBI) is a new imaging technology that was developed in 2006 and has since spread worldwide. Because of its convenience, NBI has been replacing the role of chromoendoscopy. Here we review the efficacy of NBI with/without magnification for detection, characterization, and management of colorectal polyps, and future perspectives for the technology, including education. Recent studies have shown that the next-generation NBI system can detect significantly more colonic polyps than white light imaging, suggesting that NBI may become the modality of choice from the beginning of screening. The capillary pattern revealed by NBI, and the NBI International Colorectal Endoscopic classification are helpful for prediction of histology and for estimating the depth of invasion of colorectal cancer. However, NBI with magnifying colonoscopy is not superior to magnifying chromoendoscopy for estimation of invasion depth. Currently, therefore, chromoendoscopy should also be performed additionally if deep submucosal invasive cancer is suspected. If endoscopists become able to accurately estimate colorectal polyp pathology using NBI, this will allow adenomatous polyps to be resected and discarded; thus, reducing both the risk of polypectomy and costs. In order to achieve this goal, a suitable system for education and training in in vivo diagnostics will be necessary.

[Two Cases of Rectal Cancer Resected Curatively after Chemotherapy with CapeOX plus Bmab]

We report 2 cases of locally far-advanced rectosigmoid cancer that were initially unresectable, but were successfully excised after treatment with CapeOX plus Bmab chemotherapy(capecitabine, L-OHP, and bevacizumab). Case 1: A 72-year-old man who complained of severe constipation initially received sigmoid colostomy because of far-advanced rectosigmoid cancer. After 4 courses of CapeOX plus Bmab chemotherapy administration, the size of the primary tumor remarkably decreased and curative resection could be performed. There has been no signs of recurrence for 27 months. Case 2: A 73-year-old man who complained of tenesmus initially received ileostomy because of far-advanced rectosigmoid cancer that directly invaded the appendix, ileum, and urinary bladder. After he received 3 courses of CapeOX plus Bmab chemotherapy, the primary tumor was found to have shrunk remarkably. Therefore, surgery was performed and the tumor was resected curatively. From these experiences, we conclude that some patients with locally far-advanced colorectal cancer can be treated effectively with CapeOX plus Bmab chemotherapy in a neoadjuvant setting.

Prospective evaluation of the proportion of sessile serrated adenoma/polyps in endoscopically diagnosed colorectal polyps with hyperplastic features

BACKGROUND AND STUDY AIMS

Sessile serrated adenoma/polyps (SSA/Ps) are considered precursors of colorectal cancers with microsatellite instability. However, it is still difficult to differentiate SSA/Ps from hyperplastic polyps endoscopically; therefore, the prevalence of SSA/Ps remains uncertain in clinical practice. This study aimed to clarify the proportion of SSA/Ps in endoscopically diagnosed colorectal polyps with hyperplastic features (E-HPs).

PATIENTS AND METHODS

Patients aged ≥ 40 years undergoing colonoscopy for standard clinical indications at our center were prospectively enrolled between June 2013 and May 2014. During colonoscopy, 0.05 % indigo carmine dye was sprayed throughout the colorectum to highlight lesions. All detected lesions were diagnosed by high definition magnifying narrow-band imaging and were resected endoscopically or surgically, apart from rectosigmoid E-HPs ≤ 5 mm. The number of rectosigmoid E-HPs ≤ 5 mm was recorded, and some were resected for use as tissue samples.

RESULTS

A total of 343 patients (male: 42.9 %; mean age: 61.5 years) were included. Among 3838 E-HPs (distal: 96.4 %) detected in 294 patients, 792 were resected and analyzed. All of 21 SSA/Ps identified in 17 patients were included in E-HPs, and the overall proportion of SSA/Ps in E-HPs was 2.7 %. However, this proportion increased with the size of E-HPs (≤ 5 mm: 0.7 %; 6 - 9 mm: 29.0 %; ≥ 10 mm: 70 %) and was higher in the proximal colon than in the distal colorectum (10.9 % vs. 0.9 %). In addition, no SSA/P was found in the rectum, and no SSA/P had cytological dysplasia.

CONCLUSIONS

The overall proportion of SSA/Ps in E-HPs was 2.7 %, although this proportion was higher in the proximal colon and increased with the size of E-HPs. SSA/Ps were common in routine colonoscopy, with a prevalence of at least 5.0 %.

STUDY REGISTRATION

UMIN000010832.

The addition of high magnifying endoscopy improves rates of high confidence optical diagnosis of colorectal polyps

BACKGROUND AND STUDY AIMS

The real-time optical diagnosis of colorectal polyps with high confidence predictions can achieve high levels of accuracy. Increasing the rates of high confidence optical diagnosis can improve the clinical application of real-time optical diagnosis in routine practice. The primary aim of this prospective study was to evaluate whether high magnifying endoscopy improves the rates of high confidence narrow-band imaging (NBI) - based optical diagnosis for differentiating between neoplastic and non-neoplastic colorectal lesions according to the NBI international colorectal endoscopic (NICE) classification.

PATIENTS AND METHODS

Consecutive adult patients undergoing colonoscopy with a high magnifying (maximum, × 80) colonoscope between April and August 2012 were recruited. The optical diagnosis for each polyp was evaluated during colonoscopy in two consecutive stages by the same endoscopist, who first used NBI with non-magnifying endoscopy (NBI-NME), then NBI with magnifying endoscopy (NBI-ME). A level of confidence was assigned to each prediction.

RESULTS

The analysis included 124 patients (mean age, 56.4 years; male-to-female ratio, 72:52) with 248 polyps smaller than 10 mm. Of the 248 polyps, 210 were 1 to 5 mm in size and 38 were 6 to 9 mm in size; 77 polyps were hyperplastic, 4 were sessile serrated adenomas/polyps, 160 were low grade adenomas, 5 were high grade adenomas, and 2 were deep submucosal invasive carcinomas. The rate of high confidence optical diagnosis when NBI-ME was used was significantly higher than the rate when NBI-NME was used for diminutive (1 - 5 mm) polyps (92.9 % vs 79.5 %, P < 0.001) and for small (6 - 9 mm) polyps (94.7 % vs 84.2 %, P = 0.048).

CONCLUSION

High magnifying endoscopy significantly improved the rates of high confidence NBI-based optical diagnosis of diminutive and small colorectal polyps.

STUDY REGISTRATION

UMIN 000007608.

Narrow-band imaging observation of colorectal lesions using NICE classification to avoid discarding significant lesions

AIM: To assess the risk of failing to detect diminutive and small colorectal cancers with the “resect and discard” policy.

METHODS: Patients who received colonoscopy and polypectomy were recruited in the retrospective study. Probable histology of the polyps was predicted by six colonoscopists by the use of NICE classification. The incidence of diminutive and small colorectal cancers and their endoscopic features were assessed.

RESULTS: In total, we found 681 cases of diminutive (1-5 mm) lesions in 402 patients and 197 cases of small (6-9 mm) lesions in 151 patients. Based on pathology of the diminutive and small polyps, 105 and 18 were non-neoplastic polyps, 557 and 154 were low-grade adenomas, 18 and 24 were high-grade adenomas or intramucosal/submucosal (SM) scanty invasive carcinomas, 1 and 1 were SM-d carcinoma, respectively. The endoscopic features of invasive cancer were classified as NICE type 3 endoscopically.

CONCLUSION: The risk of failing to detect diminutive and small colorectal invasive cancer with the “resect and discard” strategy might be avoided through the use of narrow-band imaging observation with the NICE classification scheme and magnifying endoscopy.

Minimal incision transinguinal repair for incarcerated obturator hernia

BACKGROUND

Patients with incarcerated obturator hernia are usually elderly, frail, and physically inactive women with serious comorbidities. Although a laparotomy is standard surgical intervention for emergency incarcerated or strangulated obturator hernia, it is invasive particularly for these high-risk patients. The aim of this study is to show the feasibility of minimum open inguinal approach to reduce surgical risk for preoperatively diagnosed incarcerated obturator hernia.

METHODS

Between April 2008 and July 2012, 3 consecutive incarcerated obturator hernia patients at Kamitsuga General Hospital who were diagnosed preoperatively by computed tomography underwent the following procedure. First a 4 cm inguinal hernia incision and preperitoneal dissection through the opening of the deep inguinal ring are made. The obturator hernia can be easily found 2 cm dorsally from the Cooper's ligament extraperitoneally. A small incision is made at medial sharp edge of the hernia defect. The hernia sac and its content can then be reduced. If the incarcerated bowel is viable, a prosthetic mesh is placed as a patch. If the bowel is necrotic, the damaged bowel loop is withdrawn through the wound and easily reconstructed extra-abdominally.

RESULTS

All operations were successfully completed with this procedure. All patients recovered without incident.

CONCLUSIONS

Minimal incision transinguinal repair for diagnosed incarcerated obturator hernia is feasible and provides an improved option to more invasive procedures.

Enhanced persistency of resting and active periods of locomotor activity in schizophrenia

Patients with schizophrenia frequently exhibit behavioral abnormalities associated with its pathological symptoms. Therefore, a quantitative evaluation of behavioral dynamics could contribute to objective diagnoses of schizophrenia. However, such an approach has not been fully established because of the absence of quantitative biobehavioral measures. Recently, we studied the dynamical properties of locomotor activity, specifically how resting and active periods are interwoven in daily life. We discovered universal statistical laws ("behavioral organization") and their alterations in patients with major depressive disorder. In this study, we evaluated behavioral organization of schizophrenic patients (n = 19) and healthy subjects (n = 11) using locomotor activity data, acquired by actigraphy, to investigate whether the laws could provide objective and quantitative measures for a possible diagnosis and assessment of symptoms. Specifically, we evaluated the cumulative distributions of resting and active periods, defined as the periods with physical activity counts successively below and above a predefined threshold, respectively. Here we report alterations in the laws governing resting and active periods; resting periods obeyed a power-law cumulative distribution with significantly lower parameter values (power-law scaling exponents), whereas active periods followed a stretched exponential distribution with significantly lower parameter values (stretching exponents), in patients. Our findings indicate enhanced persistency of both lower and higher locomotor activity periods in patients with schizophrenia, probably reflecting schizophrenic pathophysiology.

NBI and NBI Combined with Magnifying Colonoscopy

Although magnifying chromoendoscopy had been a reliable diagnostic tool, narrow-band imaging (NBI) has been developed in Japan since 1999 and has now replaced the major role of chromoendoscopy because of its convenience and simplicity. In this paper, we principally describe the efficacy of magnifying chromoendoscopy and magnifying colonoscopy with NBI for detection, histological prediction, estimation of the depth of early colorectal cancer, and future prospects. Although some meta-analyses have concluded that NBI is not superior to white light imaging for detection of adenomatous polyps in screening colonoscopy, NBI with magnification colonoscopy is useful for histological prediction, or for estimating the depth of invasion. To standardize these diagnostic strategies, we will focus on the NBI International Colorectal Endoscopic (NICE) classification proposed for use by endoscopists with or without a magnifying endoscope. However, more prospective research is needed to prove that this classification can be applied with satisfactory availability, feasibility, and reliability. In the future, NBI might contribute to the evaluation of real-time histological prediction during colonoscopy, which has substantial benefits for both reducing the risk of polypectomy and saving the cost of histological evaluation by resecting and discarding diminutive adenomatous polyps (resect and discard strategy).

A case report of undifferentiated carcinoma with osteoclast-like giant cells of the pancreas and literature review

Osteoclast-like giant cell tumors rarely arise in the pancreas. Here we report the case of a 78-year-old woman who was diagnosed with a well-defined 3 cm multilocular mass in the pancreatic body by the use of ultrasonography, computed tomography and magnetic resonance imaging. The rim and the septa of the tumor were well enhanced. The distal pancreas was removed with the spleen and the peripancreatic lymph nodes. Macroscopically, the mass was composed predominantly of a multilocular cystic tumor filled with hemorrhagic necrosis, and partly composed of solid components. A histopathological study showed a proliferation of multinucleated osteoclast-like giant cells and spindle cells. Although the predominant tumor cells were strongly positive for vimentin and CD68 and negative for epithelial markers, there were some sparsely scattered cytokeratin-positive neoplastic glands. Seventeen months after surgery, the patient is still alive and has had no recurrence. Below we review 32 cases of osteoclast-like giant cell tumor of the pancreas that have been reported in English literature since 2000.

[Complete histological response in gastric cancer stage IV after neoadjuvant chemotherapy including S-1 combined with CDDP--report of a case]

A 60-year-old man complaining of black stool, body weight loss, and anemia, was examined and diagnosed with advanced gastric cancer (M, type 3, por 2, cT3, cN3, cH0, cP0, cM0, cStage IV). A poor prognosis was predicted, yet we tried neoadjuvant chemotherapy (NAC) expecting downstaging of the tumor. Considering the efficacy and safety, we chose S-1+CDDP as the NAC regimen. S-1 (120 mg/day) was administered orally for 21 days, followed by CDDP (75 mg/body) div on day 8. Distal partial gastrectomy and lymph node dissection (D2) were performed, with Billroth I reconstruction. Histological examination of the resected stomach and lymph nodes revealed no residual cancer cells, suggesting complete histological remission (grade 3) according to the Japanese classification of gastric carcinoma.

[A case of localized AL-type amyloidosis of the stomach]

A 78-year-old woman was admitted to our hospital for treatment of liver cirrhosis and an esophageal varix. Endoscopy revealed a protruding nodular lesion with a transparent smooth surface proximal to the pylorus, which was accompanied by a partly yellow-whitish spot. A depressed lesion with an even edge was found. Histologically, the protruding lesion and depressed lesion showed amyloid deposits, mainly in the mucosal layer. The lesions were found to correspond to AL type amyloidosis by immunochemical analysis. General examination showed no other amyloid deposits. Thus, we diagnosed localized amyloidosis of the stomach.

Simple way to improve accuracy in diagnosis of quadrant inflammatory disease: how to avoid adverse laparotomy by using plain CT

BACKGROUND/AIMS

It has been reported that contrast computed tomography (CT) provides a rapid and accurate diagnosis of acute appendicitis, and could potentially prevent adverse appendectomy. In the present study, we evaluated the diagnostic value of precontrast CT combined with that of serum C reactive protein (CRP) concentration for right lower quadrant inflammatory diseases.

METHODOLOGY

One hundred consecutive patients who had rebound tenderness and muscular rigidity or guarding on right lower quadrant underwent an emergency abdominal CT without contrast medium and laboratory tests. Based on the CT findings, 10 patients with peritonitis and 41 patients with definite acute appendicitis underwent emergency operations. Of 19 patients with negative CT findings, 11 patients who had positive CRP levels also underwent emergency appendectomies. The remaining patients, of whom 8 had negative CRP levels and 30 had CT findings of other inflammatory diseases, underwent conservative therapy and were examined again later on.

RESULTS

The final diagnosis was acute appendicitis in 58 cases, other intestinal diseases in 21, gynecological disease in 6, urolithiasis in 1, and unknown in 14. Among 86 patients who underwent emergency operations and had a pathological diagnosis, CT had a sensitivity of 81% for the diagnosis of appendicitis, with a specificity of 89%, and an accuracy of 84%. CT combined with serum CRP concentration yielded a sensitivity of 100%, an accuracy of 97%, and a specificity of 89%. The adverse appendectomy rate was 3%. None of the patients underwent a delayed appendectomy. CT differentiated other inflammatory diseases from acute appendicitis in 23 patients.

CONCLUSIONS

It may be concluded that precontrast CT scan combined with serum CRP can provide a rapid and accurate diagnosis of acute appendicitis and other right lower quadrant inflammatory diseases.

Changes in immune function following surgery for esophageal carcinoma

Changes in immune function due to surgical injury have been well-documented. Immunosuppression is one of the causes of infectious complications leading to organ dysfunction in critical illness. It is not known what kind of surgery in the daily clinical practice causes immunosuppression. Stress response and immune function following surgery for esophageal carcinoma, assuming a highly-stressed operation, were studied and then compared with the stress response and immune function following gastric surgery, a moderately-stressed procedure. Forty patients who underwent esophagectomy and 39 patients receiving gastric operation were studied. The concentrations of serum interleukin-6 (IL-6) were measured preoperatively, at 1, 2, and 6 h, and at 1, 3, and 10 d after operation. Total protein, serum albumin, rapid turnover protein, serum CRP, and cortisol were measured before operation and at 1, 3, 7, and 21 d after operation. ConA- and PHA-stimulated lymphocyte proliferation, IgA, IgG, and IgM were also measured preoperatively, and on 7 and 21 d following surgery. The patients were fed exclusively by total parenteral nutrition (TPN). A striking rise of IL-6 was observed, with a peak in both groups at 1 to 6 h following operation. The peak values were 419+/-30 pg/mL, which was approximately twice as high in the esophagectomy patients as in the gastrectomy patients (195+/-40 pg/mL). CRP and cortisol also increased after operation, and these increases were also significantly greater in the esophagectomy patients. ConA- and PHA-stimulated lymphocyte proliferation decreased significantly 7 d after esophagectomy (P<0.05), but was unchanged in the patients receiving gastrectomy. Suppression of cellular immunity correlated significantly with serum cortisol, and was preceded by a rise in serum IL-6. The IgA, IgG, and IgM levels, however, remained unchanged from their preoperative values throughout the study in both groups. Nutritional status in terms of serum protein, albumin, and rapid turnover protein, decreased postoperatively, but there was no difference between the two groups. It is, therefore, concluded that cell-mediated immunosuppression, preceded by a hyperinflammatory response, is an observable reaction in patients following esophageal surgery, but not in patients undergoing gastric surgery.

Dominant negative forms of Akt (protein kinase B) and atypical protein kinase Clambda do not prevent insulin inhibition of phosphoenolpyruvate carboxykinase gene transcription

Transcriptional regulation of phosphoenolpyruvate carboxykinase (PEPCK), the rate-limiting enzyme in hepatic gluconeogenesis, by insulin was investigated with the use of adenovirus vectors encoding various mutant signaling proteins. Insulin inhibited transcription induced by dexamethasone and cAMP of a chloramphenicol acetyltransferase (CAT) reporter gene fused with the PEPCK promoter sequence in HL1C cells stably transfected with this construct. A dominant negative mutant of phosphoinositide (PI) 3-kinase blocked insulin inhibition of transcription of the PEPCK-CAT fusion gene, whereas a constitutively active mutant of PI 3-kinase mimicked the effect of insulin. Although a constitutively active mutant of Akt (protein kinase B) inhibited PEPCK-CAT gene transcription induced by dexamethasone and cAMP, a mutant Akt (Akt-AA) in which the phosphorylation sites targeted by insulin are replaced by alanine did not affect the ability of insulin to inhibit transcription of the fusion gene. Akt-AA almost completely inhibited insulin-induced activation of both endogenous and recombinant Akt in HL1C cells. Furthermore, neither a kinase-defective mutant protein kinase Clambda (PKClambda), which blocked insulin-induced activation of endogenous PKClambda, nor a dominant negative mutant of the small GTPase Rac prevented inhibition of PEPCK-CAT gene transcription by insulin. These data suggest that phosphoinositide 3-kinase is important for insulin-induced inhibition of PEPCK gene transcription and that a downstream effector of phosphoinositide 3-kinase distinct from Akt, PKClambda, and Rac may exist for mediating the effect of insulin.

Effects of total parenteral nutrition on endotoxin translocation and extent of the stress response in burned rats

Postburn endotoxin translocation has been well documented. However, the relationship between the secretion of catabolic hormones, degree of endotoxin translocation, and intestinal atrophy has not been previously demonstrated. In this experiment, modulation of the secretion of catabolic hormones according to the route of nutrient administration was examined in burned animals. A total of 55 rats, with and without a burn injury, were orally or parenterally fed. Urinary excretion of epinephrine and norepinephrine (U-EN) of each rat was measured for 48 h after burn injury as an indicator of the stress response. Evaluations of intestinal atrophy and endotoxin contents in the liver and spleen were also done 48 h after burn injury. U-EN after burn injury in rats administered total parenteral nutrition (TPN) was higher than in those fed orally. Endotoxin translocation and intestinal atrophy after thermal injury were also augmented by TPN. A significant positive correlation between U-EN and endotoxin content of the liver, and a negative correlation between U-EN and weight of the intestine, were observed. TPN enhances the stress response after burn injury. An increase in endotoxin translocation and intestinal atrophy by TPN are closely related to enhancement of the stress response.

Effects of soybean oil emulsion and eicosapentaenoic acid on stress response and immune function after a severely stressful operation

OBJECTIVE

To investigate the effects of soybean oil emulsion and oral or enteral administration of eicosapentaenoic acid (EPA) on stress response, cytokine production, protein metabolism, and immune function after surgery for esophageal cancer.

SUMMARY BACKGROUND DATA

It has been reported that safflower oil, rich in n-6 polyunsaturated fatty acid (n-6 PUFA), affects the survival rate of septic animals and decreases the immune function. It has also been reported that the administration of fish oil, in contrast, reduces these stress responses and stress-induced immunosuppression. In humans, the effects of soybean oil emulsion and the administration of EPA on stress response and immune function after surgery have not been established.

METHODS

Patients who underwent esophagectomy with thoracotomy were divided into three groups. Seven patients were fed by total parenteral nutrition (TPN) with soybean oil emulsion, which accounted for 20% of total calories. Seven patients were given oral or enteral administration of 1.8 g/day EPA, in addition to TPN with soybean oil emulsion. Nine patients served as the control group; these patients received fat-free TPN. Serum interleukin-6 (IL-6), C-reactive protein, concanavalin A (con A)- or phytohemagglutinin (PHA)-stimulated lymphocyte proliferation, natural killer cell activity, and stress hormones were measured.

RESULTS

The postoperative level of serum IL-6 was significantly higher in the group receiving soybean oil emulsion than in the fat-free group. Oral or enteral supplementation of EPA with soybean oil emulsion significantly reduced the level of serum IL-6 compared with the patients receiving soybean oil emulsion. Con A- or PHA-stimulated lymphocyte proliferation decreased significantly on postoperative day 7 in all groups of patients. The supplementation of EPA with soybean oil emulsion significantly improved the lymphocyte proliferation and natural killer cell activity on postoperative day 21 compared with the group receiving soybean oil emulsion.

CONCLUSIONS

Soybean oil emulsion amplifies, and the supplementation of EPA reduces, the stress response and stress-induced immunosuppression.

Requirement of atypical protein kinase clambda for insulin stimulation of glucose uptake but not for Akt activation in 3T3-L1 adipocytes

Phosphoinositide (PI) 3-kinase contributes to a wide variety of biological actions, including insulin stimulation of glucose transport in adipocytes. Both Akt (protein kinase B), a serine-threonine kinase with a pleckstrin homology domain, and atypical isoforms of protein kinase C (PKCzeta and PKClambda) have been implicated as downstream effectors of PI 3-kinase. Endogenous or transfected PKClambda in 3T3-L1 adipocytes or CHO cells has now been shown to be activated by insulin in a manner sensitive to inhibitors of PI 3-kinase (wortmannin and a dominant negative mutant of PI 3-kinase). Overexpression of kinase-deficient mutants of PKClambda (lambdaKD or lambdaDeltaNKD), achieved with the use of adenovirus-mediated gene transfer, resulted in inhibition of insulin activation of PKClambda, indicating that these mutants exert dominant negative effects. Insulin-stimulated glucose uptake and translocation of the glucose transporter GLUT4 to the plasma membrane, but not growth hormone- or hyperosmolarity-induced glucose uptake, were inhibited by lambdaKD or lambdaDeltaNKD in a dose-dependent manner. The maximal inhibition of insulin-induced glucose uptake achieved by the dominant negative mutants of PKClambda was approximately 50 to 60%. These mutants did not inhibit insulin-induced activation of Akt. A PKClambda mutant that lacks the pseudosubstrate domain (lambdaDeltaPD) exhibited markedly increased kinase activity relative to that of the wild-type enzyme, and expression of lambdaDeltaPD in quiescent 3T3-L1 adipocytes resulted in the stimulation of glucose uptake and translocation of GLUT4 but not in the activation of Akt. Furthermore, overexpression of an Akt mutant in which the phosphorylation sites targeted by growth factors are replaced by alanine resulted in inhibition of insulin-induced activation of Akt but not of PKClambda. These results suggest that insulin-elicited signals that pass through PI 3-kinase subsequently diverge into at least two independent pathways, an Akt pathway and a PKClambda pathway, and that the latter pathway contributes, at least in part, to insulin stimulation of glucose uptake in 3T3-L1 adipocytes.

[Inoperable esophageal carcinoma managed by combined chemotherapy (CBDCA, 5-FU and VDS) and radiotherapy]

Eleven inoperable patients with advanced esophageal carcinoma were treated with chemotherapy (carboplatin, 5-FU, vindesine) and concomitant radiotherapy. Two patients (T2) received this treatment due to their poor general condition and refusal of operation, and 9 patients for infiltration of tumor into the adjacent organs (T4). Administration of carboplatin (30 mg/body) and 5-FU (250 mg/body) together with radiotherapy (1.8 Gy/d) for 5 days a week was performed. This chemoradiation therapy was carried out for 5 consecutive weeks. In addition, vindesine (1-3 mg/body) was administered in the 1st and 4th week. After evaluation, endoscopic balloon dilatation was performed in 6 patients with stenosis of the esophagus. The general response rate was 80%. CR was noted in 2 patients of T2 but 1 patient of T4 developed severe leucopenia and immunosuppression, and died of septic MOF. All but the MOF case could take enough food orally following the endoscopic dilatation. The 1-year survival rate in the T4 group (45%) was significantly better than the non-treatment group (0%). In conclusion, this treatment is beneficial for patients with inoperable esophageal carcinoma to obtain a satisfactory QOL and survival rate.