Clinical Outcomes of Follow-Up Observation After Endoscopic Submucosal Dissection for Esophageal Squamous Cell Carcinoma Invading the Muscularis Mucosa Without Lymphovascular Involvement

BACKGROUND

The therapeutic approach after endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) diagnosed as pathological T1a-muscularis mucosa (pT1a-MM) without lymphovascular involvement (LVI) remains uncertain. We aimed to determine whether observation after ESD is acceptable for patients without LVI showing pT1a-MM cancer.

METHODS

We retrospectively registered 566 ESCC patients who were treated with ESD at ten institutions between January 2007 and December 2015. Of those, 447 cases showing pT1a-epithelium/lamina propria mucosa (EP/LPM) without LVI and vertical margin (VM) (EP/LPM group), and 41 cases showing pT1a-MM without LVI and VM (MM group) were analyzed in this investigation. The clinical outcomes were assessed between the groups.

RESULTS

The 5 year cumulative incidence of metastatic recurrence was 0.5% and 3.3% in the EP/LPM and MM groups, respectively (P = 0.121). Two cases showing pT1a-EP/LPM and one showing pT1a-MM experienced lymph node recurrence. The 5 year cumulative incidence of local recurrence was 1.5% and 3.8% in the EP/LPM and MM groups, respectively (P = 0.455). The 5 year disease-specific survival (DSS) rate was 99.3% and 96.6% in the EP/LPM and MM groups, respectively (P = 0.118), whereas the 5 year overall survival rate was significantly higher in the EP/LPM group than in the MM group (92.6% versus 81.1%, respectively; P = 0.021).

CONCLUSIONS

As regards metastatic recurrence and DSS, ESCC patients with pT1a-MM without LVI showed favorable outcomes that were equivalent to those with pT1a-EP/LPM, even when they were not treated with additional therapy after ESD.

Risk and prognostic factors of invasive gastric cancer detection during surveillance endoscopy: Multi-institutional cross-sectional study

OBJECTIVES

Esophagogastroduodenoscopy (EGD) is important for the detection of curable gastric cancer (GC). However, there are no appropriate surveillance data during routine endoscopic inspections. This study aimed to clarify the risk factors of pT1b or deeper GC detection during surveillance endoscopy.

METHODS

This was a retrospective, multicenter, cross-sectional study conducted in 15 Japanese hospitals. We retrospectively analyzed patients with GC who had previously undergone surveillance endoscopy at each institution from January 2014 to March 2020. Patients who had undergone gastrectomy, non-infection of Helicobacter pylori (Hp), and those with intervals <3 months or >10 years from a previous endoscopy were excluded.

RESULTS

In total, 1085 patients with GCs detected during surveillance endoscopy were enrolled. The multivariate logistic analysis revealed that current Hp infection (odds ratio [OR] 2.18; 95% confidence interval [CI] 1.50-3.16) and a surveillance interval of >1.5 years (OR 1.96; 95% CI 1.35-2.84) were independent risk factors for pT1b or deeper GC. The 5-year disease-specific survival (5y-DSS) rate of GC was significantly lower in patients with surveillance interval of >1.5 years than in those with surveillance interval of ≤1.5 years (93.7% vs. 98.3%, P < 0.001). Similarly, the 5y-DSS rate of GC was significantly lower in patients with active Hp infection than in those without (93.7% vs. 99.4%, P < 0.001).

CONCLUSION

In this study, a surveillance interval of >1.5 years and current Hp infection were independent risk factors for detecting pT1b or deeper GC. Additionally, these factors were poor prognostic factors of the detected GC during surveillance endoscopy.

Endoscopic Submucosal Dissection for Early Gastric Cancer in Patients Aged 85 Years Old or Older Is Associated with a Good Prognosis Compared to Conservative Treatment without Any Invasive Procedure

INTRODUCTION

Studies have reported the feasibility of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in elderly people with respect to both short- and long-term outcomes. As the elderly population in society increases, the requirement for managing super-elderly patients aged ≥85 years with EGC will also increase. This study aims to identify the long-term clinical outcomes of ESD for clinical T1N0 EGC in patients aged ≥85 years.

METHODS

A total of 370 consecutive patients aged ≥85 years with clinical T1N0 EGC who were managed in 11 institutions were reviewed retrospectively. On the basis of treatment strategy, we compared the overall survival (OS) and disease-specific survival (DSS) after performing propensity score-matched analysis between patients undergoing ESD (ESD group) and those not undergoing treatment (conservative treatment group). The potential prognostic factors were also investigated in the propensity score-matched patients.

RESULTS

After propensity score matching, we found that the 3-year OS and DSS rates were significantly higher in the ESD group than in the conservative treatment group (OS, 82.2% vs. 50.5%; p < 0.001; DSS, 100% vs. 80.1%; p = 0.008). Furthermore, ESD was identified as a significant factor for prolonged OS, whereas Charlson comorbidity index (CCI) ≥3 and prognostic nutritional index (PNI) <36.2 were associated with reduced OS.

CONCLUSION

ESD was associated with improved OS in patients with clinical T1N0 EGC aged ≥85 years compared with the absence of treatment. Furthermore, CCI and PNI were helpful for patient selection.

Subepithelial Serotonin Reduces Small Intestinal Epithelial Cell Tightness via Reduction of Occluding Expression

BACKGROUND

The precise pathogenesis of irritable bowel syndrome (IBS) remains unresolved; however, recent studies have reported that patients with diarrhea-predominant IBS exhibit an increased small intestinal permeability and increased number of enterochromaffin cells containing high 5-hydroxytryptamine (5HT; serotonin) levels. In this study, we investigated whether 5HT has the potential to modulate small intestinal epithelial cell permeability, focusing on tight junction-associated proteins.

METHODS

The differentiated Caco-2 cell monolayer on porous filters (Millicell) was used. Then, 5HT was added to the lower Millicell compartment for 7 days. Intestinal epithelial cell permeability was assessed by measuring the flux of paracellular permeability markers. We further assessed the expression of occludin in the 5HT-stimulated Caco-2 monolayer.

RESULTS

We found that 5HT did not affect the viability of Caco-2 cells at concentrations up to 100 µM during the experimental period. Administration of 5HT to the basal side of Caco-2 cells increased the flux of 3H-labeled mannitol (182 Da) but did not increase that of FITC-dextran (4000 Da). Among the tight junction proteins, the expression of occludin was specifically decreased by stimulation with 5HT at a concentration of 100 µM.

CONCLUSION

In conclusion, excessive 5HT in the basal side increased the permeability of intestinal epithelial cells via reduction of occludin expression.

Complete one-to-one correspondence between magnifying endoscopic and histopathologic images: the KOTO method II

Recent advances in magnifying endoscopy with narrow-band imaging/blue laser imaging have aided in the diagnosis of gastrointestinal lesions. However, it requires knowledge of the relationship between magnifying endoscopic and histopathological images. We propose a novel method which makes possible a complete correspondence between magnifying endoscopic and histopathological images at the single glandular duct level. The KOTO method II enables three-dimensional visualization of the correlation between the endoscopic surface pattern of the mucosa and histopathological images. This method may be helpful in the development of diagnosis using magnifying endoscopy.

Clinical Outcomes of Vonoprazan-Treated Patients after Endoscopic Submucosal Dissection for Gastric Neoplasms: A Prospective Multicenter Observation Study

BACKGROUND

Vonoprazan (VPZ) has the potential to prevent delayed bleeding and promote ulcer healing after endoscopic submucosal dissection (ESD) similar to proton pump inhibitors (PPIs).

OBJECTIVE

We aimed to evaluate the outcomes of VPZ-treated patients after ESD and compared the efficacy and feasibility in preventing a delayed bleeding and in healing an artificial ulcer after ESD between the VPZ and PPI therapies.

METHODS

This was a prospective, observation study in 11 Japanese medical institutions. We enrolled and evaluated 223 patients who underwent gastric ESD followed by VPZ treatment (VPZ group). We selected 385 patients who underwent gastric ESD followed by PPI treatment as historical controls (PPI group) to compare the outcomes between the VPZ and PPI groups using a propensity score matching analysis.

RESULTS

Among the 223 patients treated with VPZ, 173 were men and 50 were women with a median age of 72 years and with a median tumor size of 12.0 mm. Rates of en bloc resection and complete resection were 99.1 and 94.2%, respectively. Lymphovascular invasion was found in 6 (6.3%) cases. Intraoperative perforation and delayed bleeding occurred in 3 (1.3%) and 10 patients (4.5%), respectively. Scarring of artificial post-ESD ulcer was found in 153 patients (68.6%) at 6 weeks after ESD. The 205 pairs of propensity score-matched patients were comparable between the VPZ and PPI groups. The rate of delayed bleeding in the VPZ and PPI groups was 3.9 and 4.4%, respectively (difference, 0.5 percentage points; 95% confidence interval, -3.7 to 2.8%; non-inferiority, p = 0.01). Therefore, VPZ therapy demonstrated non-inferiority against PPI therapy in reducing the rate of delayed bleeding. The scar-stage ulcer at 6 weeks in the VPZ group and 8 weeks in the PPI group was 68.3 and 74.6%, respectively (p = 0.19).

CONCLUSIONS

VPZ therapy showed an efficacy and feasibility in preventing a delayed bleeding after ESD similar to the PPI therapy. VPZ for 6 weeks and PPI for 8 weeks were similarly effective for an artificial ulcer healing after ESD.

Prognostic risk factors associated with esophageal squamous cell carcinoma patients undergoing endoscopic submucosal dissection: a multi-center cohort study

BACKGROUND

Long-term outcomes of endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) have not been assessed in a large, multicenter cohort. We aimed to evaluate long-term outcomes of ESD for ESCC in a real-world setting.

METHODS

We retrospectively recruited 659 patients who underwent ESD for ESCC at ten institutions from January 2007 to December 2015. Of these, 566 patients were analyzed and classified into three groups according to the pathologic invasion depth after ESD: epithelium/lamina propria mucosa (EP/LPM group: 454 patients), muscularis mucosa/submucosa invasion ≤ 200 μm below the inferior margin of the muscularis mucosa (MM/SM1 group: 81 patients), and submucosa invasion > 200 μm below the MM inferior margin (SM2 group: 31 patients).

RESULTS

The 5-year overall survival rates in the EP/LPM, MM/SM1, and SM2 groups were 92.6%, 80.0%, and 62.7%, respectively, while the 5-year disease-specific survival rates were 99.7%, 96.9%, and 88.3%, respectively. Multivariate analyses revealed that the invasion depth, Charlson Comorbidity Index (CCI), and prognostic nutritional index (PNI) were independent prognostic factors. Hazard ratios in the MM/SM1 and SM2 groups were 2.25 (95% confidence interval [CI] 1.04-4.83; P = 0.038) and 3.18 (95% CI 1.08-9.34; P = 0.036), respectively, compared to those in the EP/LPM group, while those for patients with a CCI ≥ 3 and PNI ≤ 47.75 were 3.25 (95% CI 1.79-5.89; P < 0.001) and 2.42 (95% CI 1.26-4.65; P = 0.008), respectively.

CONCLUSIONS

This study identified that invasion depth, presence of comorbid diseases and preoperative nutritional status are independent prognostic risk factors associated with ESCC patients undergoing ESD.

Efficacy and safety of endoscopic submucosal dissection using a scissors-type knife with prophylactic over-the-scope clip closure for superficial non-ampullary duodenal epithelial tumors

BACKGROUND AND STUDY AIM

This study aimed to assess the safety and feasibility of endoscopic submucosal dissection (ESD) using a scissors-type knife with prophylactic closure using over-the-scope clip (OTSC) for superficial non-ampullary duodenal epithelial tumors (SNADETs).

PATIENTS AND METHODS

Consecutive patients who underwent ESD for SNADETs >10 mm between January 2009 and July 2019 were retrospectively enrolled. We performed ESD using either a needle-type knife (Flush Knife-ESD) or a scissors-type knife (Clutch Cutter-ESD). Mucosal defects were prophylactically closed using three methods: conventional clip, laparoscopic closure, or OTSC.

RESULTS

A total of 84 lesions were resected using the Flush Knife-ESD and the Clutch Cutter-ESD (37 and 47 patients, respectively), and conventional clip, laparoscopic closure, and OTSC for mucosal defect closure after ESD were applied in 13, 13, and 56 lesions, respectively. The R0 resection rate was significantly higher in the Clutch Cutter-ESD than that in the Flush Knife-ESD (97.9% vs 83.8%, respectively, P = 0.040). The intraoperative perforation rate was significantly lower in the Clutch Cutter-ESD than in the Flush Knife-ESD (0% vs 13.5%, respectively, P = 0.014). Complete closure rates of conventional clip, laparoscopic closure, and OTSC were 76.9%, 92.3%, and 98.2%, respectively (P = 0.021); and delayed perforation rates were 15.4%, 7.7%, and 1.8%, respectively (P = 0.092).

CONCLUSIONS

Endoscopic submucosal dissection using a scissors-type knife with prophylactic OTSC closure is safe and feasible for the low-invasive treatment of SNADETs.

Effectiveness of including probiotics to Helicobacter pylori eradication therapies

The eradication rate of Helicobacter pylori (H. pylori) with proton pump inhibitors, amoxicillin, and clarithromycin has reportedly decreased. Some studies have found probiotics to be useful in eradicating H. pylori, but these effects have not been sufficiently investigated. We aimed to elucidate the role of probiotics in eradicating H. pylori infection. Patients in our hospital with H. pylori infection that received standard treatment from January 2015 to December 2016 were retrospectively evaluated (n = 468). They were divided into three groups based on their treatment regime, being either proton pump inhibitors, amoxicillin, or clarithromycin (PPI group), vonoprazan, amoxicillin, or clarithromycin (VPZ group), and proton pump inhibitors, amoxicillin, or clarithromycin/probiotics (Miya-BM^®) (PPI + MBM group). We retrospectively evaluated the H. pylori eradication rate and reported side effects. According to intention-to-treat analyses, the eradication rate of H. pylori was significantly higher in the PPI + MBM group (87.1%) than in the PPI group (70.1%). There was no difference in side effects between any of the three groups. In conclusion, Miya-BM^® may have an additive effect when included with eradication therapies for H. pylori.

High-Fat Diet Causes Constipation in Mice via Decreasing Colonic Mucus

BACKGROUND

Constipation is one of the most common gastrointestinal complaints. Although the causes of constipation are varied, dietary habits have a significant influence. Excessive fat intake is suggested as one of the main causes of constipation; however, the exact mechanism is unknown.

AIMS

To investigate whether a high-fat diet (HFD) causes constipation in mice and to clarify the underlying mechanism, focusing on the amount of colonic mucus.

METHODS

Six-week-old male C57BL/6 mice were randomly divided into two groups: mice fed with HFD and those with normal chow diet (NCD). Fecal weight, water content, total gastrointestinal transit time, and colon transit time were measured to determine whether the mice were constipated. The colonic mucus was evaluated by immunostaining and quantified by spectrometry. Malondialdehyde (MDA) was measured using the thiobarbituric acid (TBA) test as a marker for oxidative stress.

RESULTS

Compared to the NCD group, the weight of feces was less in the HFD group. In the functional experiment, the total gastrointestinal transit time and colon transit time were longer in the HFD group. Furthermore, HFD significantly reduced the amount of colonic mucus. In addition, the reduction in colonic mucus caused by surfactant resulted in constipation in the NCD group.

CONCLUSIONS

HFD causes constipation with delayed colon transit time possibly via the reduction in colonic mucus in mice.

Efficacy and Feasibility of Magnifying Blue Laser Imaging without Biopsy Confirmation for the Diagnosis of the Demarcation of Gastric Tumors: A Randomized Controlled Study

BACKGROUND

Accurate diagnosis of the demarcation line (DL) of gastric tumors is essential for curative complete resection by endoscopic submucosal dissection (ESD). It is controversial to perform only magnifying endoscopy for diagnosing the DL of gastric tumors prior to ESD. This study aimed to evaluate the diagnostic accuracy for the DL of gastric adenomas and well-differentiated adenocarcinomas using only magnifying blue laser imaging (M-BLI) compared with that using both M-BLI and biopsy confirmation.

METHODS

In this prospective, single-center study, 96 well-differentiated adenocarcinomas and 32 gastric adenomas were enrolled between July 2015 and December 2016. A total of 122 lesions with a clear DL on M-BLI were randomly allocated to undergo M-BLI only (the M-BLI group) or M-BLI with biopsy confirmation (the M-BLI-BC group), performed as biopsies in 4 directions from noncancerous tissues ≈ 5 mm outside the lesion before ESD. The primary end point was to clarify the noninferiority of M-BLI without biopsy confirmation compared with that with biopsy confirmation, in terms of the diagnostic accuracy and complete resection.

RESULTS

There were no significant differences in sex, median age, color, circumference, macroscopic type, biopsy-based diagnosis, and Helicobacter pylori infection between the 2 groups. The diagnostic accuracy for the DL was 100 and 95.0% and the complete resection was 100 and 100% in the M-BLI and M-BLI-BC groups, respectively.

CONCLUSION

The diagnostic ability of M-BLI is excellent in diagnosing the demarcation of gastric adenoma and well-differentiated adenocarcinoma. Biopsy confirmation is not needed for these lesions with a clear DL by M-BLI.

Effectiveness of including probiotics to Helicobacter pylori eradication therapies

The eradication rate of Helicobacter pylori (H. pylori) with proton pump inhibitors, amoxicillin, and clarithromycin has reportedly decreased. Some studies have found probiotics to be useful in eradicating H. pylori, but these effects have not been sufficiently investigated. We aimed to elucidate the role of probiotics in eradicating H. pylori infection. Patients in our hospital with H. pylori infection that received standard treatment from January 2015 to December 2016 were retrospectively evaluated (n = 468). They were divided into three groups based on their treatment regime, being either proton pump inhibitors, amoxicillin, or clarithromycin (PPI group), vonoprazan, amoxicillin, or clarithromycin (VPZ group), and proton pump inhibitors, amoxicillin, or clarithromycin/probiotics (Miya-BM^®) (PPI + MBM group). We retrospectively evaluated the H. pylori eradication rate and reported side effects. According to intention-to-treat analyses, the eradication rate of H. pylori was significantly higher in the PPI + MBM group (87.1%) than in the PPI group (70.1%). There was no difference in side effects between any of the three groups. In conclusion, Miya-BM^® may have an additive effect when included with eradication therapies for H. pylori.

Efficacy of Magnifying Narrow Band Imaging for Delineating Horizontal Margins of Early Gastric Cancer

BACKGROUND/AIMS

The aim of this study was to evaluate the diagnostic accuracy of magnifying narrow-band imaging (M-NBI) with histopathological confirmation in identifying the demarcation line (DL) of early gastric cancer (EGC).

METHODS

EGCs resected by endoscopic submucosal dissection after identifying the DL using M-NBI following histopathological confirmation were included. After determining the DL for the entire EGC lesion using M-NBI, at least 4 biopsies were taken from non-cancerous tissues outside the EGC lesion for histopathological confirmation.

RESULTS

A total of 330 EGCs were analyzed in this study. The rate of biopsy-negative and negative horizontal margin were 96.7% (319/330) and 97.9% (323/330) in EGC respectively. Tumors larger than 20 mm showed a higher risk for showing remnant cancer cells on biopsies taken outside the DL. Risk factors for a positive horizontal resection margin were tumor size > 20 mm and moderately or poorly differentiated adenocarcinomas.

CONCLUSION

The assessment of demarcation of EGC using M-NBI was excellent in well-differentiated (WD) adenocarcinoma and lesions below 20 mm in size. However, histopathological confirmation is needed to assess the demarcation of non-WD adenocarcinomas and EGC over 20 mm in size.

Can image-enhanced endoscopy improve the diagnosis of Kyoto classification of gastritis in the clinical setting?

Endoscopic diagnosis of Helicobacter pylori (H. pylori) infection, the most common cause of gastric cancer, is very important to clarify high-risk patients of gastric cancer for reducing morbidity and mortality of gastric cancer. Recently, the Kyoto classification of gastritis was developed based on the endoscopic characteristics of H. pylori infection-associated gastritis for clarifying H. pylori infection status and evaluating risk factors of gastric cancer. Recently, magnifying endoscopy with narrow-band imaging (NBI) has reported benefits of the accuracy and reproducibility of endoscopic diagnosis for H. pylori-related premalignant lesions. In addition to NBI, various types of image-enhanced endoscopies (IEEs) are available including autofluorescence imaging, blue laser imaging, and linked color imaging. This review focuses on understanding the clinical applications and the corresponding evidences shown to improve the diagnosis of gastritis based on Kyoto classification using currently available advanced technologies of IEEs.

Clinical and Pathological Challenges in the Diagnosis of Gastric-Type Differentiated Adenocarcinoma in the Stomach: A Study of Endoscopic Submucosal Dissection Cases

BACKGROUND/AIMS

Gastric-type differentiated adenocarcinoma (GDA) of the stomach is a rare variant of gastric cancer that is highly infiltrating and exhibits early metastasis. However, the endoscopic and pathological features of "early-stage" GDA remain unknown. The aim of this study is to characterize early-stage GDA.

METHODS

We retrospectively enrolled 479 differentiated-type early gastric cancer cases who underwent endoscopic submucosal dissection (ESD). GDA cases were selected based on morphology and immunohistochemistry. Clinicopathological data were compared between gastric- and intestinal-type differentiated adenocarcinomas (IDAs).

RESULTS

Thirteen lesions were classified as GDAs. GDAs as well as IDAs showed irregular microvascular and microsurface patterns with clear demarcation line on magnifying endoscopy with narrow band imaging (M-NBI). The rate of pathological misdiagnosis of GDAs in biopsy specimens was higher than that of IDAs (p = 0.016). GDA was significantly associated with positive lymphovascular invasion (p = 0.016). There was one intramucosal lesion with lymphatic invasion in GDA.

CONCLUSIONS

Although M-NBI is useful to detect GDA, the pathological diagnosis of GDAs in biopsy specimens often remains challenging. When suspicious lesions are not diagnosed as GDA, they should be followed up intensively, or diagnostic ESD has to be performed. ESD specimens should be carefully evaluated because of a higher incidence of lymphovascular invasion.

Linked color imaging identifies important risk factors associated with gastric cancer after successful eradication of Helicobacter pylori

BACKGROUND AND AIMS

Limited studies have evaluated the risk factors of gastric cancer (GC) after eradication of Helicobacter pylori (H pylori) using endoscopic findings. We aimed to investigate GC detection-related endoscopic findings after eradication of H pylori using linked color imaging (LCI), a novel image-enhanced endoscopy.

METHODS

This single-center, cross-sectional study evaluated background mucosa-associated endoscopic findings described in the Kyoto classification of gastritis in patients with newly detected GC after eradication of H pylori (CA group, n = 109) and those without GC (NC group, n = 85) using white-light imaging (WLI) and LCI.

RESULTS

Severe atrophy and map-like redness were significantly more frequent in the CA group than in the NC group using WLI (79.8% vs 63.5%, P = .01; 61.5% vs 37.7%, P = .001, respectively) and LCI (79.8% vs 63.5%, P = .01; 78.0% vs 45.9%, P < .0001, respectively). Regular arrangement of collecting venules (RAC) was significantly less frequent in the CA group than in the NC group using WLI (40.3% vs 64.7%, P = .0009) and LCI (37.6% vs 62.4%, P = .0006). Map-like redness was an independent positive risk factor (WLI: odds ratio [OR], 2.05; 95% confidence interval [CI], 1.09-3.87; P = .03; LCI: OR, 3.62; 95% CI, 1.88-6.97; P < .001), whereas RAC was an independent negative risk factor (WLI: OR, 0.42; 95% CI, 0.21-0.82; P = .01; LCI: OR, 0.46; 95% CI, 0.23-0.93, P = .03) for detection of GC after eradication of H pylori.

CONCLUSIONS

Map-like redness, which was identified more frequently using LCI than WLI, and the absence of RAC were associated with detection of GC after eradication of H pylori.

Transforming growth factor β1-induced collagen production in myofibroblasts is mediated by reactive oxygen species derived from NADPH oxidase 4

Intestinal fibrosis with stricture formation is a severe complication of Crohn's disease (CD). Though new therapeutic targets to enable the prevention or treatment of intestinal fibrosis are needed, markers of this condition and the basic mechanisms responsible have not been established. NADPH oxidase (NOX) 4 has already been reported to play a key role in models of fibrogenesis, including that of the lung. However, its importance in intestinal fibrogenesis remains unclear. In this study, we examined the role of NOX4 in collagen production by intestinal myofibroblasts stimulated with transforming growth factor (TGF)-β1. Using LmcMF cells, an intestinal subepithelial myofibroblast (ISEMF) line, we first examined the induction of collagen production by TGF-β1. Subsequently, we investigated the role of NOX4 in TGF-β1-induced collagen I production in these cells using SB525334 (an SMAD2/3 inhibitor), diphenyleneiodonium (an NOX inhibitor), and Nox4 small interfering RNA (siRNA). Production of collagen was assessed with Sirius red staining, and Nox4 expression was measured by quantitative real-time PCR. Reactive oxygen species (ROS) production was determined using DCFDA and fluorescent microscopy. We observed that TGF-β1 induced collagen production via NOX4 activation and ROS generation in LmcMF cells. Nox4 siRNA and inhibitors of TGF-β1 receptor and NOX significantly reduced TGF-β1-induced ROS and collagen production. Thus, in the present study, we revealed that collagen production in ISEMFs is induced via an NOX4-dependent pathway. This work supports a function for NOX4 in intestinal fibrogenesis and identifies it as a potential therapeutic target in recalcitrant fibrotic disorders of CD patients.

How to adjust endoscopic findings to histopathological findings of the stomach: a "histopathology-oriented" correspondence method helps to understand endoscopic findings

BACKGROUND

Endoscopic findings have now become nearly as detailed as histopathological findings. Thus, one-to-one correspondence and precise feedback of histopathological findings is very desirable but may be very difficult to accomplish. We describe a systematic process called the Kyoto One-to-One Correspondence Method (the KOTO Method) that allows detailed adjustments of endoscopic findings to match histopathological findings.

METHODS AND RESULTS

By comparing endoscopic and stereoscopic images of the gastric mucosa, we could obtain one-to-one correspondence between endoscopic images and equivalent histology in 44 of 47 fields.

CONCLUSIONS

The histological structure of gastric cancers of the same histological subtype may not be similar. One-to-one correspondence between endoscopic images and gastric mucosal histology (histopathology-oriented correspondence) will improve endoscopic diagnosis and provide more useful information for pathological diagnosis.

Early-Stage Gastric Cancer Can Be Found in Improved Atrophic Mucosa over Time from Successful Helicobacter pylori Eradication

BACKGROUND/AIMS

Early-stage gastric cancer (EGC) is detected even after successful Helicobacter pylori eradication. This study is aimed at clarifying the clinicopathological characteristics of EGC detected after successful H. pylori eradication.

METHODS

This retrospective study analyzed 57 cases of EGC detected after successful H. pylori eradication and resected endoscopically at Kyoto Prefectural University of Medicine, between January 2009 and June 2014. Clinicopathological findings of 57 cases (H. pylori-eradicated group) were investigated, and compared with those in active H. pylori infection resected in the same period (H. pylori-positive group).

RESULTS

Most EGCs were detected in patients with severe atrophic mucosa, both in H. pylori-eradicated and H. pylori-positive groups, while the percentage of EGC detected in patients with mild atrophic mucosa gradually increased over time from successful eradication (H. pylori-positive: 7%, up to the fourth year since eradication: 11%, after the fifth year since eradication: 32%). The percentage of EGC detected in patients with mild atrophic mucosa after the fifth year since eradication was significantly higher than that in patients with active H. pylori infection (p = 0.004).

CONCLUSION

After the fifth year following eradication, we should be alert to the incidence of EGC, irrespective of the severity of mucosal atrophic change.

Rebamipide upregulates mucin secretion of intestinal goblet cells via Akt phosphorylation

Mucin is produced and secreted by epithelial goblet cells and is a key component of the innate immune system, acting as a barrier in the intestinal tract. However, no studies have been conducted investigating the increase in mucin secretion to enhance the intestinal barrier function. The present study investigated whether rebamipide (Reb) acts as a secretagogue of intestinal mucin and the underlying mechanisms involved, thereby focusing on the effect on goblet cells. The LS174T cell line was used as goblet cell‑like cells. Using Reb‑treated LS174T cells, the level of mucin content was assessed by periodic acid‑Schiff (PAS) staining, and mucin 2, oligomeric mucus/gel‑forming (MUC2) mRNA expression was assessed using quantitative polymerase chain reaction (PCR). Furthermore, MUC2 secretion in the supernatant was quantified by the dot blot method. The present study additionally investigated the involvement of the epidermal growth factor receptor/Akt serine/threonine kinase 1 (Akt) pathway in mucin secretion by western blotting. The results suggested that Reb strongly enhanced the positivity of PAS staining in LS174T cells, thereby suggesting increased intracellular mucin production. The PCR results indicated that Reb significantly increased MUC2 mRNA in whole cell lysate of LS174T cells. In order to assess the subsequent secretion of mucin by LS174T, MUC2 protein expression in the supernatant was assessed using the dot blot method and it was demonstrated that Reb significantly increased the secretion of MUC2 in a concentration‑dependent manner. The p‑Akt was significantly increased by Reb treatment, and an Akt inhibitor specifically suppressed MUC2 secretion. Overall, Reb increased mucin secretion directly via p‑Akt. Reb‑increased mucin may act as a strong non‑specific barrier against pathogenic stimulants in various intestinal diseases.

Diagnostic ability of magnifying endoscopy with blue laser imaging for early gastric cancer: a prospective study

BACKGROUND

Blue laser imaging (BLI) is a new image-enhanced endoscopy technique that utilizes a laser light source developed for narrow-band light observation. The aim of this study was to evaluate the usefulness of BLI for the diagnosis of early gastric cancer.

METHODS

This single center prospective study analyzed 530 patients. The patients were examined with both conventional endoscopy with white-light imaging (C-WLI) and magnifying endoscopy with BLI (M-BLI) at Kyoto Prefectural University of Medicine between November 2012 and March 2015. The diagnostic criteria for gastric cancer using M-BLI included an irregular microvascular pattern and/or irregular microsurface pattern, with a demarcation line according to the vessel plus surface classification system. Biopsies of the lesions were taken after C-WLI and M-BLI observation. The primary end point of this study was to compare the diagnostic performance between C-WLI and M-BLI.

RESULTS

We analyzed 127 detected lesions (32 cancers and 95 non-cancers). The accuracy, sensitivity, and specificity of M-BLI diagnoses were 92.1, 93.8, and 91.6 %, respectively. On the other hand, the accuracy, sensitivity, and specificity of C-WLI diagnoses were 71.7, 46.9, and 80.0 %, respectively.

CONCLUSIONS

M-BLI had improved diagnostic performance for early gastric cancer compared with C-WLI. These results suggested that the diagnostic effectiveness of M-BLI is similar to that of magnifying endoscopy with narrow-band imaging (M-NBI).

Real-time monitoring of trans-epithelial electrical resistance in cultured intestinal epithelial cells: the barrier protection of water-soluble dietary fiber

OBJECTIVES

In this study we aimed to verify a real-time trans-epithelial electrical resistance (TEER) monitoring system in a Caco-2 monolayer and to investigate the therapeutic effect of partially hydrolyzed guar gum (PHGG), a dietary fiber, against interferon (IFN)-γ-induced intestinal barrier dysfunction using this monitoring system.

METHODS

We measured TEER using a real-time monitoring system and evaluated epithelial paracellular permeability using fluorescein isothiocyanate-conjugated dextran (4 kDa; FD4) in Caco-2 monolayers treated with IFN-γ for 48 h. The expression and distribution of tight junction (TJ)-associated proteins, ZO-1 and occludin, were analyzed by Western blot and immunocytochemistry, respectively. In some experiments PHGG was added prior to IFN-γ treatment in order to investigate its protective effect on barrier function.

RESULTS

IFN-γ treatment significantly decreased TEER and increased FD4 flux across Caco-2 monolayers, indicating a great influence of IFN-γ on the intestinal epithelial paracellular permeability. In contrast, the pretreatment of PHGG significantly reduced the IFN-γ-induced increment of FD4 flux without affecting TEER. Neither IFN-γ nor PHGG treatment affected the expressions of TJ-associated proteins, while immunocytochemistry showed that IFN-γ-induced redistribution of occludin was clearly restored by PHGG.

CONCLUSIONS

Real-time TEER monitoring enabled us to evaluate the dynamic changes of intestinal epithelial barrier function. PHGG may have a protective effect against IFN-γ-induced barrier dysfunction by attenuating the paracellular hyperpermeability; thus, its promotion as a functional food is anticipated.

Linked color imaging improves endoscopic diagnosis of active Helicobacter pylori infection

BACKGROUND AND STUDY AIMS

Linked color imaging (LCI) is a new image-enhanced endoscopy technique using a laser light source to enhance slight differences in mucosal color. The aim of this study was to compare the usefulness of LCI and conventional white light imaging (WLI) endoscopy for diagnosing Helicobacter pylori (H. pylori).

PATIENTS AND METHODS

We retrospectively analyzed images from 60 patients examined with WLI and LCI endoscopy between October 2013 and May 2014. Thirty patients had H. pylori infections, and other thirty patients tested negative for H. pylori after eradication therapy. Four endoscopists evaluated the 2 types of images to determine which was better at facilitating a diagnosis of H. pylori infection.

RESULTS

H. pylori infection was identified with LCI by enhancing the red appearance of the fundic gland mucosa. The accuracy, sensitivity, and specificity for diagnosing H. pylori infection using WLI were 74.2 %, 81.7 %, and 66.7 %, respectively, while those for LCI were 85.8 %, 93.3 %, and 78.3 %, respectively. Thus, the accuracy and sensitivity for LCI were significantly higher than those for WLI (P = 0.002 and P = 0.011, respectively). The kappa values for the inter- and intraobserver variability among the 4 endoscopists were higher for LCI than for WLI.

CONCLUSIONS

H. pylori infection can be identified by enhancing endoscopic images of the diffuse redness of the fundic gland using LCI. LCI is a novel image-enhanced endoscopy and is more useful for diagnosing H. pylori infection than is WLI.

The role of mitochondria-derived reactive oxygen species in the pathogenesis of non-steroidal anti-inflammatory drug-induced small intestinal injury

Non-steroidal anti-inflammatory drugs (NSAIDs) have been implemented in clinical settings for a long time for their anti-inflammatory effects. With the number of NSAID users increasing, gastroenterological physicians and researchers have worked hard to prevent and treat NSAID-induced gastric mucosal injury, an effort that has for the large part being successful. However, the struggle against NSAID-induced mucosal damage has taken on a new urgency due to the discovery of NSAID-induced small intestinal mucosal injury. Although the main mechanism by which NSAIDs induce small intestinal mucosal injury has been thought to depend on the inhibitory effect of NSAIDs on cyclooxygenase (COX) activity, recent studies have revealed the importance of mitochondria-derived reactive oxygen species (ROS) production, which occurs independently of COX-inhibition. ROS production is an especially important factor in the increase of small intestinal epithelial cell permeability, an early stage in the process of small intestinal mucosal injury. By clarifying the precise mechanism, together with its clinical features using novel endoscopy, effective strategies for preventing NSAID-induced small intestinal damage, especially targeting mitochondria-derived ROS production, may be developed.

Transcatheter arterial embolization with N-butyl cyanoacrylate for acute life-threatening gastroduodenal bleeding uncontrolled by endoscopic hemostasis

PURPOSE

To investigate the feasibility, efficacy, and safety of transcatheter arterial embolization with N-butyl cyanoacrylate (NBCA) for gastroduodenal nonvariceal bleeding uncontrolled by endoscopic hemostasis.

MATERIALS AND METHODS

Between January 2006 and December 2011, a total of 317 patients underwent emergent endoscopic therapy for nonvariceal gastroduodenal bleeding, but hemostasis was not achieved in 20 cases. Emergent surgery was performed immediately following endoscopy in two patients. Arteriography was performed in the remaining 18 patients, and embolization with NBCA was performed in 15 patients (mean age, 71.3 y) in whom the bleeding site was detected on arteriography. For embolization, NBCA was mixed with iodized oil at a ratio of 1:1.5-1:4, and no other embolic material was used in the procedure. Technical and clinical success rates, recurrent bleeding, procedural time, complications, and clinical outcomes were determined for each procedure.

RESULTS

Embolization with NBCA was technically and clinically successful in all procedures, without major complications. No patient receiving embolization with NBCA experienced recurrent bleeding or required further treatment after the one-session procedure. All patients were discharged after clinical improvement. The time between puncture of the femoral artery and completion of embolization ranged from 25 to 240 minutes (mean, 66 min), and the time between the microcatheter reaching the ultimate catheter location selected for embolization and hemostasis ranged from 142 to 550 seconds (mean, 322s).

CONCLUSIONS

In this limited series, embolization with NBCA was found to be a safe, feasible, and effective treatment for gastroduodenal arterial bleeding when endoscopic hemostasis had failed.

Optical Direct and Indirect Excitation of Er3+ Ions In Silicon

Optical direct and indirect excitation of erbium (Er) ions in silicon substrates was performed in order to investigate the high efficiency of Er3+− related 1.54µm emission (4I13/2→4I15/2) for direct excitation that is not concerned with the indirect band gap and low quantum efficiency of a Si host. The samples were prepared by ion-implantation or thermal diffusion methods. In each sample, photoluminescence (PL) showed the peaks originating from 4I13/2→4I15/2 of Er3+ ions.

In Er thermally diffused samples, optical excitation for energy level 4I11/2 of Er3+ ions was successfully effected by photoluminescence excitation spectroscopy (PLE). The PLE spectra consisted six peaks (963. lnm, 965.Onm, 976.lnm, 978.9nm and 980.9nm) which were caused by direct excitation (4I15/2→4I11/2) of Er3+ ions. The emission directly excited is about 2 times more intense than the indirectly excited emission. The six peaks originating from the splitting of the 4I11/2 levels meant that Er3+ ions were in the sites of noncubic symmetry. The samples prepared by Er ion-implantation did not show the effect.

A case of retinitis pigmentosa associated with Coats’ syndrome

The association of bilateral retinitis pigmentosa with Coats' syndrome is reported. Four lesions of vascular telangiectasis with yellowish exudates were treated by xenon photocoagulation or cryocautery. Seven months later, new vascular changes occurred in another quadrant of the fundus. Since xenon photocoagulation could not be performed because of the patient's aversion to pain, argon laser photocoagulation was used but found ineffective. Cryocautery was necessary to treat the exudation over one quadrant, though xenon photocoagulation was effective in small lesions.

[Histochemical studies of glycosaminoglycans in the developing eyelids of experimental microphthalmic (Cts) mice]

PURPOSE

The Cts mouse is a mutant strain which induces congenital cataract and small eyes in homozygotes. The process of eyelid development in Cts mice was examined histochemically.

MATERIALS AND METHODS

Prenatal (from day 14 of gestation) and postnatal (to day 14) animals of unaffected and homozygous mice were examined. Sensitized high iron diamine staining was done after chondroitinase B/testicular hyaluronidase double digestion, and sensitized low iron diamine staining was done after Streptomyces hyaluronidase digestion.

RESULTS

The main chondroitin sulfate isomer in the dermis of the eyelid changed from chondroitin sulfate A/C to chondroitin sulfate B at birth in the unaffected mice. In the homozygotes, the same change took place 4 days after birth. In the dermis of the eyelid, hyaluronic acid was first detected on day 14 of gestation and gradually increased until birth in both unaffected and homozygous mice. There was slightly more hyaluronic acid in homozygous mice until 4 days after birth.

CONCLUSION

The present study showed that the maturation of glycosaminoglycan molecular species in the eyelid was retarded in Cts homozygotes.

Expression of tenascin-C and the integrin alpha 9 subunit in regeneration of rat nasal mucosa after chemical injury: involvement in migration and proliferation of epithelial cells

Nasal mucosa covered by pseudostratified ciliated epithelia can be injured by microbial infection and physical and chemical agents. To elucidate mechanisms of regeneration, erosion of rat nasal mucosa was produced by intranasal instillation of trichloroacetic acid, and tissue specimens were then sequentially obtained after 1-14 days. Since tenascin-C (TN-C) and its receptor, alpha 9 beta 1 integrin, are assumed to play important roles in regeneration of stratified squamous epithelia, their expression was evaluated by immunohistochemistry and in situ hybridization. Three to five days after the injury, TN-C mRNA was found in epithelial cells of migrating fronts and in epithelial sheets recovering ulcerated surfaces between the fronts and normal regions. TN-C deposition was increased under such sheets. Enhanced alpha 9 staining was also evident in the involved epithelium. 5-Bromo-2'-deoxyuridine incorporation assays revealed significant increase in proliferating cells in cell sheets over TN-C deposits at 3-7 days. Therefore, we conclude that regenerating epithelial cells produce and secrete TN-C, associated with an increase in alpha 9 expression, and that interactions between these molecules could regulate migration and proliferation of the epithelial cells in an autocrine manner.

[Histological studies in the developing eyelids of congenital microphthalmic (Cts) mice]

The Cts mouse is a mutant of the Jcl:ICR strain with congenital cataract and small eyes in homozygotes. In the present study, attempts were made to measure postnatally the palpebral fissure and to examine the process of eyelid development by light microscopy in both normal (+/+) and homozygous (Cts/Cts) mice. The width of the palpebral fissure in homozygotes was significantly smaller than in unaffected mice. To investigate the process of eyelid development, tissue specimens from normal and Cts homozygous mice were prepared with hematoxylin and eosin, and observed by light microscopy on days 14, 16, and 18 of gestation and on days 0, 7, and 14 after birth. In both groups, the eyelid fused on day 16 of gestation and opened completely on day 14 after birth. The primordium of the orbicularis oculi muscle was defined on day 16 of gestation, and the primordia of hair follicles and Meibomian glands were detected on day 18 of gestation. In the present study, there were no significant differences in the process of eyelid development between normal and homozygous mice. Eyelid development has thus far been thought to be self-determining and not affected by tissue interaction, and the present findings support this line of thought.

Protective effects of local hypothermia in vitrectomy under fluctuating intraocular pressure

The effects of local hypothermia on the blood-aqueous barrier and retina were investigated in experimental vitrectomy under wide-ranging fluctuations of intraocular pressure. After anesthetized albino rabbits had undergone closed vitrectomy, their vitreous cavities were continuously irrigated for 60 minutes. Perfusion pressures were fluctuated alternately between 10 and 80 mmHg. The rabbits were divided into two groups in accordance with their intraocular perfusion temperatures: 8 degrees C and 22 degrees C. Electroretinograms were taken both before and after the irrigation. Protein and prostaglandin E2 (PGE2) concentrations in the aqueous humor were measured on the 1st and 7th postoperative days. Histologic examination was performed on the eyes enucleated on the same days. There were no significant differences in either a- or b-wave amplitudes between the 8 degrees C and 22 degrees C groups. Both aqueous protein and PGE2 concentrations were significantly higher in the 22 degrees C group than in the 8 degrees C group on the 1st postoperative day. Histologically, the ciliary body showed remarkably more stromal edema in the 22 degrees C group than in the 8 degrees C group. The severity of the retinal damage did not seem to differ between the two groups. Local hypothermia during vitrectomy under fluctuating intraocular pressure inhibits the breakdown of the blood-aqueous barrier in the early postoperative stages.

Clinical evaluation of posterior embryotoxon in one institution

To elucidate the pathogenesis of posterior embryotoxon, we estimated its incidence in our clinic and evaluated its associated ocular and systemic anomalies. Slit-lamp and gonioscopic examinations were performed on 440 randomly selected patients at Nagoya City University Hospital over a 10-month period. Posterior embryotoxon was detected in 107, 50 bilateral and 57 unilateral, cases (24.3%). Twelve (11.2%) of the 107 cases had open-angle glaucoma. Accompanying ocular anomalies included six cases of sclerocornea, two each of persistent pupillary membrane and familial exudative vitreoretinopathy, and 1 each of melanocytoma of the optic nervehead, choroidal nevus and subconjunctival dermoid cyst. Associated systemic anomalies included three cases of Alagille syndrome, two of congenital biliary atresia, and one each of congenital facial palsy with microtia, congenital adrenal hyperplasia, empty sella syndrome, Hirschsprung disease and Wilson disease. Many of these ocular and systemic anomalies were caused by the maldevelopment of neural crest cells. Patients with posterior embryotoxon should be examined for the possible presence of open-angle glucoma and for ocular and systemic anomalies related to maldevelopment of neural crest cells.

[Four cases of persistent hyperplastic primary vitreous]

We evaluated four cases of persistent hyperplastic primary vitreous (PHPV) encountered at Nagoya City University Hospital in 1995. PHPV was seen unilaterally in three cases and bilaterally in one. The series comprised two males and two females, ranging in age from three to eight months, with an average of 4.8 months. Case 1 had a white strand running from the optic disc to the posterior surface of the lens in the left eye. Case 2 showed leukocoria in the right eye and central corneal opacity in the left. Magnetic resonance imaging (MRI) revealed total retinal detachment in both eyes. Case 3 exhibited retinal folds running from the optic disc to the posterior surface of the lens in the left eye. Case 4 showed elongation of the ciliary processes and leukocoria in the right eye. Ipsilateral total retinal detachment was seen in MRI. Three eyes of two cases were microphthalmic. Associated ocular anomalies included, posterior embryotoxon, sclerocornea, hypoplasia of the iris stroma and peripapillary staphyloma. There were accompanying systemic anomalies such as arachnoidal cyst, syndactyly, microcephalus, heart anomalies, pulmonary atresia and asplenia. Patients with PHPV should be carefully examined for the possible presence of other ocular and systemic anomalies caused by neural crest disorders.

Local hypothermia protects the retina from ischaemic injury in vitrectomy

AIMS

Hypothermic irrigating solutions were used during vitrectomy in pressure induced ischaemic eyes so that their effects on retinal function and histological changes could be investigated.

METHODS

After anaesthetised albino rabbits underwent closed vitrectomy, their vitreous cavities were continuously irrigated for 30 minutes at a perfusion pressure of 140 mm Hg. The rabbits were divided into three groups according to their intraocular perfusion temperatures--8 degrees C, 22 degrees C, and 38 degrees C. Electroretinograms were taken before and after irrigation. Glutamate levels in the vitreous were examined after irrigation. Eyes were enucleated on the seventh postoperative day and examined histologically.

RESULTS

On the seventh postoperative day, the recovery rate of a-wave amplitudes was significantly lower in the 38 degrees C group than in the 8 degrees C group, and that of b-wave amplitudes was significantly lower in the 38 degrees C group than in either the 8 degrees C or 22 degrees C group. Retinal damage in the 38 degrees C group revealed more severe histological impairment than in either the 8 degrees C or 22 degrees C group. Oedema of the inner retinal layer was significant in both the 22 degrees C and 38 degrees C groups. Glutamates reached peak values 30 minutes after the end of ischaemia in the 38 degrees C group. However, no significant glutamate increases were detected 15 to 60 minutes after ischaemia in either the 8 degrees C or 22 degrees C group.

CONCLUSION

Local hypothermia during vitrectomy in acute ischaemic eyes appears to decrease retinal damage.

[Developmental eye abnormalities in mouse fetuses induced by retinoic acid]

To clarify the relationship between neural crest cells and ocular anomalies, pregnant mice were treated intraperitoneally with 12.5 mg/kg retinoic acid suspended in corn oil on day 7 of pregnancy (RA group). Control mice were given an equal volume of corn oil (control group). Each group consisted of 5 mother mice, and the offsprings were removed on day 18 of gestation. The fetal mortality was 46.3% in the RA group and 2.2% in the control group. Twenty-two live fetuses of the RA group and 45 of the control group were grossly observed, and the eyes were examined histologically. In the RA group, gross malformations such as microphthalmos (95.5%), cleft lip and palate (36.4%), and central nervous system anomalies (31.8%) were observed, and in the control group, malformations such as microphthalmos (6.7%), central nervous system anomalies (2.2%), and low set ears (2.2%) were seen. Histological examination revealed microphthalmos (47.7%), anophthalmos (38.6%), faulty closure of the embryonic fissure (36.4%), developmental abnormalities of the vitreous (34.1%), aphakia (22.7%), goniodysgenesis (18.2%), and faulty separation of the lens vesicle (15.9%) in the RA group. These anomalies arose from abnormal neural crest cell migration induced by retinoic acid. They were detected in only 3.3, 1.1, 3.3, 8.9, 1.1, 2.2 and 2.2%, respectively of the control group.

[Histochemical studies on the separation of the lens vesicle]

We studied histologically the changes and distribution patterns of glycosaminoglycan molecular species during the separation of the lens vesicle in the mouse. Embryos were obtained by sacrificing pregnant mice of the Jcl: ICR strain on day 10.5 and 11 of pregnancy. Serial frontal sections were stained with hematoxylin-eosin and a sensitized high iron diamine method. To identify glycosaminoglycan molecular species in tissues, enzyme digestion (double digestions with chondroitinase B and testicular hyaluronidase) and chemical modification (nitrous acid treatment) were performed in combination with the sensitized high iron diamine method. Before separation of the lens vesicle, the glycosaminoglycan molecular species, identified in the basement membrane of the presumed corneal epithelium and intercellular matrices between the presumed corneal epithelium and lens vesicle, were chondroitin sulfate A/C and B, and those in the lens capsule were chondroitin sulfate A/C. After separation of the lens vesicle, heparan sulfate emerged in the basement membrane of the presumed corneal epithelium and intercellular matrices between the presumed corneal epithelium and lens vesicle. These results are thus taken to indicate that the changes and distribution patterns of glycosaminoglycan molecular species play an important role during separation of the lens vesicle.

[A case of nonrhegmatogenous retinal detachment in Dandy-Walker Syndrome]

A 2-month-old female presented with nonrhegmatogenous retinal detachment in Dandy-Walker syndrome. At the fist examination, coloboma involving the optic disc in both eyes was detected. The left eye showed microphthalmos with sclerocornea, persistent pupillary membrane, hypoplasia of the iris stroma, and bullous retinal detachment near the optic disc. Chromosomal analysis revealed a mosaic pattern: 46, XX/47, XXX. Increased intracranial pressure associated with Dandy-Walker syndrome was detected by a neurosurgeon at the age of 3 months. The patient was followed for several weeks, and then nonrhegmatogenous retinal detachment appeared in the right eye. Subretinal fluid alternately increased and decreased in both eyes. A ventriculo-peritoneal shunt was performed at the age of 6 months, and the retinal detachment was remarkably reduced in both eyes after lowering of intracranial pressure. Coloboma involving the optic disc, sclerocornea, persistent pupillary membrane, hypoplasia of iris stroma, and Dandy-Walker syndrome were thought to be caused by the abnormal development of neural crest cells. We surmised that the retinal detachment in this case might have resulted from a communicating pathway between the subarachnoid space and the subretinal space. We concluded that the etiology of retinal detachment associated with optic disc anomaly should be investigated to determine adequate treatment.

[Histochemical studies on two cases of Peters' anomaly]

We examined glycosaminoglycan molecular species in the corneal stroma and the sclera histochemically in two cases of Peters' anomaly. Paraffin-embedded sections were stained with either hematoxylin-eosin or sensitized high iron diamine combined with enzyme digestion and then examined with a light microscope. In the center of the cornea, the histological specimens revealed defects of the corneal endothelium and Descemet's membrane, together with a local defect of the corneal stroma. Disorganized lens materials were detected in the corneal stroma. In the peripheral cornea, the undifferentiated iris adhered to the corneal posterior surface. Based upon the findings mentioned above, these two cases were diagnosed as having Peters' anomaly caused by faulty separation of the lens vesicle. The sclera showed normal structures in the specimen stained with hematoxylin-eosin. In both cases, the corneal stroma involved nearly equal amounts of chondroitin sulfate A/C and B. The sclera, on the other hand, contained a large amount of chondroitin sulfate A/C and a relatively small amount of chondroitin sulfate B. Keratan sulfate was never detected in either the cornea or the sclera. Thus, disorders of glycosaminoglycan molecular species were detected in the sclera as well as in the corneal stroma.

Histology of fetal eyes with oculocutaneous albinism

The diagnosis of tyrosinase-negative oculocutaneous albinism (OCA) was made in a 19-week-old fetus by skin biopsy. Because the parents had an 11-year-old son with tyrosinase-negative OCA, they requested that the fetus be aborted at the 20th week of gestation. A histological analysis of the eyes was performed. Throughout the retina, the ganglion cell layer was separated from the inner neuroblastic layer by the inner plexiform layer. However, the number of ganglion cells was decreased and the nerve fiber layer was immature. Bipolar and horizontal cells had begun to segregate into the inner nuclear layer. Rods and cones were identifiable in the posterior, but not peripheral, retina. Cones were more numerous in the center of the retina, and no rod-free area was identifiable. In addition, the ciliary body (epithelial folds, blood vessels in the mesodermal connective tissue core, and ciliary muscle) was less developed than in a normal fetus. Melanosomes in the retinal pigment epithelium only contained filaments without melanization and were therefore classified as stage I or II melanosomes. However, the ciliary epithelium also contained some stage III melanosomes with melanin adherent to the filaments.

[Histochemical studies on glycosaminoglycans in Bruch's membrane of experimental microphthalmic mice]

The Cts mouse is a mutant mouse of the Jcl:ICR strain which has congenital cataracts and small eyes in homozygotes. Therefore, this mouse could be a model for autosomal dominant cataract with microphthalmia in humans. In the present study, attempts were made to demonstrate light-microscopically the molecular species of glycosaminoglycans (GAG) in Bruch's membrane of Cts mice on day 14, 16, and 18 of gestation and at 0, 4, and 7 days after birth by means of combined sensitized high iron diamine staining and testicular hyarulonidase digestion procedures. In Bruch's membrane of the unaffected mice at all stages examined, no substantial amount of chondroitin sulfate A/C could be detected. In homozygous mice, however, a large amount of chondroitin sulfate A/C was contained in Bruch's membrane. These results indicate that the abnormal change in GAG molecular species induced the functional disorder of Bruch's membrane and could play a certain role in the etiology of microphthalmia in homozygotes.

[Microphthalmos and its pathogenic classification]

Congenital microphthalmos is a common malformation encountered clinically. Microphthalmos in adults is here defined as eyes whose axial length is below 20.4 mm in males and 20.1 mm in females; in under 14-year-old children, it is eyes at least 3 square root of 2/3 below the mean for age-similar controls. Experimental animals with hereditary microphthalmos have been widely investigated, and many environmental factors given to pregnant animals frequently induce microphthalmos. In both clinical and experimental microphthalmos, there are conspicuous variations in size, and various kinds of ocular and systemic complications. Recently, fetal alcohol syndrome produced by alcohol intake during pregnancy has been reported. In this syndrome, microphthalmos is one of the important symptoms. Experimentally, microphthalmos also developed at a high incidence among mouse fetuses whose mothers were given ethanol during pregnancy. The present investigator established a preliminary etiological classification of microphthalmos in 1984. In this paper summing up newly obtained results, the relationship to neural crest cells and histochemical changes of glycosaminoglycan molecular species, the author presents a final pathogenic classification of microphthalmos, which consists of developmental disturbance of the optic vesicle, malformation of the optic cup, mesenchymal dysgenesis of the anterior ocular segment, maldevelopment of the lens, maldevelopment of the vitreous, faulty closure of the embryonic fissure and developmental disturbance of the wall of eyeball.

[Hypothermic effects on uveal blood flow and postoperative inflammation in vitrectomy]

Hypothermic effects on uveal blood flow and postoperative inflammation were evaluated in experimental vitrectomy on albino rabbits. Solutions used for intraocular perfusion were maintained at 9 degrees C and 22 degrees C. Following the vitrectomy, the rabbits' intraocular spaces were irrigated for 60 minutes. The temperature at various sites and the uveal blood flow were measured before and during the procedure. Aqueous protein concentrations were checked on postoperative days 1, 7, and 14. Another solution maintained at 37 degrees C was used as a control. There was a larger decrease in temperature at the retina than there was at the choroid and the ciliary body. Blood flow at the ciliary body decreased to 76.0% and 77.0% at the choroid after 60 minutes of irrigation at 9 degrees C. The decrease at 22 degrees C were 91.0% and 88.3%, respectively. Aqueous protein concentrations at both 9 degrees C and 22 degrees C were significantly lower than at 37 degrees C on the first postoperative day in the eyes irrigated for 60 minutes. In the eyes irrigated for 30 minutes, however, no significant differences were seen. Hypothermia during a prolonged vitrectomy operation seems to decrease inflammation in early postoperative stages.

[Multicenter prospective study of retinopathy of prematurity--IV. Comparison with the data from University of Miami]

We investigated the records of 360 cases of retinopathy of prematurity (ROP) in 12 institutions in Japan (we treated the severe progressive "plus" disease by coagulation therapy), and compared them with data from University of Miami (Ophthalmology 94: 620-629, 1987), as representative of the natural course of ROP without coagulation therapy in those days. The timing of the first examination and the first positive diagnosis were later at University of Miami than in Japan. The time of maximal severity of the disease and occurrence of regression were also later the University of Miami than in Japan. In Japan, the first examination was performed at 29 weeks of postconceptional age or at 3 weeks after birth. At the University of Miami, the first examination was performed at 32 weeks of postconceptional age. If the severe progressive "plus" disease is to be properly treated by photo-coagulation or cryotherapy, it is essential to commence fundus examination earlier.

[Multicenter prospective study of retinopathy of prematurity--II. Optimum timing of the first examination]

We reviewed the records of 360 cases of retinopathy of prematurity (ROP) in 12 institutions in Japan, and investigated the optimum timing of the first examination. On the basis of the onset of ROP and the timing of the first treatment, the first ophthalmological examination should be performed 3 weeks after birth or 29 weeks of postconceptional age at the latest. Regarding the visibility of the fundus, there was little hazy media after 29 weeks of postconceptional age. Under the basic policy that the severe progressive "plus" disease should be properly treated, we concluded that the first ophthalmological examination should be performed 3 weeks after birth at the latest. When the gestational age at birth is less than 26 weeks, funduscopy at the post conceptional age of 29 weeks is advisable.

[Multicenter prospective study of retinopathy of prematurity--III. Timing of the coagulation therapy and the course of retinopathy of prematurity after coagulation]

We reviewed the records of 360 cases of retinopathy of prematurity (ROP) in 12 institutions in Japan, and investigated the timing of the coagulation therapy and the course of ROP after coagulation. The first coagulation therapy was performed at 9.6 weeks after birth and 35.9 weeks of postconceptional age on the average. The severity index in individual infants also showed that the disease became worse during the period from 32 to 36 weeks of postconceptional age. However, the fundus was clearly visible and there was no primary hazy media during this period. On the basis of the results of the timing of the first treatment, the visibility of the fundus, and the severity index in individual infants, we concluded that an ophthalmological examination with special care should be performed during the period from 32 to 36 weeks of postconceptional age.