Impact of linked color imaging and blue laser imaging on the diagnosis of esophageal squamous cell carcinoma in iodine unstained areas

The pink color sign in iodine unstained areas is useful to differentiate esophageal squamous cell carcinoma (ESCC) from other lesions. However, some ESCCs have obscure color findings which affect the ability of endoscopists to differentiate these lesions and determine the resection line. Using white light imaging (WLI), linked color imaging (LCI) and blue laser imaging (BLI), 40 early ESCCs were retrospectively evaluated using images before and after iodine staining. Visibility scores for ESCC by expert and non-expert endoscopists were compared using these three modalities and color differences measured for malignant lesions and surrounding mucosa. BLI had the highest score and color difference without iodine staining. Each determination with iodine was much higher than without iodine regardless of the modality. With iodine, ESCC mainly appeared pink, purple and green using WLI, LCI and BLI, respectively and visibility scores determined by non-experts and experts were significantly higher for LCI (both p < 0.001) and BLI (p = 0.018 and p < 0.001) than for WLI. The score with LCI was significantly higher than with BLI among non-experts (p = 0.035). With iodine, the color difference using LCI was twice that with WLI and one with BLI was significantly larger than with WLI (p < 0.001). These greater tendencies were found regardless of location, depth of cancer or intensity of pink color using WLI. In conclusion, areas of ESCC unstained by iodine were easily recognized using LCI and BLI. Visibility of these lesions is excellent even by non-expert endoscopists, suggesting that this method is useful to diagnose ESCC and determine the resection line.

Usefulness of linked color imaging for the detection of obscure early gastric cancer: Multivariate analysis of 508 lesions

OBJECTIVES

Early gastric cancers (EGCs) of the elevated type or with submucosal invasion are easily found by routine endoscopy. However, most early cancers are challenging to detect because of subtle morphological or color differences from surrounding atrophic mucosa and intestinal metaplasia. Linked color imaging (LCI) enhances mucosal color difference, making it easier to detect EGCs. The aim of this study is to clarify the advantages and possible disadvantages of LCI for screening for obscure EGC.

METHODS

A total of 665 malignant gastric lesions resected using endoscopic submucosal dissection between January 2015 and April 2018 were retrospectively reviewed. Obviously detectable lesions were not included in the main analysis when determining the target lesion. White light imaging (WLI)/LCI images of 508 endoscopically obscure malignant lesions were included in the final analysis and evaluated by three non-expert and three expert endoscopists using visibility scores for detection and extent.

RESULTS

The detection visibility scores using LCI were significantly higher than those using WLI regardless of lesion characteristics including location, size, histological type, depth of invasion, and Helicobacter pylori status. The detection score improved in 46.4% cases and deteriorated in 4.9% when the modality changed from WLI to LCI. A mixed-effects multivariate logistic regression analysis showed that use of LCI (odds ratio [OR] 2.57), elevated type (OR 1.92), invasion to submucosa (OR 2.18) were significantly associated with improved visibility of EGC.

CONCLUSIONS

Linked color imaging significantly improves visibility of EGC regardless of differences in lesion morphology, histology, location, depth of invasion, and H. pylori status compared to conventional WLI.

Improved detection of early gastric cancer with linked color imaging using an ultrathin endoscope: a video-based analysis

Background and study aims  Ultrathin endoscopy causes a minimal gag reflex and has minimal effects on cardiopulmonary function. Linked color imaging (LCI) is useful for detection of malignancies in the digestive tract. The aim of this study was to clarify whether LCI with ultrathin endoscopy facilitates detection of early gastric cancer (EGC) despite its lower resolution compared with high-resolution white light imaging (WLI) with standard endoscopy. Patients and methods  This was a retrospective analysis with prospectively collected video, including consecutive 166 cases of EGC or gastric atrophy alone. Ninety seconds of screening video was collected using standard and ultrathin endoscopes with both WLI and LCI for each case. Three expert endoscopists assessed each video and the sensitivity of detecting EGC calculated. Color difference calculations were performed. Results  Sensitivities using ultrathin WLI, ultrathin LCI, standard WLI, and standard LCI for the identification of cancer were 66.0 %, 80.3 %, 69.9 %, and 84.0 %, respectively. The color difference between malignant lesions and surrounding mucosa with ultrathin LCI and standard LCI were significantly higher than using ultrathin WLI or standard WLI, supported subjectively by the visibility score. Ultrathin LCI color difference and visibility score were significantly higher than standard WLI. Conclusions  LCI with a low-resolution ultrathin endoscope is superior to WLI with a high-resolution standard endoscope for gastric cancer screening. This suggests that the high color contrast between EGC and the surrounding mucosa is more important than high-resolution images.

[Effects of Various Antidepressants on Hemodynamics during General Anesthesia]

BACKGROUND

It is known that serious refractory hypotension during anesthesia may develop in some patients treated with antidepressants. However the detail of this phenomenon remains unclear.

METHODS

We performed a retrospective study based on written anesthesia records from April 2011 through September 2012 (n=5,578). We picked up patients who had received various types of antidepressants. We excluded cases in which neuraxial anesthesia had been performed, and preoperative general condi- tion or performed operation had affected hemodynam- ics greatly. 91 of 5,578 patients were included. All 91 patients received general anesthesia using propofol. We checked type of antidepressants taken and use of vasopressors during anesthesia.

RESULTS

Type of antidepressants taken by 91 patients had no effect on the frequency of vasopressor administration. However, 7 of 91 patients showed treatment-resistant refractory hypotension by ephed- rine and phenylephrine. Catecholamines (noradrenaline, dobutamine) were effective. Frequency of refractory hypotension was significantly higher with serotonin and noradrenaline reuptake inhibitors (SNRI) or with two combined antidepressants.

CONCLUSIONS

Type of antidepressants had no effect on frequency of vasopressor administration. Treat- ment-resistant refractory hypotension by ephedrine and phenylephrine was significantly higher with SNRI or two combined antidepressants. Sympathetic nerve activity may be influenced by interaction of anesthetics and antidepressants in some patients.

Laser Imaging Facilitates Early Detection of Synchronous Adenocarcinomas in Patients with Barrett's Esophagus

Barrett's adenocarcinoma may occur in multiple sites, and recurrence and metachronous lesions are the major problems with endoscopic resection. Therefore, early detection of such lesions is ideal to achieve complete resection and obtain improved survival rates with minimally invasive treatment. Laser imaging systems allow multiple modalities of endoscopic imaging by using white light laser, flexible spectral imaging color enhancement (FICE), blue laser imaging (BLI), and linked color imaging even at a distant view. However, the usefulness of these modalities has not been sufficiently reported regarding Barrett's adenocarcinoma. Here, we report on a patient with three synchronous lesions followed by one metachronous lesion in a long segment with changes of Barrett's esophagus, all diagnosed with this new laser endoscopic imaging system and enhanced by using FICE and/or BLI with high contrast compared with the surrounding mucosa. Laser endoscopic imaging may facilitate the detection of malignancies in patients with early Barrett's adenocarcinoma.

Gel immersion endoscopy: a novel method to secure the visual field during endoscopy in bleeding patients (with videos)

BACKGROUND AND AIMS

It is difficult to secure the visual field during endoscopy for GI bleeding or colonoscopy without preparation because the injected water is rapidly mixed with fresh blood or stool. We developed a novel method to secure the visual field in these situations.

METHODS

Clear gel with the appropriate viscosity to prevent rapid mixing is injected through the accessory channel, instead of water. A vinyl tube was used as an in vitro GI bleeding model. After filling the lumen with indigo carmine dye, air insufflation and water injection are not effective for securing the visual field. However, after gel injection, the bleeding source is observed clearly in the space occupied by the gel. The efficacy of this method was evaluated subjectively in clinical use. From February 2014 until June 2015, gel immersion was used in 17 consecutive patients when the visual field could not be secured with routine insufflation.

RESULTS

Of these 17 patients, gel injection was very effective in 10, effective in 5, slightly effective in 1, and not effective in 1. There were no adverse events associated with this method.

CONCLUSION

Gel immersion endoscopy is safe and effective for securing the visual field, creating a space for endoscopic visualization and treatment in otherwise difficult situations.

A case of Ramsay Hunt syndrome in living-kidney transplant recipient

A 36-year-old woman underwent ABO-incompatible living-donor kidney transplantation. Immunosuppression was achieved by quadruple therapy with tacrolimus, basiliximab, mycophenolate mofetil (MMF), and prednisone. Desensitization and removal of anti-ABO antibody was achieved by administration of MMF for 4 weeks before transplantation followed by intravenous administration of rituximab, double-filtered plasmapheresis, and plasma exchange. At 1 month after transplantation, she complained of left ear pain without vesicle rash, tinnitus, and vertigo. Physical examination revealed left facial paralysis and nystagmus. T2 fluid-attenuated inversion recovery magnetic resonance imaging (MRI) visualized swelling of the left facial nerve. Real-time polymerase chain reaction showed the existence of varicella zoster virus DNA in the patient's tears and saliva. The final diagnosis was Ramsay Hunt syndrome without vesicle rash, which is called zoster sine herpete. The patient was treated by intravenous administration of acyclovir (3 mg/kg, 3 times per day) in addition to the reduction of the MMF dose. For facial nerve palsy, prednisolone was prescribed for 3 days and then gradually tapered. These treatments improved the symptoms of tinnitus and vertigo after a month; the facial nerve palsy completely disappeared after 10 months. This case demonstrated MRI to be a useful modality for the early diagnosis of Ramsay Hunt syndrome without vesicle eruption.

Changes in quality of life in deceased versus living-donor kidney transplantations

OBJECTIVE

In Japan, >80% of kidney transplantations (KTs) are performed from living donors because of a severe shortage of deceased donors. Moreover, >90% of deceased donors are non-heart-beating donors. In this study, we compared the quality of life (QOL) of the recipients between living- and deceased-donor KT performed in our hospital.

METHODS

QOLs of 91 recipients (11 deceased donors and 80 living donors) were analyzed using the Short Form 36 before and 1, 2, and 3 years after KT. Changes in QOLs were compared between deceased-donor KT (group DD) and living-donor KT (group LD).

RESULTS

In group DD, physical (PCS) and mental (MCS) component summary scores before transplantation were 43.7 and 48.7, respectively. PCS decreased to 35.3 at 1 year and 34.2 at 2 years, but increased to 52.6 at 3 years. MCS as 43.2 at 1 year, 52.2 at 2 years, and 44.5 at 3 years. In group LD, PCS and MCS before transplantation were 36.9 and 42.6, respectively. PCS increased to 43.3 at 1 year, 47.6 at 2 years, and 51.0 at 3 years, and MCS increased to 47.8 at 1 year, 50.1 at 2 years, and 49.6 at 3 years.

CONCLUSIONS

The recipients of living-donor KT showed an improvement of QOL immediately after transplantation. However, in the recipients of deceased-donor KT, physical QOL (PCS) decreased for 2 years after transplantation. The reasons seem to be long waiting period and the use of non-heart-beating donors in deceased-donor KT in Japan.

Results of kidney transplantation from ABO-incompatible living donors in a single institution

ABO-incompatible kidney transplantation has become a popular alternative to kidney transplantation in Japan because of the severe shortage of cadaveric donors. In our institution, 21 cases of ABO-incompatible kidney transplantation were performed from April 2004, to October 2007. Recipient age was 42.8 +/- 14.5 years old; there were 9 men and 12 women. Duration of hemodialysis was 1,914 +/- 2,343 days. Donor operation was performed using a complete laparoscopic procedure. Recipient's splenectomy was performed using a hand-assisted laparoscopic procedure and kidney transplantation was performed with a standard method using an extraperitoneal approach. Pretransplant immunosuppressive protocol includes an administration of mycophenolate mofetil, tacrolimus, predonisolone, splenectomy, double filtration plasmapheresis (DFPP), and plasma exchange (PE). All patients showed an immediate graft function and their serum creatinine levels promptly decreased to 1.48 +/- 0.99 mg/dL on day 7 and 1.21 +/- 0.72 mg/dL on day 30. Both immunoglobulin (Ig)M and IgG titers were maintained at much lower levels for 7 days after transplantation in all patients. Cytomegalovirus antigenemia was observed in 11 patients (52.4%). One patient (4.8%) developed a Pneumocystis Carinii pneumonia and the formation of lymphocele was observed in one patient (4.8%). Total patient survival at 3 years was 95.2%, and graft survival at 3 years was 90.5%, which were almost equal to those in the patients who underwent ABO-matched, compatible kidney transplantation.

Two cases of calcineurin inhibitor-associated reversible posterior leukoencephalopathy syndrome in renal transplant recipients

Reversible posterior leukoencephalopathy syndrome (RPLS) is one of the important side effects of calcineurin inhibitors (CNIs). Magnetic resonance imaging (MRI) of the brain is useful for the diagnosis of RPLS, showing the edema primarily in the cortex and subcortical white matter of the posterior brain regions. Interruption of CNIs is essential for the treatment of patients with RPLS. Herein we have described 2 cases (1.7%) of RPLS induced by CNIs after kidney transplantation. The first case was a 56-year-old man with chronic renal failure due to diabetic nephropathy who received a living-related kidney transplantation in 2006. Initial immunosuppressive therapy consisted of cyclosporine, mycophenolate mofetil (MMF), prednisolone, and basiliximab. Four months after transplantation, he developed unconsciousness and paralysis. The second case was a 24-year-old woman with end-stage renal disease due to Alport syndrome who received an ABO-incompatible living-related kidney transplantation. Initial immunosuppressive therapy consisted of tacrolimus, MMF, prednisolone, and basiliximab. On postoperative day 3, she developed convulsions and unconsciousness. In both patients, RPLS was diagnosed with neurological symptoms and MRI findings at early stage of the disease, and they recovered rapidly from the disease by the interruption of CNIs. Our data demonstrated that early diagnosis and immediate interruption of CNIs were essential for the treatment of RPLS after kidney transplantation.

Possible Involvement of Urokinase-Type Plasminogen Activator Release From Human Peripheral Blood Lymphocytes in the Pathophysiology of Chronic Allograft Nephropathy

BACKGROUND

Little is known of the fibrinolytic host immune mechanisms responsible for induction of chronic allograft nephropathy (CAN), defined as a loss in glomerular filtration rate (GFR) caused by tubular atrophy and interstitial fibrosis, often with fibrous intimal thickening in the small arteries. However, chronic rejection has been reported to be associated with decreased activity of the fibrinolytic system. In our previous study, [Deamino-Cys1, D-Arg8]-vasopressin (dDAVP) induced urokinase-type plasminogen activator (uPA) release from human peripheral T lymphocytes via arginine vasopressin (AVP) V2-receptor-mediated reaction enhanced by an AVP V1-receptor antagonist. Therefore, we examined the level of uPA released from peripheral T lymphocytes by AVP in transplant patients with CAN in comparison with control groups.

PATIENTS AND METHODS

In this study, we evaluated in vitro uPA releasing activity of lymphocytes obtained from renal allograft patients with well-functioning grafts (n = 9), CAN (n = 5), or acute rejection episodes (n = 5) compared with lymphocytes from healthy volunteers with normal renal function (n = 12) or patients with renal insufficiency (n = 5).

RESULTS

Lymphocytes prepared from patients with chronic allograft nephropathy showed a significantly lower increase in uPA release induced by the combination of the V1-receptor antagonist and dDAVP compared with those from the other groups.

CONCLUSION

This finding suggested that a decrease in uPA release from human peripheral blood lymphocytes by AVP-related peptides may be potentially involved in the pathophysiology of CAN.

Simplified method for cryopreservation of islets using hydroxyethyl starch and dimethyl sulfoxide as cryoprotectants

Cryopreservation is an ideal method for long-term storage of human islets. Dimethyl sulfoxide (DMSO) has been used as an intracellular cryoprotectant. However, because of its toxicity, DMSO has to be added stepwise and diluted stepwise with sucrose. We combined hydroxyethyl starch (HES) as an extracellular cryoprotectant with DMSO to simplify the freeze-thawing procedure. Islets were isolated from the pancreas of beagle dogs by an automated digestion method and Ficoll purification. After overnight culture, the islets were cryogeneically stored using cooling by a programmed freezing system. After 4-week storage in liquid nitrogen, the container was rapidly thawed in a 37 degrees C water bath. The function of the islets was assessed upon static incubation immediately after thawing, showing a recovery rate of 71.16% +/- 20.14% and a stimulation index of 1.80 +/- 0.78. In conclusion use of HES allowed a decrease in DMSO concentration and simplified the freeze-thawing procedure for islets.

Application of high energy shock waves to cancer treatment in combination with cisplatin and ATX-70

BACKGROUND

The anti-tumor effects of high-energy shock waves (HESW) in combination with cisplatin (CDDP) and ATX-70, as a photosensitizer, were investigated in vitro and in vivo.

METHODS

Active oxygen generation by HESW was studied by means of electron spin resonance (ESR) system. The anti-tumor effects of HESW in combination with cisplatin (CDDP) and ATX-70 was investigated in vitro and in vivo.

RESULTS

HESW exposure induced singlet oxygen or hydroxyl radical. Adding ATX-70 enhanced the cell damage induced by HESW dose-dependently. Ascorbic acid inhibited the combined effect of HESW and ATX-70. Adding CDDP did not enhanced cell damage by HESW. The combined therapy of HESW, CDDP and ATX-70 showed further inhibition of tumor growth in vivo.

CONCLUSIONS

These results indicate that HESW activated ATX-70, and that the anti-tumor effect of HESW and ATX-70 was caused by active oxygen generation. HESW is able to be utilized with any other cancer treatment.

[Hepatectomy and intra-arterial infusion chemotherapy for hepatic metastasis of colorectal cancer]

We experienced 339 patients with primary colorectal cancer in our department. In the present study 69 cases of liver metastasis were examined for their treatments and effects. One-year, 3-year and 5-year survival rates were 49.2%, 16.2% and 6.8% in the 69 patients, respectively. Fourteen patients underwent hepatic resection plus hepatic artery infusion therapy. The overall survival rates at 1, 3 and 5 years were favorable: 88.3%, 55.6% and 29.6%, respectively. Three patients with H3 liver metastasis underwent hepatic resection plus hepatic artery infusion therapy. One patient is alive 29 months after operation, one died 25 months after operation, and the other is alive 8 months after operation. Thirteen patients with H3 liver metastasis from colorectal cancer underwent hepatic artery infusion therapy, and the one-year survival rate was 30.8%. None of the H3 patients without hepatic artery infusion therapy survived more than one year.

Resection of the inferior head of the pancreas: report of a case

We developed a new technique for partial resection of the head of the pancreas with an end-to-side pancreaticoduodenostomy, while preserving the duodenum, the common bile duct, and the upper part of the head of the pancreas around the duct of Santorini. A resection of the inferior head of the pancreas was performed in a patient with an intraductal mucin-producing tumor of the pancreas. This procedure is considered to be appropriate for treating both benign disease and noninvasive malignant disease involving either the uncinate process or the duct of Wirsung, because it removes both the uncinate process and the pancreatic tissue around the duct of Wirsung. We thus believe that a resection of the inferior head of the pancreas with an end-to-side pancreaticoduodenostomy can help play a significant role in the management of patients with benign diseases and localized malignant tumors of the pancreas.

The effect of high-energy shock wave therapy combined with cisplatin on mouse hepatoma

It is well documented that high-energy shock waves (HESW) can produce antitumor effects in vivo and in vitro. Furthermore, because HESW can be focused on a limited area, this therapy is considered applicable to the treatment of localized cancer. In this study, we investigated the effects of HESW therapy combined with cisplatin (CDDP) on MH134 hepatoma in a mouse model. Tumor growth was inhibited by 1 mg/kg CDDP treatment in combination with 2,000 HESW administration, but not by 1 mg/kg CDDP treatment only. Moreover, the CDDP concentration in the tumor increased after HESW administration. The active oxygen induced by HESW was then investigated by the electron spin resonance system, and it was found that HESW generated hydroxy-radicals. As oxygen radicals have been reported to change cell membrane potential, it is supposed that active oxygen induced by HESW changes cell membrane permeability, and that CDDP is concentrated in the tumor. Therefore, the combined therapy with HESW and CDDP showed synergistic inhibitory effects on tumor growth.

Enhancement of the antitumor effect by combined use of high-energy shock waves and ATX-70

The antitumor effects of high-energy shock waves (HESW) in combination with ATX-70 [a gallium-porphyrin complex, 2,4-bis(1-decyloxyethyl)-Ga(III)-1,3,5,8-tetramethylporphyrin++ +-6, 7-dipropionyl diaspartic acid [sequence: see text] were investigated. In vitro, the cell damage to mouse MH134 hepatoma after HESW treatment was enhanced by adding ATX-70. In vivo, HESW and ATX-70 combination therapy inhibited cell growth. However, neither HESW treatment alone nor ATX-70 treatment alone inhibited cell growth. These results imply that the antitumor effects of HESW and ATX-70 combined therapy are caused by activation of ATX-70 by HESW.