Feasibility and safety of 0.6% sodium alginate in endoscopic submucosal dissection for colorectal neoplastic lesion: A pilot study

Objectives

The usefulness of 0.6% sodium alginate (SA) as a submucosal (SM) injection solution for endoscopic SM dissection (ESD) has gained attention over the past few years. However, using ESD for colorectal neoplastic lesions is not explicitly researched as yet. Thus, we conducted this study to determine the feasibility and safety of 0.6% SA solution for colorectal ESD.

Methods

In this single-center, retrospective pilot study, a total of 100 cases treated with ESD using 0.6% SA as a SM injection solution for colorectal neoplasia at our institute were retrospectively reviewed to clarify the clinical feasibility and safety of 0.6% SA. The primary endpoint was to evaluate the complication rate, and the secondary endpoint was to determine the procedure time and the amount of solution used.

Results

Intraoperative perforation was observed in 1 case (1.0%), 2 cases (2.0%) presented with postprocedural hemorrhage, and no lethal adverse events were observed. The median ESD procedure times were 39.5 min (10-150), and the amount of solution used was less than 20 mL in 67 cases (67.0%). En-bloc resection could be achieved in 97 cases (97.0%). Although six cases underwent subsequent surgery due to the deep SM invasion (>1000 μm), there were no cases with nodal involvement, confirmed through histopathological evaluation.

Conclusions

Our findings indicate that 0.6% SA can potentially ensure safe and secure ESD for colorectal neoplasia.

Diagnostic performance of linked color imaging for gastric cancer by Helicobacter pylori infection status: A subanalysis of the large-scale, multicenter randomized controlled trial LCI-FIND

BACKGROUND

Linked color imaging (LCI) is a new image enhancement technology that facilitates the recognition of subtle differences in mucosal color. In the large-scale, multicenter randomized controlled trial LCI-FIND, LCI demonstrated good diagnostic performance for the detection of tumor lesions in the upper gastrointestinal tract. The aim of the present study was to exploratively evaluate the diagnostic performance of LCI according to H. pylori infection status as a subanalysis of LCI-FIND trial.

METHODS

The patients were randomly allocated to receive white light imaging (WLI) first, followed by LCI (WLI group), or vice versa (LCI group), and the two groups were compared for the detection of tumors. Data from this trial were analyzed by the presence/absence of H. pylori infection and further analyzed by successful or unsuccessful eradication in the H. pylori infection group.

RESULTS

The 752 patients in the WLI group and 750 patients in the LCI group who had participated in the LCI-FIND trial were included. In the successful eradication group, more gastric lesions were detected by primary mode in the LCI group than in the WLI group, indicating that more lesions were missed by WLI. Fisher's exact probability test for the comparison of the WLI and LCI groups yielded a p-value of 0.0068, with missed gastric lesions being detected 0.136 times (95% confidence interval: 0.020-0.923), significantly less with LCI than with WLI.

CONCLUSION

The current study suggests that LCI should be used for gastric cancer screening, particularly in patients with successful H. pylori eradication.

An Analysis of Delayed Bleeding in Cases of Colorectal Endoscopic Submucosal Dissection Due to Types of Direct Oral Anticoagulants in Japan

BACKGROUND & AIMS

Reported rates of delayed bleeding (DB) after endoscopic resection using direct oral anticoagulants (DOACs) are high and heterogeneous. This large-scale multicenter study analyzed cases of DB after colorectal endoscopic submucosal dissection related to various types of DOACs in Japan (the ABCD-J study) with those associated with warfarin.

METHODS

We retrospectively reviewed 1019 lesions in patients treated with DOACs and 459 lesions in patients treated with warfarin among 34,455 endoscopic submucosal dissection cases from 47 Japanese institutions between 2012 and 2021. The DB rate (DBR) with each DOAC was compared with that with warfarin. Risk factors for DB in patients treated with DOACs or warfarin were also investigated.

RESULTS

The mean tumor sizes in the DOAC and warfarin groups were 29.6 ± 14.0 and 30.3 ± 16.4 mm, respectively. In the DOAC group, the DBR with dabigatran (18.26%) was significantly higher than that with apixaban (10.08%, P = .029), edoxaban (7.73%, P = .001), and rivaroxaban (7.21%, P < .001). Only rivaroxaban showed a significantly lower DBR than warfarin (11.76%, P = .033). In the multivariate analysis, heparin bridging therapy (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.27-3.73, P = .005), rectal location (2.01, 1.28-3.16, P = .002), and procedure time ≥55 minutes (2.43, 1.49-3.95, P < .001) were significant risk factors for DB in the DOAC group. The DB risk in the DOAC group (OR, (95% CI)) was 2.13 (1.30-3.50) and 4.53 (2.52-8.15) for 1 and 2 significant risk factors, respectively.

CONCLUSIONS

Dabigatran was associated with a higher DBR than other DOACs, and only rivaroxaban was associated with a significantly lower DBR than warfarin.

Clinical factors associated with acute abdominal symptoms induced by gastric anisakiasis: a multicenter retrospective cohort study

BACKGROUND

Gastric anisakiasis typically causes severe abdominal symptoms; however, we incidentally detected asymptomatic gastric anisakiasis cases during esophagogastroduodenoscopy. The factors associated with developing acute abdominal symptoms induced by gastric anisakiasis remain unclear. Therefore, this study aimed to investigate the clinical factors associated with abdominal symptoms of gastric anisakiasis by comparing symptomatic and asymptomatic cases.

METHODS

This was a retrospective cohort study involving 264 patients diagnosed with gastric anisakiasis at nine hospitals in Japan between October 2015 and October 2021. We analyzed patients' medical records and endoscopic images and compared the clinical factors between the symptomatic and asymptomatic groups.

RESULTS

One hundred sixty-five patients (77.8%) were diagnosed with abdominal symptoms, whereas 47 (22.2%) were asymptomatic. Older age, male sex, diabetes mellitus, gastric mucosal atrophy, and gastric mucosal atrophy of the Anisakis penetrating area were significantly more common in the asymptomatic group than in the symptomatic group. Multivariate analysis revealed that age (p = 0.007), sex (p = 0.017), and presence or absence of mucosal atrophy (p = 0.033) were independent factors for the occurrence of acute abdominal symptoms. In addition, cases that were Helicobacter pylori naïve, with an elevation of white blood cells, or without an elevation of eosinophils were more common in the symptomatic group than in the asymptomatic group.

CONCLUSIONS

Age, sex, and presence or absence of gastric mucosal atrophy were the clinical factors associated with the occurrence of acute abdominal symptoms. Older and male patients and those with gastric mucosal atrophy were less likely to show abdominal symptoms. The mechanisms of the occurrence of symptoms induced by gastric anisakiasis remain unclear; however, our results will help clarify this issue in the future.

Computer-aided diagnosis of early-stage colorectal cancer using nonmagnified endoscopic white-light images (with videos)

BACKGROUND AND AIMS

Differentiation of colorectal cancers (CRCs) with deep submucosal invasion (T1b) from CRCs with superficial invasion (T1a) or no invasion (Tis) is not straightforward. This study aimed to develop a computer-aided diagnosis (CADx) system to establish the diagnosis of early-stage cancers using nonmagnified endoscopic white-light images alone.

METHODS

From 5108 images, 1513 lesions (Tis, 1074; T1a, 145; T1b, 294) were collected from 1470 patients at 10 academic hospitals and assigned to training and testing datasets (3:1). The ResNet-50 network was used as the backbone to extract features from images. Oversampling and focal loss were used to compensate class imbalance of the invasive stage. Diagnostic performance was assessed using the testing dataset including 403 CRCs with 1392 images. Two experts and 2 trainees read the identical testing dataset.

RESULTS

At a 90% cutoff for the per-lesion score, CADx showed the highest specificity of 94.4% (95% confidence interval [CI], 91.3-96.6), with 59.8% (95% CI, 48.3-70.4) sensitivity and 87.3% (95% CI, 83.7-90.4) accuracy. The area under the characteristic curve was 85.1% (95% CI, 79.9-90.4) for CADx, 88.2% (95% CI, 83.7-92.8) for expert 1, 85.9% (95% CI, 80.9-90.9) for expert 2, 77.0% (95% CI, 71.5-82.4) for trainee 1 (vs CADx; P = .0076), and 66.2% (95% CI, 60.6-71.9) for trainee 2 (P < .0001). The function was also confirmed on 9 short videos.

CONCLUSIONS

A CADx system developed with endoscopic white-light images showed excellent per-lesion specificity and accuracy for T1b lesion diagnosis, equivalent to experts and superior to trainees. (Clinical trial registration number: UMIN000037053.).

Linked color imaging provides enhanced visibility with a high color difference in upper gastrointestinal neoplasms

BACKGROUND AND AIM

The aim of this post-hoc analysis in a randomized, controlled, multicenter trial was to evaluate the visibility of upper gastrointestinal (UGI) neoplasms detected using linked color imaging (LCI) compared with those detected using white light imaging (WLI).

METHODS

The visibility of the detected UGI neoplasm images obtained using both WLI and LCI was subjectively reviewed, and the median color difference (ΔE) between each lesion and the surrounding mucosa according to the CIE L*a*b* color space was evaluated objectively. Multivariate logistic regression analysis was performed to identify factors associated with neoplasms that were missed under WLI and detected under LCI.

RESULTS

A total of 120 neoplasms, including 10, 32, and 78 neoplasms in the pharynx, esophagus, and stomach, respectively, were analyzed in this study. LCI enhanced the visibility 80.9% and 93.6% of neoplasms in pharynx/esophagus and stomach compared with WLI, respectively. LCI also achieved a higher ΔE of enhanced neoplasms compared with WLI in the pharynx/esophagus and stomach. The median WLI ΔE values for gastric neoplasms missed under WLI and later detected under LCI were significantly lower than those for gastric neoplasms detected under WLI (8.2 vs 9.6, respectively). Furthermore, low levels of WLI ΔE (odds ratio [OR], 7.215) and high levels of LCI ΔE (OR, 22.202) were significantly associated with gastric neoplasms missed under WLI and later detected under LCI.

CONCLUSION

Color differences were independently associated with missing gastric neoplasms under WLI, suggesting that LCI has an obvious advantage over WLI in enhancing neoplastic visibility.

[Liver metastasis from alpha-fetoprotein-producing gastric cancer 27 years postoperation:a case report]

A 75-year-old man with a history of distal gastrectomy for gastric cancer at 48 years of age underwent abdominal computed tomography, which revealed a left hepatic lobe tumor alongside direct gastric invasion. His blood test results revealed significant increase in serum alpha-fetoprotein (AFP) levels (32240.3ng/mL). A gastroscopy revealed that the histopathological findings of the biopsy specimens of the gastric invasion area were identical to those observed in the surgical specimens of gastric cancer, which was diagnosed 27 years earlier. The evaluation of the biopsy and surgical specimens revealed AFP positivity, which confirmed the diagnosis of the late recurrence of AFP-positive gastric cancer. Herein, we presented a rare clinical case of this malignancy. Additionally, a close, long-term postoperative follow-up is warranted in patients with AFP-producing gastric cancer.

Guidelines for endoscopic balloon dilation in treating Crohn's disease-associated small intestinal strictures (supplement to the Clinical Practice Guidelines for Enteroscopy)

Balloon-assisted enteroscopy allows endoscopic treatments in the deeper segments of the small bowel. Endoscopic balloon dilation has become a popular minimally invasive alternative for the treatment of Crohn's disease-associated small intestinal strictures. As a supplement to the Clinical Practice Guidelines for Enteroscopy, the Japan Gastroenterological Endoscopy Society's Working Committee has developed the present "Guidelines for endoscopic balloon dilation in treating Crohn's disease-associated small intestinal strictures," based on new scientific techniques and evidence. The guidelines cover standard procedures for the insertion route of the balloon endoscope, bowel preparation, indications, procedure-related complications, efficacy, target diameter and duration, management of multiple strictures, and the current state of combined and alternative treatments. Unresolved future research questions are also listed in this guideline.

A case of anisakiasis in the sigmoid colon

Colonic anisakiasis is rare because most cases of anisakiasis occur in the stomach. An accurate diagnosis is sometimes difficult because of the rarity and symptom nonspecificity. We should consider the possibility of colonic anisakiasis when examining patients who have a history of consuming raw fish.

Diagnostic ability of linked color imaging in ultraslim endoscopy to identify neoplastic lesions in the upper gastrointestinal tract

Background and study aims  Linked color imaging (LCI) is a new image-enhancing technique that facilitates the differentiation of slight differences in mucosal color tone. We performed an exploratory analysis to evaluate the diagnostic capability of LCI in ultraslim endoscopy, using data from patients examined in the LCI-Further Improving Neoplasm Detection in upper gastrointestinal (LCI-FIND) trial, a large-scale, multicenter, randomized controlled trial that demonstrated the capability of LCI for detecting neoplastic lesions in the upper gastrointestinal tract. Patients and methods  Data from the LCI-FIND prospective trial were used. In the LCI-FIND trial, 1502 patients with a history of gastrointestinal cancer were randomly assigned to two groups based on examination methods: white light imaging (WLI) followed by LCI (WLI group) and LCI followed by WLI (LCI group). The present exploratory analysis investigated the outcomes of patients who underwent ultraslim and standard endoscopies. Results  Ultraslim endoscopes were used in 223 patients and standard endoscopes in 1279 patients. The primary endpoint of the LCI-FIND trial was the percentage of patients diagnosed with a neoplastic lesion using WLI or LCI. The corresponding percentage tended to be higher with LCI than with WLI among patients who underwent ultraslim endoscopy and among those who underwent standard endoscopy; the crude risk ratio was 2.21 [95 % confidence interval (CI): 1.06-4.67], and the adjusted odds ratio was 2.46 (95 % CI: 1.07-5.63). Conclusions  Our exploratory analysis of data from the LCI-FIND trial showed that LCI is useful in identifying neoplastic lesions, when used in ultraslim endoscopy.

[Diagnosis of an ileal neuroendocrine tumor based on lymph node metastases: a case report]

A 72-year-old man was diagnosed with tumors outside of the stomach and mesentery of the small intestine on abdominal computed tomography. Histopathological examination of an endoscopic ultrasound-guided fine-needle aspiration biopsy specimen confirmed the diagnosis of lymph node metastasis of a neuroendocrine tumor (NET). Gastroscopy, colonoscopy, small bowel capsule endoscopy, somatostatin receptor scintigraphy, and 18F-fluorodeoxyglucose positron emission tomography were performed. However, the primary lesion could not be diagnosed. The patient underwent surgery, and an ileal submucosal tumor, which was not identified preoperatively in addition to the aforementioned abdominal tumors, was detected. All tumors were diagnosed as NET, and the ileal tumor was considered the primary lesion. The patient has shown no recurrence postoperatively. The current study presents a case of an ileal NET with lymph node metastases in a patient in whom the primary lesion remained preoperatively undiagnosed.

Colon Capsule Endoscopy versus CT Colonography in Patients with Large Non-Polypoid Tumours: A Multicentre Prospective Comparative Study (4CN Study)

BACKGROUND/AIMS

Non-polypoid colon lesions compared with polypoid lesions has a high malignant potential. The diagnostic performance of colon capsule endoscopy (CCE) and CT colonography (CTC) for large colorectal non-polypoid tumours, that is, laterally spreading tumours is still unclear. The aim of this study is to evaluate the performance of CCE and CTC for the diagnosis of large non-polypoid tumours.

METHODS

Thirty patients referred for endoscopic submucosal dissection of non-polypoid tumours measuring ≥20 mm were enrolled. Patients first underwent CCE, then colonoscopy (without resection) and CTC on the same day. An experienced gastroenterologist in a third hospital evaluated the CCE and recorded the location, size and morphology of all lesions detected, blinded to the colonoscopic findings. An experienced radiologist read the CTC under the same conditions. Colonoscopic findings were defined as the reference.

RESULTS

A total of 30 lesions (T1 cancer: 3, Tis cancer: 7, adenoma: 14, sessile serrated adenoma/polyp: 6) in 27 patients were observed for evaluation. The capsule excretion rate within 8 h was 85% (23/27), and all capsules went beyond the target lesions. Non-polypoid tumours tend to be depicted as polypoid on CCE. Per patient sensitivities were 0.89 (24/27) by CCE and 0.70 (19/27) by CTC (p = 0.0253, McNemar), and per lesion sensitivities were 0.87 (26/30) and 0.67 (20/30) respectively (p = 0.0143). Most lesions missed by both modalities were located in the proximal colon.

CONCLUSION

Eighty-seven per cent of non-polypoid tumours were detected by CCE, and the sensitivity using CCE was higher than that obtained using CTC (UMIN0000014772).

Linked Color Imaging Focused on Neoplasm Detection in the Upper Gastrointestinal Tract : A Randomized Trial

BACKGROUND

Linked color imaging (LCI) is a new image-enhanced endoscopy technique that allows users to recognize slight differences in mucosal color.

OBJECTIVE

To compare the performance of LCI with white light imaging (WLI) in detecting neoplastic lesions in the upper gastrointestinal tract.

DESIGN

A controlled, multicenter trial with randomization using minimization. (University Hospital Medical Information Network Clinical Trials Registry: UMIN000023863).

SETTING

16 university hospitals and 3 tertiary care hospitals in Japan.

PATIENTS

1502 patients with known previous or current cancer of the gastrointestinal tract and undergoing surveillance for gastrointestinal cancer.

INTERVENTION

WLI followed by LCI examination (WLI group) or LCI followed by WLI examination (LCI group).

MEASUREMENTS

Diagnosis of 1 or more neoplastic lesions in the pharynx, esophagus, or stomach in the first examination (primary outcome) and 1 or more neoplastic lesions overlooked in the first examination (secondary outcome).

RESULTS

752 patients were assigned to the WLI group and 750 to the LCI group. The percentage of patients with 1 or more neoplastic lesions diagnosed in the first examination was higher with LCI than with WLI (60 of 750 patients or 8.0% [95% CI, 6.2% to 10.2%] vs. 36 of 752 patients or 4.8% [CI, 3.4% to 6.6%]; risk ratio, 1.67 [CI, 1.12 to 2.50; P = 0.011]). The proportion with overlooked neoplasms was lower in the LCI group than in the WLI group (5 of 750 patients or 0.67% [CI, 0.2% to 1.6%] vs. 26 of 752 patients or 3.5% [CI, 2.3% to 5.0%]; risk ratio, 0.19 [CI, 0.07 to 0.50]).

LIMITATION

Endoscopists were not blinded.

CONCLUSION

LCI is more effective than WLI for detecting neoplastic lesions in the pharynx, esophagus, and stomach.

PRIMARY FUNDING SOURCE

Fujifilm Corporation.

Diagnostic performance of artificial intelligence to identify deeply invasive colorectal cancer on non-magnified plain endoscopic images

Background and study aims  Colorectal cancers (CRC) with deep submucosal invasion (T1b) could be metastatic lesions. However, endoscopic images of T1b CRC resemble those of mucosal CRCs (Tis) or with superficial invasion (T1a). The aim of this study was to develop an automatic computer-aided diagnosis (CAD) system to identify T1b CRC based on plain endoscopic images. Patients and methods  In two hospitals, 1839 non-magnified plain endoscopic images from 313 CRCs (Tis 134, T1a 46, T1b 56, beyond T1b 37) with sessile morphology were extracted for training. A CAD system was trained with the data augmented by rotation, saturation, resizing and exposure adjustment. Diagnostic performance was assessed using another dataset including 44 CRCs (Tis 23, T1b 21) from a third hospital. CAD generated a probability level for T1b diagnosis for each image, and > 95 % of probability level was defined as T1b. Lesions with at least one image with a probability level > 0.95 were regarded as T1b. Primary outcome is specificity. Six physicians separately read the same testing dataset. Results  Specificity was 87 % (95 % confidence interval: 66-97) for CAD, 100 % (85-100) for Expert 1, 96 % (78-100) for Expert 2, 61 % (39-80) for both gastroenterology trainees, 48 % (27-69) for Novice 1 and 22 % (7-44) for Novice 2. Significant differences were observed between CAD and both novices ( P  = 0.013, P  = 0.0003). Other diagnostic values of CAD were slightly lower than of the two experts. Conclusions  Specificity of CAD was superior to novices and possibly to gastroenterology trainees but slightly inferior to experts.

Variations in the gonadal artery with a single common trunk: embryological hypotheses by observation

BACKGROUND

A gonadal artery originates as a branch of the abdominal aorta and renal artery inferior to the level of origin of the renal arteries. Variations in multiple right testicular arteries (RTAs) arising from the abdominal aorta are common. We aimed to re-evaluate the unusual courses of gonadal arteries with a single common trunk in relation to the inferior vena cava and left renal vein and explain the developmental anatomy.

MATERIALS AND METHODS

The observational cross-sectional study was performed on 54 Japanese adult cadavers (29 men and 25 women). We examined the literature and developed embryological hypotheses on the single common trunk of the gonadal artery.

RESULTS

The gonadal artery, testicular artery, and ovarian artery arose from the abdominal aorta in 93.1%, 96.3%, and 89.6% of cases, respectively, and from the renal artery in 4.9%, 3.7%, and 6.3% of cases, respectively. We found two rare variations in the RTAs observed during the routine dissection of two male cadavers; in these two cases, a single common trunk of the RTAs originated from the abdominal aorta. A single common trunk was found in 3.7% of cadavers, 2.0% of sides, and 2.0% of arteries in the gonadal artery and in 6.9% of cadavers, 3.8% of sides, and 3.7% of arteries in the testicular artery. All cases of the single common trunk, including those in past reports, were observed only in men.

CONCLUSIONS

Knowledge of the variations in RTAs has important clinical consequences for invasive and non-invasive arterial procedures. In addition, this variation provides a new interpretation of the embryology of the gonadal artery. Variations similar to our findings have not been previously reported. Therefore, different variations concerning the RTA should be considered during surgical and non-surgical evaluations.

Inhibitory effect of lidocaine on colonic spasm during colonoscopy: A multicenter double-blind, randomized controlled trial

OBJECTIVES

Colonic spasm can interfere with colonoscopy, but antispasmodic agents can cause complications. This study aimed to assess the inhibitory effect of topical lidocaine compared with a placebo control.

METHODS

In five tertiary-care hospitals in Japan, 128 patients requiring endoscopic resection of a colorectal lesion were enrolled and randomly and double-blindly allocated to colonoscopy with topical administration of 2% lidocaine solution 20mL (LID, n = 64) or normal saline 20mL (control, n = 64). During colonoscopy, the assigned solution was applied with a spray catheter near the lesion and the area was observed for three minutes. primary endpoint was the inhibitory effect at three time-points (1, 2 and 3 minutes after dispersion), using a three-point scale (excellent, fair, poor). Secondary endpoints were rebound spasm and adverse events. All endpoints were scored in real time. Serum lidocaine levels were measured in 32 patients (LID 16, control 16).

RESULTS

There were no significant differences between groups in patient demographics. At all time-points, the proportion of patients with "excellent" scores was greater in LID group than control group, with significant differences observed at 2 minutes (p = 0.02) and 3 minutes (p = 0.02). In LID group, the rate of "excellent" scores increased by 12.5% at 2 minutes and was maintained at 3 minutes. Rebound spasm did not occur in LID group, compared with 15.6% of control group (p = 0.001). There were no adverse events in LID group. All serum lidocaine levels were below detectable levels.

CONCLUSIONS

Topical lidocaine is an effective and safe method for suppressing colorectal spasm during colonoscopy (UMIN000024733).

Multicenter observational study on functional bowel disorders diagnosed using Rome III diagnostic criteria in Japan

BACKGROUND

The Rome III diagnostic criteria had been used to diagnose functional gastrointestinal disorders (FGIDs) world wide, and functional bowel disorders (FBDs) including irritable bowel syndrome (IBS) have recently attracted the attention of Japanese physicians. However, there have been few reports on the prevalence of FBDs diagnosed by the Rome III diagnostic criteria.

AIMS

The aim of this study was to determine the prevalence of FBDs diagnosed according to the diagnostic criteria of Rome III in Japan.

PATIENTS AND METHODS

All patients who were booked for colonoscopy were enrolled from eight institutions in Japan. This study was a prospective observational study in the period from April 2013 to December 2013. Patients filled out FGID questionnaires of Rome III when they were waiting for colonoscopy.

RESULTS

Data for 1200 patients who underwent colonoscopy were analyzed. A total of 547 patients (45.6%) were diagnosed with FBDs. Out of those patients, 9.1% had IBS. According to the Rome III diagnostic criteria, 134 patients (11.2%) had functional bloating (FB), 73 (6.1%) had functional constipation (FC), 40 (3.3%) had functional diarrhea (FD), and 191 (15.9%) had unspecified functional bowel disorder (UFBD). Patients with FBDs had significantly higher rates of almost all symptoms (abdominal pain, hard or lumpy stools, loose or watery stools, and bloating) than those in the controls.

CONCLUSIONS

In Japan, the prevalence of FBDs and IBS is high, similar to that in the US. Many patients with FBDs have multiple symptoms.

Evaluation of an e-learning system for diagnosis of gastric lesions using magnifying narrow-band imaging: a multicenter randomized controlled study

Background and study aim Magnifying narrow-band imaging (M-NBI) is useful for the accurate diagnosis of early gastric cancer (EGC). However, acquiring skill at M-NBI diagnosis takes substantial effort. An Internet-based e-learning system to teach endoscopic diagnosis of EGC using M-NBI has been developed. This study evaluated its effectiveness. Participants and methods This study was designed as a multicenter randomized controlled trial. We recruited endoscopists as participants from all over Japan. After completing Test 1, which consisted of M-NBI images of 40 gastric lesions, participants were randomly assigned to the e-learning or non-e-learning groups. Only the e-learning group was allowed to access the e-learning system. After the e-learning period, both groups received Test 2. The analysis set was participants who scored < 80 % accuracy on Test 1. The primary end point was the difference in accuracy between Test 1 and Test 2 for the two groups. Results A total of 395 participants from 77 institutions completed Test 1 (198 in the e-learning group and 197 in the non-e-learning group). After the e-learning period, all 395 completed Test 2. The analysis sets were e-learning group: n = 184; and non-e-learning group: n = 184. The mean Test 1 score was 59.9 % for the e-learning group and 61.7 % for the non-e-learning group. The change in accuracy in Test 2 was significantly higher in the e-learning group than in the non-e-learning group (7.4 points vs. 0.14 points, respectively; P < 0.001). Conclusion This study clearly demonstrated the efficacy of the e-learning system in improving practitioners' capabilities to diagnose EGC using M-NBI.Trial registered at University Hospital Medical Information Network Clinical Trials Registry (UMIN000008569).

A prospective, multicenter survey on the validity of shorter periendoscopic cessation of antithrombotic agents in Japan

BACKGROUND

The management of antithrombotic agents for endoscopic procedures has recently focused on preventing periprocedural thrombosis in Western countries. However, this focus on shorter cessation of antithrombotic agents needs to be examined for its implications for post-procedural bleeding, with potential risk factors for such bleeding clarified in real-world clinical settings in Japan.

METHODS

A Sapporo consensus group convened and developed a consensus document on the criteria for cessation of antithrombotic agents. In the multicenter, prospective, observational study that followed to validate the criteria in a real-world clinical setting, of all patients ≥20 years of age receiving antithrombotic agents and undergoing endoscopic procedures, all consenting patients were enrolled. All participating facilities were followed up on their adherence to the criteria and clinical outcomes, such as the occurrence of post-procedural bleeding and thrombosis.

RESULTS

A total of 5250 patients, who accounted for 6944 endoscopic procedures, were enrolled from 19 study sites. The consensus criteria, which proved to be nearly consistent with the JSGE criteria revised in 2012, had been adhered to in a total of 6531 procedures performed in 4921 patients. Bleeding and thrombosis were reported in 53 (0.76 %) and two (0.03 %) patients, respectively, among those receiving antithrombotic agents. Post-procedural bleeding was significantly associated with high-bleeding-risk procedures, a high thromboembolic risk with heparin bridging, and the presence of renal failure/dialysis.

CONCLUSIONS

With the new criteria in place for cessation of antithrombotic agents focused on prevention of periprocedural thrombosis, endoscopic procedures may be safely performed without substantially increasing bleeding in clinical practice in Japan.

Gastrografin as an alternative booster to sodium phosphate in colon capsule endoscopy: safety and efficacy pilot study

BACKGROUND AND STUDY AIMS

Sodium phosphate is a key component of bowel preparation regimen for colon capsule endoscopy (CCE), but may cause serious complications. The aim of this study is to evaluate the use of Gastrografin, substituted for sodium phosphate, in CCE bowel preparation.

PATIENTS AND METHODS

In total, 29 patients (median age 64 years; 23 females) underwent CCE, covered by the national health insurance system of Japan. All had a history of laparotomy and/or previously incomplete colonoscopy. On the day before examination, patients ingested 1 L of polyethylene glycol + ascorbic acid with 0.5 L of water in the evening, and again the same laxative on the morning of examination. After capsule ingestion, 50 mL of Gastrografin diluted with 0.9 L of magnesium citrate was administered, and then repeated after 1 hour.

RESULTS

The capsule excretion rate was 97 % (28/29). The median colon transit time was 2 hours 45 minutes and rapid transit (< 40 minutes) through the colon occurred in one patient (3.4 %). Bowel cleansing level was adequate in 90 % of patients. The polyp (≥ 6 mm) detection rate was 52 %. Diluted Gastrografin was well tolerated by patients. No adverse events occurred.

CONCLUSION

Gastrografin can be an alternative to sodium phosphate in CCE bowel preparation regimen.

Laparoscopic-endoscopic cooperative surgery is a safe and effective treatment for superficial nonampullary duodenal tumors

The use of endoscopic submucosal dissection (ESD) for duodenal neoplasms has increased in recent years, but delayed perforation and bleeding are also known to frequently occur. We present two cases in which duodenal adenoma was successfully treated with laparoscopic-endoscopic cooperative surgery. ESD was combined with laparoscopic seromuscular sutures. The lesions in both cases were located in the second portion of the duodenum. The patients requested resection of the lesion, and we performed laparoscopic-endoscopic cooperative surgery. After the laparoscopic surgeon mobilized the duodenum, the endoscopic surgeon performed ESD for the duodenal tumor without perforation. The laparoscopic surgeon sutured the duodenal wall in the seromuscular layer to strengthen the ulcer bed after ESD. Histopathological studies confirmed that the surgical margins were tumor-free in both cases. The patients were discharged with no complications. This unique laparoscopic-endoscopic cooperative procedure is a safe and effective method for resecting superficial nonampullary duodenal tumors.

Subject-friendly entire gastrointestinal screening with a single capsule endoscope by magnetic navigation and the Internet

Ever since capsule endoscopy (CE) was introduced into clinical practice, we gastroenterologists have been dreaming of using this less invasive modality to explore the entire gastrointestinal (GI) tract. To realize this dream, we have developed a magnetic navigation system which includes real-time internet streaming of endoscopic video and some useful gadgets (position detection by means of magnetic impedance (MI) sensors and a modified capsule that is "weightless" in water). The design of the weightless capsule made it possible with 0.5T (Tesla) extracorporeal magnets to control the capsule beyond 20cm. A pair of MI sensors on the body surface could detect subtle magnetic flux generated by an intra-capsular magnet in the GI tract by utilizing the space diversity effect which eliminated the interference of terrestrial magnetism. Subjects underwent CE, during which they were free from confinement in the hospital, except for 1 hour when the capsule was manipulated in the stomach and colon. This study had a completion rate of 97.5%. The high completion rate indicates that our system (single capsule endoscopy-SCE) with further improvements could become a viable modality for screening of the entire GI tract.

Efficacy and safety of endoscopic interventions using the short double-balloon endoscope in patients after incomplete colonoscopy

BACKGROUND AND AIM

We have previously reported excellent cecal intubation rates using a short double-balloon endoscope in patients with a history of incomplete colonoscopy. However, data on the endoscopic treatment of colorectal tumors using a double-balloon endoscope are limited. The aim of the present study was to evaluate the efficacy and safety of endoscopic intervention of colorectal tumors using a short double-balloon endoscope.

METHODS

We analyzed data from a multicenter, prospective study on 110 patients (62 men, median age 66.5 years) who underwent total colonoscopy after incomplete colonoscopy to assess the characteristics of colorectal tumors, endoscopic interventions, and complications.

RESULTS

In all, 113 colorectal tumors were detected in 55 patients; 109 of the tumors were adenomas (24 advanced adenomas) and two each were intramucosal and advanced cancers. Locations of the lesions were eight in the cecum, 30 in the ascending colon, 18 in the transverse colon, 12 in the descending colon, 34 in the sigmoid colon, five in the rectosigmoid and six in the rectum. Average tumor diameter was 6.8 ± 6.3 mm. Fifty-nine polypectomies, 22 endoscopic mucosal resections, four hot biopsies, and six cold biopsies were done. All endoscopic interventions were successfully completed and no complications were noted. Two advanced cancers were located in the ascending colon and only a double-balloon endoscope could reach them to take a biopsy sample.

CONCLUSION

Double-balloon endoscopy is effective and safe for endoscopic intervention of colorectal tumors, irrespective of the location, in patients after incomplete colonoscopy.

Human intestinal spirochetosis is significantly associated with sessile serrated adenomas/polyps

It remains unclear whether or not human intestinal spirochetosis (HIS) has any associated symptoms or lesions. In this study, we assessed the prevalence of HIS in sessile serrated adenomas/polyps (SSA/Ps) and their possible association. Following identification of early cecal cancer with SSA/P accompanied by a colonization of HIS, we went on to conduct a retrospective case-control study using endoscopically resected SSA/P specimens to examine the frequency of HIS infection in SSA/Ps. Nineteen SSA/P cases and 172 controls were obtained. The rate of HIS infection was significantly higher at 52.6% (10/19) in the SSA/P cases compared to the controls at 8.1% (14/172). Our SSA/P series were associated with a remarkably higher rate of HIS than controls or than previously reported. This is the first report to provide evidence for potential association between HIS and SSA/Ps.

[A case of advanced primary colorectal carcinoma accompanied by liver metastasis in which ileus developed due to marked fibrosis with cicatricial formation in primary colorectal cancer treated by chemotherapy including bevacizumab]

A 64-year-old woman was introduced to our hospital with liver tumors. Our examination revealed that she had advanced colon carcinoma with multiple liver metastasis. Without symptoms from the primary cancer, she underwent chemotherapy of avastin FOLFOX. After 2 courses of chemotherapy, she suffered ileus and underwent operation. The resected specimen showed marked tumor necrosis and fibrosis, but few tumor cells remained in the primary lesion. We think this was a rare case of suffered ileus because of marked response of chemotherapy in primary colon carcinoma.

A multicenter, prospective trial of total colonoscopy using a short double-balloon endoscope in patients with previous incomplete colonoscopy

BACKGROUND

There is no specific insertion method for patients who previously underwent an incomplete colonoscopy. No multicenter prospective study using a double-balloon endoscope (DBE) for total colonoscopy was previously performed.

OBJECTIVE

To demonstrate the effectiveness and safety of using short DBEs in patients who previously underwent incomplete colonoscopies.

DESIGN

A multicenter, prospective trial.

SETTING

Four tertiary care academic centers and 6 community hospitals.

PATIENTS

Patients with a history of incomplete colonoscopy, ages 20 to 79 years, were included. Exclusion criteria were colonoscopy performed by endoscopists with experience in fewer than 1000 cases, history of colectomy, poor bowel preparation, inflammatory bowel disease, active bowel obstruction, and active bleeding.

INTERVENTION

Total colonoscopies using short DBEs were attempted in all patients.

MAIN OUTCOME MEASUREMENTS

Primary endpoint was the cecal intubation rate. Secondary endpoints were time to cecal intubation, complications, and tolerability.

RESULTS

A total of 110 patients (62 males, median age 66.5 years) were included. Fifty-four patients had a history of abdominal surgery. The cecal intubation rate was 100% (110/110). Median intubation time was 12 minutes (range 4-47 minutes). Mild mucosal tears without symptoms occurred in 1 patient. For 64.5% of patients, intravenous sedatives and/or analgesics were used during examinations. Based on questionnaires, 50.9% had no pain, 31.8% slight pain, and 17.3% tolerable pain. Moreover, 96.4% of patients answered that their examination was more comfortable than their previous colonoscopy.

LIMITATION

Uncontrolled trial.

CONCLUSION

The use of a short DBE is an effective and safe method for total colonoscopy in patients who previously underwent incomplete colonoscopies. (

CLINICAL TRIAL REGISTRATION NUMBER

UMIN3464.).

Exacerbation of bloody diarrhea as a side effect of mesalamine treatment of active ulcerative colitis

Mesalamine has been used as the first-line therapy for the treatment of ulcerative colitis (UC) because of its efficacy and fewer side effects. However, earlier study showed that mesalamine occasionally causes diarrhea. We are presenting a patient with active UC in whom bloody diarrhea accompanied by abdominal pain and fever occurred and the symptoms were aggravated after administration of mesalamine. In order to clarify the reason of symptoms aggravation, drug lymphocyte stimulation test and rechallenge trial with mesalamine were performed. The results indicated the possibility that aggravation was related to allergic reaction and was dose-dependent. Furthermore, we examined colonoscopic views but there was no remarkable change in before and after rechallenge trial. Based on the above result, the patient was diagnosed with mesalamine intolerance. In order to differentiate whether the exacerbation of bloody diarrhea is due to the side effects of the mesalamine or a true relapse of UC, taking careful history before and after increasing mesalamine dosage as well as being aware of side effects of mesalamine are required. Clinicians should be aware of diarrhea as a side effect of mesalamine particularly after onset of mesalamine formulation, change in mesalamine formulation, or change in mesalamine dose.

Aberrant crypt foci as precursors of the dysplasia-carcinoma sequence in patients with ulcerative colitis

PURPOSE

Long-standing ulcerative colitis (UC) predisposes patients to the development of colorectal cancer, but surveillance of colitis-associated cancer by detecting the precancerous lesion dysplasia is often difficult because of its rare occurrence and normal-looking appearance. In sporadic colorectal cancer, aberrant crypt foci (ACF) have been reported by many investigators to be precursor lesions of the adenoma-carcinoma sequence. In the present study, we analyzed the genetic background of ACF to determine whether they could be precursors for dysplasia, and we examined the usefulness of endoscopic examination of ACF as a surrogate marker for surveillance of colitis-associated cancer.

EXPERIMENTAL DESIGN

ACF were examined in 28 UC patients (19 patients with UC alone and 9 patients with UC and dysplasia; 2 of those patients with dysplasia also had cancer) using magnifying endoscopy. K-ras, APC, and p53 mutations were analyzed by two-step PCR RFLP, in vitro--synthesized protein assay, and single-strand conformation polymorphism, respectively. Methylation of p16 was analyzed by methylation-specific PCR.

RESULTS

ACF that appeared distinct endoscopically and histologically were identified in 27 out of 28 UC patients. They were negative for K-ras, APC, and p53 mutations but were frequently positive for p16 methylation (8 of 11; 73%). In dysplasia, K-ras and APC mutations were negative but p53 mutation (3 of 5; 60%) and p16 methylation (3 of 5; 60%) were positive. There was a significant stepwise increase in the number of ACF from patients with UC alone to patients with dysplasia and to patients with cancer. Univariate and multivariate analyses showed significant correlations between ACF and dysplasia.

CONCLUSIONS

We have disclosed an ACF-dysplasia-cancer sequence in colitis-associated carcinogenesis similar to the ACF-adenoma-carcinoma sequence in sporadic colon carcinogenesis. This study suggests the use of ACF instead of dysplasia for the surveillance of colitis cancer and warrants further evaluation of ACF as a surveillance marker in large-scale studies.

Clinical and endoscopic features of acute hemorrhagic rectal ulcer

BACKGROUND

Acute hemorrhagic rectal ulcer (AHRU) has increasingly been reported in Japan, whereas it has rarely been reported in the English literature and is not yet established as a disease entity. The aim of this study was to elucidate clinical and endoscopic characteristics of patients with AHRU.

METHODS

We enrolled 20 patients with 26 ulcers diagnosed as AHRU in our department between January 2001 and October 2005. Clinical features such as the underlying disorder, Karnofsky performance status (PS), and presence or absence of anticoagulant or antiplatelet therapy, as well as endoscopic findings and type of bleeding, were evaluated. Strategies for hemostasis were also reviewed.

RESULTS

The most prevalent underlying disorder was diabetes mellitus, and the number of bedridden patients with PS 4 was relatively high. In addition, more than half of the patients had been treated with anticoagulant or antiplatelet agents. Endoscopically, ulcers were characteristically solitary and irregularly shaped, and they did not show any typical localization pattern. As a hemostatic strategy, clipping alone showed a favorable result, with a hemostatic success rate as high as 76.9%.

CONCLUSIONS

This study may support the establishment of AHRU as a new clinical entity. In aged patients being treated with anticoagulant or antiplatelet agents, especially bedridden patients using aspirin, the possible appearance of this disease should be kept in mind.

Selective embolization of the splenic vein in patients with hepatic encephalopathy and splenorenal shunt

Obliteration of portal-systemic shunts is effective for portosystemic encephalopathy but is often associated with complications such as retention of ascites and worsening of esophageal varices. Selective embolization of the splenic vein was performed on six patients with hepatic encephalopathy and splenorenal shunts. Hepatic encephalopathy was not observed in four patients after the procedure. Neither retention of ascites nor rupture of esophageal varices was observed because postoperative elevation of portal venous pressure was not as great as that seen when shunt obliteration is performed. This procedure can be an effective and safe treatment option for hepatic encephalopathy with a splenorenal shunt.

[A devised method of hepatic and splenic arterial infusion chemotherapy after transcatheter peripancreatic arterial embolization for patients with advanced pancreatic cancer]

We previously reported the clinical efficacy based on hepatic and splenic arterial infusion chemotherapy (HSAIC) for patients with advanced pancreatic cancer after transcatheter peripancreatic arterial embolization (TPPAE). However, this medical treatment pointed out a few problems in which the method had its complexity and a limited use of embolus micro-coil numbers. Then, we tried to improve the method in solving those problems. In order to reduce the embolus micro-coil numbers for TPPAE, we divided the micro-coil into several parts. We also devised the method of HSAIC. We used one catheter with a side hole, so that the catheter was able to supply a therapeutic drug for arterial infusion chemotherapy, both to the common hepatic artery and splenic artery. The effective rate for eleven cases was 72.7%, and there were no significant differences from the cases treated with the conventional method of TPPAE-HSAIC. Therefore, the devised treatment was considered to be an easy and useful method for TPPAE and HSAIC.

Advanced pancreatic carcinoma showing a complete response to arterial infusion chemotherapy

We report a patient with advanced carcinoma of the pancreatic body and tail with multiple liver metastases who showed a complete response to hepatic and splenic arterial infusion chemotherapy (HSAIC) with gemcitabine and 5-fluorouracil, following transcatheter peripancreatic arterial embolization (TPPAE) and partial splenic embolization (PSE). Nonresectable advanced pancreatic carcinoma tends to have a low response to medical treatment, with the median survival time being 6 months or less for stage IV cases. We disclose herein that the median survival time of patients receiving HSAIC after TPPAE is more than three times longer than the survival time attained with conventional treatments. However, in patients with advanced carcinoma of the pancreatic tail, for which TTPAE is not applicable, survival times remain low. Thus, in the patient described here, we also performed embolization of the left gastric and short gastric arteries as well as PSE to increase the flow within the great pancreatic and caudal pancreatic arteries via the splenic artery, and gemcitabine and 5-fluorouracil were administered via the splenic artery. As a result of these procedures, marked reduction in the advanced carcinoma of the pancreatic body and tail and of liver metastases was attained.

Argon plasma coagulation for successful treatment of early gastric cancer with intramucosal invasion

BACKGROUND

In recent years, there has been an increasing number of cases of early gastric cancer (T1, NX) with intramucosal invasion, which are untreatable by surgical or endoscopic mucosal resection (EMR) because of their high risk. Currently, no adequate treatment is available for such patients.

AIM

The main objective of this study was to evaluate whether argon plasma coagulation (APC) is an effective and safe modality for treating early gastric cancer untreatable by surgical resection or EMR.

METHODS

The study group comprised 20 men and seven women diagnosed with gastric cancer with intramucosal invasion who were considered poor candidates for surgical resection or EMR due to risk factors such as severe cardiac failure or thrombocytopenia. Irradiation conditions for APC treatment were determined using swine gastric mucosa. We used an argon gas flow of 2 l/min at a power setting of 60 W and a maximum irradiation time of 15 s/cm(2). The follow up period of the 27 patients ranged from 18 to 49 months (median 30 months).

RESULTS

All lesions were irradiated easily, including areas anatomically difficult for EMR such as the gastric cardia or the posterior wall of the upper gastric body. In 26 of 27 patients (96%) there was no evidence of recurrence during the follow up period (median 30 months). One patient showed recurrence six months after the treatment but was successfully retreated. No serious complications were found in any of the 27 patients but three patients (11%) experienced a feeling of abdominal fullness.

INTERPRETATION

APC is a safe and effective modality for treatment of early gastric cancer with intramucosal invasion untreatable by surgical resection or EMR. However, further observations are necessary to determine the long term prognosis of patients undergoing this treatment.

[A case of large-cell lung cancer with liver metastasis successfully treated using combination chemotherapy with CDDP and vinorelbine]

A 38-year-old woman presented to our hospital with the chief complaint of dyspnea. A chest radiograph showed pleural effusion of the right lung and a CT scan revealed liver metastasis. A tumor biopsy done under bronchoscopy revealed large-cell carcinoma of the lungs. She was given 4 courses of a combination therapy consisting of CDDP (80 mg/m2) and vinorelbine (25 mg/m2). The primary tumor in the right lung and liver metastasis were markedly reduced in size and a partial response was obtained. The combination therapy of CDDP and vinorelbine may become a standard chemotherapy for advanced non-small cell lung cancer.

[Study on the characterizations of genus Curcuma plants on the strains of C. longa L. and C. aromatica Salisb preserved at Izu station of NIHS]

To clarify the characteristics of genus Curcuma plants, we studied the properties of six strains of Curcuma longa L. and two strains of C. aromatica Salisb. preserved at Izu Experimental Station for Medicinal Plants of National Institute of Health Sciences. Six strains of C. longa were classified into three types according to morphological characteristics, rhizome production, and differences in curcuminoid content of rhizome. The curcuminoid content of the rhizomes in each strain ranged from 2.20 mg/g to 55.23 mg/g. Strains showing a high curcuminoid content had a low rhizome yield. No difference was observed between two strains of C. aromatica in terms of morphological characteristics. C. longa can be easily distinguished by differences in the development of tuberous roots and the color of the rhizome cross section.

Malignant fibrous histiocytoma of the heart: case report and review of 46 cases in the literature

A rare case of cardiac malignant fibrous histiocytoma (MFH) is reported. A 55-year-old woman complained of palpitation due to atrial fibrillation. Echocardiography, magnetic resonance imaging, and angiography demonstrated a tumor arising from the posterior wall of the left atrium. At surgery, the tumor was almost entirely resected and histologically defined as MFH. Neither chemotherapy nor irradiation was administered. Echocardiography revealed a local recurrence two months after the surgery and the patient died of advanced cachexy and heart failure 2 years later. The details of this case are presented with a review of the literature.

Collaborative work to evaluate toxicity on male reproductive organs by repeated dose studies in rats 10). Testicular toxicity of adriamycin observed 2 and 4 weeks after a single intravenous administration

The present study was performed to clarify whether toxic effects of the antitumor drug, adriamycin (ADR) on the male genital organ can be adequately detected 2 and 4 weeks after a single intravenous administration in the rat. ADR was intravenously administered once to 10 Crj:CD (SD) male rats/group aged 6 weeks (4-week group) and 8 weeks (2-week group) at doses of 0, 2 and 6 mg/kg. The rats were sacrificed at the age of 10 weeks. For comparison 10 rats/group were killed 2 weeks after a single intravenous administration at the age of 4 weeks (immature group). Saline was administered to control rats. Histopathological examination and a quantitative morphometry were carried out after measurement of testes weights at necropsy. In rats of the 4-week and 2-week groups, mean absolute testicular weight in all groups was significantly decreased. However, changes in mean relative weight were not evident in the 2-week group. Disappearance of seminiferous epithelial cells was observed histopathologically in rats dosed with 2 and 6 mg/kg in the 2-week group. The change was more severe in the 4-week group, when reduction of spermatogenesis and giant cells were also observed at 6 mg/kg. The quantitative morphometry in the 2-week group showed decreases in the numbers of spermatogonia and spermatocytes in stages X and XII at 2 mg/kg, and in the numbers of spermatogonia in all stages and spermatocytes in all stages except stage V at 6 mg/kg. Moreover, the numbers of spermatogonia and spermatocytes in all stages and spermatids in stages II-III and V were decreased with dose related manner in the 4-week group. In contrast, no obvious change in testes weights was apparent in the immature group. However, the numbers of spermatogonia and spermatocytes in all stages were decreased at 6 mg/kg. In conclusion, testicular toxicity of ADR could be detected 2 weeks after a single administration. Susceptibility of the testes of immature rats to ADR might be less than that of older animals.

[Geobotanical studies on the island of Tanegashima (affinity of world property island Yakushima)]

A list was drawn up of wild plants growing on Tanegashiama island that were identified in our field work, and the list was compared with the flora of the rest of Japan and the flora of Taiwan. There were 166 families and 1,218 species consisting of 23 families and 159 species of Pteridophyta, 4 families and 7 species of Gymnosperma, 113 families and 700 species of the dicotyledous Angiosperma, and 26 families and 353 species of monocotyledous Angiosperma. There are 229 families and 5,500 species of plants in Japan, 196 families and 3,019 species in Kyushu, and 228 families and 3,477 species in Taiwan. There are 11 species of endemic plants on Tanegashima and Yakushima, and the best known of them is Pinus armandii Francht. var. amamiana Hatsushima. There are 181 species of flora of flora limited to the northern element, including several important medicinal plants, such as Akebia quinata Decaisne and Zanthoxylum piperitum DC. The 69 species of flora limited to the southern element include several important tropical plants, such as Messerschmidia argentea Johnston and Clerodendrum inerme Gaertn. Most of these plants are distributed on both island, but some of are distributed only Tanegashima. We concluded that one of the temperate borderlines of Japanese flora in the temperate zone is the islands of Tokara. The flora of Tanegashima and Yakushima are having a closely affinity of plant species and having the rich plant species.

Systemic lupus erythematosus with a giant rectal ulcer and perforation

A 41-year-old man with systemic lupus erythematosus (SLE) who developed pelvic inflammation due to perforation of a giant rectal ulcer is described. The patient presented with persistent diarrhea, abdominal pain and fever without development of disease activity of SLE. Endoscopic and radiological examinations revealed a perforated giant ulcer on the posterior wall at the rectum below the peritoneal evagination. The ulcerated area was decreased after a colostomy was performed at the transverse colon to preserve anal function. The patient is currently being monitored on an outpatient basis. It should be noted that life-threatening complications such as perforated ulcer of the intestinal tract could occur without SLE disease activity.

Aberrant crypt foci of the colon as precursors of adenoma and cancer

BACKGROUND

Aberrant crypt foci of the colon are possible precursors of adenoma and cancer, but these lesions have been studied mainly in surgical specimens from patients who already had colon cancer.

METHODS

Using magnifying endoscopy, we studied the prevalence, number, size, and dysplastic features of aberrant crypt foci and their distribution according to age in 171 normal subjects, 131 patients with adenoma, and 48 patients with colorectal cancer. We also prospectively examined the prevalence of aberrant crypt foci in 11 subjects (4 normal subjects, 6 with adenoma, and 1 with cancer) before and after the administration of 100 mg of sulindac three times a day for 8 to 12 months and compared the results with those in 9 untreated subjects (4 normal subjects and 5 with adenoma). All 20 subjects had aberrant crypt foci at base line.

RESULTS

We identified 3155 aberrant crypt foci, 161 of which were dysplastic; the prevalence and number increased with age. There were significant (P<0.001) correlations between the number of aberrant crypt foci, the presence of dysplastic foci, the size of the foci, and the number of adenomas. After sulindac therapy, the number of foci decreased, disappearing in 7 of 11 subjects. In the untreated control group, the number of foci was unchanged in eight subjects and slightly increased in one (P<0.001 for the difference between the groups).

CONCLUSIONS

Aberrant crypt foci, particularly those that are large and have dysplastic features, may be precursors of adenoma and cancer.