Efficacy of single-balloon overtube for endoscopic submucosal dissection in the proximal colon: A propensity score-matched analysis

OBJECTIVES

A single-balloon overtube (SBO) can improve poor scope operability during colonic endoscopic submucosal dissection (ESD). We aimed to evaluate the clinical usefulness of SBO for ESD in the proximal colon and the predictive factors for cases in which SBO is useful.

METHODS

A total of 88 tumors located in the proximal colon resected by balloon-assisted ESD (BA-ESD) using SBO and 461 tumors resected by conventional ESD (C-ESD) between June 2015 and November 2020 were considered. Seventy-eight tumors each in the BA-ESD and C-ESD groups were matched by propensity score matching. ESD outcomes were compared between the groups, and a decision tree analysis was performed to explore the predictive factors for cases in which SBO is useful.

RESULTS

There were no significant differences between the groups in the major outcomes such as en bloc resection rate (95% vs. 99%, p = 0.17), R0 resection rate (92% vs. 96%, p = 0.30), mean dissection speed (16 mm²/min vs. 16 mm²/min, p = 0.53), and intraoperative perforation rate (5% vs. 6%, p = 0.73). Even when considering cases with poor preoperative scope operability, there were no significant differences between the groups. Comparison of tumors ≥40 mm in diameter between the groups confirmed that the intraoperative perforation rate was significantly lower in the BA-ESD group than in the C-ESD group (0% vs. 24%, p = 0.0188).

CONCLUSION

SBO is useful for ESD of tumors ≥40 mm in diameter in the proximal colon to prevent intraoperative perforation, which usually has a long procedure time.

Development of multi-class computer-aided diagnostic systems using the NICE/JNET classifications for colorectal lesions

BACKGROUND AND AIM

Diagnostic support using artificial intelligence may contribute to the equalization of endoscopic diagnosis of colorectal lesions. We developed computer-aided diagnosis (CADx) support system for diagnosing colorectal lesions using the NBI International Colorectal Endoscopic (NICE) classification and the Japan NBI Expert Team (JNET) classification.

METHODS

Using Residual Network as the classifier and NBI images as training images, we developed a CADx based on the NICE classification (CADx-N) and a CADx based on the JNET classification (CADx-J). For validation, 480 non-magnifying and magnifying NBI images were used for the CADx-N and 320 magnifying NBI images were used for the CADx-J. The diagnostic performance of the CADx-N was evaluated using the magnification rate.

RESULTS

The accuracy of the CADx-N for Types 1, 2, and 3 was 97.5%, 91.2%, and 93.8%, respectively. The diagnostic performance for each magnification level was good (no statistically significant difference). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CADx-J were 100%, 96.3%, 82.8%, 100%, and 96.9% for Type 1; 80.3%, 93.7%, 94.1%, 79.2%, and 86.3% for Type 2A; 80.4%, 84.7%, 46.8%, 96.3%, and 84.1% for Type 2B; and 62.5%, 99.6%, 96.8%, 93.8%, and 94.1% for Type 3, respectively.

CONCLUSIONS

The multi-class CADx systems had good diagnostic performance with both the NICE and JNET classifications and may aid in educating non-expert endoscopists and assist in diagnosing colorectal lesions.

Long-Term Outcomes after Endoscopic Submucosal Dissection for Ulcerative Colitis-Associated Dysplasia

INTRODUCTION

The Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendations guidelines recommend surveillance colonoscopy instead of colectomy after the complete removal of "endoscopically resectable" dysplastic lesions in ulcerative colitis (UC). There are no studies on long-term outcomes of endoscopic submucosal dissection (ESD) for UC-associated neoplasia (UCAN). We aimed to evaluate the clinical outcomes of ESD for UC-associated dysplasia (UCAD) during long-term follow-up.

METHODS

We retrospectively enrolled 17 consecutive UC patients with 22 UCADs, who underwent initial ESD or total proctocolectomy at the Hiroshima University Hospital. The clinicopathological features of the patients and neoplasias and clinical outcomes of ESD were evaluated and compared with those of total proctocolectomy.

RESULTS

UCAD in the ESD and total proctocolectomy groups was mostly noted on the left side of the colon, and most lesions were superficial macroscopic lesions. In the ESD group, en bloc resection and histological complete resection rates were 83 and 67%, respectively. One patient died of malignant melanoma; however, none of the patients died of UC-associated carcinoma in both groups. Metachronous neoplasias developed in 5 of the 7 patients in the ESD group. Among the 5 patients with metachronous UCAN, 4 finally underwent total proctocolectomy and 1 underwent additional ESD.

CONCLUSIONS

ESD for UCAD is a useful method for total excisional biopsy. UC patients with UCAD resected by ESD have a high risk of developing metachronous UCAN during the follow-up period.

Effect of educational lecture on the diagnostic accuracy of Japan NBI Expert Team classification for colorectal lesions

BACKGROUND

An educational and training program is required for generalization of Japan NBI Expert Team (JNET) classification. However, there is no detailed report on the learning curve of the diagnostic accuracy of endoscopists using JNET classification. We examined the effect of an educational lecture on beginners and less experienced endoscopists for improving their diagnostic accuracy of colorectal lesions by JNET classification.

METHODS

Seven beginners with no endoscopy experience (NEE group), 7 less experienced endoscopists (LEE group), and 3 highly experienced endoscopists (HEE group) performed diagnosis using JNET classification for randomized NBI images of colorectal lesions from 180 cases (Type 1: 22 cases, Type 2A: 105 cases, Type 2B: 33 cases, and Type 3: 20 cases). Next, the NEE and LEE groups received a lecture on JNET classification, and all 3 groups repeated the diagnostic process. We compared the correct diagnosis rate and interobserver agreement before and after the lecture comprehensively and for each JNET type.

RESULTS

In the HEE group, the correct diagnosis rate was more than 90% with good interobserver agreements (kappa value: 0.78-0.85). In the NEE and LEE groups, the correct diagnosis rate (NEE: 60.2 → 68.0%, P < 0.01; LEE: 66.4 → 86.7%, P < 0.01), high-confidence correct diagnosis rate (NEE: 19.6 → 37.2%, P < 0.01; LEE: 43.6 → 61.1%, P < 0.01), and interobserver agreement (kappa value, NEE: 0.32 → 0.43; LEE: 0.39 → 0.75) improved after the lecture. In the examination by each JNET type, the specificity and positive predictive value in the NEE and LEE groups generally improved after the lecture.

CONCLUSION

After conducting an appropriate lecture, the diagnostic ability using JNET classification was improved in beginners or endoscopists with less experience in NBI magnifying endoscopy.

Impaired preload reserve is an important haemodynamic characteristics that discriminates between physiological ageing and overt heart failure with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

 Ageing process per se is a major risk factor for heart failure (HF). In fact, the incidence of HF with preserved ejection fraction (HFpEF) dramatically increases with age. Although ageing plays a central role in the development of HFpEF, not all the elderly patients develop clinical HFpEF. Multiple abnormalities in the cardiovascular system have been proposed to contribute to the development of HFpEF. However, the pathophysiology that discriminates between physiological ageing and overt HFpEF is incompletely understood.

Purpose

 The purpose of this study was to assess the effects of ageing on the cardiac structures and haemodynamics. Moreover, we evaluated the determinant factor that discriminates between physiological ageing and overt HFpEF by non-invasive preload increasing manoeuvre using leg-positive pressure (LPP) stress echocardiography.

Methods

 A total of 91 subjects were prospectively recruited in this study: 22 patients with HFpEF and 69 healthy controls. Normal controls were further stratified into 3 age groups: young (n = 19, 20-40 years of age), middle-aged (N = 25, 40-65 years) and elderly (n = 25, &gt;65 years). All subjects underwent LPP stress with a continuous external pressure of 90 mmHg around both lower limbs using dedicated airbags (Fig.). 

Results

 The left ventricular mass index (LVMI; young, 68 ± 19 g/m²; middle-age, 70 ± 18 g/m²; elderly, 84 ± 21 g/m²) and also the relative wall thickness (RWT; young, 0.34 ± 0.09; middle-age, 0.41 ± 0.06; elderly 0.55 ± 0.10) increased with ageing, which was accelerated in HFpEF (LVMI: 111 ± 32 g/m², RWT; 0.63 ± 0.19, ANOVA P &lt; 0.001, respectively). Although baseline LV ejection fraction and cardiac output were quite comparable between groups, E/e’ ratio significantly increased with with ageing (ANOVA P &lt; 0.001, Fig.). During LPP stress, E/e’ ratio significantly increased in the middle-aged and elderly groups (from 8.8 ± 2.7 to 9.7 ± 3.3, and from 11.4 ± 2.4 to 13.0 ± 2.2, P &lt; 0.05, respectively), which was further deteriorated in HFpEF (from 16.8 ± 5.8 to 18.0 ± 7.6, P &lt; 0.05). On the other hand, stroke volume index (SVi) significantly increased in each healthy group during LPP stress (young; from 45 ± 10 to 50 ± 11 mL/m², middle-age; from 39 ± 7 to 44 ± 6 mL/m² and elderly; from 37 ± 7 to 43 ± 8 mL/m², all P &lt; 0.001), while SVi failed to increase in the HFpEF group (from 45 ± 13 to 45 ± 14 mL/m², P = 0.60). In a multivariate logistic regression analysis, LVMI (hazard ratio; HR 1.055, P &lt; 0.05), baseline E/e’ (HR 1.444; P &lt; 0.05), and ΔSVi (HR 0.755; P &lt; 0.05) during LPP stress were the independent parameters that characterised overt HFpEF.

Conclusions

 Striking parallels between structure-function alterations were observed in the physiological cardiovascular ageing process, which was further accelerated in patients with HFpEF. Not only structural remodeling and impaired diastolic function, but also impaired systolic reserve during preload stress is important haemodynamic feature that characterise the pathophysiology of HFpEF.

Abstract Figure.

Association between clinical risk factors and left ventricular function in patients with breast cancer following chemotherapy

Funding Acknowledgements

Type of funding sources: None.

Background

The sequential or concurrent use of two different types of agents such as anthracyclines and trastuzumab may increase myocardial injury and cancer therapeutics-related cardiac dysfunction (CTRCD), which is often the result of the combined detrimental effect of the two therapies for breast cancer patients. For risk stratification to detect the development of CTRCD, the current position paper from the European Society of Cardiology (ESC) lists several factors associated with risk of cardiotoxicity.

Purpose

Our purpose was to investigate the impact of baseline risk factors on left ventricular (LV) function in patients with preserved LV ejection fraction (LVEF) who have undergone chemotherapy for breast cancer.

Methods

We studied 86 breast cancer patients treated with anthracyclines, trastuzumab, or both. Mean age was 59 ± 13 years and LVEF was 67 ± 5%. In accordance with the current definition, CTRCD was defined as a decline in LVEF of &gt;10% to an absolute value of &lt;53% after chemotherapy. Based on the 2016 ESC position paper, clinical risk factors for CTRCD were defined as: (1) a cumulative total doxorubicin dose of ≥ 240mg/m², (2) age ≥ 65-year-old, (3) body mass index ≥ 30kg/m², (4) a previous history of radiation therapy to chest or mediastinum, (5) B-type natriuretic peptide ≥ 100pg/mL, (6) a previous history of cardiovascular disease, (7) atrial fibrillation, (8) hypertension, (9) diabetes mellitus, (10) current or ex-smoker.

Results

The relative decrease in LVEF after chemotherapy for patients with more than four risk factors was significantly greater than that for patients without (-9.3 ± 10.8% vs. -2.2 ± 10.2%; p = 0.02). However, this finding did not apply to patients with more than one, two or three risk factors. Patients with more than four risk factors also tended to show a higher prevalence of CTRCD than those without (14.3% vs. 2.8%, p = 0.12). Moreover, patients with more than four risk factors were more likely to have higher LV mass index (109.3 ± 29.0g/m² vs. 83.2 ± 21.0g/m², p &lt; 0.001), lower global longitudinal strain (18.4 ± 2.8% vs. 20.0 ± 2.6%, p = 0.06) and higher E/e’ (10.4 (8.9-13.0) vs. 9.0 (7.4-10.9), p = 0.06) compared to those without. 

Furthermore, receiver-operator characteristics curve analysis showed that an optimal cut off value of a cumulative total doxorubicin dose for developing LV dysfunction in patients with more than any of four risk factors was lower than that in those without (180 mg/m² vs. 280 mg/m²).

Conclusions

Association between clinical risk factors and LV dysfunction following chemotherapy became stronger with an increase in the number of risk factors in breast cancer patients, and was especially strong for patients treated with chemotherapy who had more than four risk factors. Our findings can thus be expected to have clinical implications for better management of patients with breast cancer referred for chemotherapy.

Abstract Figure.

Preload stress echocardiography by using dynamic postural alteration can identify high risk patients with heart failure with reduced ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Haemodynamic assessment during stress testing is not commonly performed for patients with heart failure with reduced ejection fraction (HFrEF) due to its invasiveness, less feasibility, and safety concerns. Passive leg-lifting (PLL) manoeuvres have been introduced as a simple alternative for non-invasive preload stress testing; however, the haemodynamic load imposed on the cardiovascular system is unsatisfactory, which precludes the accurate assessment of the preload reserve for patients with HF.

Purpose

The purpose of this study was to assess the haemodynamic characteristics of patients with HFrEF in response to a preload stress during dynamic postural alterations by combining the semi-sitting position (SSP) and PLL. We also evaluated whether combined postural stress could be used for risk stratification for these patients.

Methods

For this study, 101 patients with HFrEF and 35 age- and sex-matched normal controls were prospectively recruited. At each postural position (i.e., baseline, SSP, and PLL), all standard echocardiographic and Doppler variables were obtained. Adverse cardiac events were prespecified as the combined endpoints of death from or hospitalisation for deteriorated HF, or sudden cardiac death. Clinical follow-up was conducted for a median of 7 months.

Results

During PLL stress, the stroke volume index (SVi) significantly increased in both controls (from 40 ± 6 to 43 ± 6 mL/m², P = 0.03) and HFrEF patients (from 31 ± 9 to 34 ± 10 mL/m², P = 0.03). Conversely, during SSP stress, the SVi significantly decreased for both controls (from 40 ± 6 to 37 ± 6 mL/m², P = 0.03) and HFrEF patients (31 ± 9 to 28 ± 8 mL/m², P = 0.03). During the follow-up period, 16 patients developed cardiac events. In patients without events, the Frank-Starling mechanism was well preserved (Fig. A). Namely, the SVi significantly increased from 31 ± 9 to 35 ± 10 mL/m² (P = 0.02) during PLL stress, while the SVi significantly decreased from 31 ± 8 to 28 ± 8 mL/m² (P = 0.02) during SSP stress. In contrast, for patients with cardiac events, the SVi did not change during postural alterations (n.s), which indicated that the failing heart operates on the flat portion of the Frank-Starling curve (Fig. A). When patients were divided into three equal sub-groups based on the total difference in the SVi during dynamic postural stress, patients with impaired preload reserve (third trimester, ΔSVi ≤ 3.0 mL/m²) showed significantly worse event-free survival than the other two sub-groups (Fig. B; P &lt; 0.001). In a Cox proportional-hazard analysis, baseline LVEF (hazard ratio 0.93; P = 0.04), and ΔSVi during postural stress (hazard ratio 0.76; P = 0.004) were predictors of future cardiac events.

Conclusions

The combined assessment of dynamic postural stress during PLL and SPP is a simple, time-saving, and easy-to-use clinical tool for the assessment of preload reserve for patients with HFrEF. Moreover, postural stress echocardiography proved to contribute to the risk stratification for these patients.

Abstract Figure.

Cardiac resynchronization therapy improves left atrial reservoir function through resynchronization of the left atrium in patients with heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

The structural remodeling of the left atrium (LA) has been proposed as an important determinant of adverse outcomes in patients with heart failure (HF). However, little is known about the potential impact of LA mechanical dyssynchrony on its reservoir function and the prognosis of patients with HF. In addition, it has not been fully investigated whether cardiac resynchronization therapy (CRT) is also beneficial to LA function.

Purposes

The purposes of this study were to test whether left ventricular (LV) dyssynchrony may negatively affect LA synchronicity and reservoir function, and to assess whether residual LA dyssynchrony after CRT affects the prognosis in patients with HF with reduced ejection fraction (HFrEF).

Methods

This study included total of 90 subjects: 40 HFrEF with a wide-QRS complex (≧130 ms), 28 HFrEF with a narrow-QRS, and 22 age- and sex-matched normal controls. LA global longitudinal strain (LA-GLS) and LA dyssynchrony were quantified using speckle-tracking strain analysis. LA dyssynchrony was defined as the maximal difference of time-to-peak strain (LA time-diff). All wide-QRS HFrEF received CRT, and event-free survival was tracked for 24 months.

Results

At baseline, HFrEF patients showed significant LA remodeling coupled with the reduced LA reservoir function, as evidenced by larger LA volume index (LAVi: 46 ± 16 vs. 30 ± 14 mL/m², P &lt; 0.01) and smaller LA-GLS (13.0 ± 4.8 vs. 30.6 ± 10.7%, P &lt; 0.01). Of note was that, not only LV dyssynchrony (381 ± 178 vs. 177 ± 62 ms, P &lt; 0.01) but also LA dyssynchrony (298 ± 136 vs. 186 ± 78 ms, P &lt; 0.01) were significantly larger in patients with HFrEF compared to normal subjects and this applied even more to patients with a wide-QRS complex. All patients with a wide-QRS complex underwent CRT, and only responders exhibited the significant decrease in LA time-diff (from 338 ± 123 to 245 ± 141 ms, P &lt; 0.05) and increase in LA-GLS (from 11.9 ± 4.7 to 19.6 ± 10.1%, P &lt; 0.05) in parallel with the reduction in LAVi (from 48 ± 17 to 37 ± 18 mL/m², P &lt; 0.05) at 6 months after CRT. Receiver operating characteristic curve analysis identified the optimal cut-off value of LA time-diff at 6 months after CRT as 202 ms (P &lt; 0.05) and that of LA-GLS as 14.6% (P &lt; 0.05) for predicting adverse cardiac events. The patients whose LA time-diff reduced &lt;202 ms after CRT showed significantly favorable event-free survival than the others. Similarly, the patients whose LA-GLS improved &gt;14.6% after CRT exhibited significantly favorable event-free survival than the others (P &lt; 0.05, respectively). Of note was that, when the patients were restricted to CRT responders only, those who showed LA time-diff less than 202 ms at 6 months after CRT almost never experienced cardiac events (P &lt; 0.05).

Conclusions

The improved LV coordination by CRT also resulted in resynchronization of discoordinated LA wall motion and a consecutive improvement of LA reservoir function, which ultimately lead to the favorable outcome for HFrEF patients with wide-QRS complex.

Abstract Figure.

preoperative right ventricular overwork is a major determinant of residual pulmonary arterial hypertension in patients with repaired arterial septal defect

Funding Acknowledgements

Type of funding sources: None.

Background

The haemodynamic effect of atrial septal defect (ASD) is a chronic volume overload of the right heart and pulmonary vasculature. Pulmonary overcirculation is generally compensated for by the right ventricular (RV) and pulmonary arterial (PA) reserve. However, in a subset of patients, prolonged pulmonary overcirculation insidiously induces obstructive pulmonary vasculopathy, which results in postoperative residual pulmonary arterial hypertension (PAH) after ASD closure. Postoperative PAH is a major concern because it is closely associated with poor outcomes and impaired quality of life. However, to date, no clinically robust predictors of postoperative residual PAH have been clearly identified.

Purpose

This study sought to assess the haemodynamic characteristics of ASD patients in terms of mechano-energetic parameters and to identify the predictors of postoperative residual PAH in these patients.

Methods

A total of 120 ASD patients (age: 58 ± 17 years) and 46 normal controls were recruited. As previously reported, the simplified RV contraction pressure index (sRVCPI) was calculated as an index of RV external work by multiplying the tricuspid annular plane systolic excursion (TAPSE) by the pressure gradient between the RV and right atrium. RV- PA coupling was evaluated using TAPSE divided by PA systolic pressure as an index of the RV length-force relationship. These parameters were measured both at baseline and 6 months after ASD closure.

Results

As expected, baseline sRVCPI was significantly greater in patients with ASD than in controls (775 ± 298 vs. 335 ± 180 mm Hg • mm, P &lt; 0.01), which indicated significant "RV overwork". As a result, RV-PA coupling in ASD patients was significantly impaired compared to that in controls (0.9 ± 0.8 vs. 3.5 ± 1.7 mm/mm Hg, P &lt; 0.01). All 120 ASD patients underwent transcatheter or surgical shunt closure; 15 of them had residual PAH after closure. After 6 months, RV-PA coupling index significantly improved in patients without residual PAH, from 0.96 ± 0.81 to 1.27 ± 1.24 mm/mm Hg (P = 0.02). Furthermore, RV load was markedly reduced, with sRVCPI falling from 691 ± 258 to 434 ± 217 mm Hg • mm, P &lt; 0.01). However, in patients with residual PAH, RV-PA coupling index deteriorated from 0.64 ± 0.23 to 0.53 ± 0.12 mm/mm Hg (P &lt; 0.01). As a result, RV overload was not significantly relieved (sRVCPI; from 971 ± 382 to 783 ± 166 mm Hg • mm, P = 0.22). In a multivariate analysis, baseline pulmonary vascular resistance (hazard ratio 1.009; P &lt; 0.01) and preoperative sRVPCI (hazard ratio 1.003; P &lt; 0.01) revealed to be independent predictors of residual PAH.

Conclusion

In terms of mechano-energetic function, preoperative "RV overwork" can be used as a robust predictor of an impaired RV-PA relationship in ASD patients. Moreover, periodic assessment of sRVPCI may contribute to the better management for patients with unrepaired ASD.

Abstract Figure.

Association between clinical risk factors and left ventricular function in patients with breast cancer following chemotherapy

Background

The sequential or concurrent use of two different types of agents such as anthracyclines and trastuzumab may increase myocardial injury and cancer therapeutics-related cardiac dysfunction (CTRCD), which is often the result of the combined detrimental effect of the two therapies for breast cancer patients. For risk stratification to detect the development of CTRCD, the current position paper from the European Society of Cardiology (ESC) lists several factors associated with risk of cardiotoxicity following treatment with chemotherapy. However, the association between clinical risk factors and left ventricular (LV) function in breast cancer patients is currently unclear.

Purpose

Our purpose was to investigate the impact of baseline risk factors on LV function in patients with preserved LV ejection fraction (LVEF) who have undergone anthracycline or trastuzumab chemotherapy for breast cancer.

Methods

We studied 86 breast cancer patients treated with anthracyclines, trastuzumab, or both. Mean age was 59±13 years and LVEF was 67±5%. In accordance with the current definition, CTRCD was defined as a decline in LVEF of &gt;10% to an absolute value of &lt;53% after chemotherapy. Based on the 2016 ESC position paper, clinical risk factors for CTRCD were defined as: (1) a cumulative total doxorubicin dose of ≥240 mg/m2, (2) age ≥65-year-old, (3) body mass index ≥30 kg/m2, (4) a previous history of radiation therapy to chest or mediastinum, (5) B-type natriuretic peptide ≥100pg/mL, (6) a previous history of cardiovascular disease, (7) atrial fibrillation, (8) hypertension, (9) diabetes mellitus, (10) current or ex-smoker.

Results

The relative decrease in LVEF after chemotherapy for patients with more than four risk factors was significantly greater than that for patients without (−9.3±10.8% vs. −2.2±10.2%; p=0.02). However, this finding did not apply to patients with more than one, two or three risk factors. Patients with more than four risk factors also tended to show a higher prevalence of CTRCD than those without (14.3% vs. 2.8%, p=0.12). Moreover, patients with more than four risk factors were more likely to have higher LV mass index (109.3±29.0 g/m2 vs. 83.2±21.0g /m2, p&lt;0.001), lower global longitudinal strain (18.4±2.8% vs. 20.0±2.6%, p=0.06) and higher E/e' (10.4 (8.9–13.0) vs. 9.0 (7.4–10.9), p=0.06) compared to those without.

Conclusions

Association between clinical risk factors and LV dysfunction following chemotherapy became stronger with an increase in the number of risk factors in breast cancer patients, and was especially strong for patients treated with chemotherapy who had more than four risk factors. Our findings can thus be expected to have clinical implications for better management of patients with breast cancer referred for chemotherapy.

Funding Acknowledgement

Type of funding source: None

Consideration of non-valvular atrial fibrillation with left atrial appendage thrombus formation despite under appropriate oral anticoagulation therapy

Background

Atrial fibrillation (AF) is the most frequently sustained cardiac arrhythmia, with a prevalence of about 2–3% in the general population. In accordance with CHADS2 or CHA2DS2-VASc score, appropriate oral anticoagulation therapy such as warfarin or direct oral anticoagulants (DOAC) significantly reduced the risk of thromboembolic events. However, left atrial (LA) thrombus can be detected in the LA appendage (LAA) in AF patients despite appropriate oral anticoagulation therapy.

Purpose

Our purpose was to investigate the associated factors of LAA thrombus formation in non-valvular atrial fibrillation (NVAF) patients despite under appropriate oral anticoagulation therapy.

Methods

We retrospectively studied consecutive 286 NVAF patients for scheduled catheter ablation or electrical cardioversion for AF in our institution between February 2017 and September 2019. Mean age was 67.1±9.4 years, 79 patients (29.5%) were female, and 140 (52.2%) were paroxysmal AF. All patients underwent transthoracic and transesophageal echocardiography before catheter ablation or electrical cardioversion. All patients received appropriate oral anticoagulation therapy including warfarin or DOAC for at least 3 weeks prior to transesophageal echocardiography based on the current guidelines. LAA thrombus was defined as an echodense intracavitary mass distinct from the underlying endocardium and not caused by pectinate muscles by at least three senior echocardiologists.

Results

Of 286 NVAF patients with under appropriate oral anticoagulation therapy, LAA thrombus was observed in 9 patients (3.3%). Univariate logistic regression analysis showed that age, paroxysmal AF, CHADS2 score ≥3, left ventricular end-diastolic volume index (LVEDVI), left ventricular ejection fraction (LVEF), left ventricular mass index (LVMI), LA volume index (LAVI), mitral inflow E and mitral e' annular velocities ratio (E/e'), and LAA flow were associated with LAA thrombus formation. It was noteworthy that multivariate logistic regression analysis showed that LAA flow was independent predictor of LAA thrombus (OR: 0.72, 95% CI: 0.59–0.89, p&lt;0.005) as well as LVEF. Furthermore, receiver operating characteristic (ROC) curve analysis identified the optimal cutoff value of LAA flow for predicting LAA thrombus as ≤15cm/s, with a sensitivity of 88%, specificity of 93%, and area under the curve (AUC) of 0.95.

Conclusions

LAA flow was strongly associated with LAA thrombus formation even in NVAF patients with appropriate oral anticoagulation therapy. According to our findings, further strengthen of oral anticoagulation therapy or percutaneous transcatheter closure of the LAA may be considered in NVAF patients with appropriate oral anticoagulation therapy but low LAA flow, especially &lt;15cm/s.

Funding Acknowledgement

Type of funding source: None

Microvasculopathy evaluated by dual-energy computed tomography in chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension

Background

It has been previously reported that poor subpleural perfusion (PSP) in dual-energy computed tomography (DE-CT) might suggest the microvasculopathy in patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, it remains unclear whether pathological findings of microvasculopathy in CTEPH and pulmonary arterial hypertension (PAH) are equivalent. The aim is to evaluate the microvasculopathy in CTEPH and PAH by using clinical parameters and DE-CT.

Methods

We retrospectively reviewed PSP (defined as subpleural spaces either not or minimally perfused in all segments) of consecutive treatment-naïve 89 CTEPH patients and 20 PAH patients who underwent DECT from Feb. 2015 to Dec. 2019.

We also evaluated hemodynamic parameters and DE-CT parameters including quantitative evaluation of pulmonary blood volume (PBV) which was calculated as the average of entire lung iodine density.

Results

PSP was observed in 49.4% of patients in CTEPH group versus 5.0% in PAH group (p&lt;0.01).

There were no significant differences in hemodynamics and lung PBV between CTEPH group and PAH group (mean pulmonary arterial pressure; 36.4±10.4mmHg vs 38.3±8.5mmHg p=0.464, pulmonary vascular resistance; 700±388dyne*sec/cm5 vs 805±440 dyne*sec/cm5 p=0.288, lung PBV; 24.9±6.4 Hounsfield Unit vs 22.0±6.6 Hounsfield Unit p=0.06, respectively), however diffusing capacity for carbon monoxide (%DLCO/VA) was significantly lower (69.5±16.8% vs 45.7±23.7% p&lt;0.01) in PAH group.

Conclusion

PSP in DE-CT, which was observed more frequently in patients with CTEPH, might suggest the different mechanism of microvasculopathy from PAH in patients with CTEPH. Microvasculopathy in CTEPH would be diffuse very distal thrombosis. DE-CT is effective modality to detect microvasculopathy of diffuse distal thrombosis in patients with CTEPH.

DECT, Poor subpleural perfusion

Funding Acknowledgement

Type of funding source: None

Efficacy of interventional treatment for patients with chronic thromboembolic pulmonary hypertension with microvasculopathy

Background

The existence of microvasculopathy in chronic thromboembolic pulmonary hypertension (CTEPH) had been suggested. However, the impact of microvasculopathy for pathophysiology had been unknown. Recently dual-energy computed tomography (DECT) can produce a sensitive iodine distribution map in lung fields to quantify lung perfusion, which may indicate the existence of microvasculopathy according to poor subpleural perfusion.

This study aimed to examine the therapeutic efficacy of interventional treatment (pulmonary endarterectomy or/and balloon pulmonary angioplasty) in CTEPH with microvasculopathy.

Methods

We retrospectively reviewed poor subpleural perfusion (defined as subpleural spaces either not or minimally perfused in all segments) and hemodynamics of 70 consecutive CTEPH patients who underwent DECT before and after interventional therapy from January 2014 to January 2020.

Patients were divided according to poor subpleural perfusion in DECT images before treatment: a microvasculopathy group (MV group, n=37) or a non-microvasculopathy group (Non-MV group, n=33).

We evaluated clinical parameters as WHO functional class (WHO-Fc), 6-min walk distance, respiratory function test, cardiopulmonary exercise test, hemodynamic parameters, and DECT parameters at baseline and after the treatments. DECT parameters as quantitative evaluation of pulmonary blood volume (PBV) calculated as the average of entire lung iodine density.

Results

After interventional treatments, WHO-Fc improved in 33 patients in MV group, and 27 patients in Non-MV group (p=0.50).

In MV group, baseline mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance (PVR) and VE/VCO2 slope were higher (38.3±9.3 vs. 33.2±10.8 mmHg p=0.04, 818±394 vs. 539±289 dyne*sec/cm5 p&lt;0.01 and 43.7±11.3 vs. 35.2±6.9 p&lt;0.01, respectively) and PBV were lower (43.7±11.3 vs. 35.2±6.9 Hounsfield Unit p&lt;0.01) After the treatments, mPAP, PVR, VE/VCO2 slope and PBV showed almost equivalent between the groups (19.5±4.1 vs. 20.6±5.1 mmHg p=0.35, 272±111 vs 251±109 dyne*sec/cm5 p=0.42, 29.2±6.3 vs. 26.0±6.1 p=0.06 and 27.1±6.6 vs. 29.6±6.6 Hounsfield Unit p=0.13).

Diffusing capacity for carbon monoxide (%DLCO/VA) did not improve after treatment in both groups (MV group: 59.5±13.1 to 58.8±11.9% p=0.43. Non-MV group: 77.8±13.4% to 70.5±10.8% P&lt;0.01).

Conclusion

Hemodynamics, pulmonary perfusion, exercise capacities significantly improved after the treatments in spite of the existence or absence of microvasculopathy. However, DLCO which might indicate the existence of microvasculopathy did not improve. Interventional treatments could not improve microvasculopathy because of their limit of accessibilities.

Funding Acknowledgement

Type of funding source: None

Clinical usefulness of the S-O clip during colorectal endoscopic submucosal dissection in difficult-to-access submucosal layer

Background and study aims  In colorectal endoscopic submucosal dissection (ESD), the S-O clip improves the accessibility to the submucosal layer of the colon. However, its safety and usefulness in difficult colorectal ESDs are unclear. Thus, in this study, we aimed to assess the effectiveness of the S-O clip in colorectal ESD in the difficult-to-access submucosal layer. Patients and methods  From January 2016 to December 2016, 189 consecutive cases of colorectal ESD were performed at Hiroshima University Hospital before the S-O clip was introduced. Between January 2017 and June 2018, among 271 consecutive colorectal ESD cases, 41 cases were performed colorectal ESD using the S-O clip. We compared outcomes between the two groups (41 cases with S-O clip [use group] and 189 cases without S-O clip [non-use group]) using propensity score matching. Results  Prior to propensity score matching, 41 cases with the S-O clip (use group) and 189 cases without the S-O clip (non-use group) were extracted. The degree of submucosal fibrosis was more severe and the procedure time was longer in the use group than in the non-use group. In the use and non-use groups, en bloc resection (100 % vs. 94.7 %) and complete en bloc resection (100 % vs. 92.6 %) rates were satisfactory. After propensity score matching, 33 cases in each group were extracted. As a result, complete en bloc resection rate was significantly higher in the use group than in the non-use group (100 % vs. 84.9 %). Conclusion  The S-O clip is effective and can be used safely in colorectal ESD in the difficult-to-access submucosal layer.

Can surveillance colonoscopy be discontinued in an elderly population with diminutive polyps?

OBJECTIVES

Surveillance colonoscopy after endoscopic resection (ER) for adenomatous polyps reduces the incidence and mortality of colorectal cancer (CRC). However, its significance in the elderly population is uncertain. The study aimed to determine whether surveillance colonoscopy should be discontinued in the elderly population.

METHODS

We enrolled 105 patients who underwent baseline colonoscopy between January 2004 and December 2009 and were subsequently followed-up over 5 years in our institution. All had diminutive colorectal polyps and were aged <80 years at baseline colonoscopy and ≥80 years at follow-up in May 2018. Patients who had undergone colectomy or who had inflammatory bowel disease, familial adenomatous polyposis, Lynch syndrome, and no diminutive polyps were excluded. The cumulative incidence of the target lesion was evaluated. Histopathological diagnoses included low-grade dysplasia (LGD), high-grade dysplasia (HGD), and carcinoma.

RESULTS

The target lesion was detected in 15% (16/105) of the patients. There was no invasive carcinoma; however, two HGDs were detected. There were three lesions that had increased from previously detected diminutive lesions, all of which were LGDs. There were no target lesions detected after 84 years of age, and the cumulative incidence was 0.20. The cumulative incidence was significantly higher in the group with HGD than in the group with no target lesions at baseline colonoscopy. There was no HGD after age 79 years, and the cumulative incidence was 0.019.

CONCLUSION

Surveillance colonoscopy for patients with diminutive polyps may be discontinued after age 79 years.

The utility of a novel colonoscope with retroflexion for colorectal endoscopic submucosal dissection

Background and study aims  The PCF-H290TI/L produced by Olympus is a novel colonoscope equipped with some advantageous features for endoscopic treatment. It is expected to improve the potential for retroflexion and overall endoscope operability, which can reduce the difficulty of performing colorectal ESD. The aim of this study was to evaluate the utility of the novel colonoscope in colorectal ESD. Methods  Three hundred and forty-eight consecutive colorectal lesions resected via ESD between June 2014 and January 2017 at Hiroshima University Hospital were included in the retroflexion ability analysis. We compared the retroflexion potential of PCF-H290TI to that of a conventional endoscope. Two hundred and twenty-seven colorectal lesions located in the left-sided colon and resected with ESD between April 2009 and February 2018 were enrolled in the treatment outcome analysis. Treatment outcomes using PCF-H290TI compared to those of the conventional colonoscope, and outcomes of the PCF-H290TI with retroflexion compared to those of the conventional colonoscope without retroflexion were evaluated by propensity score matching. Results  The retroflexion rate with the PCF-H290TI was 76 %, which was significantly higher than the 44 % rate with the conventional scope. Endoscope operability was better and dissection speed was faster when using the PCF-H290TI with retroflexion compared to the conventional colonoscope without retroflexion. There were no significant differences between the groups in en bloc resection rate and adverse events. Conclusion  Compared to the conventional colonoscope, the PCF-H290TI/L made it easier to perform ESD via a retrograde approach regardless of tumor location, and thus may be useful for performing colorectal ESD.

Dual Red Imaging Maintains Clear Visibility During Colorectal Endoscopic Submucosal Dissection

BACKGROUND

The endoscopic lens becomes clouded and its visibility reduces during colorectal endoscopic submucosal dissection (ESD), especially in cases with submucosal fatty tissue. Dual red imaging (DRI) is a novel image-enhanced endoscopic technique that improves endoscopic visibility.

AIMS

This study aimed to evaluate the predictive factors of submucosal fatty tissue and the clinical usefulness of DRI in maintaining clear visibility during colorectal ESD.

METHODS

The study participants included 586 consecutive patients with 645 colorectal tumors who underwent ESD between January 2014 and July 2017. First, the degree of submucosal fatty tissue was evaluated by reviewing recorded images, and the clinical characteristics of the patients and tumors related to severe submucosal fatty tissue were evaluated. Second, 34 tumors resected using DRI were propensity score-matched in a 1:1 ratio to other resected tumors using white light imaging (WLI), and the degree of endoscope lens cloudiness and clinical outcomes were evaluated.

RESULTS

The proportion of tumors located in the right side of the colon, body mass index (≥ 25, BMI), and hemoglobin A1c (≥ 6.5%, HbA1c) were significantly higher in patients with severe submucosal fatty tissue. The visibility in the DRI group was significantly better than in the WLI group. Treatment outcomes in the DRI group were as good as those in the WLI group.

CONCLUSIONS

Tumor location in the right side of the colon, BMI (≥ 25), and HbA1c (≥ 6.5%) are the predictive factors of severe submucosal fatty tissue. DRI is useful in maintaining clear visibility during colorectal ESD, especially with submucosal fatty tissue.

Use of anticoagulants increases risk of bleeding after colorectal endoscopic submucosal dissection

BACKGROUND AND STUDY AIMS

Japanese guidelines for gastroenterological endoscopy have recommended temporary withdrawal of anticoagulants (warfarin, direct oral anticoagulants [DOAC], or heparin) to prevent hemorrhagic complications during endoscopic submucosal dissection (ESD) for colorectal neoplasias (CRNs). However, serious thrombosis might occur during temporary withdrawal of anticoagulants. The current study aimed to evaluate outcomes with anticoagulants in patients undergoing ESD for CRNs.

PATIENTS AND METHODS

 This study was a single-institution retrospective cohort study based on clinical records. We assessed 650 consecutive patients with 698 CRNs who underwent ESD at Hiroshima University Hospital between December 2010 and June 2016. The patients were divided into three groups: the warfarin group (19 patients with 19 CRNs), DOAC group (7 patients with 9 CRNs), and no-antithrombotics group (624 patients with 670 CRNs). We replaced warfarin with heparin 3 to 5 days before endoscopy. Although DOAC was suspended on the morning of endoscopy, we did not replace heparin.

RESULTS

 Bleeding after the procedure occurred in 26.3 % (5/19), 22.0 % (2/9), and 2.7 % (18/670) of patients in the warfarin, DOAC, and no-antithrombotics groups, respectively. In the warfarin group, four patients who bled after the procedure took not only warfarin but also other antiplatelets. En bloc resection rates were 94.7 % (18/19), 100 % (9/9), and 96.6 % (647/670) in the warfarin, DOAC, and no-antithrombotics groups, respectively. No patients experienced ischemic events in the perioperative period.

CONCLUSIONS

Among patients undergoing ESD for CRNs, risk of bleeding was higher among patients who took anticoagulants than among those who did not. In particular, careful attention to patients who took antiplatelets in addition to warfarin before ESD for CRNs is warranted.

Short-term outcomes of endoscopic submucosal dissection for superficial cecal tumors: a comparison between extension and nonextension into the appendiceal orifice

BACKGROUND

Few studies have investigated the use of endoscopic submucosal dissection (ESD) for cecal tumors extending into the appendiceal orifice. Herein, we assessed the feasibility and safety of ESD for cecal tumors extending into the appendiceal orifice.

METHODS

We retrospectively examined the outcomes of ESD for 78 patients with 78 cecal tumors (male/female ratio, 40/38; mean [standard deviation, SD] age, 67 [9] years; mean [SD] tumor size, 32 [15] mm), who underwent ESD at the Hiroshima University Hospital between October 2008 and March 2016. The indication for ESD in cecal tumors extending into the appendiceal orifice was recognition of the distal edge of the lesion in the appendix. They were classified into two groups: patients with cecal tumors extending (Group A: 29 patients, 29 tumors) and not extending (Group B: 49 patients, 49 tumors) into the appendiceal orifice. We compared the outcomes of ESD between both groups.

RESULTS

No significant differences in clinicopathological characteristics were observed between both groups. The rate of severe submucosal fibrosis in Group A (48%) was significantly higher than that in Group B (24%) (p < 0.05). The mean (SD) procedure speed in Group A (14 [10] mm²/min) was significantly slower than that in Group B (23 [16] mm²/min) (p < 0.01). The en bloc resection rates in Groups A and B were 90% and 96%, respectively. There were no significant differences in adverse events reported between both groups.

CONCLUSIONS

ESD for cecal tumors with extension into the appendiceal orifice is effective and safe.

Clinicopathologic and endoscopic features of early-stage colorectal serrated adenocarcinoma

Background

Serrated adenocarcinoma (SAC) is a distinct colorectal carcinoma variant that accounts for approximately 7.5% of all advanced colorectal carcinomas. While its prognosis is worse than conventional carcinoma, its early-stage clinicopathologic features are unclear. We therefore aimed to clarify the clinicopathologic and endoscopic characteristics of early-stage SACs.

Methods

Forty consecutive early-stage SAC patients at Hiroshima University Hospital were enrolled; SACs were classified into epithelial serration (Group A, n = 17) and non-epithelial serration (Group B, n = 23) groups. Additionally, we classified serrated adenoma into 4 types: sessile serrated adenoma (SSA), traditional serrated adenoma (TSA), unclassified, and non-serrated adenoma type.

Results

There were significant differences between Groups A and B in terms of tumor size (27.6 vs. 43.1 mm), incidences of T1 carcinoma (71% vs. 13%), and having the same color as normal mucosa (47% vs. 17%), respectively (p <0.01). In SACs >20 mm, the incidence of T1 carcinoma in Group A (70%) was significantly greater than that in Group B (13%) (p <0.05). There were significant differences in ‘Japan NBI Expert Team’ type 3 and type V pit pattern classifications between the 2 groups. The average TSA-type tumor size (42.6 mm) was significantly larger than that of the SSA (17.2 mm) and non-serrated component types (18.3 mm). The incidences of submucosal invasion in SSA- (80%), unclassified- (100%), and non-serrated-type (100%) tumors were significantly higher than that in the TSA type (11%).

Conclusions

Epithelial serration in the cancerous area and a non-TSA background indicated aggressive behavior in early-stage SACs.

Clinical impact of surveillance colonoscopy using magnification without diminutive polyp removal

BACKGROUND AND AIM

In Western countries, endoscopic removal of all adenomas during colonoscopy is recommended. The present study evaluates the usefulness of magnifying colonoscopy without removal of diminutive (≤5 mm) colorectal polyps.

METHODS

Patients with diminutive polyps who were observed for over 5 years using magnification at Hiroshima University Hospital were selected retrospectively. Lesions ≥6 mm in size, depressed lesions, and lesions with type V pit pattern were indications for endoscopic resection. We investigated the characteristics of lesions indicated for endoscopic resection detected on surveillance colonoscopy and the risk factors for the incidence of lesions indicated for endoscopic resection.

RESULTS

A total of 706 consecutive patients were enrolled. Sixty-eight lesions indicated for endoscopic resection were detected, averaging 9.0 ± 4.8 mm, and 33 (49%) lesions were located in the right colon. Pathological diagnoses were adenoma, Tis carcinoma, and T1 carcinoma in 58 (85%), eight (12%), and two (3%) lesions, respectively. Five lesions were considered to grow from previously detected diminutive polyps. Relative risks for the incidence of a lesion indicated for endoscopic resection were 1.76 (95% confidence interval [CI], 1.004-3.23) for males compared with females, 3.76 (95% CI, 2.03-7.50) for more than three polyps at initial colonoscopy compared with one polyp, and 2.84 (95% CI, 1.43-5.24) for patients with carcinoma at initial colonoscopy compared with patients with no lesion indicated for endoscopic resection. Nine carcinomas were resected endoscopically.

CONCLUSION

Diminutive low-grade adenomas detected by using magnifying colonoscopy may not necessarily require removal.

Diagnostic performance of Japan NBI Expert Team classification for differentiation among noninvasive, superficially invasive, and deeply invasive colorectal neoplasia

BACKGROUNDS AND AIMS

The Japan NBI Expert Team (JNET) classification is the first universal narrow-band imaging magnifying endoscopic classification of colorectal tumors. Considering each type in this classification, the diagnostic ability of Type 2B is the weakest. Generally, clinical behavior is believed to be different in each gross type of colorectal tumor. We evaluated the differences in the diagnostic performance of JNET classification for each gross type (polypoid and superficial) and examined whether the diagnostic performance of Type 2B could be improved by subtyping.

METHODS

We analyzed 2933 consecutive cases of colorectal lesions, including 136 hyperplastic polyps/sessile serrated polyps, 1926 low-grade dysplasias (LGDs), 571 high-grade dysplasias (HGDs), and 300 submucosal (SM) carcinomas. We classified lesions as polypoid and superficial type and compared the diagnostic performance of the classification system in each type. Additionally, we subtyped Type 2B into 2B-low and 2B-high based on the level of irregularity in surface and vessel patterns, and we evaluated the relationship between the subtypes and histology, as analyzed separately for polypoid and superficial types. We also estimated interobserver and intraobserver variability.

RESULTS

The diagnostic performance of JNET classification did not differ significantly between polypoid and superficial lesions. Ninety-nine percent of Type 2B-low lesions were LGDs, HGDs, or superficial submucosal invasive (SM-s) carcinomas. In contrast, 60% of Type 2B-high lesions were deep submucosal invasive (SM-d) carcinomas. The results were not different between each gross type. Interobserver and intraobserver agreements for Type 2B subtyping were good, with kappa values of .743 and .786, respectively.

CONCLUSIONS

Type 2B subtyping may be useful for identifying lesions that are appropriate for endoscopic resection. JNET classification and Type 2B sub classification are useful criteria, regardless of gross type.

Clinical impact and characteristics of the narrow-band imaging magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team

BACKGROUND AND AIMS

The Japan NBI Expert Team (JNET) was established in 2011 and has proposed a universal narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors. The aim of this study was to evaluate the clinical usefulness of the JNET classification for colorectal lesions.

METHODS

We analyzed 2933 colorectal lesions, which were diagnosed by NBI magnifying observation before endoscopic treatment or surgery. The colorectal lesions consisted of 136 hyperplastic polyps/sessile serrated polyps (HPs/SSPs), 1926 low-grade dysplasia (LGD), 571 high-grade dysplasia (HGD), 87 superficial submucosal invasive (SM-s) carcinomas, and 213 deep submucosal invasive (SM-d) carcinomas. We evaluated the relationship between the JNET classification and the histologic findings of these lesions.

RESULTS

The sensitivity, specificity, positive and negative predictive values, and accuracy of Type 1 lesions for the diagnosis of HP/SSP were, respectively, 87.5%, 99.9%, 97.5%, 99.4%, and 99.3%; of Type 2A lesions for the diagnosis of LGD were 74.3%, 92.7%, 98.3%, 38.7%, and 77.1%; of Type 2B lesions for the diagnosis of HGD/SM-s carcinoma were 61.9%, 82.8%, 50.9%, 88.2%, and 78.1%; for Type 3 lesions for the diagnosis of SM-d carcinoma were 55.4%, 99.8%, 95.2%, 96.6%, and 96.6%, respectively.

CONCLUSIONS

Types 1, 2A, and 3 of the JNET classification were very reliable indicators for HP/SSP, LGD, and SM-d carcinoma, respectively. However, the specificity and positive predictive value of Type 2B were relatively lower than those of others. Therefore, an additional examination such as pit pattern diagnosis using chromoagents is necessary for accurate diagnosis of Type 2B lesions.

Long-term outcomes after endoscopic submucosal dissection for superficial colorectal tumors

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is an effective procedure for en bloc resection of superficial colorectal tumors regardless of tumor size or location. However, there are few reports on long-term outcomes for patients with superficial colorectal tumors after ESD. We therefore aimed to evaluate the long-term outcomes after ESD for superficial colorectal tumors.

METHODS

ESD was performed on 257 colorectal tumors in 255 consecutive patients at Hiroshima University Hospital between June 2003 and July 2010. We investigated the following variables: patient characteristics, the American Society of Anesthesiologists score, tumor location, tumor size, growth type, histology, en bloc resection rate, achievement of curative resection, procedure time, and adverse events. The 5-year overall survival (OS), 5-year disease-specific survival (DSS), local recurrence, and metachronous tumor occurrence were also analyzed.

RESULTS

We identified 224 tumors in 222 patients who were confirmed dead or had follow-up data for more than 5 years. After a median follow-up of 79 months, 5-year OS and DSS rates were 94.6% and 100%, respectively. The local recurrence rate (1.5%) was significantly higher in patients undergoing piecemeal resection (9.1%) compared with en bloc resection (0.6%), in cases of histologic incomplete resection compared with complete resection, and in cases of non-R0 resection compared with R0 resection. The rates of total number of tumors (≥6 mm) and carcinoma metachronous tumors after ESD without additional surgical resection were 18.9% (38/201) and 4.0% (8/201), respectively.

CONCLUSIONS

Long-term outcomes after ESD for superficial colorectal tumors are favorable. Patients should be surveyed for both local recurrence and metachronous tumors after ESD.

Autopsy of anaplastic carcinoma of the pancreas producing granulocyte colony-stimulating factor

A 50-year-old man presented to a nearby hospital with high fever and anorexia. An abdominal tumor was detected, and he was referred to our hospital. A pancreatic tumor was detected by computed tomography and abdominal ultrasonography. He had high fever, leukocytosis, and high serum granulocyte colony-stimulating factor (G-CSF). We performed a tumor biopsy and histological examination revealed anaplastic carcinoma of the pancreas. Based on the diagnosis, we initiated chemotherapy using gemcitabine plus S-1. However, the tumor rapidly progressed and he deteriorated and died 123 days after admission. As immunohistochemical study showed positive staining for G-CSF in the tumor cell, we diagnosed the tumor producing G-CSF during autopsy. Anaplastic carcinoma of the pancreas producing G-CSF is very rare, with 10 cases, including ours, reported in the literature.

Clinical impact of dual red imaging in colorectal endoscopic submucosal dissection: a pilot study

BACKGROUND

Dual red imaging (DRI), a novel image-enhanced endoscopic technique, is expected to improve visibility of thin vessels, but no reports of the clinical use of DRI in colorectal endoscopic submucosal dissection (ESD) have been published. We aimed to compare the visibility of vessels, demarcation line between the submucosal and muscle layers after injection of hyaluronate sodium with minute indigo carmine, and fibrosis on DRI with that on white light imaging (WLI). We applied the principle of DRI to the image of the submucosal layer during colorectal ESD as a pilot study.

METHODS

A total of seven physicians compared 17 DRI images to the corresponding WLI images in colorectal ESD. The physicians compared the number of arteries identified on DRI with the actual number of arteries. The physicians rated the visibility of vessels, the demarcation line between the submucosal and muscle layers after injection of hyaluronate sodium with minute indigo carmine, and fibrosis. Inter-observer agreement was also examined using the kappa statistic.

RESULTS

Visibility of vessels and the demarcation line between the submucosal and muscle layers after injection of hyaluronate sodium with minute indigo carmine improved with the use of DRI compared with that using WLI. DRI can discriminate between arteries and veins clearly through the color of the vessels.

CONCLUSIONS

DRI improves the visibility of vessels, especially that of arteries, as they appear orange, and the demarcation line of the muscle layer. DRI may help to make colorectal ESD safer and faster.

Pedunculated-type T1 colorectal carcinoma with lung carcinoma metastasis at the deepest invasive portion

We present a rare case of colorectal T1 carcinoma with metastasis of previous lung carcinoma found at the deepest invasive portion. A 61-year-old man presented with cervical lymphadenopathy 18 years after undergoing surgery for right lung carcinoma [poorly differentiated adenocarcinoma stage IIb (T3N0M0)]. Contrast-enhanced computed tomography showed enlarged lymph nodes (LNs) in the neck and mediastinal regions. Combined hybrid-F-fluorodeoxyglucose positron emission-computerized tomography showed increased radionuclide uptake in multiple cervical LNs and mediastinal LNs. LN biopsy revealed a poorly differentiated adenocarcinoma, suspected to be a metastatic tumor of the lung. Subsequent colonoscopy revealed a pedunculated-type lesion with a depressed area in the ascending colon. We performed polypectomy as total excisional biopsy; this tumor was composed mainly of moderately differentiated adenocarcinoma, partially mixed with mucinous adenocarcinoma. The pathological findings of the invasive front of the colorectal carcinoma showed poorly differentiated adenocarcinoma with a morphological pattern similar to that of the previous lung carcinoma. Furthermore, immunohistochemical results for the histological type of the deepest invasive portion of the tissue specimen were positive for thyroid transcription factor-1 but negative for Caudal-type homeobox 2. From these morphological and immunohistochemical findings, the final diagnosis was moderately differentiated lung carcinoma, pTX N3 M1b (LN, colon) Stage IV.

Clinical usefulness of a single-use splinting tube for poor endoscope operability in deep colonic endoscopic submucosal dissection

BACKGROUND AND STUDY AIMS

Poor endoscope operability remains a significant challenge during colorectal endoscopic submucosal dissection (ESD). We retrospectively evaluated the experience and clinical usefulness of a new single-use splinting tube in deep colonic ESD in the setting of poor scope operability.

PATIENTS AND METHODS

Among 691 patients with colorectal tumors treated with ESD at Hiroshima University Hospital between November 2009 and July 2015, we analyzed 20 consecutive patients who underwent deep colonic ESD using a single-use splinting tube because of poor scope operability. Poor operability was defined as paradoxical movement of the endoscope, poor control with adhesions, and lesion motion with heartbeat or breathing. Technical and clinical success rates and adverse events were assessed.

RESULTS

Paradoxical movement and poor control with adhesions were improved in all cases using the single-use splinting tube. The en bloc resection rate was 95 % (19/20) and histological en bloc resection rate was 100 % (20/20). There were no complications related to use of the splinting tube.

CONCLUSIONS

Use of a single-use splinting tube helped to overcome poor scope operability in deep colonic ESD.

Clinical significance and validity of the subclassification for colorectal laterally spreading tumor granular type

BACKGROUND AND AIM

Colorectal laterally spreading tumor granular type (LST-G) is generally divided into two subtypes based on morphology. Here, we retrospectively investigated the clinical significance of a concrete, objective LST-G subclassification.

METHODS

This study examined 636 consecutive cases that were resected endoscopically or surgically. LST-G was subclassified as follows: Type 1, a lesion with homogenous uniform granules with uniform (<5 mm) nodules; Type 2, a lesion with granules and small nodules (≥5 mm, <10 mm); or Type 3, a lesion accompanied by large nodules (≥10 mm). For the validation study, 194 images were compiled from 97 cases investigated using conventional colonoscopy and chromoendoscopy with indigo carmine dye spraying. Images were distributed in a randomized order to students without prior endoscopy experience, less-experienced endoscopists (LEE group), and highly experienced endoscopists (HEE group). Diagnostic accuracy and interobserver agreement were then evaluated.

RESULTS

There was no submucosal invasion in Type 1 lesions. The incidence of deep submucosal invasive carcinoma was higher for Type 3 lesions than for Type 2 lesions. Interobserver agreement was good in each group. Diagnostic accuracy was higher in the HEE group than in the student and LEE groups. Chromoendoscopy had a higher accuracy rate than conventional colonoscopy in the LEE and HEE groups (LEE, 0.74 vs 0.69, P < 0.05; HEE, 0.84 vs 0.78, P < 0.05).

CONCLUSIONS

This subclassification of LST-G according to the diameters of granules and nodules was both useful for choosing therapeutic strategies in the clinical setting and universally applicable.

Phosphorylation of Smad2/3 at the specific linker threonine residue indicates slow-cycling esophageal stem-like cells before re-entry to the cell cycle

The stem cell compartment in the esophageal epithelium is possibly located in the basal layer. We have identified significant expression of Smad2/3, phosphorylated at specific linker threonine residues (pSmad2/3L-Thr), in the epithelial cells of murine stomach and intestine, and have suggested that these cells are epithelial stem cells. In this study, we explore whether pSmad2/3L-Thr could serve as a biomarker for esophageal stem cells. We examined esophageal tissues from normal C57BL/6 mice and those with esophagitis. Double immunofluorescent staining of pSmad2/3L-Thr with Ki67, CDK4, p63, or CK14 was performed. After immunofluorescent staining, we stained the same sections with hematoxylin-eosin and observed these cells under a light microscope. We used the 5-bromo-2-deoxyuridine (BrdU) labeling assay to examine label retention of pSmad2/3L-Thr immunostaining-positive cells. We collected specimens 5, 10, 15 and 20 days after repeated BrdU administrations and observed double immunofluorescent staining of pSmad2/3L-Thr with BrdU. In the esophagus, pSmad2/3L-Thr immunostaining-positive cells were detected in the basal layer. These cells were detected between Ki67 immunostaining-positive cells, but they were not co-localized with Ki67. pSmad2/3L-Thr immunostaining-positive cells showed co-localization with CDK4, p63, and CK14. Under a light microscope, pSmad2/3L-Thr immunostaining-positive cells indicated undifferentiated morphological features. Until 20 days follow-up period, pSmad2/3L-Thr immunostaining-positive cells were co-localized with BrdU. pSmad2/3L-Thr immunostaining-positive cells significantly increased in the regeneration phase of esophagitis mucosae, as compared with control mice (esophagitis vs.

CONTROL

6.889 ± 0.676/cm vs. 4.293 ± 0.659/cm; P < 0.001). We have identified significant expression of pSmad2/3L-Thr in the specific epithelial cells of murine esophagi. We suggest that these cells are slow-cycling epithelial stem-like cells before re-entry to the cell cycle.

Transient ligation of umbilical vessels elevates placental tissue oxygen index (TOI) values measured by near-infrared spectroscopy (NIRS) in clawn miniature pig animal model

We recently found a significant elevation in placental tissue oxygen index (TOI) values in cases of fetal growth restriction using near-infrared spectroscopy (NIRS), indicating high oxygenation in the placental tissue. We hypothesized that insufficient fetoumbilical blood flow is causatively associated with high oxygenation levels in placental tissue. We transiently (for 15 sec) ligated the whole umbilicus, umbilical arteries, or veins of pregnant Clawn miniature pigs (102-113 days of gestation) and assessed the changes in TOI values of the placenta and fetus. The ligation significantly increased placental TOI values (p<0.01, respectively), but concomitantly decreased fetal TOI values (p<0.01, respectively), suggesting a decline in oxygen inflow from the maternal to fetal circulation in the placental tissue to be causative of the elevated placental TOI values. These observations suggest the promising clinical use of placental TOI values measured noninvasively by the transabdominal application of NIRS to assess the fetoplacental circulation.

Serum CA125 level before the development of ovarian cancer

BACKGROUND

Little is known about the natural history of ovarian cancer with respect to the change of serum CA125 level.

METHODS

The Shizuoka Cohort Study on Ovarian Cancer Screening (SCSOCS) Trial contains approximately 100,000 data on serum tumor marker CA125 prospectively obtained from more than 70,000 women. We reviewed the clinical charts and collected serum samples 2 months to 9.4 years prior to the surgery were available.

RESULTS

In 396 (95%) of the 419 patients with ovarian cancer, one serum sample was present before the diagnosis (mean, 4.1 years). The change of CA125 level before the diagnosis of ovarian cancer could be clearly separated into two groups according to the length of the following intervals: 47% (107/228) of patients with non-serous-type ovarian cancers develop secondarily from slightly elevated CA125 level (35 <CA125 <65 U/ml), with a mean interval of 3.8 years. On the other hand, 75% (126/168) of patients with serous-type ovarian cancer seem to develop suddenly from a normal CA125 level (CA125 <35 U/ml), with a mean interval of 1.4 years (p=0.011).

CONCLUSIONS

The slightly elevated CA125 level is typically present many years before the diagnosis especially in patients with non-serous-type ovarian cancer. However, serous-type ovarian cancer may exhibit a rapid progression possibly through de novo carcinogenesis.

Risk of developing ovarian cancer among women with ovarian endometrioma: a cohort study in Shizuoka, Japan

Although some studies have indicated that endometriosis may increase the risk of developing ovarian cancer, there are no data from epidemiologic studies in Japan. We prospectively analyzed all cases of ovarian endometrioma enrolled in the prefecture-wide Shizuoka Cohort Study on Endometriosis and Ovarian Cancer Programme, which was initiated in 1985. To evaluate the risk of ovarian cancer by time periods subsequent to ovarian endometrioma diagnosis, a cohort of 6,398 women with a clinically documented ovarian endometrioma in Shizuoka between 1985 and 1995 was identified from the Shizuoka Cancer Registry (SCR), with follow-up through 2002. Ovarian cancer incidence among cohort members was ascertained by linkage to the SCR using a unique person-identification number. Standardized incidence ratios (SIR) and their 95% confidence intervals (CI) were computed by a use of prefecture-wide rates of ovarian cancer, adjusted for age and calendar year. During follow-up of up to 17 years of the ovarian endometrioma cohort, 46 incident ovarian cancers were identified, yielding that the ovarian cancer risk was elevated significantly among patients with ovarian endometrioma (SIR = 8.95, 95% CI = 4.12-15.3). The SIR did not increase with increasing follow-up duration. The risk increased with increasing age at ovarian endometrioma diagnosis, with a SIR equal to 13.2 (95% CI = 6.90-20.9) in women above 50 years of age. Our findings for the first time support the hypothesis that ovarian endometrioma increases the subsequent risk of developing ovarian cancer in Shizuoka, Japan.

Gastric motility after laparoscopically assisted distal gastrectomy, with or without preservation of the pylorus, for early gastric cancer, as assessed by digital dynamic x-ray imaging

This study aimed to evaluate the usefulness of digital x-ray imaging for measuring gastric motility in patients subjected to laparoscopically assisted distal gastrectomy without preservation of the pylorus (LADG) or laparoscopically assisted pylorus-preserving gastrectomy (LAPPG) for early gastric cancer. Between April 1998 and February 2002, 52 patients with preoperative stage IA gastric cancer underwent laparoscopically assisted distal gastrectomy, with 26 receiving LADG for tumors in the lower third of the stomach and 26 receiving LAPPG for tumors in the middle third of the stomach. The gastric emptying ratio at 15 min after the ingestion of the test meal was 61.8% +/- 28.0% for LADG and 42.9% +/- 18.0% for LAPPG ( p < 0.01). The motility index was 2.65% +/- 2.54% for LADG and 8.13% +/- 2.46% for LAPPG ( p < 0.001). In conclusion, LAPPG results in better motility than LADG for patients with early gastric cancer arising in the middle third of the stomach.

Local cold stress to the soles induces retroplacental hemorrhage in rats

The aim of this study was to investigate the effect of local cold stress to the soles on placental histology in rats. Pregnant rats were subjected to a cold provocation (0 degrees C, 12 degrees C) and room temperature (23 degrees C) for 15 and 30 minutes. During cold stimulation and at the control temperature, uterine blood flow and uterine contraction were measured simultaneously. Histological studies of the placentas of these rats were also performed. Cold stress at 0 degrees C and 12 degrees C significantly decreased uterine blood flow (P < .005, P < .02) compared with controls (23 degrees C). The decrease in uterine blood flow was greater at 0 degrees C than at 12 degrees C stress. Cold-induced stress (0 degrees C) also evoked an isometric tension with increased frequency and amplitude in the rat uterus (P < .003, P < .0002) compared with controls (23 degrees C). Stimulation at 12 degrees C did not induce any uterine contractions. Placental histology of rats stressed at 0 degreesC revealed hemorrhages into the decidua basalis. These findings suggest that local cold stress decreases uterine blood flow and increases uterine contraction, resulting in retroplacental hemorrhage in rats. This model may account for human abruptio placentae.

Effects of intrahepatic arterial and intraportal administration of FK 506 on liver allograft survival in rats

Rejection is still the limiting factor for successful organ transplantation, and overdosage of immunosuppressive drugs often results in severe viral infection, side-effects and toxicity. Thus, more specific immunosuppression to lessen these side-effects is highly desirable. In this study, we compared the effects of FK 506 administered by different routes (hepatic artery, portal vein and systemic circulation) on the inhibition of rejection. FK 506 was given to recipient LEW rats with PVG liver grafts via the penile vein (systemic administration), portal vein or hepatic artery (local administration) for 3 or 7 successive days after liver transplantation. In control LEW rats without immunosuppression, the PVG liver allografts were rejected between 9 and 21 days after transplantation. Intravenous administration of FK 506 for 3 days (0.32 and 1.28 mg/kg daily) only had a marginal effect on prolonging liver allograft survival (21.1 +/- 12.5 and 32.0 +/- 24.0 days, respectively; control 14.1 +/- 4.1 days). However, systemic administration of FK 506 (0.08-1.28 mg/kg daily) for 7 days suppressed liver allograft rejection markedly (42.3 +/- 5.9 to 80.5 +/- 53.4 days; control 14.1 +/- 4.1 days), and 50% of the recipient rats survived for at least 60 days after liver transplantation. Moreover, when a low dose of FK 506 (0.32 mg/kg) was infused into the hepatic artery or portal vein of the transplanted liver for 3 days only, liver allograft survival times were prolonged markedly, and 54% of rats with grafts survived for at least 60 days. This effect was almost equal to that after 7 days systemic treatment with FK 506. In conclusion, 7 days' treatment with FK 506 administered systemically was an effective regimen for the suppression of liver allograft rejection in rats. Furthermore, local immunosuppression with low-dose, short-term (3 days) FK 506 treatment administered via the hepatic artery or portal vein of the transplanted liver dramatically improved allograft salvage.

Binding of interleukin-8 to heparan sulphate enhances cervical maturation in rabbits

Cervical ripening is a cytokine-triggered process with substantial remodelling of the cervical extracellular matrix. Interleukin-8 (IL-8) is an important cytokine in cervical maturation. Glycosaminoglycans are also included in this process, but their role in not clearly understood. The effects of heparan sulphate (HS), hyaluronic acid (HA), IL-8, HS + IL-8 and HA + IL-8 on biochemical properties of the cervix were examined in non-pregnant rabbits. The changes in vascular pattern with collagen structure of the cervices and immunohistochemical studies, together with the relative collagen concentrations, were determined. A reduction in relative collagen concentration was significant after HS + IL-8, IL-8 and HA + IL-8 treatment (all P < 0.0001). Gel electrophoresis analysis showed that IL-8 bound preferentially to HS than to HA. Neutrophils were significantly increased in number (P < 0.0001) and located predominantly beneath the glandular epithelium and around the blood vessels after HS + IL-8 treatment. HS + IL-8 treatment caused cervices to increase their water content and become oedematous. The collagen fibres were considerably dissociated, the interfibrillar spaces markedly dilated, and the blood vessels notably increased and dilated. We conclude that binding to HS enhances the activity of IL-8 in inducing cervical maturation.

Non-suture end-to-end anastomoses between polytetrafluoroethylene graft and vessels for blood access

BACKGROUND

Non-suture end-to-end anastomoses between polytetrafluoroethylene grafts and blood vessels were achieved using absorbable cuff material in experimental and clinical studies. The cuff was made of a synthetic biodegradable material, a lactic-glycolic acid copolymer, similar in composition to conventional absorbable surgical sutures.

METHODS

In the experimental study, vascular anastomoses for prosthetic interposition of the infrarenal aorta in rabbits were created using the cuff method. Six months after surgery, the cuff anastomoses sites were examined angiographically and microscopically and found to be patent and smooth without neointimal hyperplasia.

RESULTS

The cuff layer had been completely absorbed. The clinical application used a similar technique and involved the creation of forearm bridge graft fistula in twelve patients for hemodialysis. In eight patients, Doppler fistula flow rate ranged from 167 ml/min to 392 ml/min. Ten of the twelve patients continued dialysis uneventfully. The one-year patency rate was 78% (7/9). The longest patency period was 920 days and the graft access continued to maintain sufficient blood flow for hemodialysis.

CONCLUSIONS

This absorbable cuff material is therefore well suited for the construction of prosthetic vascular end-to-end anastomoses.

Induction of hypercoagulability condition by chronic localized cold stress in rabbits

To evaluate the effect of cold-induced stress on renal and hepatic blood flow and coagulation parameters, rabbits' soles were exposed to ice pad (0 degrees C). Renal and hepatic blood flow was measured after 1 h and 15 days of cold stress. Coagulation parameters (0, 8th and 15th days of stress) and histological studies were performed. Renal and hepatic blood flow was significantly reduced after cold-stress. Decreased platelet count, antithrombin III (AT III) activity, increased fibrinogen (Fbg) level, shortened activated partial thromboplastin time (aPTT) and prothrombin time (PT) was found after 8 and 15 days of cold-stress. Histology showed enlarged glomeruli with fibrin deposition in kidney, ischemic changes and fibrin deposition in liver and hemorrhagic necrosis in adrenal cortex. We conclude that undesirable localized cold induced sympathetic stimulation in daily life may be a predisposing factor for coagulopathy.

Decreased renal and hepatic blood flow with preeclampsia-like histologic changes was obtained by stimulation of the celiac ganglion with LPS

Decreased renal and hepatic blood flow with preeclampsia-like histologic changes was developed by stimulation of the celiac ganglion with lipopolysaccharide (LPS) in pregnant rabbits. The renal and hepatic blood flow were measured after stimulation of the celiac ganglion with 10 microL (group 1), 100 microL (group II) and 300 microL (group III) of LPS (10 mg/mL conc.) and with 100 microL of normal saline (group IV). The bifurcation of the abdominal aorta was also stimulated with 300 microL of LPS (group V). A control experiment was also done in this study (group VI). Histopathological studies of kidney and liver tissue were also performed in this protocol. A significant reduction in renal and hepatic blood flow was observed in pregnant rabbits with the times and dosage dependent on stimulation of the celiac ganglion by LPS. Stimulation of the bifurcation of the abdominal aorta with LPS could not produce any changes in renal and hepatic blood flow. Preeclampsia-like histologic changes of kidney and liver tissue were also observed. These results suggest that exogenous stimulation of the celiac ganglion causes decreased renal and hepatic blood flow, resulting in preeclampsia-like histologic changes of kidney and liver in pregnant rabbits.

Protective effect of UW solution on postischemic injury in rat liver: suppression of reduction in hepatic antioxidants during reperfusion

Preservation with University of Wisconsin (UW) solution can maintain liver graft function and produces survival rates of recipients higher than that with Euro Collins (EC) solution. To explore the underlying mechanisms, we transplanted rat livers following cold preservation with EC or UW solution for 18 hr, and measured hepatic adenine nucleotide levels, the percentage of water content, lactate levels, and endogenous antioxidant levels (alpha-tocopherol [alpha-Toc], reduced coenzyme Q9 [CoQ9H2], reduced coenzyme Q10, [CoQ1OH2] and reduced glutathione [GSH] during preservation and after transplantation. The adenosine triphosphate levels of the liver grafts preserved with UW solution recovered after reperfusion more rapidly and reached a higher level than those preserved with EC solution. UW solution caused a reduction in hepatic water content during preservation. Conversely, EC solution induced remarkable tissue edema. In addition, UW solution reduced the rate of hepatic lactate production both during preservation and after reperfusion. The concentrations of hepatic GSH, alpha-Toc, CoQ9H2, and CoQ1OH2 immediately after the graftectomy, and after the 18 hr of preservation with both EC and UW solutions, did not differ from those in the normal liver, and decreased only after transplantation. However, UW solution suppressed significantly the reduction in hepatic GSH, alpha-Toc, and CoQ9H2 after reperfusion, compared with EC solution. These results suggest that long-term cold storage induces tissue edema, reflecting a disturbance of the microcirculation during preservation, followed by parenchymal cell damage mediated by free radicals after reperfusion. The protective effects of UW solution could be attributable to the inhibition of free radical production after reperfusion.

Vitamin K prophylaxis to prevent neonatal vitamin K deficient intracranial haemorrhage in Shizuoka prefecture

OBJECTIVE

To compare three methods of vitamin K prophylaxis for neonatal vitamin K deficient intracranial haemorrhage.

DESIGN

We designed three strategies for vitamin K prophylaxis: 1. therapeutic administration of vitamin K in a mass screening system using the hepaplastin test; 2. routine oral administration of vitamin K to newborn infants; and 3. administration of vitamin K to lactating mothers during the late neonatal period in addition to the routine method. We evaluated the efficacy of these methods by determining hepaplastin test values at the first month of age.

POPULATION

66,076 full term healthy newborn infants without any complications.

RESULTS

Of 55,513 infants in the mass screening system, 3068 infants received vitamin K therapeutically. At the first month of age, in the group where vitamin K was administered therapeutically, 56 infants (1.83%) exhibited low hepaplastin test values (< 40%) despite vitamin K administration. But extremely low values (< 20%), indicating a very high risk of neonatal intracranial haemorrhage, were observed in 34 (0.06%) of 52,445 infants who did not receive vitamin K. In the routine administration system, oral administration of vitamin K twice within the first week of life showed a lower incidence (0.19%) of low level cases than a single administration (1.56%). An additional administration of vitamin K to lactating mothers throughout the late neonatal period showed an effective result.

alpha-Tocopherol pretreatment protects the endocrine function of grafts against ischemic damage during heterotopic pancreatic transplantation

Post-ischemic injury is one of the most important problems affecting successful organ procurement and transplantation. The present study was performed to determine whether alpha-tocopherol can protect the endocrine function of pancreatic grafts against ischemia-reperfusion injury during rat heterotopic pancreatic transplantation. Rats with streptozotocin-induced hyperglycemia were used as recipients. The donor pancreas was removed and subjected to warm ischemia at 37 degrees C for 30, 60, 90 and 120 min, and then transplanted into a recipient. A 30-min period of warm ischemia did not impair the endocrine function of the pancreatic grafts, which was assessed by measuring the blood glucose levels and glucose decay constants (K), and a 60-min period of warm ischemia was considered to be the critical period for reversible tissue damage. Pretreatment with alpha-tocopherol (20 mg/kg/day, i.v.) for seven days before graftectomy significantly decreased blood glucose levels to less than 200 mg/dl and significantly increased K values in the recipient rats after transplantation when compared with placebo pretreatment. These results suggest that alpha-tocopherol pretreatment can protect the endocrine function of pancreatic grafts against injury due to warm ischemia followed by reperfusion.