Usefulness of Acetic Acid Spray with Narrow-Band Imaging for Identifying the Margin of Sessile Serrated Lesions

BACKGROUND

Sessile serrated lesions (SSLs) are precursors of colon cancer, especially in cases of large, right colon. However, they are difficult to not only detect, but only clarify the margin of the lesion, which can lead to the poor endoscopic treatment outcomes.

AIMS

This study evaluated the usefulness of acetic acid spray with narrow-band imaging (A-NBI) for the better visualization of the margin of SSLs.

METHODS

From January 2013 to March 2022, patients with superficial elevated polyps suspected of being SSLs ≥ 10 mm with an endoscopic diagnosis that had been endoscopically resected at Hiroshima City Hiroshima Citizens Hospital were enrolled. Endoscopic images with white-light imaging (WLI), narrow-band imaging (NBI), indigo-carmine (IC), and A-NBI were recorded in each lesion and were randomly arranged and assessed by 10 endoscopists. We compared the visibility score (1 to 4) and color differences (ΔE) between inside and outside of the lesions among WLI, NBI, IC, and A-NBI.

RESULTS

Forty-one lesions in 33 cases were included, and a total of 164 images were evaluated. As for the visibility score, most of the lesions were scored as 1 or 2 on WLI, whereas most were scored 4 on A-NBI. The median ΔE of A-NBI was also significantly higher than that of WLI, NBI, or IC (20.5 vs. 8.3 vs. 8.2 vs. 12.3, P < 0.01). A significant correlation was observed between the color difference and visibility score (r = 0.53, P < 0.01).

CONCLUSIONS

A-NBI may be a useful modality for identifying the margin of SSLs.

Nonrecurrence Rate of Underwater EMR for ≤20-mm Nonampullary Duodenal Adenomas: A Multicenter Prospective Study (D-UEMR Study)

BACKGROUND AND AIMS

Endoscopic resection of nonampullary duodenal adenoma is often challenging, and its technique has not yet been standardized. To overcome the practical difficulty of conventional endoscopic mucosal resection, underwater endoscopic mucosal resection (UEMR) was recently developed; therefore, we investigated the effectiveness and safety of UEMR for nonampullary duodenal adenoma.

METHODS

A multicenter, prospective cohort study was conducted at 21 institutions in Japan. We enrolled patients with no more than 2 nonampullary duodenal adenomas ≤20 mm in size, who were planned to undergo UEMR. After UEMR, follow-up endoscopies were scheduled at 2 and 12 months after the procedure, and biopsy specimens were taken from the post-UEMR scars. The primary endpoint was the proportion of patients with histologically proven nonrecurrence at follow-up endoscopy and biopsy.

RESULTS

A total of 155 patients with 166 lesions underwent UEMR. One patient with a non-neoplastic lesion in the resected specimen and 10 patients with 10 lesions who were lost to follow-up were excluded. Finally, 144 patients with 155 lesions who received all follow-up endoscopies were analyzed for the primary endpoint. The proportion of patients with proven nonrecurrence was 97.2% (n = 140 of 144; 95% confidence interval, 92.8%-99.1%) which exceeded the predefined threshold value (92%). Two cases of delayed bleeding (1.2%) occurred and they were successfully managed by clips. All recurrences were successfully treated by additional endoscopic treatment.

CONCLUSIONS

This multicenter, prospective cohort study demonstrated effectiveness and safety of UEMR for nonampullary duodenal adenomas ≤20 mm in size. (University Hospital Medical Network Clinical Trials Registry, Number: UMIN000030414).

Multicenter survey on mesalamine intolerance in patients with ulcerative colitis

BACKGROUND AND AIM

Although oral mesalamine is the first-choice drug for treating mild-to-moderate ulcerative colitis (UC), some patients show symptoms of intolerance, including exacerbation of diarrhea and abdominal pain. The present study clarified the current state and clinical courses of patients with mesalamine intolerance.

METHODS

Patients who were diagnosed with UC and administered oral mesalamine at eight hospitals in Japan with a follow-up period exceeding 1 year were analyzed.

RESULTS

Sixty-seven (11%) of 633 patients showed intolerance to at least one formulation of oral mesalamine. The frequency of mesalamine intolerance has increased in recent years, rising from 5.3% in 2007-2010 to 9.1% in 2011-2013 and 16.2% in 2014-2016. The most common complications were the exacerbation of diarrhea (n = 29), a fever (n = 25), and abdominal pain (n = 22). Readministration of mesalamine/sulfasalazine was attempted in 43 patients, mostly with other types of formulation of mesalamine, and more than half of these patients proved to be tolerant. The risk factors for mesalamine intolerance were female gender (odds ratio [OR] = 1.83; 95% confidence interval [CI], 1.08-3.12), age < 60 years old (OR = 2.82; CI, 1.19-8.33), and pancolitis (OR = 2.09; 95% CI, 1.23-3.60). There were no significant differences in the use of anti-tumor necrosis factor-α agents, colectomy, or steroid-free remission at the last visit between patients with and without mesalamine intolerance.

CONCLUSIONS

Mesalamine intolerance is not rare, and its frequency has been increasing recently. The prognosis of patients with mesalamine intolerance did not differ significantly from that of those without intolerance.

Long-term outcomes of patients with Crohn's disease who received infliximab or adalimumab as the first-line biologics

BACKGROUND AND AIM

Although previous studies compared the efficacy of infliximab (IFX) versus adalimumab (ADA) as the first-line biologics for Crohn's disease (CD), the difference in long-term prognosis based on which biologic was used first has scarcely been reported. In particular, the clinical courses after loss of response (LOR) of the first-line biologics are largely unknown.

METHODS

A multicenter, retrospective study was performed. Disease courses of biologic-naïve CD patients who were started on IFX or ADA treatment were evaluated, even after LOR of the initial biologics.

RESULTS

In total, 263 CD patients were eligible for analysis, 183 were treated with IFX first, and 80 were treated with ADA first. The median observation period was 64.2 months. The cumulative steroid-free remission rates and surgery-free rates did not differ significantly between the patients treated with IFX first and those treated with ADA first (log-rank test P = 0.42 and P = 0.74, respectively). In addition, no significant difference was observed in the rate of occurrence of events associated with ineffectiveness (modification of anti-tumor necrosis factor treatment including intensification, switch, discontinuation, or surgery) between the patient groups (log-rank test P = 0.62). The patients treated with IFX first were likely to discontinue the agent due to adverse events, whereas those treated with ADA first were likely to discontinue due to treatment failure or LOR.

CONCLUSIONS

No significant difference was observed in the long-term prognosis between biologic-naïve patients with CD who were started treatment with IFX first and ADA first.

The Progression of Esophageal Mucosa-associated Lymphoid Tissue Lymphoma after Helicobacter pylori Eradication Therapy: A Case Report and Discussion of Therapeutic Options

A 50-year-old woman with epigastric discomfort was referred to our hospital. Esophagogastroduodenoscopy showed flat, elevated, submucosal tumor-like lesions in the esophagus. Extranodal marginal zone lymphoma of the mucosa-associated lymphoid tissue (MALT lymphoma) of the esophagus was diagnosed based on the examination of an endoscopic biopsy specimen. Computed tomography showed the enlargement of a lymph node in the gastric cardia. The present case showed disease progression despite Helicobacter pylori eradication therapy and achieved partial remission after rituximab monotherapy. The patient remained in partial remission for 20 months. This case suggests that esophageal MALT lymphoma with lymph node involvement does not respond to H. pylori eradication therapy and that it requires systemic treatment.

Dexmedetomidine for conscious sedation with colorectal endoscopic submucosal dissection: a prospective double-blind randomized controlled study

Objective

Conscious sedation for colorectal endoscopic submucosal dissection (ESD) has not been standardized, and there are no studies of sedation for colorectal ESD.

Methods

We conducted a prospective double-blind randomized controlled trial to clarify the usefulness of DEX during colorectal ESD. In total 80 patients with colorectal ESD from April 2016 to May 2017 were assigned to the placebo group or the DEX group (40 cases each). The primary outcome was patient satisfaction (visual analogue scale: VAS). Secondary outcomes were evaluated for 13 factors, including patient pain level (VAS), endoscopist satisfaction (VAS), objective patient pain level viewed from the endoscopist’s perspective (VAS), rate of patient response, rate of side effects, etc., from the patient’s and endoscopist’s perspectives.

Results

Patient satisfaction was 8.4 and 9.1 (P = 0.018) in the placebo group and the DEX group, respectively. Secondary outcomes of patient pain level, endoscopist satisfaction, objective patient pain level from the endoscopist’s perspective for the placebo and DEX groups were 1.2 and 0.4 (P = 0.045), 8.2 and 9.3 (P < 0.001), and 1.2 and 0.5 (P = 0.002), respectively. All of these were significantly positive results (more comfortable and less pain) in the DEX group. The rate of a patient response was 100% in all cases. The side effects (hypoxia/bradycardia/hypotension) were 0%/0%/0% and 7.5%/7.5%/5% (P = 0.030). However, these rates were less than the reported side effect occurrence rate, and no additional medication was needed.

Conclusion

DEX enables conscious sedation, and is useful not only for patient and endoscopist satisfaction but also for pain relief. DEX is an effective sedation method for colorectal ESD.

[Gastric type adenoma with submucosal invasive carcinoma:a case study]

A 75-year-old woman visited our hospital for the examination of esophagogastroduodenoscopy (EGD) without any major complaint. The patient's medical history included hypertension, but no carcinoma. EGD revealed a 30-mm elevated lesion located in the anterior wall of the upper region of the stomach. The lesion, which was a 0-IIa+I type lesion with fading-like and light flare-like domains, was surgically removed using endoscopic submucosal dissection (ESD) and then the patient was diagnosed with gastric type adenoma with submucosal invasive carcinoma. To the best of our knowledge, this is the first report of a gastric type adenoma with submucosal invasive carcinoma and may therefore provide significant insights into the malignant potential of gastric type adenoma lesions.

Importance of Second-look Endoscopy on an Empty Stomach for Finding Gastric Bezoars in Patients with Gastric Ulcers

　Most gastric bezoars can be treated with endoscopic fragmentation combined with or without cola dissolution, whereas laparotomy or laparoscopic surgery is generally inevitable for small intestinal bezoars because they cause small bowel obstruction. Therefore, early diagnosis and management of gastric bezoars are necessary to prevent bezoar-induced ileus. To investigate the incidence of overlooked gastric bezoars during the initial esophagogastroduodenoscopy, we retrospectively reviewed the cases of 27 patients diagnosed with gastrointestinal bezoars. The bezoars were diagnosed using esophagogastroduodenoscopy (n=25), abdominal ultrasonography (n=1), and barium follow-through examination (n=1). Bezoars were overlooked in 9/25 patients (36.0%) during the initial endoscopy examination because the bezoars were covered with debris in the stomach. Of the 9 patients, 8 had concomitant gastric ulcers, and the other patient had gastric lymphoma. Although a computed tomography (CT) scan was performed before the second-look endoscopy in 8 of the 9 patients, the bezoars were mistaken as food debris on CT findings and were overlooked in these patients. In conclusion, gastric bezoars may not be discovered during the initial esophagogastroduodenoscopy and CT scan. In cases with debris in the stomach, second-look endoscopy is essential to detect bezoars.

Simultaneous Measurements of Faecal Calprotectin and the Faecal Immunochemical Test in Quiescent Ulcerative Colitis Patients Can Stratify Risk of Relapse

BACKGROUND

Both faecal calprotectin [Fcal] and the faecal immunochemical test [FIT] are useful to predict clinical relapse of ulcerative colitis [UC]. However, the difference between Fcal and FIT in ability to predict relapse has scarcely been reported. Whether the combined use of these two faecal markers increases the predictability is also unknown.

METHODS

UC patients in clinical remission who underwent colonoscopy were enrolled prospectively, and the Fcal and FIT values were examined at enrolment. Their clinical course was observed for 2 years or until relapse. The correlation between the incidence of relapse and the values of the two markers was examined.

RESULTS

A total of 113 patients were enrolled, and 48 [42%] relapsed. Fcal ≥ 75 μg/g and FIT ≥ 110 ng/mL were defined as Fcal-positive and FIT-positive, respectively, according to the receiver operating characteristic curves. Both Fcal-positive and FIT-positive statuses were independent predictive factors of clinical relapse (hazard ratio [HR] 2.29; 95% confidence interval [CI], 1.23-4.49; p = 0.0086, and HR 2.91; 95% CI, 1.49-5.50; p = 0.0022, respectively). Categorisation of patients into three groups according to the faecal marker status [FIT-positive, FIT-negative and Fcal-positive, and both negative] can efficiently stratify the risk of relapse with graded increases in risk [FIT-negative and Fcal-positive: HR 2.05; 95% CI, 1.02-4.43; p = 0.0045, and FIT-positive: HR 5.43; 95% CI, 2.57-11.76; p < 0.0001, compared with both negative].

CONCLUSIONS

Fcal vs FIT showed distinct properties regarding the prediction of relapse in UC. A risk assessment using both faecal markers could increase the predictability for relapse.

Colonic lesion characterisation skills among UK endoscopists and the impact of a brief training intervention

OBJECTIVE

To assess UK gastroenterology registrars' and consultants' competence in in vivo characterisation of polyps, plus the impact of a dedicated colonic lesion characterisation training intervention.

DESIGN

Prospective evaluation of a computer-based colonic lesion training module.

SETTING

Three UK general hospitals.

PATIENTS

High-quality endoscopic images obtained during colonoscopy in a previous study.

INTERVENTIONS

30 min computer-based training module covering in vivo characterisation of colonic lesions viewed under white light, chromoendoscopy and magnification chromoendoscopy.

MAIN OUTCOME MEASURES

Accuracy of characterisation of colonic lesions (hyperplastic vs adenoma vs cancer) before and after training and differences between groups (bowel cancer screening (BCS) nurses vs gastroenterology trainees vs consultant gastroenterologists).

RESULTS

Mean accuracy pretraining was 61.1%, 67.6% and 60.0% for the trainee, consultant and nurse groups respectively with no significant difference between the groups. Mean accuracy post-training improved significantly to 71.2%, 72.6% and 67.2% for the trainee, consultant and nurse groups (p<0.001 vs pretraining) with no significant difference between the three groups. Mean sensitivity and specificity improved significantly for the 15 participants overall.

CONCLUSIONS

The baseline level of colonic lesion characterisation skills is limited for gastroenterology consultants and trainees and does not differ from that of non-endoscopist BCS nurses. Accuracy of lesion characterisation can be modestly improved with a brief computer-based training intervention. Lesion characterisation should become a standard part of training in colonoscopy, and should be learnt alongside technical skills for endoscope handing and therapeutic procedures.

An Energy Dispersive X-ray Spectroscopy Analysis of Elemental Changes of a Persimmon Phytobezoar Dissolved in Coca-Cola

To investigate the mechanism of phytobezoar dissolution by Coca-Cola(®), persimmon phytobezoar pieces removed from a 60-year-old Japanese woman were analyzed by energy dispersive X-ray spectroscopy. The amount of calcium significantly decreased after dissolution treatment using Coca-Cola(®), suggesting a potential contribution of calcium to dissolution mechanisms. Moreover, immersion in Coca-Cola(®) for 120 hours on the exterior surface revealed that Coca-Cola(®) did not permeate persimmon phytobezoars. This is the first study to investigate the mechanisms of persimmon phytobezoar permeability and dissolution induced by Coca-Cola(®).

Feasibility of a novel colonoscope with extra-wide angle of view: a clinical study

BACKGROUND AND STUDY AIMS

Lesions may be missed during colonoscopy because of anatomical features such as mucosal folds. This feasibility study assessed the safety and efficacy of a novel colonoscope with extra-wide angle of view, which provides a simultaneous lateral-backward view to complement the forward view.

PATIENTS AND METHODS

Consecutive patients undergoing colonoscopy using the prototype colonoscope were enrolled in this multicenter, single-arm study. The number of adverse events, and the first detection of adenomas during withdrawal by the lateral-backward view and the forward view were evaluated.

RESULTS

A total of 47 patients underwent colonoscopy examination to the cecum. The mean insertion and withdrawal times were 6.4 ± 4.9 minutes and 8.6 ± 4.2 minutes, respectively. Of 47 detected polyps, 28 adenomatous polyps were found (mean size 3.3 ± 3.1 mm). A total of 29 polyps (61.7 %) and 16 adenomatous polyps (57.1 %) were first detected with the lateral-backward view. The lateral-backward view first detected 5/6 adenomatous polyps (83.3 %) in the ascending colon and all (2/2) adenomatous polyps in the sigmoid colon. No adverse events occurred during the study.

CONCLUSIONS

This exploratory study suggested that a novel colonoscope with extra-wide angle of view is safe and feasible, and has the potential to improve colorectal adenoma detection.

TRIAL REGISTER

UMIN000016450.

Prospective evaluation of endoscopic criteria characteristic of sessile serrated adenomas/polyps

BACKGROUND

Differentiating sessile serrated adenoma/polyp (SSA/P) from hyperplastic polyp (HP) is clinically important in determining the necessity of endoscopic resection or recommending appropriate surveillance. There are few reports of characterization of SSA/P using narrowband imaging and chromoendoscopy with and without magnification. We aimed to establish imaging criteria to aid real-time diagnosis of SSA/P.

METHODS

Patients with pale sessile or flat lesions of 6 mm or greater were prospectively enrolled in this multicenter trial. Nine endoscopic criteria, determined in real time, were investigated for possible association with SSA/P. Endoscopic mucosal resection was performed; specimens were retrieved and analyzed by histopathological examination.

RESULTS

In 63 patients, 89 lesions were detected, including 41 HP, 38 SSA/P, five mixed polyps, and five other lesions. Right-side colon location, lesion size of 10 mm or greater, excessive mucus, the presence of a varicose microvascular vessel (VMV) noted with high-magnification narrowband imaging, and type III(H) pit pattern were each commonly associated with SSA/P compared with HP. Multivariate analysis substantiated three independent endoscopic criteria for SSA/P: the presence of VMV (p = 0.001), lesion size of 10 mm or greater (p = 0.0017), and right-side location (p = 0.0041), with odds ratios of 8.2, 7.2, and 6.1, respectively. The presence of VMV had a significantly higher specificity (87.8%) than the other two independent endoscopic criteria (p = 0.0007 and p = 0.0008, respectively), but a lower sensitivity (57.9%), whereas a combination of the three criteria (two or more positive) increased the sensitivity significantly (89.5% and p = 0.0033) and had a higher degree of accuracy (82.3%).

CONCLUSIONS

Three endoscopic criteria individually and in combination were effective in predicting a diagnosis of SSA/P without the need for chromoendoscopy.

Predictive factors for technically difficult endoscopic submucosal dissection in the colorectum

BACKGROUND AND STUDY AIMS

Because of technical difficulty, colorectal endoscopic submucosal dissection (CR-ESD) is not widely performed. We aimed to determine risk factors for such technical difficulty as defined by long procedure duration (≥  150 min), perforation, and piecemeal resection.

PATIENTS AND METHODS

Patients with consecutive colorectal tumors treated with ESD between April 2006 and December 2010 were enrolled in a prospective cohort study. For prediction of technical difficulty, three types of factor were investigated: tumor location, tumor type, and colonoscopy-related. Cases were subsequently categorized into earlier and later periods (April 2006 - August 2008, 123 lesions; September 2008 - December 2010, 124 lesions). Variables were analyzed using multiple logistic regression, with subgroup analyses for each period.

RESULTS

247 lesions were analyzed. Flexure location was an independent risk factor for technical difficulty as measured by longer procedure duration (odds ratio [OR] 4.1, 95 % confidence interval [95 %CI] 1.1 - 14.9), piecemeal resection (4.7, 1.1 - 17.2), or perforation (8.8, 1.1 - 56.8). Tumor with scarring or locally recurrent was a risk factor for longer procedure duration (4.7, 1.7 - 13.7), and for piecemeal resection (7.8, 2.4 - 25.0). Tumor of size  ≥  50 mm or spreading across ≥  2 folds was the strongest independent risk factor for longer duration (6.3, 2.8 - 15.4), and was an independent risk factor for longer duration in both time periods (earlier, 3.3, 1.1 - 10.4; later, 27.4, 7.4 - 138.0). Flexure location was an independent risk factor for perforation (13.9, 1.5 - 129.1) and for piecemeal resection (5.1, 0.9 - 25.2) in the earlier but not the later period.

CONCLUSIONS

Factors predicting technical difficulty of CR-ESDs were clarified. Their importance was influenced by the increasing experience of the endoscopist.

Neuroproteomics: an insight into ALS

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease of unknown aetiology. Diagnosis is made through physical examination, electrophysiological findings, and by excluding other conditions. There is not a single biomarker that concludes the diagnosis. The aim of this study was to investigate differentially expressed proteins in cerebrospinal fluid (CSF) of ALS patients compared to control subjects, with the purpose to identify a panel of possible biomarkers for the disease. The differentially expressed spots/proteins were submitted to two-dimensional (2D) electrophoresis and recognized with matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry. Parkin-like and many iron and zinc binding were some of the proteins found in ALS CSF. Parkin is a ligase involved in ubiquitin-proteasome pathway and mutations in the parkin gene are the most common cause of recessive familial Parkinson's disease. Iron and zinc are involved with many important metabolic processes and are related to neurodegenerative disease. Common features of ALS comprise failure of the ubiquitin-proteasome system and increased levels of metal ions in the brain. Therefore, the identification of these proteins can be a significant step in ALS research. These and other identified proteins are discussed in this study.

[A case of diversion colitis successfully treated with 5-aminosalicylic acid]

An 84-year-old man was admitted to our hospital because of blood in the stool. He had previously undergone a subtotal colectomy and ileostomy with a mucous fistula of the sigmoid colon because of a large bowel hemorrhage of unknown origin. Five years later, a minor hemorrhage developed in the remnant rectum. The clinical history, colonoscopic findings, and the histology of the diverted colon specimens were suggestive of diversion colitis. Treatment was initiated with short-chain fatty acid enema, but slight blood loss through the stool continued;thus, the patient was administered 5-aminosalicylic acid (5-ASA) enema. Subsequently, his symptoms and endoscopic findings improved. 5-ASA enema appears to be both safe and effective in the treatment of diversion colitis following intestinal tract surgery.

A novel extra-wide-angle-view colonoscope: a simulated pilot study using anatomic colorectal models

BACKGROUND

A major factor that may contribute to a higher adenoma miss rate during colonoscopy is undetected lesions located behind haustral folds, flexures, or rectal valves.

OBJECTIVE

To assess the efficacy of a prototype, novel, extra-wide-angle-view colonoscope that provides a simultaneous lateral-backward view that complements the forward view lens.

DESIGN

A simulated pilot study of two anatomic colorectal models, each prepared with 8 polyps positioned in obvious locations and 8 polyps placed behind folds. Thirty-two endoscopists with different levels of experience performed examinations on models in a random order by using the extra-wide-angle-view colonoscope and a standard colonoscope.

MAIN OUTCOME MEASUREMENTS

The detection rates of simulated polyps.

RESULTS

The mean detection rate for all simulated polyps with the extra-wide-angle-view colonoscope was significantly higher than that with the standard colonoscope (68% vs 51%; P < .0001). The detection rate for polyps behind folds was significantly higher in the extra-wide-angle-view colonoscope than in the standard colonoscope (61.7% vs 46.9%; P = .0009).

LIMITATIONS

Not a clinical study.

CONCLUSION

The novel, extra-wide-angle-view colonoscope may represent an advancement in colorectal polyp detection. The value of the colonoscope for clinical use awaits further study.

[Classification of the bleeding pattern in colonic diverticulum is useful to predict the risk of bleeding or re-bleeding after endoscopic treatment]

We examined the re-bleeding rate after endoscopic hemostasis according to the bleeding pattern in patients with an acute lower gastrointestinal hemorrhage from colonic diverticula in 34 patients with active bleeding (Type 1) and 49 patients with exposed vessels and/or erosions in the base of diverticulum and no active bleeding (Type 2). Endoscopic hemostasis was performed by clipping the exposed vessel or erosions (direct method) or the entire diverticular orifice (reefing method). The incidence of re-bleeding was significantly higher in the Type 1 group than in the Type 2 group (p=0.002). All Type 1 cases were treated by the reefing method. In contrast, 14 of the 49 Type 2 cases were treated by the direct method, and no re-bleeding was observed in these cases. Of the other 35 Type 2 cases treated by reafing, rebleeding was seen in 5 cases. More effective endoscopic treatment is needed to prevent early re-bleeding, especially for Type 1 patients. The direct method may therefore reduce the rate of re-bleeding in Type 2 patients.

Detectability of colorectal neoplasia with fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography and computed tomography (FDG-PET/CT)

BACKGROUND

The purpose of this study was to analyze the detectability of colorectal neoplasia with fluorine-18-2-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (FDG-PET/CT).

METHODS

Data for a total of 492 patients who had undergone both PET/CT and colonoscopy were analyzed. After the findings of PET/CT and colonoscopy were determined independently, the results were compared in each of the six colonic sites examined in all patients. The efficacy of PET/CT was determined using colonoscopic examination as the gold standard.

RESULTS

In all, 270 colorectal lesions 5 mm or more in size, including 70 pathologically confirmed malignant lesions, were found in 172 patients by colonoscopy. The sensitivity and specificity of PET/CT for detecting any of the colorectal lesions were 36 and 98%, respectively. For detecting lesions 11 mm or larger, the sensitivity was increased to 85%, with the specificity remaining consistent (97%). Moreover, the sensitivity for tumors 21 mm or larger was 96% (48/50). Tumors with malignant or high-grade pathology were likely to be positive with PET/CT. A size of 10 mm or smaller [odds ratio (OR) 44.14, 95% confidence interval (95% CI) 11.44-221.67] and flat morphology (OR 7.78, 95% CI 1.79-36.25) were significant factors that were associated with false-negative cases on PET/CT.

CONCLUSION

The sensitivity of PET/CT for detecting colorectal lesions is acceptable, showing size- and pathology-dependence, suggesting, for the most part, that clinically relevant lesions are detectable with PET/CT. However, when considering PET/CT for screening purposes caution must be exercised because there are cases of false-negative results.

DNA methylation of colon mucosa in ulcerative colitis patients: correlation with inflammatory status

BACKGROUND

Although DNA methylation of colonic mucosa in ulcerative colitis (UC) has been suggested, the majority of published reports indicate the correlation between methylation of colon mucosa and occurrence of UC-related dysplasia or cancer without considering the mucosal inflammatory status. The aim of this study was to verify whether mucosal inflammation-specific DNA methylation occurs in the colon of UC.

METHODS

Of 15 gene loci initially screened, six loci (ABCB1, CDH1, ESR1, GDNF, HPP1, and MYOD1) methylated in colon mucosa of UC were analyzed according to inflammatory status using samples from 28 surgically resected UC patients.

RESULTS

Four of six regions (CDH1, GDNF, HPP1, and MYOD1) were more highly methylated in the active inflamed mucosa than in the quiescent mucosa in each UC patient (P = 0.003, 0.0002, 0.02, and 0.048, respectively). In addition, when the methylation status of all samples taken from examined patients was stratified according to inflammatory status, methylation of CDH1 and GDNF loci was significantly higher in active inflamed mucosa than in quiescent mucosa (P = 0.045 and 0.002, respectively). Multiple linear regression analysis revealed that active inflammation was an independent factor of methylation for CDH1 and GDNF. DNA methyltransferase 1 and 3b were highly expressed in colon epithelial cells with active mucosal inflammation, suggesting their involvement in inflammation-dependent methylation.

CONCLUSIONS

Methylation in colonic mucosa of UC was correlated with mucosal inflammatory status, suggesting the involvement of methylation due to chronic active inflammation in UC carcinogenesis.

Endoscopic hemostasis for hemorrhage from an ileal diverticulum

Hemorrhage from a non-Meckelian jejunoileal diverticulum is rare, and it is generally difficult to diagnose the source of the bleeding. Here, we report the case of a 59-year-old male with hemorrhage from an ileal diverticulum. Contrast computed tomography scans demonstrated the ileal diverticulum and extravasation of the contrast medium around it. The diagnosis was then made by computed tomography scans, and endoscopic mechanical hemostasis was performed under colonoscopy with three metal clips. The management of hemorrhage from jejunoileal diverticula is discussed.

Colorectal endoscopic submucosal dissection for elderly patients at least 80 years of age

BACKGROUND

Endoscopic submucosal dissection (ESD) has been used recently for successful en bloc resection of even large lesions, although no consensus appears in medical literature concerning its application to elderly patients. This prospective cohort study aimed to evaluate the efficacy and safety of colorectal ESD for patients 80 years of age or older.

METHODS

Colorectal ESD procedure findings were compared with clinical outcomes, including associated complications and mortalities, for two age groups totaling 196 consecutive patients with 202 colorectal lesions. Of the 196 patients, 31 patients (16%) were 80 years of age or older (group E), and 165 patients (84%) were younger than 80 years (group Y).

RESULTS

The median ages were 82 years in group E and 68 years in group Y. The frequency of chronic concomitant diseases was significantly higher in group E (65%) than in group Y (27%) (p = 0.003). No significant pressure decrease or need for oxygenation was observed in either group. In addition, groups E and Y did not differ significantly in terms of mean lesion sizes (40.9 vs. 39.7 mm) en bloc resection rates (84% vs. 93%), curative rates (78% vs. 84%), median procedure times (65 vs. 70 min), or associated complications (no perforation or delayed bleeding cases [0%] vs. 5 perforations [3%]) The median postprocedure hospitalization period was 3 days in both groups. Except for 10 cases requiring subsequent lymph node dissection surgery, follow-up colonoscopy examinations showed no recurrences or ESD-related mortalities in either group.

CONCLUSION

Colorectal ESD is a safe and effective treatment for elderly patients (age ≥ 80 years) despite a significantly higher frequency of chronic concomitant diseases than among younger patients.

[Thoracoscopic surgery for intractable pneumothorax under epidural and local aesthesia]

Thoracoscopic surgery under epidural and local anesthesia for intractable pneumothorax were performed in 26 patients. A total of 29 thoracoscopic operation were performed in 26 patients. Twenty-three patients undervent only a single thoracoscopic operation, and 3 patients underwent twice thoracoscopic operations. We could control the air leak of intractable pneumothorax with the covering of polyglycolic acid sheets using aerosolized fibrin glue in 25 patients. In all patients postoperative course was uneventful and there was no operative death.

Analysis of K-ras, BRAF, and PIK3CA mutations in laterally-spreading tumors of the colorectum

BACKGROUND AND AIMS

Laterally-spreading tumors (LST) are a newly-recognized category of colorectal neoplasia, and are defined as lesions larger than 10 mm in diameter and extending circumferentially rather than vertically. However, genetic features of this new category of tumors are not fully elucidated. The aim of this study was to evaluate genetic alterations in LST.

METHODS

We examined K-ras, BRAF, and phosphoinositide-3-kinase catalytic-α polypeptide (PIK3CA) mutations in 101 LST, including 68 LST-granular type (LST-G) and 33 LST-non-granular type by direct sequencing. As controls, we examined these gene mutations in 66 protruded colon adenomas (10 mm or larger) and 44 advanced colon cancers.

RESULTS

K-ras, BRAF, and PIK3CA mutations were observed in 59 (58%), zero (0%), and three (3%) LST, respectively. LST-G morphology in the right-sided colon was significantly correlated with the existence of K-ras mutations, whereas a size of 20 mm or larger was the only predictor of mutations in the left-sided colorectum. The frequency of K-ras mutations in LST was particularly marked in the left-sided colorectum compared to protruded adenomas or advanced cancers (LST vs protruded adenomas, P < 0.001; LST vs advanced cancers, P = 0.002), whereas in the right-sided colon, K-ras mutations were equally frequent. PIK3CA mutations were not familiar in either LST (3%) or advanced cancers (9%).

CONCLUSIONS

K-ras mutations were involved in colorectal LST in different manners according to tumor location.

Impact of narrow-band imaging in screening colonoscopy

Narrow band-imaging (NBI) enhances mucosal visualization of the vascular network and surface structure and helps to increase the visibility of neoplasia by improving contrast. Studies on the detectability of colorectal neoplastic lesions using NBI have primarily been reported in Western countries, but the published opinions and conclusions remain controversial at the present time. Our earlier prospective pilot study demonstrated that NBI colonoscopy significantly improved detection of flat lesions, which are more likely to be missed, particularly on the right side of the colon. It is especially important that even examiners performing routine screening colonoscopies become sufficiently familiar with flat and depressed lesions and then take full advantage of the endoscopic systems and specific image enhancement functions currently available for improved detection of flat and diminutive lesions. Adequate bowel preparation is another important consideration.

Diagnostic accuracy of narrow-band imaging and pit pattern analysis significantly improved for less-experienced endoscopists after an expanded training program

BACKGROUND

Previous reports assessing diagnostic skill using narrow-band imaging (NBI) and pit pattern analysis for colorectal polyps involved only highly experienced endoscopists.

OBJECTIVE

To evaluate diagnostic skills of less-experienced endoscopists (LEE group) for differentiation of diminutive colorectal polyps by using NBI and pit pattern analysis with and without magnification after an expanded training program.

DESIGN

Prospective study.

PATIENTS

This study involved 32 patients with 44 colorectal polyps (27 adenomas and 17 hyperplastic polyps) of < or =5 mm that were identified and analyzed by using conventional colonoscopy as well as non-magnification and magnification NBI and chromoendoscopy followed by endoscopic removal for histopathological analysis.

INTERVENTION

Before a training course, 220 endoscopic images were distributed in randomized order to residents with no prior endoscopy experience (NEE group) and to the LEE group, who had performed colonoscopies for more than 5 years but had never used NBI. The 220 images were also distributed to highly experienced endoscopists (HEE group) who had routinely used NBI for more than 5 years. The images were distributed to the NEE and LEE groups again after a training class. Magnification NBI and chromoendoscopy images were assessed by using the Sano and Kudo classification systems, respectively.

MAIN OUTCOME MEASUREMENTS

Diagnostic accuracy and interobserver agreement for each endoscopic modality in each group.

RESULTS

Diagnostic accuracy was significantly higher, and kappa (kappa) values improved in the LEE group for NBI with high magnification after expanded training. Diagnostic accuracy and kappa values when using high-magnification NBI were highest among endoscopic techniques for the LEE group after such training and the HEE group (accuracy 90% vs 93%; kappa = 0.79 vs 0.85, respectively).

LIMITATIONS

Study involved only polyps of < or =5 mm.

CONCLUSION

Using high-magnification NBI increased the differential diagnostic skill of the LEE group after expanded training so that it was equivalent to that of the HEE group.

Advantages of using thin endoscope-assisted endoscopic submucosal dissection technique for large colorectal tumors

BACKGROUND

Our purpose was to evaluate the effectiveness of a newly developed non-invasive traction technique known as thin endoscope-assisted endoscopic submucosal dissection (TEA-ESD) procedure for the removal of colorectal laterally spreading tumors (LST).

PATIENTS AND METHODS

A total of 37 LST located in the rectum and distal sigmoid colons of 37 patients were eligible for outcome analysis. Twenty-one LST were treated with TEA-ESD and were then retrospectively compared to 16 LST that had previously been treated with standard ESD. Tumor size, en bloc resection rate, procedure time, combined number of different electrical surgical knives used during each procedure and associated complications were evaluated in this case-control study.

RESULTS

There was no statistically significant difference in tumor size between the TEA-ESD group and the ESD control group (43.6+/-16 mm and 42.4+/-14 mm, respectively). All LST were successfully resected en bloc in both groups. Procedure duration was shorter for the TEA-ESD group than the ESD control group, although the difference was not statistically significant (96+/-53 minutes vs 116+/-74 minutes; P=0.18). The percentage of cases in which only one electrical surgical knife was used during the entire procedure was significantly higher in the TEA-ESD group compared to the ESD control group (85.7% vs 31.3%; P=0.0005). There were no perforations in the TEA-ESD group while the ESD control group experienced one perforation. At the present time, TEA-ESD is limited to the rectum and distal sigmoid colon.

CONCLUSION

It was technically easier, safer and more cost-effective to perform ESD for LST in the rectum and the distal sigmoid colon using the newly developed TEA-ESD traction technique.

[A case of carcinosarcoma of the esophagus treated by the chemoradiotherapy]

A 82-year-old man was admitted into our hospital complaining of dysphagia. Endoscopic examination revealed an elevated tumor in the middle esophagus, and biopsy revealed carcinosarcoma. He underwent chemo-radiotherapy, and the size of tumor decreased remarkably and almost disappeared 7 months later. However, a metastatic lesion appeared 11 months later, and eventually he died. Autopsy revealed a sarcomatous element in the metastatic part, but the primary lesion showed no recurrence. We report herein this rare case of carcinosarcoma of the esophagus that was treated with chemo-radiotherapy.

[Mucosa-associated lymphoid tissue (MALT) lymphoma of the lung; report of a case]

We experienced a case of mucosa-associated lymphoid tissue (MALT) lymphoma of the lung. The patient was 50-year-old woman. She had been pointed out a lung abnormal shadow on chest X-ray. A lung biopsy by a bronchofiberscope failed to diagnose, and an open lung biopsy under video-assisted thoracoscopic surgery (VATS) offered diagnosis as a MALT lymphoma. We performed the tumor resection (a upper-middle lobectomy of the right lung with hilar and mediastinal lymph node dissection under VATS). The post-operative course of the patient was uneventful and she has been free from the disease until now. MALT lymphoma has been a comparatively rare disease, but once the curative resection is performed the prognosis of the disease is good.

Cerebellar hemorrhage after coil embolization for a ruptured vertebral dissecting aneurysm

BACKGROUND

We present a case of ruptured vertebral dissecting aneurysm that exhibited cerebellar hemorrhage after successful embolization of the vertebral artery including the dissected site.

CASE PRESENTATION

A 59-year-old man suffered a sudden onset of severe occipital headache when he looked up. Computed tomography demonstrated subarachnoid hemorrhage. Angiography revealed a right vertebral dissecting aneurysm distal to the posterior inferior cerebellar artery. Endovascular embolization of the aneurysm was performed with preservation of the posterior inferior cerebellar artery. The next day, the patient suffered a cerebellar hemorrhage in the vermis. The intracranial pressure was controlled by external ventricular drainage. The patient was discharged with mild cerebellar ataxia and bilateral abducens nerve palsy.

CONCLUSION

In a case of vertebral dissecting aneurysm distal to the posterior inferior cerebellar artery, blood circulation in the vertebral arterial system may change after embolization of the aneurysm. In our case, the preserved posterior inferior cerebellar artery might have been hemodynamically stressed postoperatively, resulting in cerebellar hemorrhage. Therefore, strict control of blood pressure is essential in the acute stage after occlusion of the aneurysm.

[Use of an expandable metallic stent in 4 patients with superior vena syndrome]

Recently developed expandable metallic stents have been adopted to superior vena cava syndrome with good results. We inserted stents into the superior vena cava in 4 patients with superior vena cava syndrome. The results were comfortable and no complications. We should consider the stenting as the first choice for superior vena cava syndrome.

[A case of video-assisted thoracic surgery for congenital esophago-bronchial fistula]

A 42-year-old male was admitted to our hospital because barium esophagograpm showed an esophago-bronchial fistula with an esophageal deverticulum. He has had frequent episodes of cough at drinking water since childhood. A chest CT scan showed mild inflammatory change and bronchiectasis in the right S6. Division of the fistula by video-assisted thoracoscopic surgery (VATS) was performed. There was no evidence of inflammation and adherent lymph nodes around the fistula. This case was diagnosed as a congenital esophago-bronchial fistula by operative findings and clinical course. The fistula was dissected easily and divided by an auto-suturing instrument. The affected lung could be preserved. The patient was discharged on the 10th postoperative day. VATS is an effective treatment for the patients of congenital esophago-bronchial fistula (Braimbrige type I and II), if they are not accompanied with pulmonary abscess or pleural empyema.

Ultrastructure of the perineurial cell of the sciatic nerve in rats--a transmission and scanning electron microscopic study

The perineurial cells of the sciatic nerve of mature albino rats were investigated by using light microscope (LM), transmission electron microscope (TEM) and scanning electron microscope (SEM). The perineurium of the sciatic nerve was composed of several lamellae of thin perineurial cells which were held together by the zonula occludens and also by the zonula adherens. The TEM view of the perineurium revealed that the plasmalemma of the perineurial cells presented numerous caveolae similar to those described in the endothelial cells of blood capillaries. By SEM, the perineurial cells were very thin, flattened out with various shapes from rectangular to hexagonal, and arranged closely to each other in the fashion of a stone pavement around the nerve fascicles. It was possible to isolate the perineurium from the nerve and to demonstrate the cellular border of the perineurial cells by silver impregnation method. The SEM observation of the perineurial cells ascertained the figure of the cells which were seen in the silver-impregnated specimen under LM. The present authors have interest in the fact that shape and arrangement of the perineurial cells of spinal nerves resemble closely those of the myoid cells in the limiting lamina of the seminiferous tubules of the mammalian testes. The meaning and significance of the similarity between these two types of cells was discussed.

[An operative case of benign schwannoma originating in the intrathoracic vagal nerve]

A 50-years-old man was admitted with cough and abnormal shadow on the chest film. The tumor originated from the left vagal nerve in the antero-superior mediastinum. Subcapsular extirpation was performed to save the nerve function, since the tumor located in the site proximal to the branching point of the recurrence nerve. Pathological diagnosis was a benign schwannoma. Though H-E and Bodian stain did not show any nerve fibers in the schwannoma, postoperative hoarseness arose. In this country, 4 cases of subcapsular extirpation have been performed, but all of them had postoperative hoarseness. We think that postoperative hoarseness cannot be prevented by the subcapsular extirpation.

Filipin-sterol complexes in golden hamster sperm membranes with special reference to epididymal maturation

The distribution of membrane filipin-sterol complexes (FSCs) was qualitatively surveyed on freeze-fracture replicas of spermatozoa from the male reproductive tract and ejaculates of golden hamster. In the head, the acrosomal plasma membrane showed the strongest filipin labeling on the principal segment, but it was absent in the "quilt-like pattern" areas. These latter were observed in both caput and corpus epididymal spermatozoa, but were absent in mature spermatozoa. The postacrosomal plasma membrane had few FSCs and both the outer and inner acrosomal membranes were always negative to filipin. The nuclear membrane of the principal segment was constantly filipin-positive. The nuclear membrane of the postacrosomal region had more FSCs than that of the principal segment, particularly in mature spermatozoa. Many linear, "rod-like FSCs" were observed on the postacrosomal nuclear membrane of mature spermatozoa, especially in the uterine spermatozoan samples. In the neck, the plasma membrane had only a few FSCs. The redundant nuclear membrane was slightly filipin-positive, while the membrane scroll of mature spermatozoa was heavily labeled. In the tail, the plasma membrane of both the middle and principal piece was moderately labeled.

Distribution of intramembranous particles and filipin-sterol complexes in mouse sperm membranes: polyene antibiotic filipin treatment

The distribution of intramembranous particles (IMPs) and membrane filipin-sterol complexes (FSC) was examined ultrastructurally in mouse spermatozoa from the male reproductive tract and ejaculates. IMPs were qualitatively analyzed on freeze-fracture replicas of glutaraldehyde-fixed tissue, while membrane FSC were quantitatively analyzed on replicas of filipin-treated cells. The distribution pattern of IMPs of mouse spermatozoa was fundamentally similar to that of other mammalian spermatozoa. 1) In the head, the plasma membrane had a heterogeneous population density, e.g., few IMPs on the acrosomal region, particularly few on the marginal segment, and somewhat regularly arranged IMPs on the postacrosomal region. The acrosomal membrane had many IMPs in hexagonal arrays. The nuclear membrane had many IMPs on the P-face, few IMPs on the variegated E-face, and an intense population density on the P-face of the basal plate. 2) In the neck, the plasma membrane had many IMPs with square arrangements of small IMPs in some areas on the P-face; the redundant nuclear membrane had a few IMPs on both P- and E-faces. 3) In the tail, the plasma membrane had diagonal rows of IMPs in some areas amongst larger IMPs on the middle piece, while it had "zippers" composed of IMPs running parallel to the axis on the principal piece. The distribution of sperm membrane FSC may be summarized as follows: 1) In the head, the acrosomal plasma membrane, which was heavily labeled with filipin, had much more FSC in the equatorial segment than in the marginal segment throughout the study. The postacrosomal plasma membrane generally had no FSC, but some sperm in ejaculates were slightly positive to filipin. The acrosomal membranes (both outer and inner) had no FSC. The nuclear membrane in the main part of the head had less FSC in vas deferens and ejaculated sperm than in the epididymal sperm. The nuclear membrane on the basal plate had no FSC. 2) In the neck, the plasma membrane had little FSC. The redundant nuclear envelope had scattered FSC with a higher incidence in the epididymal sperm than in those from the vas deferens and ejaculates. The membrane scroll, which was elongated from the extreme caudal end of the redundant nuclear envelope, had abundant FSC in the vas deferens and ejaculated sperm. 3) The tail plasma membrane (both middle and principal piece), which was weakly labeled with filipin, had less FSC in sperm from the vas deferens and ejaculates than in those from the epididymis. The limiting membrane covering the mitochondria had no FSC.

Alterations in tight junctions of human endometrial epithelial cells during normal menstrual cycle--freeze-fracture electron microscopic study

The structural change in the tight junction between human endometrial epithelial cells during the normal menstrual cycle was observed by means of freeze-fracture replica electron microscopy. Tight junctions between epithelial cells of the endometrial basal layer showed no alterations in structure during the menstrual cycle, while those between epithelial cells of the functional layer exhibited remarkable changes synchronized with the menstrual cycle; in the early proliferative phase, the tight junctions were composed of strands running mainly parallel to the luminal surface and the depth of the junctions from the luminal surface was 0.57 +/- 0.04 micron (Mean +/- S.E.), whereas in the late proliferative phase the junction formed a prominent network of strands 0.80 +/- 0.04 micron deep. In the early secretory phase, the junctions developed mostly as a complex network, and the depth was 0.96 +/- 0.04 micron. In the late secretory phase, the network consisting of the junctions looked disorderly and the depth of the junctions was reduced to 0.71 +/- 0.04 micron. As a conclusion, it was suggested that the tight junction in the human endometrial epithelium tended to develop or diminish according to the phase of the menstrual cycle.

Quantitative analysis of zonulae occludentes between oviductal epithelial cells at diestrous and estrous stages in the mouse: freeze-fracture study

The zonulae occludentes between oviductal epithelial cells were quantitatively analyzed at diestrous and estrous stages in the mouse, using the freeze-fracture technique. Zonulae occludentes were predominantly anastomosing at the diestrous stage, while they were predominantly parallel at the estrous stage. The lowest mean value of junctional strands comprising the zonulae occludentes was 5.3 +/- 1.6. Parallel-type zonulae occludentes had more strands than the anastomosing type. Secretory cells usually had more strands than ciliated cells. The shallowest mean depth occupied by junctional domain was 0.51 +/- 0.20 micron. The depth was usually somewhat greater in anastomosing-type zonulae occludentes than in the parallel type. It was also slightly greater in ciliated cells than in secretory cells. The depth was likely to be greater at diestrous stage than at the estrous stage. However, neither the number of strands nor the depth was significantly different between diestrous and estrous stages in homologous types of zonulae occludentes. On the basis of these results, the zonulae occludentes in oviductal epithelium are considered to be morphologically of a tight type at any time period throughout the estrous cycle. The results of lanthanum tracer experiments suggest that the zonulae occludentes in the oviductal epithelium do not always function as a barrier to the exogenous tracer. These morphological phenomena are discussed in relation to mouse fertilization in vivo.