Ultrasonographic evaluation of lansoprazole-induced improvement of submucosal injury in patients with gastroesophageal reflux.

OBJECTIVE: Endoscopic ultrasonographic (EUS) changes in gastroesophageal reflux disease (GERD) after treatment with proton pump inhibitor have been poorly evaluated. We conducted a randomized, double-blind 12-wk clinical trial to compare the EUS effects of lansoprazole to histamine H2-receptor antagonist therapy in GERD. METHODS: Seventeen patients with reflux-related symptoms received 40 mg of famotidine for 6 wk or 30 mg of lansoprazole for 6 wk followed by 40 mg of famotidine or 30 mg of lansoprazole for another 6 wk, respectively. Patients underwent EUS before and at 6 and 12 wk after treatment. RESULTS: Before treatment, a variable degree of wall thickening was noted on EUS in the lower esophagus, compared with 20 normal subjects. After 6 wk of therapy, esophageal wall was significantly thicker in the famotidine group compared with the lansoprazole group (p<0.01). Surprisingly, thickening of esophageal wall and abnormal architecture were also detected in endoscopically negative reflux disease. Lansoprazole was superior to famotidine in reducing the thickness of esophageal wall. CONCLUSIONS: EUS was very useful for evaluation of submucosal injury in patients with GERD. EUS showed that a 6-wk course of lansoprazole therapy reduced thickening of esophageal wall, which was resistant to histamine H2-receptor antagonist therapy. Our results also suggest that inflammatory damage to the submucosal and muscle layers of the lower esophagus is the underlying mechanism of heartburn and associated symptoms in patients with endoscopically negative reflux disease.

Delineation of the gastric muscularis mucosae and assessment of depth of invasion of early gastric cancer using a 20-megahertz endoscopic ultrasound probe.

Using a 20 MHz endoscopic ultrasound system, delineation of the gastric muscularis mucosae and estimation of the depth of malignant invasion was attempted by in vivo scanning during the process of routine endoscopic observation or in vitro scanning of excised sections of 34 early gastric cancers in 32 patients. The muscularis mucosae was visualized as a single hypoechoic layer in 16 of 32 lesions (50%) scanned in vitro. Comparison of lesions in which delineation of the muscularis mucosae was or was not possible revealed no significant differences with respect to either the thickness of the lamina propria and muscularis mucosae or with respect to the degree of inflammatory cell infiltration of the lamina propria or the conditions of the boundary between the lamina propria and the muscularis mucosae. This indicates that improvement of the operability characteristics of the ultrasonic apparatus will be needed to achieve improved delineation of the muscularis mucosae. The accuracy of invasion depth estimation of early gastric cancer was 67% (16 of 24 lesions scanned in vivo) and 73% (8 of 11 lesions) in cases in vivo where the muscularis mucosae and the tumor were delineated on the same screen. The principal factors causing erroneous staging were the presence of dilated benign glandular ducts, ulcer scars, and attenuation of the ultrasound waves.

Application of ultrasonic probes prior to endoscopic resection of early gastric cancer.

The development of a new strip biopsy technique for endoscopic mucosectomy utilizing endoscopic saline injection and a double-channel endoscope permits the safe and simple resection of superficial type early gastric cancer which has been difficult to perform with conventional polypectomy techniques. Preresection assessment of the depth of invasion and postresection assessment of efficacy are important with regard to treatment of early gastric cancer, but conventional endoscopic ultrasonography employed for this purpose requires special equipment and involves intricate procedures. An ultrasonic probe which can be used endoscopically has recently been developed and is currently in the trial stage. The authors have conducted studies with respect to a 7.5 MHz radial scanning type Miniature Ultrasonic Probe as well as a 20 MHz manual linear scanning type Sonoprobe System. Experimental studies indicated that the former type is capable of delineating postresection ulcers, while the latter permitted delineation of tumors as hypoechoic images in 9 of 11 cases of early gastric cancer.

[Diagnosis of the infiltrating depth of the colonic cancer by endoscopic ultrasonography (EUS)].

Endoscopic ultrasonography (EUS) is the latest procedure in the field of gastroenterology and is highly evaulating now because of its unique diagnosing method. For the example, the intra- and extra-mural informations of the GI tract can be known through this technique. In this paper, we reported on the usefulness of EUS in the diagnosis of the depth invasion of the colonic cancer and introduced the new and exclusive instrument for the colon. Namely, we could obtain the accurate diagnosis in 18 out of 20 cases with the rectal or the sigmoid colon cancer. One of causes of misdiagnosis in 2 cases of early cancer was due to the ghost echo. Another cause was the cancer cells infiltration to the deeper tissue which could be recognized only by a microscope. Then, we tried to examine the entire colon in 2 cases using the new instrument and succeeded to insert the endoscope to the cecum in a short time. In conclusion, we were convinced that EUS would develop the new aspect in the diagnosis of the colonic diseases including cancer.

Endoscopic pancreatic sphincterotomy--technique and evaluation.

Endoscopic pancreatic sphincterotomy has been developed as a new method of treatment of chronic pancreatitis in our institution since 1982. We introduced pancreatic sphincterotomy as a safe technique, after performing it successfully in 21 cases of chronic pancreatitis without any complications, and relieving both abdominal and back pain in 19 of the cases. Recently, we have added endoscopic elimination of viscid pancreatic juice including protein plugs. This report describes our procedure of pancreatic sphincterotomy in detail, and evaluates it in the endoscopic treatment of chronic pancreatitis.

Endoscopic ultrasonography in the diagnosis of esophageal carcinoma, with particular regard to staging it for operability.

We report on the usefulness of endoscopic ultrasonography (EUS) for the staging of esophageal carcinoma for operability, including the diagnosis of infiltrating depth and lymph node metastases. The accurate diagnosis of the depth of invasion of a carcinoma by means of EUS was achieved in 75% of all cases. Concerning the evaluation of resectability, it should therefore be concluded that EUS can provide us with accurate information on the invasion of the carcinoma beyond the adventitia and/or its distant metastatic growth to the neighboring organs including lymph nodes. From this investigation it can be concluded that EUS is an excellent method for the staging of esophageal carcinoma with regard to its operability.

[Diagnosis of the infiltrating depth of gastric cancer by endoscopic ultrasonography].

In the diagnosis of the infiltrating depth of thirty four cases with gastric cancer, in which twenty two cases were early cancer and fourteen cases advanced cancer, the rate of the diagnostic accuracy by EUS was eighty eight % in the differentiation between early cancer and advanced cancer. While, in distinction of cancer spreading into the mucosa, the submucosa, the muscularis propria and over the subserosa, diagnostic accuracy was sixty four % in early cancer and seventy five % in advanced cancer. There were two reasons mainly in the wrong diagnosis of EUS. One was the existence of fibrosis in cases of the depressed type of early cancer and the other was the dissemination of the cancer cells extending into the deeper tissues, which could be detected only by histological examinations.

Endoscopic ultrasonography.

EUS has many advantages over x-ray and other endoscopic procedures for the detection of lesions located in the wall of the GI tract. In the oesophagus, invasion of cancer and spread to lymph nodes can be visualized by EUS before surgery. In the stomach, the invasion depth of cancer and the therapeutic effect of laser irradiation to early cancer can be studied. EUS may also be useful in the evaluation of chemotherapy in malignant lymphoma. In benign diseases of the GI tract, EUS can provide important information about submucosal tumours. It can improve the differential diagnosis of malignant and benign submucosal tumours. EUS will also contribute to the elucidation of the pathogenesis of giant folds developing in the stomach. In addition, EUS is beneficial in the diagnosis of chronic pancreatitis, pancreatic cyst, pancreatic cancer, cancer of the papilla Vateri and diseases of the biliary tract. In conclusion, we feel that endoscopic ultrasonography may prove to be a useful technique in the diagnosis of intra- and extramural lesions of the GI tract, but comparisons with conventional imaging procedures should be performed.

Endoscopic ultrasonography of lymph nodes surrounding the upper GI tract.

We investigated the usefulness of endoscopic ultrasonography (EUS) of lymph nodes surrounding the upper GI tract and tried the enhanced EUS by the method of the oral administration of '10% oil-in-water-type emulsion.' The results were as follows: The ultrasonographic visualization rate of lymph nodes surrounding the esophagus was 33.7% in total; however, it was 43.4% for those greater than 5 mm and 58.7% for those greater than 10 mm. The frequency of lymph node metastasis of esophageal cancer was 48.1% for those larger than 10mm with a round shape and 14.3% for the same size with an ellipsoid shape; for those less than 10mm, it was also low. Lymph nodes surrounding the esophagus and the stomach were enhanced by administration of 10% oil-in-water-type emulsion. The visualization rate of lymph nodes can be increased by using this new method. Endoscopic ultrasonography is very useful for the detection of swelling lymph nodes surrounding the upper GI tract before the operation.

A fundamental study of normal layer structure of the gastrointestinal wall visualized by endoscopic ultrasonography.

The gastrointestinal wall could be separated into five layers or nine layers by means of the ultrasonic endoscope, and the histological structure of these layers was ascertained by comparing endoscopic ultrasonograms of resected specimens of the gastrointestinal tract with their corresponding histology. The results were as follows: With five layers of the gastrointestinal wall, the first and the second layer corresponded to the mucosa, the third layer was the submucosa, and the fourth layer corresponded to the muscularis propria. The first layer was a border echo demonstrated inside the mucosa. The fifth layer consisted of the serosa and a border echo visualized outside the serosa. When a thin layer was visualized at the same time in both the second and the fourth layers, the gastrointestinal wall was separated into nine layers in total. With nine layers of the gastrointestinal wall, the muscularis mucosae was composed of a thin layer in the second layer and a narrow layer between a thin layer in the second layer and the third layer. A thin layer in the second layer was a border echo visualized inside the muscularis mucosae. A thin layer in the fourth layer of the gastrointestinal wall consisted of a border echo and a connective tissue between the inner circular muscle and the outer longitudinal muscle.

Pancreatic sphincterotomy and pancreatic endoprosthesis.

Recently, endoscopic sphincterotomy (EST), developed as a treatment of bile duct stone or papillary stenosis, has been used for transpapillary biliary drainage in cases of extrahepatic biliary stenosis. For the nonoperative treatment of chronic pancreatitis, we have developed this procedure into a technique for opening the pancreatic duct orifice. Pancreatic sphincterotomy was performed successfully in 10 out of 13 cases with chronic pancreatitis and improved the clinical symptoms in 9 cases. Moreover, in 3 cases we succeeded in inspecting the intrapancreatic duct by peroral pancreatoscopy, and in removing stones from the main pancreatic duct in 2 cases in this series, using the basket. Also through the opened pancreatic orifice, a pancreatic endoprosthesis was placed endoscopically into the main pancreatic duct in 3 cases to improve pancreatic drainage. This report discusses method, evaluation, and complications of pancreatic sphincterotomy in the endoscopic treatment of chronic pancreatitis, and describes successful cases of the basket removal of pancreatic stones and the placement of pancreatic endoprosthesis through the opening of the pancreatic orifice.

New development of peroral cholangioscopy--evaluation of double-angle, oblique viewing cholangioscope.

Seven years have passed since the first report on peroral cholangioscopy by Takekoshi and Takagi (1) in Japan. Recently, several types of peroral cholangioscope with a forceps channel have been made for this treatment. However, the success rate of insertion of these instruments into the common bile duct was less than 50%. Therefore, in cooperation with Fuji-Photo-Optical Co. Ltd., we have made a new scope with the aim of facilitating insertion into the bile duct. Using this new scope, called a double-angle, oblique viewing cholangioscope, we obtain good orientation in the duodenum in en-face view and close inspection of the duodenal papilla, which makes possible easier insertion into the common bile duct. This new scope proved useful in basket removal of bile duct stone, or differential diagnosis between stones and carcinoma of the biliary tract.

Anatomical and pathological aspects in ultrasonic endoscopy for GI tract.

In this paper we tried a fundamental study to analyse the normal structure of gastro-intestinal wall by endoscopic ultrasonography, because conventional examinations of gastrointestinal tract, radiography and endoscopy, can not demonstrate the intra-mural change beneath the mucosa. We have examined 71 cases by the 3 kinds of prototype echo-endoscope I-III manufactured by Olympus Co Ltd, Japan. Moreover, using a most newly echo-endoscope type III, twenty-four patients were examined to observe the changes of normal structure of wall by gastro-intestinal disease. In this fundamental study about the normal structure of gastro-intestinal wall by endoscopic echography, the submucosal layer is demonstrated as a most high echo level zone and the mucosal layer and serosal layer followed in echogenicity. On the other hand, the proper muscle layer had not any echogenicity because ultrasound passes through these layers. As a result we concluded that all layers of gastrointestinal tract can be demonstrated by endoscopic ultrasonography. Moreover, in diagnosis of gastro-intestinal disease, endoscopic ultrasonography is useful in disease of which the normal structure of wall changes directly, for example submucosal tumor, scirrhus type gastric cancer and massive infiltrated malignant disease.

[Treatment and prevention of infections with cefoxitin sodium in patients with biliary tract infections and obstructive jaundice].

UNLABELLED: A total of 24 patients who was hospitalized in the Internal Medicine Wards of Yamaguchi University attached Hospital and the university's 3 related hospitals were administered with cefoxitin. The breakdown of the patients treated with cefoxitin was 7 with cholecystitis, 7 with choledochitis and the remaining 10 for the prevention of infections with obstructive jaundice. Daily doses of 2-6 g of cefoxitin were administered for 6-40 days by intermittent intravenous drip infusion in divided doses. RESULTS: 1. Of 14 patients with biliary tract infections, 10 (71.4%) responded favorably with cefoxitin. 2. Of 10 patients with obstructive jaundice used for the prevention of infections, 8 (80%) responded favorably with cefoxitin. 3. No untoward side effects were observed. 4. Cefoxitin proved to be a safe and effective antibiotic in the treatment of biliary tract infections and for the prevention of infections in patients with obstructive jaundice.