Endoscopic ultrasonography can diagnose distal biliary strictures without a mass on computed tomography.

AIM: To assess the diagnostic ability of endoscopic ultrasonography (EUS) for evaluating causes of distal biliary strictures shown on endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP), even without identifiable mass on computed tomography (CT). METHODS: The diagnostic ability of EUS was retrospectively analyzed and compared with that of routine cytology (RC) and tumor markers in 34 patients with distal biliary strictures detected by ERCP or MRCP at Dokkyo Medical School Hospital from December 2005 to December 2008, without any adjacent mass or eccentric thickening of the bile duct on CT that could cause biliary strictures. Findings considered as benign strictures on EUS included preservation of the normal sonographic layers of the bile duct wall, irrespective of the presence of a mass lesion. Other strictures were considered malignant. Final diagnosis of underlying diseases was made by pathological examination in 18 cases after surgical removal of the samples, and by clinical follow-up for > 10 mo in 16 cases. RESULTS: Seventeen patients (50%) were finally diagnosed with benign conditions, including 6 "normal" subjects, while 17 patients (50%) were diagnosed with malignant disease. In terms of diagnostic ability, EUS showed 94.1% sensitivity, 82.3% specificity, 84.2% positive predictive value, 93.3% negative predictive value (NPV) and 88.2% accuracy for identifying malignant and benign strictures. EUS was more sensitive than RC (94.1% vs 62.5%, P = 0.039). NPV was also better for EUS than for RC (93.3% vs 57.5%, P = 0.035). In addition, EUS provided significantly higher sensitivity than tumor markers using 100 U/mL as the cutoff level of carbohydrate antigen 19-9 (94.1% vs 53%, P = 0.017). On EUS, biliary stricture that was finally diagnosed as malignant showed as a hypoechoic, irregular mass, with obstruction of the biliary duct and invasion to surrounding tissues. CONCLUSION: EUS can diagnose biliary strictures caused by malignant tumors that are undetectable on CT. Earlier detection by EUS would provide more therapeutic options for patients with early-stage pancreaticobiliary cancer.

Endoscopic submucosal dissection in 100 lesions with early gastric carcinoma.

BACKGROUND/AIMS: ESD is a new diagnostic and treatment technique for early gastric cancer. This study aimed to evaluate the therapeutic effects observed at our department. METHODOLOGY: The subject group included 95 patients with 100 early-stage gastric cancers. According to the Gastric Cancer Treatment Guidelines published by the Japanease Gastric Cancer Association (JGCA) in 2001. Sixty-seven lesions presented a tumor measuring less than 20 mm and were concave (if not flat) without ulceration (specified indication of the guidelines of the Japanese Gastric Cancer Association), and 33 lesions were expanded indications. We then compared one-piece resection rates, en-bloc resection rates (one-piece resection that is lateral- and vertical-stump negative), curative en-bloc resection rates (en-bloc resection that fulfills the following three criteria: 1. differentiated adenocarcinoma; 2. no lymphtic or venous invasion, 3a. intramucosal cancer regardless of tumor size without ulceration, 3b. intramucosal cancer 30 mm in size with ulceration, 3c. minute submucosal cancer 30 mm in size). RESULTS: Among the specified indications and expanded indications, one-piece resection rates accounted for 97.0% and 75.8%, en-bloc resection rates for 83.6% and 60.6%, and curative en-bloc resection rates for 83.6% and 57.6%. The numbers of accident cases were three (postoperative hemorrhage; n = 1 perforation; n = 2) and four (postoperative hemorrhage; n = 1, perforation; n = 3), respectively. CONCLUSIONS: These studies indicated higher one-piece resection rates, en-bloc resection rates and curative en-bloc resection rates for lesions based on the guidelines than those based on the expanded guidelines.

A randomized prospective trial comparing unsedated endoscopy via transnasal and transoral routes using 5.5-mm video endoscopy.

We performed a randomized prospective trial to compare unsedated endoscopy via transnasal and transoral routes using a small-caliber endoscope. Two hundred patients referred for diagnostic esophagogastroduodenoscopy (EGD) were randomly allocated to two groups: those undergoing transnasal (TN) and transoral (TO) endoscopy. We examined the insertion rate, examination duration, nasal pain, pharyngeal pain, number of occurrences of pharyngeal reflex, severity of discomfort throughout the examination, and rate of adverse events. Patients were asked to rate the severity of their pain or discomfort on a 10-cm visual analog scale (VAS). We identified statistically significant differences between the TN and TO groups in rate of insertion (95% versus 100%, respectively, P < 0.05) and examination duration (9.7 +/- 3.0 min versus 8.4 +/- 2.7 min, respectively, P < 0.005). Severity of discomfort throughout the examination was comparable in the TN and TO groups (3.0 +/- 1.8 versus 2.9 +/- 2.3, NS). Nasal bleeding occurred as an adverse event in 4.1% of patients in the TN group. Patients in the TO group were more likely than those in the TN group to prefer the present method in the subsequent endoscopic examination (99.0% versus 82.1%, P < 0.00005). These results indicated that transoral insertion is superior to transnasal insertion in endoscopy procedures performed with small-caliber endoscope.