Diagnostic yield of proximal jejunal lesions with third-generation capsule endoscopy.

Objectives: Capsule endoscopy (CE) has been shown to have poor diagnostic performance when the capsule passes quickly through the small bowel, especially the proximal jejunum. This study aimed to evaluate the diagnostic yield of proximal jejunal lesions with third-generation CE technology. Methods: We retrospectively examined 138 consecutive patients, 76 (55.0%) of whom were men. The patients' median age was 70 years, and proximal jejunal lesions were detected by CE and/or double-balloon endoscopy at Hiroshima University Hospital between January 2011 and June 2021. We analyzed the diagnostic accuracy of CE for proximal jejunal lesions and compared the characteristics of the discrepancy between the use of CE and double-balloon endoscopy with Pillcam SB 2 (SB2) and Pillcam SB 3 (SB3). Results: SB2 and SB3 were used in 48 (35%) and 90 (65%) patients, respectively. There was no difference in baseline characteristics between these groups. Small-bowel lesions in the proximal jejunum comprised 75 tumors (54%), 50 vascular lesions (36%), and 13 inflammatory lesions (9%). The diagnostic rate was significantly higher in the SB3 group than in the SB2 group for tumors (91% vs. 72%, p < 0.05) and vascular lesions (97% vs. 69%, p < 0.01). For vascular lesions, in particular, the diagnostic rate of angioectasia improved in the SB3 group (100%) compared with that in the SB2 group (69%). Conclusions: SB3 use improved the detection of proximal jejunal tumors and vascular lesions compared with SB2 use.

Predictive factors for the progression of primary localized stage small-bowel follicular lymphoma.

BACKGROUND: Primary small-bowel follicular lymphoma (FL) is mainly diagnosed as a duodenal lesion during esophagogastroduodenoscopy. Recently, with the widespread use of small-bowel endoscopy, FL in the jejunum and ileum has been detected. Most patients with small-bowel FL are diagnosed at the localized stage, and a watch-and-wait policy is used. However, the predictive factors for the progression of small-bowel FL have not been clarified. This study retrospectively examined the predictive factors for the progression of primary localized stage small-bowel FL based on clinicopathological and endoscopic findings. METHODS: We enrolled 60 consecutive patients with primary small-bowel FL diagnosed at two tertiary hospitals between January 2005 and December 2020, with localized stage, low grade, and low tumor burden with the watch-and-wait policy. We examined the predictive factors for progression according to the clinicopathological and endoscopic findings. Endoscopic findings were focused on the color tone, circumferential location of follicular lesions (circumference ≥ 1/2 or < 1/2), fusion of follicular lesions (fusion [ +] or [ -]), and protruded lesions (≥ 6 mm or < 6 mm). RESULTS: Progressive disease was observed in 12 (20%) patients (mean observation period, 76.4 ± 55.4 months). In the multivariate analysis, "circumference ≥ 1/2" and "fusion (+)" were significant predictive factors for progression. According to the Kaplan-Meier analysis, progression-free survival was significantly shorter in the "circumference ≥ 1/2" and/or "fusion (+)" group than in the "circumference < 1/2" and "fusion ( -)" group. CONCLUSIONS: Endoscopic findings of "circumference ≥ 1/2" and "fusion (+)" were significant predictive factors for the progression of primary localized stage small-bowel FL.

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.

Characteristics and Treatment Outcomes of Small-bowel Angioectasia in Systemic Sclerosis Patients: A Retrospective Observational Study.

Objective Systemic sclerosis (SSc) is defined as an autoimmune disease presenting with fibrosis of various organs and vascular endothelial damage. Vascular lesions, including small-bowel angioectasias, are also frequently detected in SSc patients. Polidocanol injection (PDI) is a safe and effective hemostatic treatment for gastrointestinal bleeding. We evaluated the outcomes of PDI for small-bowel angioectasia in SSc patients. Methods We retrospectively evaluated 65 consecutive SSc patients (61 women; mean age, 64.3 years old) who underwent capsule endoscopy (CE) and/or double-balloon endoscopy at Hiroshima University Hospital between April 2012 and December 2019. Patients Patients were stratified according to the presence of small-bowel angioectasia. Among patients who underwent CE during the same period, those with small-bowel angioectasia without concomitant diseases were compared with SSc patients with small-bowel angioectasia. Clinical and endoscopic characteristics, treatment outcomes, and the incidence of metachronous small-bowel angioectasia after PDI were evaluated. Results SSc patients with small-bowel angioectasia exhibited significantly lower hemoglobin levels and a significantly higher incidence of skin telangiectasia than those without small-bowel angioectasia. On a multivariate analysis of the presence of small-bowel angioectasia, anemia and skin telangiectasia were significant independent factors. SSc patients with small-bowel angioectasia included a higher proportion of women and exhibited a significantly higher incidence of metachronous small-bowel angioectasia than X. The characteristics of small-bowel angioectasia and outcomes of PDI were not significantly different between the two groups. No post-treatment rebleeding cases or adverse events were noted. Conclusion CE should be performed for SSc patients with anemia and/or skin telangiectasia. PDI is effective for SSc patients with small-bowel angioectasia.

Endoscopic Delivery Method Using a Retrieval Net for Patients with Small-Bowel Capsule Endoscopy Stagnation in the Stomach.

With the increasing use of capsule endoscopy (CE), screening tests for the small bowel can be performed with minimal invasiveness. However, occasionally, the entire small bowel cannot be observed because of decreased peristalsis of the stomach. For such cases, we perform delivery of CE by an endoscope. We retrospectively examined the usefulness of the endoscopic delivery method using a retrieval net for patients with CE stagnation in the stomach. From 2,270 patients who underwent small-bowel CE at Hiroshima University Hospital from January 2013 to January 2020, 29 consecutive patients (1.3% of the total number) in whom the small bowel could not be observed due to CE stagnation in the stomach at the time of the initial CE underwent the endoscopic delivery method using a retrieval net for secondary small-bowel CE. This study included 16 male (55%) and 13 female (45%) patients with a mean age of 69.2 ± 13.2 years. 11 patients (38%) had a history of gastrointestinal surgical resection. The entire small bowel could be observed in 19 patients (66%), and CE reached the terminal ileum in the remaining patients. A history of gastrointestinal surgical resection was significantly more frequent in the group where the entire small bowel could not be observed. The rate of small-bowel lesion detection was 55% (16/29). There were no adverse events associated with our endoscopic delivery method. Thus, the endoscopic delivery method using a retrieval net for patients with initial CE stagnation in the stomach may be safe and useful for the detection of small-bowel lesions.

Capsule endoscopy findings reflect the gastrointestinal conditions of patients with systemic sclerosis.

Systemic sclerosis (SSc) is characterized by fibrosis of the skin and various internal organs. However, there is limited knowledge concerning small-bowel lesions. We evaluated the clinical state of patients with SSc according to the capsule endoscopy (CE) findings. Sixty-five consecutive patients with SSc (61 females; mean age, 64.3 years) underwent CE at Hiroshima University Hospital between April 2012 and December 2019. SSc was subclassified into diffuse and limited cutaneous SSc. Among the 65 patients, 55 (51 females; mean age, 64.5 years; diffuse cutaneous SSc, 27 patients) were evaluated for the presence of fibrosis in the gastrointestinal tract by biopsy. Small-bowel lesions were detected in 27 (42%) patients with SSc. Type 1b angioectasia (Yano-Yamamoto classification) was more frequent in limited cutaneous SSc patients (p = 0.0071). The average capsule transit time of the esophagus was significantly longer in diffuse cutaneous SSc patients (p = 0.0418). There were more cases of Type 1a angioectasia in SSc patients without fibrosis. The average capsule transit time of the esophagus was significantly longer in SSc patients with fibrosis. Thus, this study revealed that the frequency of small-bowel angioectasia and gastrointestinal motility in patients with SSc differed depending on SSc subclassification and the presence of fibrosis.

Genomic analysis for the prediction of prognosis in small-bowel cancer.

The current understanding of clinicopathological features and genomic variants of small-bowel cancer is limited, in part due to the rarity of the disease. However, understanding of these factors is necessary for the development of novel therapeutic agents for small-bowel cancer. Thus, we aimed to identify the clinicopathological features and genomic variants associated with its prognosis and recurrence. We retrospectively examined 24 consecutive patients with primary small-bowel cancer surgically treated between May 2005 and August 2018 and collected 29 tumor specimens. The 29 lesions were subjected to mismatch repair status evaluation, using immunohistochemistry (IHC), and targeted genomic sequencing, after which they were analyzed using a panel of 90 cancer-related genes. IHC revealed that 45% (13/29) of the lesions exhibited deficient mismatch repair. The most common genomic variants in small-bowel cancers were in TP53 (48%, 13/27), followed by KRAS (44%, 12/27), ARID1A (33%, 9/27), PIK3CA (26%, 7/27), APC (26%, 7/27), and SMAD4, NOTCH3, CREBBP, PTCH1, and EP300 (22%, 6/27 each). Overall survival and disease-specific survival of patients with tumor mutational burden (TMB) ≥10 mutations/Mb (n = 17) were significantly better than those of patients with TMB <10 mutations/Mb (n = 6). Additionally, patients with a mutant SMAD4 had poorer recurrence-free survival than those with wild-type SMAD4. Our results suggested that TMB and SMAD4 mutations were associated with the prognosis of small-bowel cancer patients. Thus, cancer genomic analysis could be useful in the search for biomarkers of prognosis prediction in small-bowel cancers.

Exacerbation of Portal Hypertensive Enteropathy after Endoscopic Injection Sclerotherapy for Esophageal Varices.

INTRODUCTION: Portal hypertensive enteropathy (PHE) is a well-known small-bowel lesion that occurs with liver cirrhosis (LC) and is associated with increased hepatic venous pressure. However, it is unclear how esophageal varices (EV) treatment actually affects PHE. We aimed to analyze the effects of EV treatment on PHE. METHODS: Among LC patients who underwent capsule endoscopy (CE) more than twice to confirm PHE at our hospital from February 2009 to September 2018, we targeted those with no change in the Child-Pugh classification after EV treatment for the prevention of bleeding. Patients were assigned to groups based on the EV treatment method (endoscopic injection sclerotherapy [EIS] group or endoscopic variceal ligation [EVL] group). We analyzed the PHE findings before and after treatment, and we investigated changes in the collateral vein using computed tomography imaging. RESULTS: We analyzed 42 LC patients (27 men; mean age, 65.3 years); 20 were in the EIS group and 22 were in the EVL group. Exacerbation of PHE was significantly prevalent in the EIS group (90%) compared to that in the EVL group (50%). CE of PHE showed significantly prevalent exacerbation of villous edema in the EIS group (65%) compared to that in the EVL group (23%). Stenosis or disappearance of the feeding vessel (55%) and exacerbation of the hepatofugal collateral vein (35%) were significantly prevalent in the EIS group. CONCLUSIONS: EIS exacerbates PHE, especially villous edema, in LC patients with changes in collateral circulation.

Diagnostic Yield of Colon Capsule Endoscopy in Detection of Superficial Colorectal Lesions.

BACKGROUND: The efficacy of second-generation PillCam -COLON2 capsule endoscopy (CCE2) in detecting colorectal superficial lesions remains unclear. OBJECTIVE: We sought to determine the diagnostic yield of CCE2 in the detection of colorectal superficial lesions. METHODS: We performed CCE2 in 60 consecutive patients between April 2011 and -December 2017. Lesions ≥6 mm in size were detected in 34 patients (25 males, average age: 60.5 years). We performed endoscopic resection and histopathological analysis of all resected lesions within 3 months after CCE2. We considered the optical colonoscopy (OC) findings as the gold standard and evaluated CCE2 sensitivity. RESULTS: Sixty-seven lesions (≥6 mm) were detected via OC, with 27 colorectal superficial lesions and 40 protruded lesions. CCE2 sensitivity for ≥6-mm-sized, superficial, and protruded lesions was 84, 78, and 88%, respectively. No significant intergroup differences were observed. CCE2 false-negative colorectal superficial lesions accounted for 31% of right-sided colon lesions and 50% of sessile serrated adenomas/polyps (SSA/Ps). The CCE2 false-negative protruded lesions accounted for 17% of right-sided colon lesions. CONCLUSION: CCE2 sensitivities for colorectal superficial and protruded lesions were not significantly different. However, flat-type SSA/Ps in the right colon, especially when the transit time is fast, have a risk of demonstrating CCE2 false-negative results.

Clinical Utility of Emergency Capsule Endoscopy for Diagnosing the Source and Nature of Ongoing Overt Obscure Gastrointestinal Bleeding.

BACKGROUND AND AIMS: In patients with ongoing overt obscure gastrointestinal bleeding (OGIB), prompt detection of the bleeding source is crucial to treatment success. However, there is no consensus on the optimal timing of diagnostic capsule endoscopy (CE). We investigated the clinical utility of emergency CE for detecting the source of ongoing overt OGIB. METHODS: We retrospectively evaluated 146 consecutive patients who, between February 2009 and July 2018, underwent emergency CE at Hiroshima University Hospital to detect the source of ongoing overt OGIB. Patients with a bleeding source located outside the small bowel were excluded. The remaining 127 patients were stratified according to the timing of CE relative to the onset of bleeding: patients in group A (n = 15, 12 men; mean age: 75 years; age range: 62-83 years) underwent CE within 48 hours of bleeding onset, whereas patients in group B (n = 112, 73 men; mean age: 65 years; age range: 17-88 years) underwent CE at >48 hours after bleeding onset. All patients underwent double-balloon endoscopy, and the final diagnosis was compared against the CE findings. RESULTS: The CE lesion detection rate was significantly higher in group A (12/15 patients, 80%) than in group B (53/112 patients, 47%) (p = 0.0174). There was no significant difference between the two groups regarding the patients' background characteristics. Vascular lesions were the most frequent finding in both groups. The diagnostic concordance rate between emergency CE and double-balloon endoscopy was 100% in group A and 92.9% in group B. Rebleeding after endoscopic treatment was confirmed in only one patient in group B. CONCLUSIONS: Emergency CE represents a useful diagnostic modality in patients with ongoing overt OGIB, potentially improving detection rates and reducing rebleeding risk.

Experience with Balloon Dilatation in Crohn's and Non-Crohn's Benign Small-Bowel Strictures: Is There a Difference?

BACKGROUND/AIM: Endoscopic balloon dilation (EBD) has been effective for small-bowel strictures in patients with Crohn's disease (CD). However, its efficacy and indication for small-bowel strictures in non-CD patients have not been established. This study evaluated the clinical efficacy and safety of EBD for small-bowel strictures in non-CD patients compared with CD patients. METHODS: Ninety-eight consecutive patients (mean age, 53 years; average observation period, 45 months) with small-bowel strictures diagnosed by double-balloon endoscopy were retrospectively evaluated at Hiroshima University Hospital from August 2003 to April 2017. The average number of procedures, short-term and long-term EBD success rates, and safety profiles between the non-CD and CD groups were examined. RESULTS: Surgery was selected as the initial treatment in 44 cases (45%) (non-CD group, 27 (61%); CD group, 17 (39%)) as EBD is not indicated. Fourteen non-CD patients had strictures due to malignant tumors, while 13 patients had benign strictures. Twenty-three patients (non-CD, 12; CD, 11) underwent EBD. Forty-three EBD procedures were performed for 17 stricture sites (average: 2.5 procedures/site) in non-CD patients and 41 EBD procedures for 18 stricture sites (average: 2.3 procedures/site) in CD patients. The short-term success rate was 100% (23/23), whereas the long-term success rate was 92% (11/12) in non-CD patients and 82% (9/11) in CD patients. No significant differences in the surgery-free rate occurred between both groups. Furthermore, one adverse event, bleeding after EBD, was encountered in the non-CD group (8%, 1/12). CONCLUSION: EBD for small-bowel strictures demonstrated good clinical outcomes in non-CD patients.

The Clinical Usefulness of the PillCam Progress Indicator for Route Selection in Double Balloon Endoscopy.

Objective The utility of capsule endoscopy (CE) findings in the route selection for double balloon endoscopy (DBE) has not been adequately discussed. The PillCam Progress Indicator in the RAPID 6.5 software program graphically demonstrates the progress of the capsule endoscope through the small-bowel. This study aimed to clarify the usefulness of the PillCam Progress Indicator in choosing the initial DBE route. Methods We retrospectively examined 50 consecutive patients with 50 target lesions detected on both CE and DBE at Hiroshima University Hospital from January 2011 to February 2018. In this study, we selected antegrade DBE on the basis of % Capsule Progress <50% as a clinical trial. The association between the PillCam Progress Indicator data and the DBE route to the target lesion was analyzed. Results The target lesion was reached via the initial DBE route in 96% (48/50) of cases. The cutoff values for selecting an antegrade route for DBE were 50% for % Capsule Progress and 42% for % SB Time. At the cutoff value, the sensitivity, specificity, and positive and negative predictive values for route selection were 100%, 91%, 93%, and 100% for % Capsule Progress and 96%, 91%, 93%, and 95% for % SB Time. Conclusion The PillCam Progress Indicator was useful for determining the appropriate initial DBE route.

Endoscopic submucosal dissection for early esophageal neoplasms using the stag beetle knife.

AIM: To determine short- and long-term outcomes of endoscopic submucosal dissection (ESD) using the stag beetle (SB) knife, a scissor-shaped device. METHODS: Seventy consecutive patients with 96 early esophageal neoplasms, who underwent ESD using a SB knife at Kure Medical Center and Chugoku Cancer Center, Japan, between April 2010 and August 2016, were retrospectively evaluated. Clinicopathological characteristics of lesions and procedural adverse events were assessed. Therapeutic success was evaluated on the basis of en bloc, histologically complete, and curative or non-curative resection rates. Overall and tumor-specific survival, local or distant recurrence, and 3- and 5-year cumulative overall metachronous cancer rates were also assessed. RESULTS: Eligible patients had dysplasia/intraepithelial neoplasia (22%) or early cancers (squamous cell carcinoma, 78%). The median procedural time was 60 min and on average, the lesions measured 24 mm in diameter, yielding 33-mm tissue defects. The en bloc resection rate was 100%, with 95% and 81% of dissections deemed histologically complete and curative, respectively. All procedures were completed without accidental incisions/perforations or delayed bleeding. During follow-up (mean, 35 ± 23 mo), no local recurrences or metastases were observed. The 3- and 5-year survival rates were 83% and 70%, respectively, with corresponding rates of 85% and 75% for curative resections and 74% and 49% for non-curative resections. The 3- and 5-year cumulative rates of metachronous cancer in the patients with curative resections were 14% and 26%, respectively. CONCLUSION: ESD procedures using the SB knife are feasible, safe, and effective for treating early esophageal neoplasms, yielding favorable short- and long-term outcomes.

Gastric and enteric anisakiasis successfully treated with Gastrografin therapy: A case report.

We report a case of a 59-year-old woman who was diagnosed with gastric and small intestinal anisakiasis, which was successfully treated with endoscopic extraction and Gastrografin therapy. She was admitted to our hospital with epigastric pain and vomiting one day after eating raw fish. She exhibited tenderness in the epigastrium without obvious rebound tenderness or guarding. Computed tomography (CT) demonstrated segmental edema of the intestinal wall with proximal dilatation and a small number of ascites. Because enteric anisakiasis was suspected based on the patient's history of recent raw fish consumption and abdominal CT, we performed gastroscopy and confirmed that nine Anisakis larvae were attached to the gastric mucosa. All of the Anisakis larvae were extracted via endoscopy, and the patient was diagnosed with gastric and enteric anisakiasis. Additionally, in the hospital, we performed ileography twice using Gastrografin, which led to shortened hospital stay. Based on the clinical results of this case, we suggest that Gastrografin therapy is a safe, convenient, and useful method to extract enteric Anisakis larvae.

Endoscopic submucosal dissection of early colorectal neoplasms with a monopolar scissor-type knife: short- to long-term outcomes.

Background and study aims Endoscopic submucosal dissection (ESD) for colorectal neoplasms remains challenging because of technical issues imposed by the complex anatomical features of the large intestine. We evaluated the feasibility, and the short- and long-term clinical outcomes of ESD for early colorectal neoplasms performed using the Stag-beetle Knife Jr. (SB Knife Jr.) Patients and methods We retrospectively assessed 228 patients who underwent ESD for 247 colorectal lesions with the SB Knife Jr. Clinicopathological characteristics of the neoplasms, complications, and various short- and long-term outcomes were evaluated. Results Mean tumor size was 34.3 mm and median procedure time was 76 minutes. The SB Knife Jr. achieved 98.4 % en bloc resection, 93.9 % complete resection, and 85.4 % curative resection. No perforations occurred during the procedure, and a delayed bleeding rate of 2.4 % was observed. Long-term outcomes were favorable with no distant recurrence, 1.1 % local recurrence, a 5-year overall survival rate of 94.1 % and 5-year tumor-specific survival rate of 98.6 % in patients with cancer. Conclusions ESD using the SB Knife Jr. is technically efficient and safe in treating early colorectal neoplasms and is associated with favorable short- and long-term outcomes.

A case of ileus due to radiation enteritis 19 years after radiotherapy.

A 73-year-old female visited our hospital complaining of nausea and epigastric pain because of ileus. She had a history of two laparotomy procedures in her youth, interferon treatment for chronic hepatitis C, and radiation therapy for uterine cervical cancer 19 years ago. Transanal double-balloon enteroscopy demonstrated annular stenosis with ulceration of the anal side of the dilated small intestine. Therefore, surgical resection was performed, and late radiation enteritis was diagnosed on histopathological examination. We report a case of ileus due to radiation enteritis 19 years after radiotherapy.

Safety and efficacy of self-expandable metallic stents in malignant small bowel obstructions.

In this report, we present 3 cases of malignant small bowel obstruction, treated with palliative care using endoscopic self-expandable metallic stent (SEMS) placement, with the aim to identify the safety and efficacy of this procedure. Baseline patient characteristics, procedure methods, procedure time, technical and clinical success rates, complications, and patient outcomes were obtained. All 3 patients had pancreatic cancer with small bowel strictures. One patient received the SEMS using colonoscopy, while the other 2 patients received SEMS placement via double balloon endoscopy using the through-the-overtube technique. The median procedure time was 104 min. The technical and clinical success rates were 100%. Post-treatment, obstructive symptoms in all patients improved, and a low-residue diet could be tolerated. All stents remained within the patients until their deaths. The median overall survival time (stent patency time) was 76 d. SEMS placement is safe and effective as a palliative treatment for malignant small bowel obstruction.