Factors related to difficult self-expandable metallic stent placement for malignant colonic obstruction: A post-hoc analysis of a multicenter study across Japan.

BACKGROUND AND AIM: Colorectal cancer patients often present with large bowel obstruction. Elective placement of a self-expandable metallic stent (SEMS) can relieve obstruction, but can be challenging. Previous studies have compared cases by outcomes only, but the present study investigated successful cases only to identify factors related to prolonged and difficult SEMS placement in patients with malignant colonic obstruction. METHODS: A post-hoc analysis of a multicenter clinical trial conducted between March 2012 and October 2013 at 46 facilities across Japan (UMIN000007953) was carried out; 511 patients who required SEMS placement for acute colorectal obstruction or symptomatic stricture secondary to malignant neoplasm were enrolled. Technical success rates and procedure times were recorded. Clinical and interventional parameters were investigated for their potential effect on procedure time by univariate and multivariate analyses. RESULTS: Technical success rate of SEMS placement was 98%. Median procedure time was 30 (range, 4-170) min. In 27% of patients, procedure time exceeded 45 min, indicating technically difficult placement. Multivariate analyses showed significant associations between technically difficult placement and a ColoRectal Obstruction Scoring System (CROSS) score of 0 before SEMS placement (odds ratio [OR], 1.6; P < 0.05), tumor site in the right colon (OR, 2.5; P < 0.0001), stricture length ≥5 cm (OR, 2.2; P < 0.001), peritoneal carcinomatosis (OR, 1.7; P < 0.05), and multiple SEMS placement (OR, 8.0; P < 0.01). CONCLUSION: Clinicians must anticipate technical challenges in cases with peritoneal carcinomatosis, a CROSS score of 0, or expansive strictures; such cases require experienced clinicians to carry out SEMS placement.

Transformation of jejunoileal follicular lymphoma into diffuse large B-cell lymphoma detected using double-balloon enteroscopy.

Jejunoileal follicular lymphomas (FLs) are rare and have been reported to undergo histological transformation (HT). We report a case of jejunoileal FL transformation into diffuse large B-cell lymphoma (DLBCL). An 82-year-old woman presented with a 5.5 cm ulcerated jejunal mass, identified through double-balloon enteroscopy. The histopathology report revealed diffuse atypical lymphoid cells, which confirmed the presence of DLBCL. Neoplastic follicles confirmed the presence of FL. Genetic analysis revealed a match between the FL and DLBCL. Following a segmentectomy and chemotherapy, the patient is in remission. Based on this case, we should consider the possibility of jejunoileal FLs transforming into DLBCL.

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.

Clinical usefulness of transabdominal ultrasonography prior to patency capsule for suspected small-bowel strictures.

OBJECTIVE: Patency capsule (PC) examination has made it possible to perform capsule endoscopy (CE) in patients with a suspected small-bowel stricture. However, PC has some drawbacks, so we assessed the usefulness of transabdominal ultrasonography (TUS) prior to PC in patients with suspected small-bowel strictures to avoid unnecessary PC examination. PATIENTS AND METHODS: Fifty-two patients who underwent TUS prior to PC were enrolled in this study. TUS findings were classified as follows: intestinal narrowing and distension at the oral side (Type A); extensive bowel wall thickening (Type B); focal bowel wall thickening (Type C) or no abnormality detected (Type D). We evaluated the TUS and PC findings for the detection of small-bowel strictures. RESULTS: Double-balloon endoscopy (DBE) revealed small-bowel strictures in 13 of 50 patients (26%). TUS yielded Type B or C findings in 12 of 13 patients (92%), while PC revealed strictures in all 13 patients. In Crohn's disease (CD) patients with Type B TUS findings, 8 of 9 (89%) had small-bowel strictures on DBE. However, only two of six non-CD patients (33%) with Type B TUS findings had small-bowel strictures. The incidence of Type B strictures was significantly higher in CD patients. CONCLUSIONS: CD patients with Type B TUS findings should not undergo PC or CE because of the high rate of small-bowel strictures. Non-CD patients diagnosed with Type B TUS strictures, as well as patients diagnosed with Type C or D strictures should undergo CE after confirming small-bowel patency using PC.

A trial of the use of patency capsules in combination with overnight capsule endoscopy.

BACKGROUND: The PillCam® patency capsule (PPC) was developed to minimize the risk of capsule retention during capsule endoscopy (CE). Typically, the use of patency capsules prior to CE requires patients to be monitored over a period of time. To reduce the need for frequent outpatient visits during PPC examination and CE, we developed the overnight CE (ON-CE) procedure. METHODS: Between October 2012 and January 2014, a total of 19 patients (15 males and 4 females, mean age 48.4 years) were administered PPC to assess the patency of the small intestine prior to ON-CE at JA Onomichi General Hospital in Hiroshima, Japan. RESULTS: PPC confirmed patency of the small intestine in 15 of the 19 patients. Of these 15 patients, 14 proceeded to ON-CE. The CE was cancelled in 1 patient and the cecal intubation time exceeded 8 h in another patient. For the remaining 12 patients, the mean small intestine observation coverage was 92.3% and the mean cecal intubation time was 325 min. There were no adverse events and the discharge of the capsule was confirmed in all cases. CONCLUSION: When patency of the gastrointestinal tract was confirmed with the PPC, ON-CE was performed safely and effectively.

Effectiveness of polaprezinc for low-dose aspirin-induced small-bowel mucosal injuries as evaluated by capsule endoscopy: a pilot randomized controlled study.

BACKGROUND: Treatment of low-dose aspirin (LDA)-induced small-bowel injury has not been established. Polaprezinc, a chelate of zinc and L-carnosine, may be efficacious for such injury. We conducted a pilot randomized controlled study to investigate whether polaprezinc is effective against LDA-induced small-bowel injuries. METHODS: Consecutive patients under long-term (>3 months) LDA treatment and who agreed to participate in our study underwent initial capsule endoscopy (CE). Patients with LDA-induced small-bowel injury apparent upon initial CE (n = 20) were randomized into a polaprezinc (150 mg/day for 4 weeks) group and a control (no polaprezinc treatment) group. All underwent follow-up CE after 4 weeks. Changes in the number and characteristics of small-bowel mucosal injuries were compared within and between the two groups. RESULTS: The median number of reddened lesions and erosions/ulcers upon follow-up CE in the polaprezinc group significantly decreased (P < 0.05). However, there was no significant difference in the median number of reddened lesions and erosions/ulcers upon follow-up CE in the control group. CONCLUSIONS: Co-administration of polaprezinc may be effective against small-bowel mucosal injury associated with long-term LDA therapy.

Feasibility of spiral enteroscopy in Japanese patients: study in two tertiary hospitals.

BACKGROUND AND AIM: Despite recent advances in enteroscopy, such as balloon enteroscopy, accessing the small intestine remains challenging. Spiral enteroscopy is a novel technique in which an endoscope is fitted with a rotating overtube that has a soft spiral fin at the tip. Whereas spiral enteroscopy is beginning to be carried out in Western countries, it is not common in many Asian countries. The aim of the present study was to evaluate the efficacy and safety of spiral enteroscopy in Japanese patients. METHODS: We prospectively conducted spiral enteroscopy in patients with suspected or known small bowel disease. All procedures were carried out using a spiral overtube. The main outcome measurements of the study were diagnosis rate, endoscopic intervention rate, and complication rate. RESULTS: Thirty-two patients underwent spiral enteroscopy. Spiral enteroscopy diagnosed 16 patients (50%) with small intestinal lesions, including six malignant lymphomas (19%), three erosions or ulcers (9%), three polyps (9%), two angioectasias (6%), one carcinoma (3%), and one submucosal tumor (3%). Additionally, four patients underwent endoscopic interventions (13%). Mallory-Weiss syndrome occurred in one patient (3%). No perforation occurred in any patient (0%). CONCLUSIONS: Our initial experience of spiral enteroscopy suggests that it can be introduced safely, but it is relatively invasive and technically demanding. More experience is needed to conduct spiral enteroscopy easily and safely.

Diagnostic yield of capsule endoscopy vs. double-balloon endoscopy for patients who have undergone total enteroscopy with obscure gastrointestinal bleeding.

BACKGROUND/AIMS: The usefulness of capsule endoscopy (CE) and of double-balloon endoscopy (DBE) for detection of small-bowel lesions is widely accepted. We compared CE- and DBE-based detection of small-bowel lesions in patients with obscure gastrointestinal bleeding (OGIB) who underwent total enteroscopy by both CE and DBE. METHODOLOGY: One hundred eighteen consecutive patients (70 men, 48 women; mean age 62.9±18.4 years) with OGIB underwent both CE and DBE. CE was performed and DBE was then performed within 1 week by both retrograde and antegrade approaches. Differences in detection rates were analyzed. RESULTS: Overall, small-bowel lesions were detected by CE in 53 patients (44.9%) and by DBE in 63 patients (53.4%) (p=0.01); agreement between CE and DBE findings was good (kappa statistic=0.76). Total enteroscopy was achieved by both modalities in 54 patients; CE detected small-bowel lesions in 25 of these patients (46.3%), and DBE detected lesions in 28 of these patients (51.9%) (p=0.25); agreement between CE and DBE findings was very good (kappa statistic=0.88). CONCLUSIONS: Our data support preferential use of noninvasive CE for patients with OGIB and subsequent DBE examination in most cases.

Outcome of patients who have undergone total enteroscopy for obscure gastrointestinal bleeding.

AIM: To assess the diagnostic success and outcome among patients with obscure gastrointestinal bleeding who underwent total enteroscopy with double-balloon endoscopy. METHODS: Total enteroscopy was attempted in 156 patients between August 2003 and June 2008 at Hiroshima University Hospital and achieved in 75 (48.1%). It is assessed whether sources of bleeding were identified, treatment methods, complications, and 1-year outcomes (including re-bleeding) after treatment, and we compared re-bleeding rates among patients. RESULTS: The source of small bowel bleeding was identified in 36 (48.0%) of the 75 total enteroscopy patients; the source was outside the small bowel in 11 patients (14.7%) and not identified in 28 patients (37.3%). Sixty-one of the 75 patients were followed up for more than 1 year (27.2 ± 13.3 mo). Four (6.6%) of these patients showed signs of re-bleeding during the first year, but bleeding did not recur after treatment. Although statistical significance was not reached, a marked difference was found in the re-bleeding rate between patients in whom total enteroscopy findings were positive (8.6%, 3/35) and negative (3.8%, 1/26) (3/35 vs 1/26, P = 0.63). CONCLUSION: A good outcome can be expected for patients who undergo total enteroscopy and receive proper treatment for the source of bleeding in the small bowel.

Clinical validity of endoscopic submucosal dissection for submucosal invasive gastric cancer: a single-center study.

BACKGROUND: The 2010 Japanese Gastric Cancer Association guidelines for the treatment of submucosal invasive gastric cancer (SM-GC) specify size 30 mm or less, differentiated-dominant histology, lack of vessel involvement, and submucosal invasion of less than 500 µm (SM1) as expanded criteria for curative endoscopic resection. Our purpose in this study was to confirm the validity of the expanded indications for curative endoscopic submucosal dissection (ESD) of SM-GC. METHODS: The study subjects were 173 patients with SM-GC resected by ESD at Hiroshima University Hospital between April 2002 and September 2010, including 99 patients for whom 3-plus years' follow-up information was available. Post-ESD outcomes were compared between cases of SM1-GC that met the expanded ESD criteria, those that did not, and SM2-GC cases. RESULTS: Complete resection was achieved for 93.2% of the SM1-GCs that met the expanded criteria. There was neither metastasis to lymph nodes or other organs nor local recurrence among the SM1-GCs. Disease-specific survival did not differ significantly between patients that were simply followed up after ESD and those that were treated by additional surgical resection. CONCLUSIONS: Our outcome data support the clinical validity of ESD without additional surgical resection for SM1-GCs that meet the expanded criteria.

Removal of a sewing needle penetrating the wall of the third portion of the duodenum by double-balloon endoscopy.

We describe successful removal a sewing needle penetrating the wall of the third portion of the duodenum by means of double-balloon endoscopy (DBE). The patient was a 47-year-old woman who accidentally swallowed a sewing needle and was admitted to our hospital. Abdominal radiography and abdominal computed tomography revealed a metallic object in the third portion of the duodenum. DBE performed by the antegrade approach, revealed that the sewing needle had penetrated the duodenal wall. The sewing needle was retrieved with biopsy forceps and pulled out together with the endoscope through the flexible overtube that remained positioned in the duodenum. There was no injury to the patient's esophagus or gastrointestinal wall. Our experience in this case suggests that sharp foreign bodies in the gastrointestinal tract can be safely removed by means of DBE.

Risk factors for bleeding after endoscopic submucosal dissection of gastric epithelial neoplasm.

BACKGROUND: Although endoscopic submucosal dissection (ESD) is standard therapy in Japan for gastric epithelial neoplasm, the complication rate is unsatisfactory, with postoperative bleeding as the major complication. The aim of the present study was to determine risk factors for post-ESD bleeding in patients with gastric epithelial neoplasm. PATIENTS AND METHODS: The study included 764 patients in whom 924 gastric epithelial neoplasms were resected endoscopically between June 2005 and December 2009: the period during which preventative coagulation for all exposed vessels on the artificial ulcer with hemostatic forceps upon completion of ESD was performed routinely. We analyzed the risk factors for bleeding after ESD in relation to the various clinical factors. RESULTS: The post-ESD bleeding rate was 3.0%. Dialysis (vs no dialysis, P = 0.034), operation time ≥75 min (vs <75 min, P = 0.012) and poor control of bleeding during ESD (vs good control, P = 0.014) were significantly related to post-ESD bleeding. Poor control of bleeding during ESD (vs good control; P = 0.04) and operation time ≥75 min (vs <75 min; P = 0.012) were significantly related to bleeding after second-look endoscopy. CONCLUSIONS: Patients at high risk for post-ESD bleeding in gastric epithelial neoplasm were those undergoing dialysis, those in whom operation time was ≥75 min, and those in whom bleeding during ESD was poorly controlled. The latter two are risk factors for bleeding even after second-look endoscopy.

Improved detectability of small-bowel lesions via capsule endoscopy with computed virtual chromoendoscopy: a pilot study.

OBJECTIVE: Real-time video capsule endoscopy (CE) with flexible spectral imaging color enhancement (FICE) improves visibility of small-bowel lesions. This article aims to clarify whether CE-FICE also improves detectability of small-bowel lesions. PATIENTS AND METHODS: A total of 55 patients who underwent CE at Hiroshima University Hospital during the period November 2009 through March 2010 were enrolled in the study. Five patients were excluded from the study because residues and transit delays prevented sufficient evaluation. Thus, 50 patients participated. Two experienced endoscopists (each having interpreted more than 50 capsule videos) analyzed the images. One interpreted conventional capsule videos; the other, blinded to interpretation of the conventional images, interpreted CE-FICE images obtained at settings 1-3 (setting 1: red 595 nm, green 540 nm, blue 535 nm; setting 2: red 420 nm, green 520 nm, blue 530 nm; setting 3: red 595 nm, green 570 nm, blue 415 nm). Lesions were classified as angioectasia, erosion, ulceration, or tumor. Detectability was compared between the two modalities. Time taken to interpret the capsule videos was also determined. RESULTS: Seventeen angioectasias were identified by conventional CE; 48 were detected by CE-FICE at setting 1, 45 at setting 2, and 24 at setting 3, with significant differences at settings 1 and 2 (p = 0.0003, p < 0.0001, respectively). Detection of erosion, ulceration, and tumor did not differ statistically between conventional CE and CE-FICE, nor did interpretation time (conventional CE 36 ± 6.9 min; CE-FICE setting 1, 36 ± 6.4 min; setting 2, 38 ± 5.8 min; setting 3, 35 ± 6.7 min). CONCLUSIONS: CE-FICE is superior in the lesion detection in comparison with conventional CE and improves detection of angioectasia.

Improved visibility of lesions of the small intestine via capsule endoscopy with computed virtual chromoendoscopy.

BACKGROUND: We can now enhance video capsule endoscopy (CE) images in real time by means of a flexible spectral imaging color enhancement (FICE) digital processing system. Reports on the clinical usefulness of this system are few. OBJECTIVE: To clarify whether visualization of lesions of the small intestine is improved by FICE image analysis. DESIGN: A retrospective study. SETTING: Academic medical center. METHODS: Five physicians compared FICE images with corresponding conventional images of 145 lesions obtained from 122 patients who underwent video CE at our hospital. The lesions were classified as angioectasia (n=23), erosion/ulceration (n=45), or tumor (n=75), and 3 different sets of FICE images were viewed (ie, at 3 different wavelength settings). Physicians rated the visibility of the lesions on FICE images as follows: +2 (improved visibility), +1 (somewhat improved visibility), 0 (visibility equivalent to that of conventional video CE visibility), -1 (somewhat decreased visibility), and -2 (decreased visibility). Scores for each lesion were totaled (per FICE setting) and evaluated. Intraobserver agreement was also examined. RESULTS: With FICE setting 1 (red 595 nm, green 540 nm, blue 535 nm), improvement was achieved for 87% (20/23) of angioectasia images, 53.3% (26/47) of erosion/ulceration images, and 25.3% (19/75) of tumor images. With setting 2 (red 420 nm, green, 520 nm, blue 530 nm), improvement was achieved for 87% (20/23), 25.5% (12/47), and 20.0% (15/75), respectively. With setting 3, only equivalence was achieved. Intraobserver agreement was good to satisfactory at 5.4 or higher. LIMITATIONS: Single-center study. CONCLUSIONS: CE-FICE improves visibility of small-bowel angioectasia, erosion/ulceration, and tumor.