Evaluation of a new method, "non-injection resection using bipolar soft coagulation mode (NIRBS)", for colonic adenomatous lesions.

BACKGROUND/AIMS: Endoscopic resection of all colorectal adenomatous lesions with a low complication rate, simplicity, and negative residuals is challenging. Hence, we developed a new method called "non-injection resection using bipolar soft coagulation mode (NIRBS)" method, adapted for colorectal lesions. In addition, we evaluated the effectiveness of this method. METHODS: We performed NIRBS throughout a 12-month period for all colorectal lesions which snare resection was acceptable without cancerous lesions infiltrating deeper than the submucosal layer. RESULTS: A total of 746 resected lesions were included in the study, with a 4.5 mm mean size (range, 1-35 mm). The major pathological breakdowns were as follows: 64.3% (480/746) were adenomas, and 5.0% (37/746) were intraepithelial adenocarcinomas (Tis lesions). No residuals were observed in any of the 37 Tis lesions (mean size, 15.3 mm). Adverse events included bleeding (0.4%) but no perforation. CONCLUSIONS: NIRBS allowed the resection of multiple lesions with simplicity because of the non-injection and without perforating due to the minimal burn effect of the bipolar snare set in the soft coagulation mode. Therefore, NIRBS can be used to resect adenomatous lesions easily, including Tis lesions, from small to large lesions without leaving residuals.

Gastric hamartomatous inverted polyp: Report of three cases with a review of the endoscopic and clinicopathological features.

Objectives: A gastric hamartomatous inverted polyp (GHIP) is a rare submucosal tumor characterized histopathologically by a submucosal inverted proliferation of cystically dilated hyperplastic gastric glands. Only 42 GHIPs have been reported in English literature. Few GHIPs have been reported to accompany adenocarcinomas. We reported on three patients with a GHIP and reviewed the clinicopathological and endoscopic features of GHIPs. Methods: This study included two men and one woman with a GHIP. The endoscopic, histopathological, and immunohistochemical features of the endoscopically resected specimens were analyzed. A gene mutation analysis was also performed. Results: All the tumors were located in the body of the stomach, with a median size of 20 mm. Two tumors were sessile, and the remaining tumor had a pedunculated appearance. The overlying mucosa mainly appeared normal but was reddish in one tumor. The histopathological examination of the tumors revealed a well-circumscribed and lobular submucosal proliferation of cystically dilated hyperplastic glands. The immunohistochemical analysis revealed that the MUC5AC-positive foveolar epithelium was located in the center, and MUC6-positive pseudo-pyloric or pepsinogen-I and H+/K+ ATPase-positive fundic-type glands were located at the periphery of two tumors. No carcinomatous components were noted in any of the tumors. Moreover, no significant mutations in oncogenes or tumor suppressor genes were noted. Conclusions: Our review revealed that approximately three fourths of GHIP cases showed an submucosal tumor-like feature, whereas endoscopic features, including the endoscopic ultrasonography findings, were not characteristic. Because an endoscopic diagnosis of a GHIP may be difficult, complete endoscopic resection may be required for a pathological diagnosis.

Development of Severe Acute Pancreatitis Following Uncovered Metallic Stent Placement: A Rare Case Report.

Self-expandable metallic stents (SEMSs) are widely used for malignant biliary stricture (MBS). Acute pancreatitis is an early complication following SEMS placement. In the present case, the patient developed severe acute pancreatitis after SEMS placement for MBS because of metastatic lymph nodes. Endoscopic retrograde cholangiopancreatography, endoscopic sphincterotomy and an endoscopic nasobiliary drainage tube placement were performed. After seven days, an uncovered SEMS was placed; however, severe acute pancreatitis occurred, and the SEMS was drawn out emergently. In SEMS placement for patients with MBS caused by non-pancreatic cancer, SEMS should be selected carefully while considering each patient's case.

Recent advances of endoscopic retrograde cholangiopancreatography using balloon assisted endoscopy for pancreaticobiliary diseases in patients with surgically altered anatomy: Therapeutic strategy and management of difficult cases.

Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic modality established for diagnosis and treatment of pancreaticobiliary diseases. However ERCP in patients with surgically altered anatomy (SAA) has been difficult, and more invasive therapies have been primarily selected. The development of balloon assisted endoscopes (BAEs) innovatively facilitated ERCP in such patients. Recent advances of BAEs and other devices greatly contributed to increasing success of ERCP using BAEs (BAE-ERCP). Furthermore, interventions using Endoscopic Ultrasound (EUS-intervention) have been reported to be useful for pancreaticobiliary diseases in patients with SAA, which provide more options for endoscopic therapies and are also expected as a rescue therapy for difficult cases of BAE-ERCP. In order to thoroughly complete endoscopic treatment for pancreaticobiliary diseases with SAA, it is important to standardize the BAE-ERCP procedures based on the features of respective endoscopes and to establish a strategy for endoscopic treatment which includes analysis of BAE-ERCP difficult cases and selection of cases for rescue therapy. In addition, it is essential to be acquainted with the characteristics of possible adverse events of the procedure and to be able to deal with them for safe accomplishment of endoscopic treatment.

Evaluation of complications after endoscopic retrograde cholangiopancreatography using a short type double balloon endoscope in patients with altered gastrointestinal anatomy: a single-center retrospective study of 1,576 procedures.

BACKGROUND AND AIM: Endoscopic retrograde cholangiopancreatography (ERCP) using balloon-assisted endoscope such as double-balloon endoscope is even effective for patients with surgically altered anatomy. Yet comprehensive studies on complications of ERCP using balloon-assisted endoscope have not been made. We analyzed the characteristics and the causes of complications of ERCP using double-balloon endoscope (DB-ERCP) procedures and aimed to suggest effective managements. METHODS: A total of 1576 procedures of DB-ERCP in 714 patients with surgically altered gastrointestinal anatomy in our hospital were evaluated retrospectively using a statistic analysis. RESULTS: The overall complication occurrence rate was 5.8%. By type of complications are perforation 3.2%, mucosal laceration 0.5%, hemorrhage 1.0%, pancreatitis 0.6%, respiratory disorder 0.4%, and others 0.2%. By type of surgical reconstruction methods were Roux-en-Y reconstruction with choledocho-jejunal anastomosis 4.2%, Roux-en-Y reconstruction without choledocho-jejunal anastomosis 6.7%, pancreaticoduodenectomy 4.5%, pylorus preserving pancreaticoduodenectomy 4.2%, Billroth II gastrectomy (B-II) 11.6%, and other reconstruction method (others) 7.4%. The contributing factors calculated by a multivariate analysis were B-II (odds ratio: 1.864, 95% confidence interval: 1.001-3.471, P = 0.050) and the presence of naïve papilla (odds ratio: 3.268, 95% confidence interval: 1.426-7.490, P = 0.005). CONCLUSIONS: DB-ERCP is a safe method with a total complication rate of 5.8% that could be considered within an acceptable range. The most common complication was the injury of the digestive tract such as perforation. Affecting risk factors for complications were B-II and the presence of naïve papilla. DB-ERCP procedures should be performed carefully of these factors.

Utility of endoscopic ultrasound-guided fine-needle aspiration cytology in rapid on-site evaluation for the diagnosis of gastric submucosal tumors: Retrospective analysis of a single-center experience.

BACKGROUND: Recently, there have been reports of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology being used for the diagnosis of various kinds of tumors. This method has also been adopted in the diagnosis of gastric submucosal tumors (SMTs). The aim of this study was to analyze the utility of EUS-FNA cytological examination in rapid on-site evaluation (ROSE) for gastric SMTs. METHODS: Retrospective analyses of the cytological specimens of EUS-FNA in ROSE for gastric SMTs and determination of the diagnostic accuracy of EUS-FNA combined with immunohistochemical analysis of cell blocks and surgically resected specimens were performed. RESULTS: A total of 110 patients were enrolled in this study. The most common cytodiagnosis was spindle cell tumor (62 patients, 55.5%), followed by negative for tumor (34 patients), and malignant lymphoma and adenocarcinoma (five patients each). Cell blocks were prepared for 60 of the patients (96.8%), cytologically diagnosed with spindle cell tumor. Immunohistochemical analyses using cell block revealed gastrointestinal stromal tumor (GIST, c-kit+ /desmin- , 49 patients) and leiomyoma (desmin+ /c-kit- , five patients). Thus, using EUS-FNA specimens, 83.1% of GIST patients were pre-operatively diagnosed. CONCLUSIONS: EUS-FNA cytological examination in ROSE for gastric SMTs aided in the collection of sufficient amounts of tumor tissues for preparing cell blocks. This method led to a high rate of accurate pre-operative diagnosis in patients with gastric SMTs.

Utility of newly developed short-type double-balloon endoscopy for endoscopic retrograde cholangiography in postoperative patients.

BACKGROUND AND AIM: The utility of conventional short-type double-balloon endoscopy (DBE) for pancreatobiliary disease in patients with postoperative anatomy had been widely acknowledged and accepted. However, some technical difficulties yet remained. In an attempt to solve these problems, the new short-type DBE (N-short DBE) was uniquely designed for therapeutic endoscopic retrograde cholangiography (ERC) in postoperative patients. The aim of this study was to evaluate the usefulness of N-short DBE for ERC in postoperative patients. METHODS: From August 2015 to April 2016, ERC using N-short DBE (DB-ERC) was performed in 100 postoperative patients (112 procedures). We retrospectively studied the success rate of reaching the blind end, the median time to reach the blind end, the diagnostic success rate, the therapeutic success rate, the median time to complete ERC-related interventions, the overall success rate, the median time to complete DB-ERC, and adverse events. RESULTS: The success rate of reaching the blind end was 99.1%. The median time to reach the blind end was 10 min (interquartile range [IQR], 6-19 min). The diagnostic success rate was 98.2%. The therapeutic success rate was 100%. The median time to complete ERC-related interventions was 36 min (IQR, 22-62 min). The overall DB-ERC success rate was 97.3%. The median time to complete DB-ERC was 54 min (IQR, 37-73 min). The occurrence of adverse events was 2.7%. CONCLUSIONS: The N-short DBE for ERC in postoperative patients is useful and safe. DB-ERC is promising therapeutic modality in such patients and should be selected as the first-line policy.

Review of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography using several endoscopic methods in patients with surgically altered gastrointestinal anatomy.

The endoscopic approach for biliary diseases in patients with surgically altered gastrointestinal anatomy (SAGA) had been generally deemed impractical. However, it was radically made feasible by the introduction of double balloon endoscopy (DBE) that was originally developed for diagnosis and treatments for small-bowel diseases. Followed by the subsequent development of single-balloon endoscopy (SBE) and spiral endoscopy (SE), interventions using several endoscopes for biliary disease in patients with SAGA widely gained an acceptance as a new modality. Many studies have been made on this new technique. Yet, some problems are to be solved. For instance, the mutual unavailability among devices due to different working lengths and channels, and unestablished standardization of procedural techniques can be raised. Additionally, in an attempt to standardize endoscopic procedures, it is important to evaluate biliary cannulating methods by case with existence of papilla or not. A full comprehension of the features of respective scope types is also required. However there are not many papers written as a review. In our manuscript, we would like to evaluate and make a review of the present status of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography applying DBE, SBE and SE for biliary diseases in patients with SAGA for establishment of these modalities as a new technology and further improvement of the scopes and devices.