Negative effect of fatty liver on visualization of pancreatic cystic lesions at screening transabdominal ultrasonography.

RATIONALE, AIMS, AND OBJECTIVES: The aim of this observational study is to identify factors by which some pancreatic cystic lesions (PCLs) were undetectable at transabdominal ultrasonography (TAUS), using magnetic resonance imaging (MRI) as reference standard. METHODS: The database for 781 consecutive subjects who underwent a health checkup including fat computed tomography and upper abdominal MRI as option was searched. The presence of fatty liver and fatty pancreas was diagnosed by TAUS, and atrophic pancreas was determined by reevaluating the image of the pancreas in the chest computed tomography for screening. Subjects with PCL detected and those undetected at TAUS were statistically compared in clinical characteristics. RESULTS: The prevalence of PCL detected at MRI was 17.8% in the general population. Multivariate logistic regression analysis showed that fatty liver, body mass index, and the size of PCL were significantly associated with the factors influencing the visualization of PCL at TAUS (odds ratio [OR]: 0.337, 95% confidence interval [CI]: 0.154-0.734, P = 0.006; OR: 0.852, 95% CI: 0.737-0.985, P = 0.030; OR:1.120, 95% CI: 1.045-1.200, P = .001). Thirty-six PCLs (64.3%) in a total of 56 PCLs were undermeasured by TAUS. Additionally, nine (56%) out of 16 PCLs (≥ 15 mm) were undermeasured by 5 mm or more by TAUS, although a significantly higher detection rate was observed for PCLs (≥ 15 mm) in comparison with that for PCLs (< 15 mm) (80% vs 33.6%, P = .000). CONCLUSIONS: It should be noted that coexisting fatty liver may lower the detection of PCL, and its size may be underestimated by TAUS.

Pancreatic Fat Content Detected by Computed Tomography and Its Significant Relationship With Intraductal Papillary Mucinous Neoplasm.

OBJECTIVES: Intraductal papillary mucinous neoplasms (IPMNs) are premalignant lesions of pancreatic ductal adenocarcinomas (PDACs). Fat accumulation in the pancreas is increasingly recognized as a cause of PDAC. We aimed to identify factors that are relevant between IPMN and metabolic-related factors, including pancreatic fat. METHODS: The database for 781 subjects who underwent a health checkup and upper abdominal magnetic resonance imaging was searched and computed tomography attenuation indexes (pancreatic and spleen attenuation, pancreas-to-spleen attenuation ratio) were decided by measuring the regions of interest in the pancreas and spleen on nonenhanced images, using Hounsfield units. Eighty-five subjects from each of the IPMN and noncyst groups were matched for age, sex, and glycemic status and statistically compared in clinical characteristics. RESULTS: There was no difference in metabolic-related factors except for apolipoprotein A1 and high-density lipoprotein cholesterol between the 2 groups in univariate analysis. Multivariate logistic regression analysis showed that both indexes were significantly associated with IPMN (odds ratio, 0.905 [95% confidence intervals, 0.851-0.963; P = 0.002]; odds ratio, 0.006 [95% confidence intervals, 0.000-0.152; P = 0.002]). CONCLUSIONS: Pancreatic fat content measured by computed tomography was significantly associated with IPMN. These results suggest that IPMN may develop secondary to pancreatic steatosis that could be an overlapping risk factor for PDAC and IPMN.

The impact of visceral adipose tissue as best predictor for difficult colonoscopy and the clinical utility of a long small-caliber scope as rescue.

BACKGROUND: There have been many reports about a variety of factors associated with incomplete colonoscopy or difficult colonoscopy with long cecal intubation time (CIT). The aim of this retrospective study was to analyze the factors related to difficult colonoscopy under conscious sedation and demonstrate the clinical utility of a small-caliber scope as rescue by using the data from a large number of subjects who underwent health check-ups. METHODS: Consecutive 1036 cases over a 12-month period (April 2015 to March 2016) were enrolled and 619 subjects were divided into two groups: Easy colonoscopy (CS) Group (CIT ≤ 10 min); Difficult CS Group (CIT > 10 min or incomplete colonoscopy by a standard scope). The two groups were compared by subjects and colonoscopy characteristics with univariate analysis followed by multivariate logistic regression analysis. Reasons for incomplete colonoscopy were also assessed. RESULTS: Cecal intubation rate increased from 97.9% to 99.9% (1007/1008) by the rescue scope. Main reasons for incomplete colonoscopy were tortuosity in the left hemicolon (38%), redundancy in the right hemicolon (29%), pain (19%) and fixation (14%). Moreover, 95% (20/21) of rescue colonoscopies were completed without additional sedation. Higher BMI (21 kg/m2 ≤ BMI) and intermediate visceral adipose tissue (VAT) (75 cm2 ≤ VAT < 150 cm2) were significantly associated with easy CS (80.7% vs 19.3%, P = 0.004; 56.3% vs 43.7%, P = 0.001) by univariate analysis. Age, gender, and VAT, not BMI, were independently associated with difficult colonoscopy by multivariate analysis (OR (95% CI), P: 0.964 (0.942, 0.985), 0.001; 1.845 (1.101, 3.091), 0.020; 2.347 (1.395, 3.951), 0.001). Subgroup analysis by gender also showed VAT as the best predictor for both genders. CONCLUSION: Difficult colonoscopy was significantly associated with advancing age, female gender and, lower (< 75 cm2) or higher (150 cm2 ≤) VAT. These subjects may benefit from having complete and more comfortable colonoscopy examinations by using the small-caliber scope rather than the standard scope.

Polyp detection rate in transverse and sigmoid colon significantly increases with longer withdrawal time during screening colonoscopy.

BACKGROUND: The guidelines for colonoscopy present withdrawal time (WT) and adenoma detection rate (ADR) as the quality indicator. The purpose of this retrospective study is to analyze the predicting factors with polyp detection rate (PDR) as a surrogate for ADR by using comprehensive health checkup data, and assess the correlation between PDR per each colonic segment and WT, and factors influencing WT. METHODS: One thousand and thirty six consecutive health checkup cases from April 2015 to March 2016 were enrolled in this study, and 880 subjects who undertook colonoscopy without polyp removal or biopsy were divided into the two groups (polyp not detected group vs polyp detected group). The two groups were compared by subjects and clinical characteristics with univariate analysis followed by multivariate analysis. Colonoscopies with longer WT (≥ 6 min) and those with shorter WT (< 6 min) were compared by PDR per each colonic segment, and also by subjects and clinical characteristics. RESULTS: A total of 1009 subjects included two incomplete colonoscopies (CIR, 99.9%) and overall PDR was 35.8%. A multiple logistic regression model demonstrated that age, gender, and WT were significantly related factors for polyp detection (odds ratio, 1.036; 1.771; 1.217). PDR showed a linear increase as WT increased from 3 min to 9 min (r = 0.989, p = 0.000) and PDR with long WT group was higher than that with short WT group per each colonic segment, significantly in transverse (2.3 times, p = 0.004) and sigmoid colon (2.1 times, p = 0.001). Not only bowel preparation quality but also insertion difficulty evaluated by endoscopist were significant factors relating with WT (odds ratio, 3.811; 1.679). CONCLUSION: This study suggests that endoscopists should be recommended to take more time up to 9 min of WT to observe transverse and sigmoid colon, especially when they feel no difficulty during scope insertion.

Association of Visceral Fat Area, Smoking, and Alcohol Consumption with Reflux Esophagitis and Barrett's Esophagus in Japan.

BACKGROUND: Central obesity has been suggested as a risk factor for gastroesophageal reflux disease. The aim of this study was to evaluate the association of visceral fat area and other lifestyle factors with reflux esophagitis or Barrett's esophagus in Japanese population. METHODS: Individuals who received thorough medical examinations including the measurement of visceral fat area by abdominal computed tomography were enrolled. Factors associated with the presence of reflux esophagitis, the severity of reflux esophagitis, or the presence of Barrett's esophagus were determined using multivariable logistic regression models. RESULTS: A total of 2608 individuals were eligible for the analyses. Visceral fat area was associated with the presence of reflux esophagitis both in men (odds ratio, 1.21 per 50 cm2; 95% confident interval, 1.01 to 1.46) and women (odds ratio, 2.31 per 50 cm2; 95% confident interval, 1.57 to 3.40). Current smoking and serum levels of triglyceride were also associated with the presence of reflux esophagitis in men. However, significant association between visceral fat area and the severity of reflux esophagitis or the presence of Barrett's esophagus was not shown. In men, excessive alcohol consumption on a drinking day, but not the frequency of alcohol drinking, was associated with both the severity of reflux esophagitis (odds ratio, 2.13; 95% confident interval, 1.03 to 4.41) and the presence of Barrett's esophagus (odds ratio, 1.71; 95% confident interval, 1.14 to 2.56). CONCLUSION: Visceral fat area was independently associated with the presence of reflux esophagitis, but not with the presence of Barrett's esophagus. On the other hand, quantity of alcohol consumption could play a role in the development of severe reflux esophagitis and Barrett's esophagus in Japanese population.

Clinical practice guidelines for gastrointestinal stromal tumor (GIST) in Japan: English version.

Diagnostic and treatment strategies for gastrointestinal stromal tumors (GISTs) have evolved greatly since the introduction of molecularly targeted therapies. Although several clinical practice guidelines are extant, such as those published by the National Comprehensive Cancer Network and the European Society of Medical Oncology, it is not clear as to whether these are appropriate for clinical practice in Japan. Therefore, clinical practice guidelines for the optimal diagnosis and treatment of GIST tailored for the Japanese situation have often been requested. For this reason, the Japanese Clinical Practice Guideline for GIST was proposed by the GIST Guideline Subcommittee, with the official approval of the Clinical Practice Guidelines Committee for Cancer of the Japan Society of Clinical Oncology (JSCO), and was published after assessment by the Guideline Evaluation Committee of JSCO. The GIST Guideline Subcommittee consists of members from JSCO, the Japanese Gastric Cancer Association (JGCA), and the Japanese Study Group on GIST, with the official approval of these organizations. The GIST Guideline Subcommittee is not influenced by any other organizations or third parties. Revision of the guideline may be done periodically, with the approval of the GIST Guideline Subcommittee, either every 3 years or when important new evidence that might alter the optimal diagnosis and treatment of GIST emerges. Here we present the English version of the Japanese Clinical Practice Guideline for GIST prepared by the GIST Guideline Subcommittee.

Clinical impact of a newly developed capsule endoscope: usefulness of a real-time image viewer for gastric transit abnormality.

BACKGROUND: A new capsule endoscope has been developed by Olympus Medical Systems. The visualization and usefulness of its real-time image viewer for gastric transit abnormality were evaluated by using this new device. METHODS: Thirty-seven consecutive patients were enrolled. In cases of gastric transit abnormality (gastric transit > 60 min, detected by the real-time viewer), intramuscular metoclopramide (10 mg) was administered. Diagnostic yield and gastric and small bowel transit times in ten patients receiving (group A) and 27 not receiving (group B) metoclopramide were analyzed. RESULTS: Median gastric transit time was longer in group A than in group B (110 vs. 24 min; P < 0.0001). Conversely, median small bowel transit time was shorter in group A than in group B (270 vs. 347 min; P < 0.05). Further, small bowel transit was complete in 9/10 patients (90%) in group A, and in 23/27 patients (85%) in group B, but the difference was not significant. Overall diagnostic yield was 78% (29/37 patients), and there was no significant difference in the ratio of abnormal findings documented between group A (8/10, 80%) and group B (21/27, 78%) patients. CONCLUSIONS: This new technology allowed clear image interpretation, and the real-time viewer was useful for detecting gastric transit abnormalities and determining a need for metoclopramide administration in patients undergoing capsule endoscopy.

Decreased levels of adiponectin in obese patients with gastroesophageal reflux evaluated by videoesophagography: possible relationship between gastroesophageal reflux and metabolic syndrome.

BACKGROUND: Body mass index (BMI) and obesity are reportedly associated with symptoms of gastroesophageal reflux disease (GERD). The present study was designed to investigate the effect of metabolic disorders including obesity on the levels of functional gastroesophageal reflux by videoesophagography. METHODS: Twenty-one patients with GERD-associated symptoms were examined by videoesophagography. On their initial visit, all patients completed the Japanese version of the Carlsson-Dent self-administered questionnaire (QUEST). The findings of videoesophagography were evaluated by the X-ray severity scores for gastroesophageal reflux (XRSS), which were defined for the total diagnosis of functional gastroesophageal reflux. Correlation between XRSS scores and physical or metabolic markers was evaluated. RESULTS: The mean XRSS in the QUEST-positive group (4.7+/-0.6) was significantly higher than that in the QUEST-negative group (3.3+/-0.5, P<0.05). XRSS correlated positively with BMI (P<0.05) and waist circumference (P<0.05), but negatively with high-density lipoprotein-cholesterol (P<0.05), serum adiponectin (P<0.05) and active ghrelin (P<0.05). In the multivariate analysis, serum adiponectin level, BMI and triglyceride independently affected the XRSS. CONCLUSION: Videoesophagography is a useful diagnostic modality for the evaluation of patients with GERD symptoms. Functional gastroesophageal reflux is seen in obese patients, especially with decreased levels of adiponectin.

Sporadic gastric neurofibroma underneath early cancer: MDCT gastrography and histological findings.

We report the case of a sporadic gastric submucosal neurofibroma underneath a T1 stage cancer. A 61-year-old man underwent gastroscopy because of epigastralgia and was diagnosed as having T1 stage gastric cancer by an experienced gastroenterologist. Subsequently performed computed tomography (CT) showed poorly circumscribed wall thickening underneath the converged folds on three-dimensional images. On a dynamic enhancement study, the thickened wall was seen to be enhanced gradually from the arterial phase to the equilibrium phase. Based on these findings, we diagnosed stage T2 cancer. Total gastrectomy was performed, and the surgically removed specimen revealed that the wall thickening was caused by a submucosal neurofibroma and that cancer existed in this neurofibroma, invading the submucosa. This patient had no family history of neurofibromatosis, and so the lesion was diagnosed as early gastric cancer with a sporadic submucosal neurofibroma. Coexistence of gastric cancer and a submucosal tumor is rare, but such a case is one of the pitfalls of a CT diagnosis of T stage gastric cancer.

Interim results of sentinel node biopsy during laparoscopic gastrectomy: possible role in function-preserving surgery for early cancer.

INTRODUCTION: Intraoperative detection of sentinel nodes (SNs) has been used clinically to predict regional lymph node (LN) metastasis in patients with breast cancer and malignant melanoma. Intraoperative lymphatic mapping and SN biopsy can potentially be combined with minimally invasive surgery. However, few reports have demonstrated the validity of SN biopsy during laparoscopic gastrectomy. The aim of this study was to investigate the feasibility and accuracy of laparoscopic lymphatic mapping in predicting LN status in patients with gastric cancer. METHODS: A total of 35 patients with gastric cancer diagnosed preoperatively as T1, N0 were enrolled. Endoscopic injection of technetium-99m-radiolabeled tin colloid was completed 16 hours before surgery, and radioactive SNs were identified with a gamma probe intraoperatively. Isosulfan blue dye was injected endoscopically during the operation. Laparoscopy-assisted gastrectomy with LN dissection was performed. All resected LNs were evaluated by routine pathology examination. RESULTS: SNs were detected in 33 (94.3%) of 35 patients. The mean number of SNs was 3.9, and the diagnostic accuracy according to SN status was 97.0% (32/33), as one patient with a false-negative result was observed. The patient with the false-negative specimen was finally diagnosed as having advanced gastric cancer with invasion into the proper muscular layer and severe lymphatic vessel invasion, causing destruction of normal lymphatic flow by the tumor. CONCLUSIONS: Radio-guided SN mapping during laparoscopic gastrectomy is an accurate diagnostic tool for detecting lymph node metastasis in patients with early-stage gastric cancer. Validation of this method requires further studies on technical issues, including indications, tracers, methods of lymph node retrieval, and diagnostic modalities of metastasis.

Operative indications for relatively small (2-5 cm) gastrointestinal stromal tumor of the stomach based on analysis of 60 operated cases.

BACKGROUND: Removal of the primary lesion with a clear operative margin is the standard treatment for gastrointestinal stromal tumor (GIST) of the stomach. However, there are few reports on the operative indications for relatively small GIST. METHODS: Clinicopathologic features and survival data of all 60 patients with GIST of the stomach treated at Keio University Hospital from 1993 to 2004 were analyzed. Laparoscopic wedge resection was used as the primary procedure for tumors between 2 to 5 cm. Tumors larger than 5 cm were resected by laparotomy or laparoscopy-assisted operation. RESULTS: Thirty-five lesions (58.3%) were resected by laparoscopic wedge resection, 3 by laparoscopic operation with a small skin incision and 22 by conventional open procedures. The mean size of the tumors was 42.5 mm, with a range of 18 to 150 mm and a median value of 35.5 mm. All operative margins were clear, but 1 patient had liver metastases at the time of resection of the primary lesion. The median follow-up period was 53 months and the 5-year disease-free survival rate (DFS) was 96.1%. No local recurrence or distant metastasis was encountered in patients with tumors smaller than 4 cm. A statistically significant correlation was observed between tumor size and mitotic count in this cohort (P = .010). Tumors from the intermediate- (n = 14) and high-risk (n = 10) groups as classified by the Risk Assessment Classification showed significantly worse DFS than the low-risk and very low risk group (n = 35) (89.9% vs 100% in 5-year DFS, P = .045). Even among tumors smaller than 3 cm, 2 of 14 cases (14.3%) were classified into the intermediate-risk group. CONCLUSIONS: Although a prospective randomized trial remains to be performed, this study provides additional evidence suggesting that the early removal of GIST, at 5 cm or less in size, provides better DFS than later removal of the tumor at a larger size.

[Radiological diagnosis of ulcerative colitis].

In cases with ulcerative colitis, barium enema is valuable in objectively determining the stage (active, inactive) and defining the extent and aggressiveness of the disease that often varies during the course. The preparation, findings, and differential diagnosis of the technique are reviewed.

Experimental study of the rat for the assessment of barium coating on the gastric mucosa: efficacy of ranitidine and acetylcysteine administration.

PURPOSE: In order to improve the preparation method for barium examination of the stomach by ranitidine and acetylcysteine use, the effect on the rat gastric mucosa caused by the administration of ranitidine and acetylcysteine was studied. MATERIALS AND METHODS: Rat stomach that had been treated with ranitidine or acetylcysteine at different intervals and examined in vivo was excised and coated with a barium suspension. A radiograph was subsequently taken and evaluated in regard to the removal of gastric mucus and imaging of the areae gastricae (AG). The removal of mucus was assessed by six blind observers. The imaging of AG was estimated as a percentage of the imaged AG area per total gastric corpus. RESULTS: No change was seen on the radiograph with ranitidine preparation, while the mucus was distinctly removed and AG well-imaged in the group studied 15 minutes after the peroral administration of acetylcysteine. CONCLUSION: Proper preparation for barium study of the stomach should involve treatment with a mucolytic agent about 15 minutes before the examination. H2-blockers must be used supplementally in the short term.

Surgery for advanced gastric cancer after coronary artery bypass grafting using the right gastroepiploic artery: report of a case.

Ischemic heart disorders are often treated by coronary artery bypass grafting (CABG) using the right gastroepiploic artery (RGEA). We report the case of a 57-year-old man with a history of CABG using the RGEA, who underwent D2 radical total gastrectomy followed by Roux-en-Y anastomosis, with successful dissection of the #6 lymph nodes, while preserving the RGEA. The patient had a 9-month history of gastric cancer, during which time the Maruyama Vaccine (Specific Substance Maruyama, or SSM) was given as alternative therapy. This case report serves to demonstrate that radical gastrectomy can be safely performed after CABG using the RGEA, and that gastric cancer will progress in spite of SSM therapy.

[New preparation method for barium enema: efficacy and administration of oral intestinal lavage solution with gastrointestinal prokinetic agent].

The modified Brown's method is commonly used in Japan as preparation for barium enema; however, in a few cases, its cleansing effect is not satisfactory even with the use of adequate diet. To develop a new method of preparation for barium enema, we examined the use of an oral intestinal lavage solution (PEG-ELS) with mosapride and compared it with the modified Brown's method. We administered mosapride and PEG-ELS by four different methods. These methods were assessed by the amount of remaining feces and the adequacy of barium coating. Methods in which mosapride was taken separately before and after the intake of PEG-ELS were more effective than the method using mosapride and the modified Brown's method. Lesion detection was almost the same as that with the modified Brown's method. In conclusion, preparation for barium enema using mosapride before and after PEG-ELS intake is more effective than the modified Brown's method.

Rare case of early mucosal gastric cancer presenting with metastasis to the bulbar conjunctiva.

Early gastric cancer has an excellent outcome following surgical treatment. In particular, mucosal gastric cancer (m-cancer) very rarely results in metastatic dissemination and may be successfully treated by local surgical resection. We report a 64-year-old Japanese woman who presented with a recurrent cystic lesion on the left bulbar conjunctiva, with a biopsy specimen revealing metastatic signet-ring cell carcinoma. Gastrointestinal investigations revealed an early gastric cancer in the lesser curvature of the stomach. Biopsy specimen of the gastric lesion indicated poorly differentiated adenocarcinoma, which was identical to findings in the lesion in the bulbar conjunctiva. She underwent a distal gastrectomy and made an uneventful recovery. Histopathological analysis indicated a gastric signet-ring cell carcinoma that was limited to the mucosal layer, without evidence of lymphatic spread. Although the exact mechanism of metastatic dissemination to the bulbar conjunctiva is unclear, this case is very unusual, because ocular metastases almost invariably occur in the context of documented and established malignant disease. This is, to our knowledge, the first reported case of a patient with gastric mucosal cancer who presented with a conjunctival metastatic deposit and who subsequently received curative surgical treatment for both conditions.

Surgically treated Cronkhite-Canada syndrome associated with gastric cancer.

Cronkhite-Canada syndrome is generally accepted to be a benign disorder, with 374 reported cases to the present. Worldwide, there have been 18 previously reported cases of Cronkhite-Canada syndrome associated with gastric cancer. In this report we describe a case of a 52-year-old man with the clinical features of Cronkhite-Canada syndrome combined with gastric cancer. Although the gastric tumor was located at the antrum of the stomach, we performed a total gastrectomy because of the edematous swelling and high risk of malignancy in the remnant stomach. As Cronkhite-Canada syndrome may be a premalignant condition for gastric cancer, as well as for colorectal cancer, we suggest periodic examination of the stomach, colon, and rectum for patients with Cronkhite-Canada syndrome.