Hirotaka Kouno

Genome-wide association studies identify PRKCB as a novel genetic susceptibility locus for primary biliary cholangitis in the Japanese population

&NA; A previous genome‐wide association study (GWAS) performed in 963 Japanese individuals (487 primary biliary cholangitis [PBC] cases and 476 healthy controls) identified TNFSF15 (rs4979462) and POU2AF1 (rs4938534) as strong susceptibility loci for PBC. In this study, we performed GWAS in additional 1,923 Japanese individuals (894 PBC cases and 1,029 healthy controls), and combined the results with the previous data. This GWAS, together with a subsequent replication study in an independent set of 7,024 Japanese individuals (512 PBC cases and 6,512 healthy controls), identified PRKCB (rs7404928) as a novel susceptibility locus for PBC (odds ratio [OR] = 1.26, P = 4.13 × 10‐9). Furthermore, a primary functional variant of PRKCB (rs35015313) was identified by genotype imputation using a phased panel of 1,070 Japanese individuals from a prospective, general population cohort study and subsequent in vitro functional analyses. These results may lead to improved understanding of the disease pathways involved in PBC, forming a basis for prevention of PBC and development of novel therapeutics.

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.

Endoscopic full-thickness resection for inverted Meckel’s diverticulum using double-balloon enteroscopy

Meckel’s diverticulum contains all layers of the small bowel wall and is usually treated by surgery [1, 2]. Inverted Meckel’s diverticulum is rare, with only two reports of endoscopic resection [3, 4]. As preoperative diagnosis of an inverted Meckel’s diverticulum is difficult [5], it was not diagnosed prior to resection in either case, and consequently perforation due to endoscopic resection was reported in one case [3]. In the current case, we diagnosed the condition preoperatively, and subsequently used two detachable snares prior to resection to prevent hemorrhage or perforation. We then safely treated the inverted Meckel’s diverticulum using endoscopic full-thickness resection with double-balloon enteroscopy (DBE). A 78-year-old man was admitted to our institution because of anemia and a positive fecal occult blood test. Abdominal ultrasound identified a hypoechoic polypoid lesion, with a hyperechoic head (▶Video1). A contrasted abdominal computed tomography scan also identified an elongated pedunculated polypoid lesion, with fat tissue in its center, in the distal ileum (▶Video1). Capsule endoscopy demonstrated a submucosal tumor-like lesion (▶Video1), and selective contrast-enhanced radiography indicated an elongated intraluminal polypoid lesion that was approximately 8 cm in size (▶Video1). Retrograde DBE indicated that the polypoid lesion exhibited intestinal villous mucosa on the surface at the head and typical mucosal features at the stalk of the antimesenteric attachment (▶Fig. 1). This indicated that the lesion was an inverted Meckel’s diverticulum, and endoscopic full-thickness resection with DBE was attempted. First, the stem of the polyp was closed with two detachable snares before resection to prevent hemorrhage or perforation. Then, conventional polypectomy with DBE was performed. The resection surface was closed with four clips after the polypectomy (▶Fig. 2, ▶Video1). Histopathological analysis revealed an 80×10mm inverted Meckel’s diverticulum without ectopic tissue (▶Video1). The patient was discharged 2 days later without adverse events. Endoscopy_UCTN_Code_TTT_1AP_2AD

Endoscopic submucosal dissection using a stag beetle knife for early esophageal cancer in lower esophageal diverticula

re 1. Esophageal ESD using the stag beetle (SB) knife. A single-channel endoscope (H260Z) and a high-frequency electric surgical unit (VIO 300D; Tübingen, Germany) were used. A, Visualization of the esophageal cancer (white arrows) in the lower esophageal diverticula. B, Circumferential sal cutting done with the SB knife. C, D, ESD performed directly grasping the submucosal layer with the SB knife. E,Mucosal defect after the ESD. F, cted lesion in a single piece. Histopathology confirmed a squamous cell carcinoma tumor confined to the lamina propria, with a negative lateral and margin.

Impact of ribavirin dose reduction on the efficacy of pegylated interferon plus ribavirin combination therapy for elderly patients infected with genotype 1b and high viral loads

Aim:  To examine the impact of ribavirin dose reduction on the efficacy of pegylated interferon (PEG IFN) plus ribavirin combination therapy for elderly patients infected with genotype 1b and high viral loads.

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 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.

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.

An Improvement of an Ileus in the Jejunal Pouch by Aspiration with the Overtube of a Balloon Endoscopy: A Case Report

We report a case of an 86-year-old Japanese woman diagnosed with a food-induced ileus whose condition improved by aspiration with the overtube of a balloon endoscopy. She had undergone a total gastrectomy for gastric cancer and reconstruction by Roux-en Y anastomosis and jejunum pouch 17 years earlier. She complained of constipation and loss of appetite lasting more than 1 wk before admission. Her left abdomen showed gradual fullness, and tenderness was also found at the same site. Contrast computed tomography (CT) of the abdomen showed that the jejunal pouch lumenwas markedly expanded by food residue and was pressed into the intestinal tract of the small intestine. Gastrointestinal endoscopy revealed that the food residue was fluid and flowed back up into the esophagus, and the jejunum pouch was filled with food residue. As the patient was elderly, we attempted to aspirate the food residue with the overtube of a balloon endoscopy device. Food-induced ileus has been improved by surgery in the past; however, in determining treatment for ileus it is always necessary to consider the individual patients’ conditions, including the gastrointestinal contents.