Junichiro Nasu

Endoscopic submucosal dissection of esophageal cancer using the Mucosectom2 device: a feasibility study

BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD) is being increasingly used for superficial esophageal cancers. However, esophageal ESD is technically difficult, time consuming, and less safe compared with endoscopic mucosal resection (EMR). To perform ESD safely and more efficiently, various types of knives have been developed. This study compared the efficacy of our newly developed device, Mucosectom2, with that of conventional devices for esophageal ESD. PATIENTS AND METHODS Between May 2007 and February 2011, ESD was performed for 172 esophageal lesions. Of these, 120 lesions were treated by conventional devices only, whereas 52 lesions were treated by conventional devices and the Mucosectom2. Procedure time, en bloc and R0 resection rates, and adverse events were retrospectively compared between the conventional and Mucosectom2 groups. RESULTS The median procedure time was 48.0 minutes in the conventional group and 21.5 minutes in the Mucosectom2 group; the procedure time was significantly shorter in the Mucosectom2 group than in the conventional group (P < 0.0001). The en bloc and R0 resection rates were lower in the conventional group than those in the Mucosectom2 group, although these differences were not significant. The rate of exposure of the muscle layer in the Mucosectom2 group was significantly lower than in the conventional group (P = 0.04). The rates of perforation and postoperative bleeding were not significantly different between the two groups. CONCLUSIONS This feasibility study suggests that, compared with conventional ESD devices, the Mucosectom2 may decrease the time required for esophageal ESD. Although our groups appeared comparable, they were studied at different times. Endoscopic expertise and endoscope quality may have differed during these periods, thereby affecting the results of our study. A prospective trial is therefore required to confirm our results.

Pneumocystis carinii pneumonia in patients with ulcerative colitis

Pneumocystis carinii pneumonia (PCP) causes pneumonia in immunocompromised patients suffering from diseases such as leukemia, malignant lymphoma, and other cancers, and those treated with corticosteroids and/or immunosuppressive agents. However, it has rarely been reported in patients with ulcerative colitis (UC). We report three patients with UC who developed PCP during corticosteroid and/or azathioprine (AZA) administration. Case 1 was a 26-year-old woman with an 8-month history of ulcerative colitis. She had hematochezia, and colonoscopy showed severe pancolitis. She had a blood transfusion and was treated with prednisolone, at a dose of 60 mg/day. Her disease was unresponsive to therapy with prednisolone. AZA at 100 mg/day was added. Her symptoms improved gradually, but AZA was stopped on the day 34 after the beginning of administration because of leukocytopenia. The following day she had a high-grade fever. Laboratory data were as follows: white blood cell count (WBC), 2500/mm3; lymphocyte count (Ly), 650/mm3; hemoglobin (Hb), 10.3 g/dl; and platelet count (Plt), 24.1 104/mm3. Arterial blood gases in room air were: pH 7.44, PCO2, 36.0 mmHg; and PO2, 56.0 mmHg. The CD4/CD8 ratio in peripheral blood was decreased, at 0.5. X-ray and computed tomography (CT) of the chest revealed bilateral “ground-glass” shadows (Fig. 1). Case 2 was a 68-year-old woman with an 11-year history of left-sided ulcerative colitis. She presented with acute colitis. We started pulse steroid therapy. The response was excellent and she entered the remission stage on clinical tests. She developed a high fever 2 days after the start of maintenance therapy with prednisolone at a dose of 7.5 mg/day. Laboratory data were as follows: WBC, 6200/mm3; Ly, 990/mm3; Hb, 10.5 g/dl; and Plt, 35.9 104/ mm3. Arterial blood gases in room air were: pH 7.47, PCO2, 32.7 mmHg; and PO2, 70.0 mmHg. The CD4/CD8 ratio in peripheral blood was normal (1.1). Chest X-ray and CT showed bilateral “ground-glass” shadows. Case 3 was a 29-year-old man with a 4-month history of ulcerative colitis. He presented with acute colitis exacerbation. Colonoscopy showed total colitis. We changed the corticosteroid from prednisolone, 40 mg/day, to betamethasone, 4 mg/day. AZA, 100 mg/day, was added and the response was satisfactory. Then we began to reduce betamethasone gradually, to 1.5 mg/day. His clinical course was excellent and he was discharged. Four months later, he was readmitted with a high fever. Laboratory data were as follows: WBC, 3400/mm3; Ly, 880/mm3; Hb, 11.0 g/dl; and Plt, 15.6 104/mm3. Arterial blood gases in room air were: pH, 7.39; PCO2, 41.0 mmHg; and PO2, 91.0 mmHg. Chest X-ray was normal, but chest CT revealed faint “ground-glass” shadow in the right lung (Fig. 2). In all three patients, polymerase chain reaction (PCR) for detection of P. carinii in sputa was positive, and we diagnosed PCP. Cytomegalovirus antigen in peripheral blood was negative in all the patients. After the diagnosis of PCP, they were treated

A Prospective Analysis of Efficacy and Long-Term Outcome of Radiation Therapy for Gastric Mucosa-Associated Lymphoid Tissue Lymphoma

Background/Aims: Few studies exist on the efficacy and long-term outcome of radiation therapy (RT) for gastric mucosa-associated lymphoid tissue (MALT) lymphoma. Methods: Twenty-two patients with stage I or stage II1 disease were prospectively evaluated, including 14 patients without Helicobacter pylori(H. pylori) infection and 8 patients with persistent lymphoma after H. pylori eradication. RT dose was 30 Gy in daily fractions of 1.5 Gy. All patients underwent endoscopic and histological follow-up regularly. Results: The study included 22 patients with a mean age of 63 years. The t(11;18)(q21;q21) translocation occurred in 8 of the 22 cases. All patients showed complete remission without any serious toxicity. At a median follow-up evaluation 74 months (range 27–159) after completion of RT, the overall and relapse-free survival rates after 5 years were 91 and 84%, respectively. Although no patient showed local recurrence of lymphoma, distant recurrence was detected in 3 patients, all of whom were H. pylori negative; MALT lymphoma relapsed in two patients with the t(11;18)(q21;q21) translocation, and diffuse large-cell lymphoma developed in one patient without the translocation. Conclusion: RT provides excellent local control of the gastric MALT lymphoma. However, continuous follow-up is mandatory as relapse may occur in other sites.

Intramucosal gastric mixed adenoneuroendocrine carcinoma completely resected with endoscopic submucosal dissection

Composite tumors in the stomach composed of adenocarcinoma and neuroendocrine carcinoma are rare. We herein report a case of intramucosal gastric mixed adenoneuroendocrine carcinoma (MANEC) that was treated with endoscopic submucosal dissection (ESD). A 77-year-old man who had previously received ESD for early gastric adenocarcinoma underwent esophagogastroduodenoscopy for screening, which showed a depressed lesion on the lesser curvature of the antrum. The tumor was removed en bloc via ESD and pathologically diagnosed as MANEC. The tumor was located within the mucosal layer, and no lymphovascular invasion was evident. Seven months after the ESD procedure, the patient is currently feeling well without recurrence or metastasis.

Proton pump inhibitor step-down therapy for GERD: A multi-center study in Japan

AIM To investigate the predictors of success in step-down of proton pump inhibitor and to assess the quality of life (QOL). METHODS Patients who had heartburn twice a week or more were treated with 20 mg omeprazole (OPZ) once daily for 8 wk as an initial therapy (study 1). Patients whose heartburn decreased to once a week or less at the end of the initial therapy were enrolled in study 2 and treated with 10 mg OPZ as maintenance therapy for an additional 6 mo (study 2). QOL was investigated using the gastrointestinal symptom rating scale (GSRS) before initial therapy, after both 4 and 8 wk of initial therapy, and at 1, 2, 3, and 6 mo after starting maintenance therapy. RESULTS In study 1, 108 patients were analyzed. Their characteristics were as follows; median age: 63 (range: 20-88) years, sex: 46 women and 62 men. The success rate of the initial therapy was 76%. In the patients with successful initial therapy, abdominal pain, indigestion and reflux GSRS scores were improved. In study 2, 83 patients were analyzed. Seventy of 83 patients completed the study 2 protocol. In the per-protocol analysis, 80% of 70 patients were successful for step-down. On multivariate analysis of baseline demographic data and clinical information, no previous treatment for gastroesophageal reflux disease (GERD) [odds ratio (OR) 0.255, 95% CI: 0.06-0.98] and a lower indigestion score in GSRS at the beginning of step-down therapy (OR 0.214, 95% CI: 0.06-0.73) were found to be the predictors of successful step-down therapy. The improved GSRS scores by initial therapy were maintained through the step-down therapy. CONCLUSION OPZ was effective for most GERD patients. However, those who have had previous treatment for GERD and experience dyspepsia before step-down require particular monitoring for relapse.

The characteristics and outcomes of small bowel adenocarcinoma: a multicentre retrospective observational study

Background:Small bowel adenocarcinoma (SBA) is a rare malignancy that accounts for 1–2% of gastrointestinal tumours. We investigated the clinical characteristics, outcomes, and prognostic factors of primary SBA.Methods:We retrospectively analysed the characteristics and clinical courses of 205 SBA patients from 11 institutions in Japan between June 2002 and August 2013.Results:The primary tumour was in the duodenum and jejunum/ileum in 149 (72.7%) and 56 (27.3%) patients, respectively. Sixty-four patients (43.0%) with duodenal adenocarcinoma were asymptomatic and most cases were detected by oesophagogastroduodenoscopy (EGD), which was not specifically performed for the detection or surveillance of duodenal tumours. In contrast, 47 patients (83.9%) with jejunoileal carcinoma were symptomatic. The 3-year survival rate for stage 0/I, II, III, and IV cancers was 93.4%, 73.1%, 50.9%, and 15.1%, respectively. Multivariate analysis revealed performance status 3–4, high carcinoembryonic antigen, high lactate dehydrogenase (LDH), low albumin, symptomatic at diagnosis, and stage III/IV disease were independent factors for overall survival (OS). Ten patients (18.5%) with stage IV disease were treated with a combination of resection of primary tumour, local treatment of metastasis, and chemotherapy; this group had a median OS of 36.9 months.Conclusions:Although most SBA patients were diagnosed with symptomatic, advanced stage disease, some patients with duodenal carcinoma were detected in early stage by EGD. High LDH and symptomatic at diagnosis were identified as novel independent prognostic factors for OS. The prognosis of advanced SBA was poor, but combined modality therapy with local treatment of metastasis might prolong patient survival.

Whipple's Disease: A Case Report with Long-term Endoscopic Follow-up.

A 72-year-old man presented with anorexia and 15-kg weight loss over 3 years. Endoscopy revealed yellow, shaggy mucosa alternating with erythematous, eroded mucosa in the duodenum. Biopsy specimens showed massive infiltration of periodic acid-Schiff-positive macrophages in the lamina propria, consistent with Whipples disease. The patient was treated with intravenous ceftriaxone for four weeks, followed by oral trimethoprim-sulfamethoxazole. His condition improved, and he gradually gained weight. Although the endoscopic findings improved with continuous trimethoprim-sulfamethoxazole administration, macrophage infiltration of the duodenal mucosa persisted. However, the patient has been symptom-free for eight years.