Junji Kohisa

Simultaneous Combined Balloon-occluded Retrograde Transvenous Obliteration and Partial Splenic Embolization for Portosystemic Shunts

PURPOSE To evaluate the efficacy and safety of simultaneous combined balloon-occluded retrograde transvenous obliteration (B-RTO) and partial splenic embolization (PSE) for gastric varices and/or hepatic encephalopathy. MATERIALS AND METHODS B-RTO was performed in 19 consecutive patients with gastric varices and/or hepatic encephalopathy, of whom 10 received simultaneous combined B-RTO and PSE (group 1) and nine received B-RTO monotherapy (group 2). To evaluate the safety of these techniques, we analyzed 20 patients who received PSE monotherapy during the same period as a control group (group 3). Outcomes were retrospectively assessed. RESULTS No significant differences were observed in baseline characteristics among the three groups except for significantly lower platelet counts and larger spleen volumes in group 3. In all cases in groups 1 and 2, gastric varices disappeared and hepatic encephalopathy improved after treatment. Procedure times were not significantly different between groups 1 and 2 (P = .7435). In group 1, the volume of sclerosing agent required for B-RTO was significantly lower (P = .0355) and exacerbation of esophageal varices was significantly less frequent (P = .0146) than in group 2. Few serious complications occurred in patients who received combined therapy. CONCLUSIONS This study indicates that concomitant PSE may help diminish the increase in portal venous pressure after B-RTO for portosystemic shunts, and may allow a reduction in the volume of hazardous sclerosing agent used. It is worth evaluating the efficacy of simultaneous B-RTO and PSE in a prospective study.

Vonoprazan 20 mg vs lansoprazole 30 mg for endoscopic submucosal dissection-induced gastric ulcers

AIM To compare the healing effects of vonoprazan and lansoprazole on gastric ulcers induced by endoscopic submucosal dissection (ESD). METHODS Data were obtained from a total of 26 patients. Fourteen patients were randomized to the vonoprazan group and 12 were randomized to the lansoprazole group. Patients were administered either 20 mg vonoprazan or 30 mg lansoprazole per day after ESD. Endoscopic images just after ESD, on day 8, and on day 28 were used for the evaluation of the shrinking rate of ESD ulcers. The shrinking rates and the incidence of delayed bleeding were compared between the 2 groups. RESULTS The shrinking rates of ESD ulcers on day 8 [vonoprazan group: 61.8% (range: 24.0%-91.1%), lansoprazole group: 71.3% (range: 25.2%-88.6%)] and on day 28 [vonoprazan group: 95.3% (range: 76.2%-100%), lansoprazole group: 97.2% (range: 81.1%-99.8%)] were not statistically different between the 2 groups. On day 28, most of the ulcers in both groups healed to more than 90%, whereas 3 of 14 (21.4%) in the vonoprazan group and 1 of 12 (8.3%) in the lansoprazole group had delayed ulcer healing, which was not statistically different (P = 0.356). The frequency of delayed bleeding was 0 in the both groups. Taken together, there were no significant differences between the two drug groups. CONCLUSION Our study indicates that vonoprazan is potent for the management of ESD ulcers although lansoprazole is also sufficient and cost-effective.

Efficient palliative involved-field radiotherapy on highly progressive diffuse large B-cell primary gastric lymphoma with liver cirrhosis

We report the case of a 73-year-old woman having diffuse large B-cell primary gastric lymphoma with a cirrhotic liver caused by hepatitis C virus infection. She visited our hospital with symptoms of nausea and vomiting, which appeared to be caused by stenosis due to the tumor. Metastatic tumors were seen in the gastric and jugular lymph nodes. The clinical stage was IVB with a high risk of poor prognosis according to the international index. Because of poor hepatic reserve function, standard chemotherapy could not be administered. To maintain her quality of life, palliative involved-field radiotherapy was performed. The symptoms and tumor markers significantly improved, and computed tomography and endoscopy indicated the disappearance of the primary gastric tumor. Two months after radiotherapy and her return home, she died of pneumonia. Autopsy showed neither lymphoma cells nor stenosis of gastric lesion. The significant anti-tumor effect on primary tumor in our case suggests that the involved-field radiotherapy, although palliative, can be a therapeutic option for primary gastric lymphoma patients with various complications.

Efficacy and Safety of Pancreas-Targeted Hydrodynamic Gene Delivery in Rats

Development of an effective, safe, and convenient method for gene delivery to the pancreas is a critical step toward gene therapy for pancreatic diseases. Therefore, we tested the possibility of applying the principle of hydrodynamic gene delivery for successful gene transfer to pancreas using rats as a model. The established procedure involves the insertion of a catheter into the superior mesenteric vein with temporary blood flow occlusion at the portal vein and hydrodynamic injection of DNA solution. We demonstrated that our procedure achieved efficient pancreas-specific gene expression that was 2,000-fold higher than that seen in the pancreas after the systemic hydrodynamic gene delivery. In addition, the level of gene expression achieved in the pancreas by the pancreas-specific gene delivery was comparable to the level in the liver achieved by a liver-specific hydrodynamic gene delivery. The optimal level of reporter gene expression in the pancreas requires an injection volume equivalent to 2.0% body weight with flow rate of 1 mL/s and plasmid DNA concentration at 5 μg/mL. With the exception of transient expansion of intercellular spaces and elevation of serum amylase levels, which recovered within 3 days, no permanent tissue damage was observed. These results suggest that pancreas-targeted hydrodynamic gene delivery is an effective and safe method for gene delivery to the pancreas and clinically applicable.

Efficacy of EUS for detection of a buried fish bone in the esophagus

Fish-bone foreign bodies in the esophagus are a common emergency. They should be removed to prevent perforation and abscess formation, especially in the anterior and posterior areas of the esophagus, where impactions can lead to severe outcomes such as tracheal fistulas or involvement of blood vessels. This case suggests that EUS is effective for the detection of fish bones buried in the esophagus. An 85-year-old woman started having throat pain 4 days after having had a fish dinner and visited a nearby clinic. The fish bone was visualized on reconstructed CT. She was referred to our hospital for removal of the fish bone. Initial EGD was performed, but the fish bone could not be visualized and was detected only by the localized swelling of the esophageal wall and an intramural hematoma. CT after the initial EGD showed the fish bone still in the anterior esophageal wall (Fig. 1).

Gastrointestinal: A case of hypereosinophilic syndrome with esophageal involvement

A 38-year-old woman was admitted for an investigation into the cause of her dysphagia. Laboratory examination revealed an elevated peripheral eosinophil level (7198/μL, 36.5%). A bone marrow biopsy showed hypercellularity with markedly increased eosinophils, but clonal abnormalities were absent (Fig. 1). Therefore, she was diagnosed with idiopathic hypereosinophilic syndrome (HES). Endoscopy showed no evidence of anatomical lesions or neoplasia, and esophageal mucosa biopsies showed no evidence of eosinophilic infiltration. High-resolution manometry revealed hypercontractions, with a distal contractile integral value of 11 871.7 mmHg/s/cm (Fig. 2a). Endoscopic ultrasound showed a hypo-echoic, thickened esophageal muscle layer with a measured thickness of 4.3 mm (Fig. 2b). Because the peripheral eosinophil levels rapidly increased up to more than 70 000/μL, methylprednisolone pulse therapy was initiated. Thereafter, her symptoms improved, including a prompt decrease in the eosinophil count. High-resolution manometry and endoscopic ultrasound were repeated and revealed normal esophageal peristalsis with a distal contractile integral value of 3929.5 mmHg/s/cm (Fig. 2a, inset) and decreased muscle layer thickening (diameter, 1.5 mm; Fig. 2b, inset). The marked bone marrow eosinophil infiltration and the effectiveness of steroid therapy indicated that her dysphagia was caused by eosinophilic infiltration of the esophageal muscle layer due to HES. According to the World Health Organization classification, the definition of idiopathic HES depends on the following: (i) primary and secondary causes of hypereosinophilia must be excluded, (ii) an absolute eosinophilic count of >1500/mm must persist for at least 6 months, and (iii) organ damage must be present. In patients with HES, dermatologic or pulmonary involvement is relatively common; however, esophageal involvement manifesting with hypercontractions had not previously been reported. We have reported that eosinophilic infiltration of the esophagealmuscular layer without epithelial findings occurs in patients with a Jackhammer

Disappearance of multiple pancreatic cysts after prednisolone treatment in a patient with autoimmune pancreatitis

Autoimmune pancreatitis (AIP) with multiple pancreatic cysts is rare. The severe narrowing of the branched pancreatic ducts found in active AIP with a chronic pancreatitis background may have caused pancreatic juice outflow obstruction, resulting in multiple cysts. Oral steroid therapy resolved the stenosis, resulting in disappearance of the cysts.

Endoscopic ultrasound-guided fine-needle aspiration for diagnosing a rare extraluminal duodenal gastrointestinal tumor

Duodenal gastrointestinal stromal tumors (GISTs) are extremely rare disease entities, and the extraluminal type is difficult to diagnose. These tumors have been misdiagnosed as pancreatic tumors; hence, pancreaticoduodenectomy has been performed, although partial duodenectomy can be performed if accurately diagnosed. Developing a diagnostic methodology including endoscopic ultrasonography (EUS) and fine-needle aspiration (FNA) has allowed us to diagnose the tumor directly through the duodenum. Here, we present a case of a 50-year-old woman with a 27-mm diameter tumor in the pancreatic uncus on computed tomography scan. EUS showed a well-defined hypoechoic mass in the pancreatic uncus that connected to the duodenal proper muscular layer and was followed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Histological examination showed spindle-shaped tumor cells positively stained for c-kit. Based on these findings, the tumor was finally diagnosed as a duodenal GIST of the extraluminal type, and the patient underwent successful mass resection with partial resection of the duodenum. This case suggests that EUS and EUS-FNA are effective for diagnosing the extraluminal type of duodenal GISTs, which is difficult to differentiate from pancreatic head tumor, and for performing the correct surgical procedure.