Kazuko Beppu

Endoscopic submucosal dissection of large colorectal tumors by using a novel spring-action S-O clip for traction (with video)

BACKGROUND Endoscopic submucosal dissection (ESD) allows en bloc resection of large GI neoplasms, regardless of their size; however, technical difficulties associated with ESD in the colorectum make it less widely applied in the treatment of tumors in this region. To address this difficulty, we designed a rubber strip-based traction device, called the S-O clip (Sakamoto-Osada clip) and reported previously that ESD with this device was effective for complete resection of large, superficial colorectal neoplasms. In this report, we describe a novel spring-action version of the S-O clip (spring S-O clip) that improves the facility of clip use during ESD of colorectal tumors. OBJECTIVE To evaluate the efficacy and safety of the spring S-O clip for ESD of colorectal neoplasms. DESIGN Case series. SETTING Juntendo University Hospital. MAIN OUTCOME MEASUREMENTS The efficacy and safety of the spring S-O clip traction device during ESD of colorectal tumors. RESULTS In 3 cases, a large, superficial neoplasm in the right side of the colon was removed safely and successfully en bloc without complication. Procedure times for the 3 cases were 44, 27, and 49 minutes, with resected specimens measuring 40, 24, and 35 mm, respectively. LIMITATION Uncontrolled study. CONCLUSION This limited case series demonstrates that spring S-O clip-assisted ESD is safe and effective for en bloc resection of large superficial neoplasms in the right side of the colon.

Correlations among total colonoscopic findings, clinical symptoms, and laboratory markers in ulcerative colitis

Background and Aim:  Colonoscopy plays an integral role in the diagnosis, management and surveillance of ulcerative colitis (UC). In the present study we assessed the relationship between endoscopic and histological findings, clinical symptoms, and laboratory data.

Comparison of several activity indices for the evaluation of endoscopic activity in UC: inter- and intraobserver consistency.

Background: This study evaluated inter‐ and intraobserver agreement in the assessment of ulcerative colitis (UC) activity using 4 established indices and a newly designed Modified 6‐point Activity Index. Method: In all, 279 endoscopic pictures of inflammatory lesions from 93 UC patients were displayed twice to 4 expert and 4 trainee endoscopists, at an interval of 1 month. Each picture was assessed for inflammatory changes using established indices (Matts, Schroeder [a.k.a. Mayo Score], Baron, and Blackstone) and our new Modified 6‐point Activity Index. Weighted kappa statistics were used to estimate intra‐ and interobserver variation. Results: The Matts and Schroeder indices gave a “good” degree of concordance for expert endoscopists in terms of inter‐ and intraobserver agreements (0.74–0.78); this was not so evident with the Baron and Blackstone indices (0.61–0.73). For trainee endoscopists, all scores for inter‐ and intraobserver weighted kappa values using established indices (0.41–0.51) were lower than for the experts. The degree of concordance using the Modified 6‐point Activity Index was rated as “good” for inter‐ and intraobserver agreements for expert endoscopists (0.65 and 0.79), and as “moderate” for trainee endoscopists (0.54 and 0.64). Conclusions: Accurate assessment of UC disease activity from endoscopic findings benefited from experience. For expert endoscopists, the Matts and Schroeder indices proved the most reliable of the 4 established indices. Current endoscopic technologies may be adequate for assessing UC activity, particularly if modified to permit a finer classification of disease severity based on 6 grades, as with our newly developed Modified 6‐point Activity Index. (Inflamm Bowel Dis 2009;)

Metastatic renal cell carcinoma diagnosed by capsule endoscopy and double balloon endoscopy

Summary Background Renal cell carcinoma commonly metastasizes to lung, liver, and bone. Small intestinal metastases are exceedingly rare. Case Report A 75-year-old man presented at our hospital with tarry stools. He had undergone a right nephrectomy for renal cell carcinoma (RCC) 6 years previously; in addition, he had received antiplatelet treatment for ischemic heart disease. Esophagogastroduodenoscopy, total colonoscopy, and computed tomography did not identify any cause for the gastrointestinal bleeding. He underwent capsule endoscopy (CE), which revealed an ulcerated submucosal tumor in the jejunum. We performed a double-balloon endoscopy (DBE), and histological findings identified a clear cell carcinoma. We diagnosed metastasis from the RCC. We performed a jejunectomy to resect the tumor and thus eliminate the source of the bleeding. Conclusions CE and DBE are useful diagnostic tools. We recommend investigating the possibility of small intestinal metastases in cases of intestinal bleeding or anemia in patients with a history of malignant tumor.

Optimal timing for resuming antithrombotic agents and risk factors for delayed bleeding after endoscopic resection of colorectal tumors.

Aim. To examine optimal timing for resuming antithrombotic agents and risk factors for delayed bleeding after endoscopic resection of colorectal tumors. Method. Of 1,970 polyps larger than 10 mm removed by polypectomy, endoscopic mucosal resection, or endoscopic submucosal dissection, delayed bleeding, which was designated as bleeding that occurred 6 or more hours after endoscopic treatment, occurred in 52 cases (2.6%); 156 nonbleeding cases matched for age and gender were controls in this single-institution retrospective case-control study. We investigated (1) patient-factors: resuming antithrombotic agents within 5 days following endoscopic resection, hypertension, and diabetes mellitus; and (2) tumor-factors: morphology, size, location, and resection technique by conditional logistic regression. Results. By multivariate analysis resumption of anticoagulants within 5 days was a significant risk factor for delayed bleeding (OR 10.2; 95% CI = 2.7–38.3; P = 0.0006). But resuming a thienopyridine within 5 days was not (OR 0.9; 95% CI = 0.1–2.6; P = 0.40). Other patient- and tumor-factors were not significant. Conclusion. Resuming anticoagulants within 5 days after endoscopic treatment was associated with delayed bleeding whereas resuming thienopyridines was not.

Asymptomatic anisakiasis of the colon incidentally found by colonoscopy

Asymptomatic anisakiasis of the colon is a rare condition that is difficult to diagnose. A 42-year-old man with no symptoms was referred to our department because of elevated serum carcinoembryonic antigen (CEA) levels detected previously at another hospital. A colonoscopy was performed to find the reason for these elevated CEA levels, and Anisakis larvae were identified by chance in the ascending colon wall. This is only the fourth case of asymptomatic anisakiasis of the colon to be reported worldwide.

Clinicopathological characteristics of colorectal cancer less than 10 mm in diameter and invading submucosa and below

Background and Aims:  Identifying the invasive depth of cancers less than 10 mm in diameter remains a challenge. This study examines the clinicopathological characteristics of colorectal cancers less than 10 mm in diameter and invading submucosal layer (SM)3 and below, which require surgery and must never be treated by endoscopic mucosal resection.

Jejunal capillary hemangioma treated by using double-balloon endoscopy (with video)

Vascular tumors of the small bowel are rare, accounting for only 5% to 10% of all benign tumors of the small intestine. 1,2 The main presenting symptom of capillary hemangioma is bleeding. In most cases, partial resections of the small bowel are necessary. Here, we report a rare case of capillary hemangioma of the small bowel treated by endoscopic mucosal resection by using double-balloon endoscopy (DBE).

Colonic mucosal lesions associated with long-term or short-term administration of nonsteroidal anti-inflammatory drugs

Aim  The effects of short‐ or long‐term administration of nonsteroidal anti‐inflammatory drugs (NSAIDs) on the colon have not been well characterized. We assessed the risk of developing colonic mucosal lesions according to the duration of exposure to NSAIDs: short‐term and/or long‐term use.

The 'Loop Clip' is useful for closing large mucosal defects after colorectal endoscopic submucosal dissection: a preliminary clinical study.

Endoscopic submucosal dissection (ESD) is applied for the treatment of large early-stage superficial colorectal cancers. Bleeding and perforation are common complications of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Metallic clips have been used for endoscopic closure of mucosal defects to reduce the risk of these complications, but they can only be used for small defects even though the presence of large mucosal defects increases the risk of complications. Some cases of delayed perforations after ESD require surgical treatment. To overcome such complications, we developed a simple technique using a new closure device named the ‘Loop Clip’ that can close large mucosal defects following ESD (Fig. 1). However, the number of cases in that report was small. We report a greater number of cases and provide in-depth data. After we obtained assent and written informed consent from the patients who were thought to be high risk, such as patients who required continual anticoagulant therapy, 28 patients (19 men, nine women; median age 70.3 years) with 28 flat-type colorectal tumors (right colon 20, left colon two, rectum six) larger than 20 mm in diameter with using loop clip-assisted method after ESD were studied. The exclusion criteria were tumors suspicious of submucosal massive invasive cancers. Using the loop clip was approved by Juntendo University Institutional Review Board. Mean tumor size in these patients was 30.6 8.0 mm. Mean procedure time was 13.1 7.2 min. Closure was achieved in all cases at any location (Fig. 2). Complete closure without residual ulcer was achieved in 83.3% (20/24), which were smaller than 40 mm in tumor size. These preliminary results suggest that the loop clip-assisted method is useful for closure of large mucosal defects at any location. Only one delayed bleeding (3.6%) occurred in the patient who received anticoagulant therapy during this procedure