Kengo Onochi

Impact of a transparent hood on the performance of total colonoscopy : a randomized controlled trial

BACKGROUND Clinical demand for total colonoscopy (TCS) is increasing. Improvement of the cecal intubation rate and shortening of the examination time would expand the capacity for TCS. OBJECTIVE To assess the efficacy of a transparent hood attached to the tip of a colonoscope for cecal intubation in TCS. DESIGN Prospective, randomized, controlled study. SETTING Single tertiary-referral center. INTERVENTIONS TCS. MAIN OUTCOME MEASUREMENTS Cecal intubation time and rate, complications, patient discomfort, and detection rate of colonic polyps. METHODS Patients who were to undergo screening and/or surveillance TCS for colorectal cancer were invited to participate in the study. Cecal intubation time and rate, complications, patient discomfort, and detection rate of colonic polyps were evaluated. RESULTS A total of 592 patients enrolled in this study were randomly allocated to the hood group and no-hood group. The mean (SD) cecal intubation time in the hood group and the no-hood group was 10.2 +/- 12.5 minutes and 13.4 +/- 15.8 minutes, respectively (P = .0241). The effect of its use was more prominent in the expert endoscopists group compared with those with moderate experience. The cecal intubation rate and the detection rate of small polyps in the 2 groups were similar. The grade of patient discomfort was significantly lower in the hood group. No complications were encountered with the use of the hood. CONCLUSIONS Use of a transparent hood on the tip of a colonoscope shortened the time required for cecal intubation and decreased patient discomfort; such use was more effective among experts in shortening the examination time.

Salvage endoscopic submucosal dissection for the esophagus-localized recurrence of esophageal squamous cell cancer after definitive chemoradiotherapy

1. Kawai K, Akasaka Y, Murakami I, et al. Endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1974;20:148-51. 2. Classen M, Demling L. Endoskopische sphincterotomie der papilla vateri und steinextraktion aus dem ductus choledochus [In German]. Dtsch Med Wochenschr 1974;99:469-76. 3. Geenen JE, Vennes JA, Silvis SE. Resume of a seminar on endoscopic retrograde sphincterotomy (ERS). Gastrointest Endosc 1981;27:31-8. 4. Soehendra N, Grimm H, Berger B, et al. Endoskopische behandlungsmogglichkeiten [In German]. 1988;1:2-9. 5. Cotton PB. Nonoperative removal of bile duct stones by duodenoscopic sphincterotomy. Br J Surg 1980;67:1. 6. Sievert CE, Silvis SE. Evaluation of electrohydraulic lithotripsy on human gallstones. Am J Gastroenterol 1985;80:854. 7. Leung JWC, Chung SSC. Electrohydraulic lithotripsy with peroral choledochoscopy. Br J Med 1989;299:595-8. 8. Siegel JH, Ben Zvi JS, Pullano WE. Electrohydraulic lithotripsy. Gastrointest Endosc 1990;36:134-6. 9. Kozarek RA, Low DE, Ball TJ. Tunable dye laser lithtripsy: in vitro studies and in vivo treatment of choledocholithiasis. Gastrointest Endosc 1988;34:418-21. 10. Ell C, Lux G, Hochberger J, et al. Laserlithotripsy of common bile duct stones. Gut 1988;29:746-51. 11. Cotton PB, Kozarek RA, Shapiro RH, et al. Endoscopic laser lithotripsy of large bile duct stones. Gastroenterology 1990;99:1128-33. 12. Ponchon T, Gagnon P, Valette PJ, et al. Pulsed dye laser lithotripsy of bile duct stones. Gastroenterology 1991;100:1730-6.

Long-tube insertion with the ropeway method facilitated by a guidewire placed by transnasal ultrathin endoscopy for bowel obstruction: a prospective, randomized, controlled trial

BACKGROUND It is often difficult to insert a long intestinal tube in the small bowel of patients with bowel obstruction, and it often results in long procedure time and severe patient distress. OBJECTIVE To assess the usefulness of the ropeway method by using a guidewire placed with the assistance of transnasal ultrathin endoscopy in long-tube insertion for patients with bowel obstruction. DESIGN Prospective, randomized, controlled, single-center study. PATIENTS AND INTERVENTIONS Thirty-four consecutive patients with bowel obstruction requiring decompression participated in the study and were randomized to the insertion of a long tube with the ropeway method (ILTR) group (ie, insertion along an endoscopically placed guidewire that was passed through only the distal 4 cm of the tube) or insertion by a conventional method group (C group). MAIN OUTCOME MEASUREMENTS The time required for the procedure (main), success rate, x-ray exposure time, and intensity of patient distress measured with a visual analog scale of 1 to 5 (better to worse). RESULTS The mean (+/- standard deviation) duration of the procedure in the successful cases in the ILTR group and the C group was 16.1 +/- 5.6 minutes and 26.4 +/- 13.8 minutes, respectively (P = .010). The success rate was 100% in the ILTR group and 88% in the C group (P = .48). The mean (+/- standard deviation) x-ray exposure time and intensity of patient distress were, respectively, 16.4 +/- 8.7 minutes and 33.2 +/- 12.3 minutes (P < .001) and 2.6 +/- 0.7 and 3.7 +/- 1.2 (P = .016). LIMITATIONS Single-center study and small sample size to evaluate overall safety. CONCLUSIONS Long-tube insertion for bowel obstruction with the ropeway method facilitated by transnasal ultrathin endoscopy was superior to conventional fluoroscopic placement with regard to overall procedure success, time required, and patient comfort.

Advanced feasibility of endoscopic submucosal dissection for the treatment of gastric tube cancer after esophagectomy

The incidence of esophageal cancer is increasing worldwide. However, progress in surgical techniques and the development of novel therapeutic modalities such as adjuvant chemoradiation therapy combined with surgery have improved the postoperative survival up to 34% to 51% at 5 years. Therefore, long-term survival cases are no longer rare. Generally, gastric tubes are substituted for the reconstitution after the esophagectomy for the treatment of esophageal cancer. In association with the increase in the number of long-term follow-up cases after esophagectomy, the occurrence of secondary malignancies such as adenocarcinoma arising in gastric tubes has been reported. Until a decade ago, repeat surgery was considered for the treatment of adenocarcinoma in gastric tubes. However, this did not achieve satisfactory clinical outcomes because of its high operative risks. Recently, the use of EMR has been emphasized for treatment in patients with superficial lesions. Although the clinical risks of EMR associated with gastric tube cancer (GTC) treatment are significantly lower than those associated with surgery, EMR cannot always be used to resect GTC completely because of its technical limitations regarding the tumor sizes. Therefore, endoscopic submucosal dissection (ESD) is currently used as a therapeutic option for treating GTC. However, ESD for GTC also carries limitations with respect to the anatomical features of gastric tubes, particularly the suture line and staples with the possibility of fibrosis. We therefore investigated the feasibility of

The feasibility of endoscopic submucosal dissection for superficial esophageal cancer in patients with cirrhosis (with video)

Endoscopic submucosal dissection (ESD) was initially developed for gastric cancer and is currently accepted as an established procedure for superficial cancer of the esophagus. The most important advantage of ESD compared with EMR is that it can provide a high en bloc resection rate and precise histologic assessment even for large lesions. On the other hand, the disadvantage of ESD is a higher risk of bleeding and perforation than for EMR. Previous reports described that esophageal ESDrelated adverse events, such as postoperative bleeding and perforation, are considerably serious risks. However, ESD for patients with cirrhosis may carry a higher risk of these adverse events because of the low platelet count, coagulopathy, and portal hypertensive gastroenteropathy, including esophageal varices, in these patients. As a result, endoscopists have been hesitant to apply ESD for the treatment of esophageal cancer in patients with cirrhosis.

True Primary Enterolith Treated by Balloon-assisted Enteroscopy

Primary enterolith is a rare condition that can induce ileus and intestinal perforation. We report the first case of a true primary enterolith treated by balloon-assisted enteroscopy. The patient presented with a small intestinal ileus. After its improvement following the insertion of an ileus tube, radiography with amidotrizoate sodium meglumine detected a round, movable defect in the ileum measuring 42 mm diameter. The patient was diagnosed with a primary enterolith based on her past history. The enterolith was fractured and removed using balloon-assisted enteroscopy. This case suggests that balloon-assisted enteroscopy may be an effective non-invasive treatment option for enteroliths.

Successful treatment with infliximab for refractory para-ileostomal ulceration in a patient with Behҫet’s disease

Behҫet’s disease (BD) is a chronic disorder involving multiple organ systems including the small and large intestines. A 46-year-old female diagnosed with intestinal BD presented with ileocecal perforation and diffuse peritonitis and subsequently underwent ileocolic resection with ileostomy. After surgery, she suffered from refractory para-ileostomal ulceration associated with BD. Most importantly, however, treatment with infliximab was significantly effective in healing the ulceration. This is the first report of para-ileostomal ulceration associated with BD successfully treated with infliximab, suggesting the possible use of infliximab as a therapeutic option for para-stomal ulcers related to BD.

Mesenteric lymph node abscess due to Yersinia enterocolitica : case report and review of the literature

Abstract We describe the case of a 74-year-old female with a mesenteric lymph node abscess caused by a Yersinia enterocolitica infection. She had been administered an immunosuppressive drug and was admitted to the hospital due to a high fever, right lower abdominal pain and advanced leukocytosis. We initially diagnosed her with lymphadenitis based on the symptoms and the imaging studies. However, conservative treatment with antibiotics did not yield any improvement, and abscess formation was suspected. Surgical treatment was performed, and the culture from the drainage fluid grew Y. enterocolitica. The histological findings suggested that an ulcerative lesion of the terminal ileum was the entry port of Y. enterocolitica. The pathogen infected the mesenteric lymph nodes and spread along the ileocecal lymphatic vessels, resulting in the formation of an abscess. We also provide a review of the previously published literature on lymph node abscesses due to Y. enterocolitica infections.

Su1819 Evaluation of the Expanded Indication of Endoscopic Submucosal Dissection for Superficial Esophageal Squamous Cell Neoplasms

[Background and Aim] Since the technical advance and the development of new devices, endoscopic submucosal dissection (ESD) is widely utilized for the treatment of superficial esophageal squamous cell neoplasms (ESCNs). In the treatment of ESCNs without nodal metastasis, ESD achieves the similar clinical outcomes to those of esophagectomy and chemoradioherapy and is much less invasive than them. The intensive studies of histopathological analysis of surgically resected ESCNs have proven that the cases of non-invasive carcinoma (EP, carcinoma in situ) and intra-mucosal invasive carcinoma limited to the lamina propria mucosae (LPM) had an extremely low risks of lymph node and distant metastasis. Based on these findings, the Japanese guideline for the treatment of esophageal cancer states that both EP and LPM cases are suitable for ESD. On the other hand, the lymph node metastasis rate of ESCNs invading to the muscularis mucosae (MM) including both with and without lymphovascular invasion has been reported as 7-10 %. Thus, ESD treatment had not been positively recommended for MM cases. However, it is assumed that MM cases without lymphovascular invasion have no lymph node metastasis. Thus, there exists the possibility that MM cases without lymphovascular invasion can be suitable for ESD. In this study, therefore, we evaluated expanded ESD indication to the MM cases without lymphovascular invasion, by analyzing surgically resected specimens histopathologically and investigating the clinical outcomes both after surgery and ESD of MM cases without lymphovascular invasion. [Methods] MM cases without lymphovascular invasion surgically treated between January 2001 and December 2010 (11 cases) and those treated with ESD between January 2006 and August 2012 (30 cases) at Akita University Hospital were enrolled in this study. [Results] In the detailed histopathological analysis of the surgically resected specimens of 11 MM cases without lymphovascular invasion, no lymph node metastasis was detected. No recurrence or metastasis developed in any of these 11 cases until today. In the analysis of the ESD-treated, 30 MM cases were proven to have no lymphovascular invasion by the histopathological examination of the specimens endoscopically resectd en bloc. Then, no additional therapy such as chemoradiotherapy was performed for these cases. However, all of the 30 cases are still alive without recurrence or metastasis during the followup period (4-81 months, average 33.8 months). [Conclusion] Our current study elucidated that MM cases without lymphovascular invasion has no risk of lymph node metastasis, and clinical outcomes of the ESD-treated MM cases without lymphovascular invasion are extremely satisfactory. These data suggest that ESD indication for superficial ESCNs treatment can be expanded to the MM cases without lymphovascular invasion.

Su1113 Salvage Endoscopic Submucosal Dissection is an Effective and Safe Treatment for the Esophagus-Localized Recurrence of Esophageal Cancer After Chemoradiotherapy

G A A b st ra ct s corpus were most likely to extend to more than one location (57%; 95%CI: 36-76%), this increase was significantly higher (p 0.014) than the increase of intragastric extent found in patients with only IM in the antrum or angulus at inclusion (22.9%; 95%CI: 13.9-31.9%). The proportion of patients with multi-located PM increased from 24.% at baseline to 44% at surveillance (p 0.014). Using the OLGIM classification, 19% of patients scored grade III to IV. No correlations could be found between sex, PPI or NSAID use, interval between baseline and surveillance endoscopy, and progression or regression of the severity and extent or OLGIM score. Current or past Hp infection was identified in 46% and was correlated with a more severe PM at surveillance (R2 0.166 p 0.05). IM was the PM mostly identified in subsequent endoscopies (Regression in 27% vs 44% in AG and 100% in LGD). Conclusion: Premalignant gastric lesions found in the corpus have the highest risk of progression during surveillance. Past or current Hp infection is correlated with progression of extent and severity of PM. This study demonstrates the importance of IM as marker for follow-up instead of AG or LGD.