Kengo Takimoto

SEDATION WITH DEXMEDETOMIDINE HYDROCHLORIDE DURING ENDOSCOPIC SUBMUCOSAL DISSECTION OF GASTRIC CANCER

Aim:  Although the treatment of early gastric cancer with endoscopic submucosal dissection (ESD) has been widely carried out, a standardized method of sedation for ESD has not been established. The purpose of the present study was to evaluate the efficacy and safety of sedation with dexmedetomidine (DEX).

Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to prevent delayed perforation after duodenal endoscopic submucosal dissection

Delayed perforation after duodenal endoscopic submucosal dissection (ESD) occurs at a high rate because the duodenal wall is very thin and the artificial ulcer after resection is exposed to bile and pancreatic juice. We investigated the application of the combination of a polyglycolic acid (PGA) sheet and fibrin glue. PGA sheets comprise materials widely used in surgery for absorbable thread. Fibrin glue is a heated blood product and is used for hemostasis during operations. We developed a combined method using both materials. We have used this method in two cases. One case involved an elevated lesion located in the lower duodenal angle of the duodenum. The other involved an elevated lesion in the second portion of the duodenum. About 1 week after ESD, the PGA sheets remained covering the ulcer and delayed perforation did not occur. We were able to easily carry out this method for several parts of the duodenum. This method may be helpful for the prevention of delayed perforation after duodenal ESD.

Endoscopic diagnosis of superficial non‐ampullary duodenal epithelial tumors in Japan: Multicenter case series

To verify the current status in Japan on endoscopic diagnosis of superficial non‐ampullary duodenal epithelial tumors (SNADET) by a multicenter case series through a questionnaire survey.

Rituximab alone was effective for the treatment of a diffuse large B-cell lymphoma associated with hemophagocytic syndrome

We report here the case of a 63-year-old man who had a diffuse large B-cell lymphoma associated with hemophagocytic syndrome (HPS). The lymphoma involved the spleen, bilateral adrenal glands, and paraaortic lymph nodes of the abdomen. In both the bone marrow and lymph nodes, hemophagocytosis was evident, and the laboratory findings were consistent with HPS. The lymphoma cells showed a CD4+, CD5+, CD10−, CD19+, CD20+, CD25+ and surface immunoglobulin µα/κ+ immunophenotype. The patient was unintentionally treated with rituximab alone, resulting in complete resolution of the lymphomatous lesions as well as the features of HPS in response to the initial two doses of rituximab, although he developed gastric hemorrhage requiring vigorous resuscitation. After the completion of eight doses of rituximab, the patient remains free of disease with an excellent performance status.

Gastric fundal varices: new aspects of nonsurgical treatment in Japan

Bleeding from gastric varices is a life-threatening event that presents a therapeutic challenge for clinicians. This Viewpoint discusses the advance in nonsurgical treatment of gastric fundal varices, including the new radiologic technique of balloon-occluded retrograde transvenous obliteration.

Filling and shielding for postoperative gastric perforations of endoscopic submucosal dissection using polyglycolic acid sheets and fibrin glue

Background and study aims: Many medical institutions in Japan perform endoscopic mucosal dissection (ESD) to treat early gastric cancer. Perforations can occur during ESD, and clipping has been reported as useful for treating small pinhole perforations. However, it is often difficult to close postoperative perforations because they usually have large diameters, and the muscle layer around the perforated region is often fragile, so additional open surgery is the only currently used method to treat large perforations and delayed perforations. Another method for large perforation is needed to treat perforations endoscopically. Ono et al. reported a case in which a postoperative perforation was closed using a polyglycolic acid (PGA) sheet and fibrin glue. In addition, it has been used by the authors’ group to repair duodenal injuries that occur during ESD. We report 3 cases in which PGA sheets and fibrin glue were successfully used to repair postoperative gastric perforations endoscopically. This method is simple, safe, and effective, and is a new way to treat large perforations and delayed perforations that occur following ESD.

Management of acute gastric variceal bleeding

Sirs, Although it was not mentioned by Siproudhis et al., similar results have been obtained previously when chronic anal fissure was treated with glyceryl trinitrate ointment and placebo. These results were based on a much larger group (119 patients) than that described by Siproudhis et al. Usually, such a high rate of healing of chronic anal fissure or of symptomatic improvement, as presented by both groups of authors, is not observed in the placebo group (British Medical Journal Online, in response to the Editorial in the British Medical Journal 2003; 327: 354–5). Siproudhis et al. did not account for this fact in their Discussion, although, in the Introduction, they mentioned that chronic anal fissures very rarely heal spontaneously. Random variables may be responsible for this fact. It was not stated in the study whether any of the patients were administered nitric oxide donors or calcium blockers orally, which might have helped to heal fissures in patients in the placebo group. It was not obvious, either, whether patients with symptomatic haemorrhoids were included in the study — this might have influenced the results. Moreover, in the case of small groups of patients, the numbers of patients resistant to botulinum toxin-A (BT-A) have a large influence on the results. A significant rate of subjective improvement in the group of patients treated with placebo could be attributed to the inclusion of laxatives, ointments and suppositories. The authors did not mention this in their Discussion, where they compared their work with that carried out by Maria et al. It is a pity that, in cases in which no positive effects of treatment were observed, the patients were not administered an additional injection of 100 U. As the effects of the toxin last for about 3 months, it could have been established whether the cumulative dose of BT-A in the group previously treated with BT-A had a positive effect on treatment (which could have been expected) and whether the other group, treated with placebo, was equally sensitive to BT-A. We agree with Siproudhis et al. that the dose of Dysport used in their study was equal to the dose of Botox applied by Maria et al. However, it was not stated whether the botulinum treatment in both cases was identical. Siproudhis et al. tried, but did not manage, to dispel the doubts in this respect saying, However, the internal anal sphincter is easy to identify ... , as it is not known how deep the toxin was administered in both studies. In addition, Jost et al., the first to use botulinum toxin in anal fissure treatment, reported that it is very difficult to be sure that the injection has been administered into the internal anal sphincter as it is very thin (although it can be felt during manual examination). The results of the work by Siproudhis et al. should be interpreted as follows: there were no differences found between 100 U of Dysport and placebo with regard to the treatment of chronic anal fissure. It cannot be stated, however, whether such a result exists because of the size of the population examined, although the authors stated that, we did not observe any trend, whatever variable was considered, towards significant results . My research group has observed that the administration of higher doses of BT-A can improve the results of chronic anal fissure treatment. Brisinda et al. also reported that ...higher doses led to a higher success rate . They observed 96% anal fissure healing after the application of 35 U of Botox (1 labelled unit of Botox is equivalent to 3–6 labelled units of Dysport). The title Lack of efficacy of botulinum toxin in chronic anal fissure , with no doses mentioned, is misleading. We must remember that the results of BT-A treatment depend on the toxin dose.

Gastric mucosa-associated lymphoid tissue lymphoma complicated with hemophagocytic syndrome in an elderly woman

Dear Editor, Hemophagocytic syndrome (HPS) has been described in association with a variety of lymphomas, most commonly Tor NK-cell-type tumors [1]. More rarely, HPS occurs in association with aggressive B-cell tumors, including diffuse large B-cell lymphoma and intravascular large B-cell lymphoma [2, 3]. Although these lymphoma-associated forms of HPS generally show a poor prognosis [1], appropriate therapy for the underlying lymphoma can lead to the resolution of this condition [2]. Here, we report an elderly patient with mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach, who developed HPS during the course of the disease. An 80-year-old woman, who had been treated for cognitive disorder in a psychiatric clinic, presented with upper abdominal discomfort. Endoscopy of the upper gastrointestinal tract revealed multiple mucosal lesions from the lower body to the antrum of the stomach, including superficial erosions/ulcers and “gastritis-like” erythema (Fig. 1a). A biopsy demonstrated mucosal infiltrates of small lymphoid cells showing a monocytoid appearance associated with lymphoepithelial lesions, being compatible with gastric MALT lymphoma (Fig. 1b). Tests for Helicobacter pylori were positive. Triple therapy comprising lansoprazole, amoxicillin, and clarithromycin was initiated; however, the patient soon discontinued treatment due to the development of an allergic skin rash. As the patient’s symptoms persisted, she was finally admitted to our hospital 4 months after the initial presentation. On examination, she was febrile and icteric, and the abdomen showed hepatosplenomegaly. There was no superficial lymphadenopathy. The blood counts were: hemoglobin, 11.5 g/dl; white blood cell count, 2,500/μl with 86% neutrophils; and platelet count, 117×10/μl. The blood chemistry values included: total bilirubin, 9.2 mg/dl; asparate aminotransferase, 1,446 IU/l; alanine aminotransferase, 387 IU/l; alkaline phosphatase, 1,439 IU/l; lactate dehydrogenase, 1,851 IU/l; and γ-glutamyl transpeptidase, 143 IU/l. The level of triglyceride was 294 mg/dl, fibrinogen—83 mg/dl, fibrinogen/fibrin degradation product—15.5 μg/ml, ferritin—2,929 ng/ml, and soluble interleukin-2 receptor was as high as 17,388 U/ml. A computed tomographic scan and ultrasonography of the abdomen revealed hepatosplenomegaly and wall thickening of the gall bladder (Fig. 1c); the latter finding suggested portal cellular infiltration [4]. Bone marrow specimens obtained from the iliac crest revealed hypocellular marrow with increased numbers of macrophages ingesting blood cells (Fig. 1d); no lymphoma cells were apparent on microscopic examination or flow cytometric analysis. A diagnosis of gastric MALT lymphoma complicated with HPS was made. The patient was treated with chemotherapy consisting of vincristine, cyclophosphamide, prednisolone, and doxorubicin, in combination with rituximab. HPS responded well to the treatment; H. Ohno (*) Department of Hematology, Takeda General Hospital, 28-1, Mori-minami-cho, Ishida, Fushimi-ku, Kyoto 601-1495, Japan e-mail: hitoshi-ono@fm2.seikyou.ne.jp

Inflammatory tumor in pancreas: a novel complication after endoscopic injection of cyanoacrylate for gastric fundal varices.

To the Editor: Bleeding from gastric fundal varices (FV), a complication of portal hypertension resulting from cirrhosis, can be massive and remains a major therapeutic challenge. We read with great interest the article by Sato et al.1 in the Journal of Gastroenterology, about inflammatory tumor of the tail of the pancreas as a late complication after endoscopic ablation of FV with n-butyl2-cyanoacrylate (NBCA). Their endoscopic treatment was performed twice. We speculate that they used 2 ml of NBCA diluted with Lipiodol (at a ratio of 1.4 : 0.6) per injection. Did they performed two treatment sessions, or were two injections given at one treatment session? We strongly agree with the use of NBCA for achieving hemostasis of bleeding from FV.2 However, because most FV are associated with a large gastrorenal shunt,3 the value of NBCA for treating large (>12-mm-diameter) FV without active bleeding is controversial, due to the potential for systemic complications related to embolization through the gastrorenal shunt.4 Therefore, after achieving initial hemostasis with NBCA, portal hemodynamics should be evaluated to decide the most appropriate subsequent therapeutic strategy. Balloon-occluded retrograde transvenous obliteration (BRTO) is a recently developed method for treating FV associated with a gastrorenal or gastrophrenic shunt; the method employs ethanolamine oleate, a common sclerosant.5 B-RTO achieves excellent prevention of recurrent bleeding with few major complications (such as fever, hemoglobinuria, and worsening of esophageal varices), even in patients with poor liver function.6 The main limitation in using B-RTO in an emergency setting is the requirement for temporary control of bleeding with or without NBCA. Recently, multi-detector row computed tomographic angiography has been able to provide excellent visualization of draining vessels such as gastrorenal or gastrophrenic shunts.7 When FV are not associated with catheterizable draining veins, additional endoscopic obliterative therapy may be justifiable. For the elective treatment of FV, the optimal ratio of NBCA to Lipiodol has not yet been determined. A ratio of more than 70% means that hardening starts to occur in the injection catheter.3 Accordingly, NBCA-Lipiodol mixture with a high ratio must be injected rapidly, and distal embolization is likely to occur. Eradication of the feeding veins, as well as the varices, is necessary for the prevention of recurrent bleeding.8 Slow injection of an NBCA-Lipiodol mixture (with a ratio of more than 40% and less than 70%3) until visualization of the feeding vein occurs under fluoroscopic monitoring9 might be useful to avoid the novel complication reported by Sato et al.1 Akio Matsumoto, Kengo Takimoto, Yuuki Yamauchi, Masashi Kuchide, and Hideto Inokuchi Department of Gastroenterology, Takeda General Hospital, 281 Ishida Moriminami-cho, Fushimi-ku, Kyoto 601-1495, Japan