Kenji Tominaga

Predictive histopathologic factors for lymph node metastasis in patients with nonpedunculated submucosal invasive colorectal carcinoma.

PURPOSERisk factors for lymph node metastasis in patients with nonpedunculated submucosal invasive colorectal carcinoma remain to be characterized. This study examines the relationship between lymph node metastasis and clinicopathologic factors in nonpedunculated submucosal invasive colorectal carcinoma.METHODSThe study cohort comprised 155 patients who had undergone surgical treatment for nonpedunculated submucosal invasive colorectal carcinoma. The clinicopathologic factors investigated included gender, age, tumor location, macroscopic type, tumor size, histologic type and grade, intramucosal growth pattern, lymphatic invasion, venous invasion, degree of focal dedifferentiation at the submucosal invasive front, status of the remaining muscularis mucosa, and the depth and width of submucosal invasion.RESULTSLymph node metastases were found in 19 patients (12.3 percent). Univariate analysis showed that lymphatic invasion, focal dedifferentiation at the submucosal invasive front, status of the remaining muscularis mucosa, and depth of submucosal invasion all had a significant influence on lymph node metastasis. Multivariate analysis showed lymphatic invasion (P = 0.014) and high-grade focal dedifferentiation at the submucosal invasive front (P = 0.049) to be independent factors predicting lymph node metastasis. No lymph node metastasis was found in tumors with a depth of submucosal invasion of <1.3 mm.CONCLUSIONSLymphatic invasion and high-grade focal dedifferentiation at the submucosal invasive front are important predictors of lymph node metastasis in patients with nonpedunculated submucosal invasive colorectal carcinoma. Depth of submucosal invasion can be used as an identifying marker for patients who do not require subsequent surgery after endoscopic resection.

A prospective randomized study on the benefits of a new small-caliber colonoscope

BACKGROUND AND STUDY AIMS We compared the performance efficiency of a newly developed small-caliber colonoscope (PCF-PQ260 L) with passive bending, high force transmission, and an outer diameter of 9.2 mm with that of a standard colonoscope, in female and male patients, particularly with regard to passage through acute angulations or into the proximal colon. PATIENTS AND METHODS A total of 330 patients were randomly allocated to undergo small-caliber (n = 164) or standard (n = 166) colonoscopy. The patients were assessed for pain using a visual analogue scale (0 = none, 100 = extremely painful), and for cecal intubation, withdrawal time, difficulty of colonoscopy, dosage and level of sedation used, and any complications. RESULTS Median maximum pain and overall pain during colonoscopy were significantly lower in the small-caliber group than in the standard group in women (25 vs. 45, P < 0.001 and 15 vs. 26, P = 0.001, respectively), whereas no significant differences were seen in men (8 vs. 10, P = 0.103 and 16 vs. 20, P = 0.166, respectively). Furthermore, no significant differences were seen between groups in cecal intubation rate or time to cecum in all patients or by sex. CONCLUSIONS Use of the small-caliber colonoscope reduced pain in female patients, but offered no advantage over standard colonoscopy in male patients. The performance of the small-caliber colonoscope was equivalent to that of the standard colonoscope in terms of cecal intubation rate and time to cecum, regardless of the sex of the patient.

EFFICACY OF MAGNIFYING COLONOSCOPY FOR THE DIAGNOSIS OF COLORECTAL NEOPLASIA: COMPARISON WITH HISTOPATHOLOGICAL FINDINGS

Background:  Some authors have reported a good correlation between the shape and arrangement in the orifice of mucosal crypt (pit pattern) in the diagnosis of colorectal lesions and histopathological findings. However, there remains no good consensus on the definition of irregularity in configurations.

Favorable long-term clinical outcome of uncovered D-weave stent placement as definitive palliative treatment for malignant colorectal obstruction.

BACKGROUND: Most self-expandable metallic stents for colorectal placement are uncovered because of the high migration rate of covered stents. However, the optimal stent design for colorectal use remains unclear. OBJECTIVE: The purpose of this study was to evaluate the efficacy and safety of a double-wire woven uncovered stent for definitive palliative treatment of malignant colorectal obstruction. DESIGN: This study was a prospective, single-arm, observational clinical study of patients enrolled between December 2005 and September 2010. SETTINGS: This study was conducted at a referral hospital in Japan. PATIENTS: Twenty-four consecutive patients with malignant colorectal obstruction were included in the study. INTERVENTIONS: A double-wire woven uncovered stent was placed by use of a standard through-the-scope endoscopic placement technique. MAIN OUTCOME MEASURES: Technical, initial clinical, and long-term clinical success were measured. Long-term clinical success was defined as sustained relief of obstructive symptoms without reintervention until the patient’s death. RESULTS: The Karnofsky performance status score before stent placement was 60 (median, interquartile range, 42.5–67.5). Twenty of 24 patients had primary colorectal cancer, and 4 had extracolorectal malignancies. The site of obstruction was the ascending colon in 10 patients, descending colon in 4 patients, sigmoid colon in 7 patients, and rectum in 3 patients. Technical, initial, and long-term clinical success rates were 100%, 100%, and 83%. Median stent patency time was 149 days (interquartile range, 45–198 days). Median survival time after stent placement was 155 days (interquartile range, 68–231 days). Four patients (17%) had negative outcomes including stent occlusion by tumor ingrowth (8%) and stent migration (8%). The highest Karnofsky performance status score after stent placement was 70 (median; interquartile range, 50–70). The Karnofsky performance status score improved after stent placement (p = 0.002). LIMITATIONS: This study was limited because it was a single-arm, single-center study, and it had a small sample size. CONCLUSIONS: Endoscopic placement of double-wire woven uncovered stents is effective and safe as definitive palliative treatment for patients with malignant colorectal obstruction.

Comparison of modified introducer method with pull method for percutaneous endoscopic gastrostomy: prospective randomized study.

Aim:  The pull method is associated with a high incidence of percutaneous endoscopic gastrostomy (PEG) site infection. The introducer method has been shown to be less likely to cause infection, because it avoids the passage of a tube through the oropharynx. The aim of the present study was to compare the modified introducer method with the pull method for PEG.

Factors associated with delayed gastric emptying in patients with stent placement for malignant gastric outlet obstruction

Background and study aims: Delayed gastric emptying (DGE) is an important factor in determining the clinical outcome in patients with stent placement for malignant gastric outlet obstruction but the factors associated with DGE remain unclear. The aim of this study was to investigate whether clinicopathologic data could be used to identify the factors for DGE in such patients. Patients and methods: A prospective, single-arm, observational clinical study was performed in a referral hospital in Japan. A total of 54 patients with stent placement for malignant gastric outlet obstruction were enrolled. A gastric emptying scintigraphy test was performed 1 week after stent placement. The relationship between DGE and clinicopathologic factors was investigated, and also the relationship between DGE and stent patency time, eating period (when the patient was able to maintain oral intake), and survival time. Results: A total of 38.9 % (21 /54) of patients had DGE. The following were identified as independent predictive factors of DGE: opioid use (odds ratio, 5.32; 95 % confidence interval [95 %CI], 1.07 – 26.41; p = 0.04), chemotherapy before stent placement (odds ratio, 8.03; 95 %CI, 1.85 – 34.95; p = 0.006), and smaller stent diameter (odds ratio, 13.59; 95 %CI, 1.72 – 107.41; p = 0.01). No relationship was found between DGE and the level of oral intake, stent patency time, eating period, and survival time. Conclusions: The factors associated with DGE after stent placement include those associated with the patient’s tumor as well as factors relating to their treatment, including stenting. The clinical and functional results after stent placement appear to be unrelated to the gastric emptying findings.

Left renal pseudocyst associated with alcoholic chronic pancreatitis.

We report a case of a man in his forties with left renal pseudocyst formation associated with alcoholic chronic pancreatitis. Laboratory tests revealed white blood cell count 17.8×109/L (reference range: 4–9×109/L); C-reactive protein 20.4 mg/dL (0.0–0.3 mg/dL); serum amylase 305 U/L (65–160 U/L); lipase 81 U/L (5–35 U/L); blood urea nitrogen 21 mg/dL …

Gastric epithelioid-cell granuloma in a paediatric patient with Crohn's disease.

A youth in his later teenage years was referred to our hospital with erythema nodosum in his lower extremities. He had previously received surgical treatment for an anal fistula at another hospital. The patient presented with weight loss and fever but had no abdominal pain, diarrhoea, bloody stools, no upper gastrointestinal symptoms and a faecal culture was negative. Ileocolonoscopy revealed longitudinal ulcers in the terminal ileum and multiple erosions from caecum to rectum. Crohns disease (CD) seemed the most likely …

Missed ascending colon cancer in an older patient with extensive ulcerative colitis.

A man in his early 70s with a 15-year history of extensive ulcerative colitis (UC) was referred for surveillance ileocolonoscopy (SI). He had no high-risk factors for UC-associated colorectal cancer (CRC)1 except for the extent of active mucosal inflammation. Two years ago, he had undergone an SI with surveillance biopsy of the entire colorectum with no dysplasia or CRC detected. He had no surveillance the previous year despite a recommendation for annual SI. An ascending colon cancer was detected in the subsequent ileocolonoscopy (figure 1). There was no colorectal dysplasia, but biopsy revealed active …

Gastrointestinal bleeding caused by gastritis cystica polyposa

A man in his 50s presented with a 2-day history of melaena. He had undergone a Billroth II (B-II) gastrectomy for a benign duodenal ulcer 32 years ago. He had a history of heavy alcohol intake and smoked 20 cigarettes per day. Laboratory testing revealed anaemia. Oesophagogastroduodenoscopy revealed a small amount of blood in the gastric remnant and a polypoid lesion at the B-II gastroenterostomy …