Masaki Taruishi

Efficacy of high-frequency ultrasound probes for the preoperative staging of invasion depth in flat and depressed colorectal tumors ☆ ☆☆ ★

BACKGROUND Flat and depressed nonpolypoid types of colorectal tumors have drawn much attention. Since endoscopic mucosal resection technique is available, it is of great importance to distinguish intramucosal carcinoma from invasive carcinoma because determination of the invasion depth is essential for choosing this therapy. The usefulness of high-frequency (20 MHz) ultrasound probes for preoperative staging of invasion depth in this type of colorectal tumor was evaluated. METHODS Forty-nine cases of flat and depressed tumors were examined with the ultrasound probe and diagnostic accuracy was confirmed by comparing ultrasonic images with the pathologic findings of the specimens resected either by endoscopic mucosal resection or surgical operation. RESULTS The normal colonic wall was visualized as a nine-layered structure and the muscularis mucosae was depicted in 37 (76%) of 49 cases. Flat and depressed tumors were visualized as hypoechoic lesions and the invasion depth was accurately diagnosed in 43 (88%) of 49 lesions. CONCLUSIONS High-frequency ultrasound probes proved to be useful in determining the invasion depth and therapeutic strategy in flat and depressed colorectal tumors.

Invasion depth diagnosis of depressed type early colorectal cancers by combined use of videoendoscopy and chromoendoscopy

BACKGROUND Depressed type early colorectal cancers are found less frequently than other polypoid cancers although they have a higher submucosal invasion rate. Recently videocolonoscopy and chromoendoscopy have become available and precise descriptions of these lesions are now routine. Because endoscopic mucosal resection is designated for intramucosal and focally extended submucosal (m-sm1) cancers, an evaluation of the characteristic findings indicating invasion depth with these modalities is important. METHODS Between January 1991 and March 1996, 64 depressed type early colorectal cancers were detected and treated. When a faint abnormality of the mucosa was suspected by routine videocolonoscopy, 0.1% of indigo carmine solution was sprayed on the mucosal surface (chromoendoscopy). Colonoscopic findings of m-sm1 cancers and moderately and massively extended submucosal (sm2-3) cancers were retrospectively reviewed and compared with confirmed histologic findings. RESULTS Characteristic colonoscopic findings needed for surgical operation were as follows: (1) expansion appearance, (2) deep depression surface, (3) irregular bottom of depression surface, and (4) folds converging toward the tumor. By using these findings, the invasion depth of depressed type early colorectal cancers could be correctly determined in 58 of 64 lesions (91%). CONCLUSIONS Characteristic colonoscopic findings obtained by a combination of videocolonoscopy and chromoendoscopy are useful for determination of the invasion depth of depressed type colorectal cancers, an essential factor in choosing a treatment modality.

Experimental ileitis in dogs and colitis in rats with trinitrobenzene sulfonic acid —Colonoscopic and histopathologic studies—

SummaryUsing a novel experimental model of chronic enterocolitis described by Morriset al., we observed sequential changes of mucosal lesions endoscopically and performed histopathological studies. Fisher rats were rectally administered 25 mg of trinitrobenzene sulfonic acid (TNBS) dissolved in 0.5 ml of 50% ethanol (ET). The combination treatment of TNBS and ET produced colitis in rats for over 3 weeks. TNBS itself did not induce any lesions. ET alone induced mucosal lesions, but their severity was much smaller than that induced by TNBS/ET. As an animal model much closer to human inflammatory bowel disease, we have newly developed a camine model of chronic ileitis. Adult mongrel dogs were administered 10 ml of 100% ethanol and 1 g of TNBS dissolved in 10 ml of distilled water (i.e., 100 mg/ml solution) through a 4-lumen double balloon tube which was inserted into the ileum. The TNBS/ET-induced ileitis in dogs persisted for 8 weeks. The mucosal lesions induced by TNBS/ET were characterized as annular or longitudinal ulcers accompanied by extensive lymphocyte infiltration and granulomas, which were similar to macro- and microscopic findings observed in human Crohn’s disease. Endoscopic examinations were a valuable tool to obtain sequential information on the development of inflammatory changes in each individual animal. Our canine model would provide various advantages for the study of functional impairment in chronic enterocolitis as well as for the detection of potential therapeutic agents in the human counterpart.

Endoscopic Scoring System for Experimental Colitis with Trinitrobenzene Sulfonic Acid in Rats

Abstract: Experimental colitis models require serial sacrifice of animals to confirm the evolution of the inflammatory process. Endoscopy may possibly enable us to detect sequential changes in the lesions throughout the inflammatory process without killing animals. Using rat colitis induced with trinitrobenzene sulfonic acid (TNBS) after the study by Morris et al. the accuracy of endoscopic examination was investigated by comparing endoscopic findings with histologic findings.

Unruptured cystic artery pseudoaneurysm accompanied by Mirizzi syndrome: a report of a case

Pseudoaneurysm of the cystic artery is a rare complication of cholecystitis. 34 cases have been reported from 1976 to 2012, searched on MEDLINE and most of the cases have presented with gastrointestinal bleeding. We report the third case of an unruptured pseudoaneurysm of the cystic artery associated with calculous cholecystitis. An 85-year-old female presented to the emergency unit with epigastric pain and jaundice. Laboratory data and contrast-enhanced computed tomography (CT) revealed calculous cholecystitis and Mirizzi syndrome accompanied by a pseudoaneurysm in the gallbladder. Color Doppler ultrasonography (US) clearly demonstrated the pulsatile pseudoaneurysm. After biliary drainage and antimicrobial therapy, selective hepatic angiography with the aim of providing transcatheter arterial embolization was performed but the pseudoaneurysm had already thrombosed spontaneously. Open cholecystectomy was successfully carried out. Histological specimens demonstrated the pseudoaneurysm with organized thrombus in the epithelial wall of the gallbladder thickened with severe fibrosis. It is suggested that cholecystitis with unusual symptoms such as gastrointestinal bleeding requires immediate enhanced CT and US with Doppler imaging in order not to overlook a rare but life-threatening pseudoaneurysm.

7122 Can endoscopic retrograde ileography alone assess the disease activity in crohn's disease ?

Background: The ileum is frequently affected site of the small intestine in Crohns disease (CD). However, precise evaluation of disease activity is sometimes difficult by small bowel enteroclysis (SBE) because of multiple overlapping loops. We have reported the usefulness of balloon occluded endoscopic retrograde ileography (ERIG) that is a combination of colonoscopic and radiological ileal examination for the evaluation of the disease activity not only in the colon but also in the distal ileum at one procedure (Taruishi M. et al. Radiology; in press). Aim: To evaluate weather ERIG alone can represent the disease activity of the whole small intestine without SBE information. Patients and Methods: Between May 1990 and May 1999, 50 times of both ERIG and SBE were performed within two weeks in 33 cases of known CD. Three cases were colitis, 12 were ileocolitis and 18 were ileitis type of CD. Written informed consent was obtained. Briefly, ERIG procedures were as follows. Total colonoscopy was performed, followed by intubation to the ileum. After a guide wire was introduced through the forceps channel into the ileum, only colonoscope was removed. Silicon balloon tube was inserted into the terminal ileum and fixed by the expanded balloon. After barium surfate and air was injected followed by several turning of position, double contrasted radiography was obtained. Disease activity was diagnosed independently on ERIG and SBE.We compared the disease activity assessed by ERIG with that by SBE. Results: Of 50 procedures, both ERIG and SBE revealed identical CD activity; active disease in 25 procedures and remission in 9. On the other hand, in 10 procedures ERIG showed active disease but SBE did not, and SBE showed active disease but ERIG did not in 6 procedures. ERIG could represent and evaluate the disease activity of whole small bowel in 44 (88%) of 50 procedures. The reasons to fail in evaluating the disease activity by ERIG alone were visualization of only short part of the distal ileum (less than about 100 cm) in 4 procedures, severe stricture in 1 procedure and active disease affected only in the jejunum and remission in the ileum in 1 procedure. Conclusion: Because most CD affected distal ileum, ERIG could represent the disease activity of CD not only in the colon but also in the whole small bowel, and assess it at one procedure without SBE.

4478 Endoscopic prediction of early postsurgical recurrence in patients with crohn's disease.

Background/Aim: High relapse rate of re-stenosis at the site of intestinal anastomosis in postsurgical patients with Crohns disease is reported from several study groups. These studies revealed that appearance of endoscopic changes at the site of anastomosis frequently preceded to production of typical symptoms. However, it is still unclear when endoscopic observation should be performed, or how we can detect risky patients of earlier recurrence of anastomotic re-stenosis. To find out the predictive markers for earlier recurrence, we have prospectively observed the sequential changes of endoscopic features appeared at the site of anastomosis, from immediately after surgery to recurrence of typical stenotic lesions. Patients/Methods: Twenty-nine patients with Crohns disease who underwent intestinal/colonic resection in Asahikawa Medical College Hospital from 1990 to 1999 were subjected in this study. All the patients had ileocolonic or colo-colonic anastomosis, which were accessible by colonoscopy. Endoscopic observation and combined endoscopic retrograde ileography (ERIG) were performed at 1,6, and 12 months after surgery. One year after surgery, these observations were repeated at once a year. Results: At 1 month after surgery, 24.9% (7/29) patients already had small aphthous ulcer(s) at the site of anastomosis. These lesions were not disappeared, then incidence of relapsing these lesions were increased ( 6 months; 48.3% (14/29) 12 months; 65.5% (19/29)). Stenotic lesions due to multiple or longitudinal ulceration of anastomosis were detected from 2 years after surgery, in the patients of ulcer(+) at 12 months (31.6% (6/19)). However, no patients developed stenotic lesions within 5 years after surgery among 10 patients of ulcer (-) at 12 months. Significant statistical correlation in Logrank test was detected between ulcer (+) at 12 months and development of stenosis, or requirement of re-operation. Other factors such as disease duration, administration of 5-ASA, nocternal nutritional supprement with elemental diet, or methods of anastomosis did not correlate with postsurgical relapse rate in our patients. Conclusion: Developement of aphthous or small ulcer(s) within a year after surgery at the site of anastomosis is a risk factor of earlier re-stenosis or re-operation. Endoscopic evaluation of anastomotic areas at 12 months after surgery is necessary in management for postsurgical CD patients.