Masanobu Mizuguchi

Endoscopic submucosal tumorectomy for gastrointestinal submucosal tumors restricted to the submucosa: a new form of endoscopic minimal surgery

BACKGROUND Endoscopic minimally invasive therapy for submucosal tumors of the gastrointestinal tract by use of endoscopic ultrasound has not yet come into widespread use, and this technique has not been fully evaluated. We therefore investigated this method of treatment in patients with gastrointestinal submucosal tumors. METHODS Forty-five patients with suspected gastrointestinal submucosal tumors (esophagus [5], stomach [1], duodenum [16], colon [23]) based on barium enema studies and endoscopy underwent endoscopic ultrasound by the water-filled or balloon method. The layer of origin and the internal echogenicity of the lesions were evaluated. After confirming that the tumors were submucosal, the lesions were resected using injection of physiological saline solution and electrocautery. RESULTS Using a one-channel or two channel method, all tumors were completely resected without serious complications and the diagnosis was histologically confirmed. Ulceration at the site of resection healed within 2 to 4 weeks (mean 23 days) and there has been no local recurrence. CONCLUSIONS Our technique of endoscopic submucosal tumorectomy appears to be a safe and useful diagnostic-cum-therapeutic procedure for gastrointestinal submucosal tumors.

Endoscopic ultrasonography for demonstrating loss of multiple-layer pattern of the thickened gallbladder wall in the preoperative diagnosis of gallbladder cancer

Abstract The purpose of this study was to elucidate the roles of endoscopic ultrasonography (EUS), conventional US, CT, and MRI in differential diagnosis of gallbladder wall thickening. We scrutinized images for the presence of the multiple-layer patterns of the thickened gallbladder walls during preoperative images (EUS, n = 22; US, n = 23; CT, n = 20; MRI, n = 15) and retrospectively correlated them with surgical results in 25 patients. The pathological diagnoses included 7 gallbladder cancers, 9 cases of chronic cholecystitis, 5 cases of xanthogranulomatous cholecystitis, and 4 cases of adenomyomatosis. Multiple-layer patterns of gallbladder wall were observed in patients with inflammatory and benign diseases by US, EUS, CT, and MRI. This pattern was demonstrated by EUS more efficiently compared with other means of imaging. All subjects with loss of multiple layers were finally diagnosed by use of EUS as having gallbladder cancer at surgery. Loss of multiple-layer patterns of the gallbladder wall demonstrated by EUS was the most specific finding in diagnosing gallbladder cancer.

Oral dimethyl sulfoxide for systemic amyloid A amyloidosis complication in chronic inflammatory disease: a retrospective patient chart review.

BackgroundAmyloid A amyloidosis is an obstinate disease complication in chronic inflammatory disease, and there are few effective therapies. The objective of this study was to investigate the effect of oral dimethyl sulfoxide (DMSO) on amyloid A amyloidosis.MethodsFifteen secondary amyloid A amyloidosis patients (4 men, 11 women; age, 23–70 years) were treated with DMSO between 1995 and 2003. DMSO was administered orally in all patients at a dose of 3–20 g/day. The clinical symptoms together with the renal and gastrointestinal functions were evaluated before and after treatment.ResultsAmong the 15 patients, amyloid A amyloidosis was a complication of rheumatoid arthritis (RA) in 10, of Crohns disease in 4, and of Adult Stills disease in 1. Nine cases mainly involved the kidney, with renal dysfunction and proteinuria, five mainly involved the gastrointestinal tract, with protein-losing gastroenteropathy and intractable diarrhea, and one involved both gastrointestinal and renal amyloidosis. DMSO treatment was successful in 10 (66.7%) of the 15 patients (RA, 6/10; Crohns disease, 4/4; Adult Stills disease, 0/1). Eight weeks of DMSO administration improved the renal function and proteinuria in five out of ten renal amyloidosis patients, but had no effect on those patients with severe and/or advanced renal dysfunction. With regard to gastrointestinal amyloidosis, gastrointestinal symptoms, including diarrhea and protein-losing gastroenteropathy, were improved in six patients. No serious side effects were encountered with the DMSO treatment.ConclusionsOral administration of DMSO is an effective treatment for amyloid A amyloidosis, especially for gastrointestinal involvement and the early stage of renal dysfunction.

Gastric lesions in 76 patients with adult T‐cell leukemia/lymphoma: Endoscopic evaluation

Adult T‐cell leukemia/lymphoma (ATLL) is caused by human T‐lymphotropic virus type I. Gastric lesions in ATLL have not been described precisely, whereas the clinical features of ATLL have been well documented. The goal of the present study was to review gastric lesions, including gastric involvement, of patients with ATLL who were admitted to our hospital.

Rectal Stenosis Associated with Fungal Peritonitis: A Complication of Continuous Ambulatory Peritoneal Dialysis

Masako Uchida, Division of Nephrology, Department of Internal Medicine, Saga Medical School, Sanbonsugi, Nabeshimamachi, Saga 840-01 (Japan) Dear Sir, Fungal peritonitis is a rare but serious complication in patients on continuous ambulatory peritoneal dialysis (CAPD). We report on a patient on CAPD who developed severe rectal stenosis during the course of fungal peritonitis. Case Report A 56-year-old Japanese woman with a history of CAPD for 1.5 years was admitted to our hospital with the diagnosis of Staphylo-coccus aureus peritonitis on October 8 in 1988. After admission, she received cefazolin and tobramycin intraperitoneal and consequently abdominal pain rapidly disappeared. But she began to complain of abdominal pain again on the 13th hospital day. The bacteriological examination of the peritoneal fluid on the 18th hospital day revealed Candida parapsilosis as a causative agent. An X-ray film of the abdomen disclosed a curl-type Tenckhoff catheter placed in the pelvis. We started antifungal treatment with intravenous miconazole and oral fluorocytosine. Since peritonitis did not improve in spite of the treatment, we removed the Tenckhoff catheter on the 20th hospital day. Some fibrin clots were noted in a curl portion of the removed catheter. The peritonitis improved gradually, accompanied by the decrease of abdominal pain. On the 24th hospital day, she developed tarry stool without any symptoms such as hypotension, abdominal pain and aggravation of peritonitis. Emergent gastroduodenoscopic examination showed no significant abnormality. Melena disappeared gradually over several days. Hematocrit did not change during this episode. Barium enema examination performed on the 46th hospital day revealed severe stenosis about 5 cm in length in the upper third of the rectum (fig. 1). A colonoscopic examination showed clear stricture without mucosal changes such as atrophy, edema, hyperemia and fibrosis. A computed tomographic scan of the pelvis revealed no spaceoccupying lesion which surrounded the rectum. Examination of the small intestine showed no significant abnormality. Fig. 1. Barium enema examination reveals severe stenosis about 5 cm in length in the upper third of the rectum. Discussion

Human T-cell lymphotropic virus-associated primary gastric lymphoma.

Adult T-cell leukemia/lymphoma (ATLL) was the first human cancer found to be closely associated with the retrovirus human T-cell lymphotropic virus type I (HTLV-I) (1–5), and it shows diverse clinical features (5, 6). According to a report by the Japan Lymphoma Study Group (7), clinical subtypes of ATLL are divided into four groups: lymphoma, acute, chronic, and smoldering. One characteristic clinical feature of ATLL is involvement of many organs (1–9), and gastrointestinal involvement is important for diagnostic criteria in the lymphoma and acute types of ATLL (6, 7). We previously demonstrated in gastric endoscopic examination that the ratio of gastric involvement of ATLL cells was 23 of 76 cases of ATLL (30.3%), and this ratio was related to the survival period of ATLL patients (9). The stomach is the common extranodal organ for non-Hodgkin’s lymphoma, and most primary gastric non-Hodgkin’s lymphomas are of B-cell origin, and primary gastric T-cell lymphoma is not common (10). ATLL is a T-cell origin lymphoma, and this is the first clinical report of collected cases of HTLV-I associated primary gastric lymphoma (primary gastric ATLL), although there have been several reports on gastric involvement of ATLL (9, 11–14). We describe three primary gastric ATLL cases among 114 ATLL patients. In these cases, involvement of ATLL is limited to the stomach and the regional lymph nodes. General Data. Between 1981 and 1997, 114 patients visiting our hospital were diagnosed as having ATLL. Diagnosis of ATLL was made by the following criteria: 1) the presence of anti-HTLV-I antibodies; 2) lymphoid neoplasia proven histologically and/or hematologically: abnormal lymphoid cells with nuclear irregularity of lobulations and cloverleaf forms; 3) T-cell nature of tumor; and 4) monoclonal integration of HTLV-I provirus in chromosomal DNA (15). The classification of clinical subtypes of ATLL is according to the report of the Japan Lymphoma Study Group (7). Clinical subtypes of ATLL are divided into four groups: lymphoma, acute, chronic and smoldering types (lymphoma: 58 cases, acute: 20 cases, chronic: 6 cases, and smoldering: 4 cases). Eighteen of 58 lymphoma-type ATLL patients had gastric involvement of ATLL cells, and 3 of the 58 cases were primary gastric ATLL. Gastric lesions of ATLL were diagnosed when the tumor cells, which had T-cell nature indicated by positive surface marker (16) and HTLV-I genomic integration with either in situ hybridization or polymerase chain reaction (16), were demonstrated in the gastric tissue specimens. Primary lymphoma in the stomach was diagnosed according to the criteria of Dawson et al (17), which include the following features: no palpable adenopathy or mediastinal adenopathy on radiographic examination; a normal peripheral blood smear; disease mainly confined to the stomach at laparotomy or diagnostic imaging; lymphadenopathy being regional or retroperitoneal in location; and a lack of hepatic or splenic involvement. Manuscript received June 5, 1999; revised manuscript received October 5, 2000; accepted December 28, 2000. From the Departments of *Internal Medicine and Gastrointestinal Endoscopy, †Surgery, ‡Radiology and §Pathology, Saga Medical School, Saga, Saga 849-8501, Japan. Address for reprint requests: Dr. Kazuma Fujimoto, Department of Internal Medicine and Gastrointestinal Endoscopy, Saga Medical School, Nabeshima, Saga, Saga 849-8501, Japan. Digestive Diseases and Sciences, Vol. 46, No. 7 (July 2001), pp. 1381–1386

Bleeding and stenosis caused by reflux esophagitis was not common in emergency endoscopic examinations: a retrospective patient chart review at a single institution in Japan

BackgroundBleeding and stenosis are serious complications of reflux esophagitis, although few studies have been performed in Japan regarding these complications. This study aimed to indicate the characteristics of reflux esophagitis observed during emergency endoscopic examination in Japan.MethodsAll subjects who had emergency endoscopic examination performed between 1990 and 2004 at Saga Medical School Hospital were evaluated. Patients with endoscopic reflux esophagitis were evaluated with a retrospective patient chart review.ResultsA total of 1621 subjects underwent emergency endoscopy; 1420 of the endoscopies were because of hematemesis or melena. Endoscopic examination revealed that 19 cases with bleeding were caused by reflux esophagitis (19/1621, 1.2%). The 19 patients with bleeding and the four patients with stenosis (0.2%) had emergency endoscopy performed for complications of reflux esophagitis. The Los Angeles classification of these 23 cases showed that most were severe esophagitis (grade A, 0; B, 2; C, 8; and D, 13). The frequency of comorbidity with diabetes mellitus and collagen disease and the proportion of heavy drinkers were higher in patients who received emergency endoscopy because of reflux esophagitis than in those diagnosed with reflux esophagitis but who received emergency endoscopy because of other diseases.ConclusionsRelatively small numbers of patients with reflux esophagitis undergo emergency endoscopy in Japan, and most such patients have underlying diseases, including diabetes mellitus and collagen disease. This finding is supported by a previous report that severe esophagitis is not common in Japan.

CASE REPORT: Primary Gastrointestinal Follicular Center Lymphoma Resembling Multiple Lymphomatous Polyposis

The most common site of extranodal involvement by non-Hodgkin lymphoma is the gastrointestinal tract, accounting for 30–69% of all cases (1, 2), whereas gastrointestinal lymphoma is a relatively rare tumor accounting for 1–10% of gastrointestinal malignant neoplasms (1, 2). The most common type of nonHodgkin lymphoma in the gastrointestinal tract is B-cell lymphoma, including mucosa-associated lymphoid tissue lymphoma, but B-cell follicular center lymphoma is not usual (3). The macroscopic feature of multiple lymphomatous polyposis generally indicates gastrointestinal involvement of mantle cell lymphoma (4). We report on a case of primary gastrointestinal follicular center lymphoma with multiple polypoid lesions extending widely from the duodenum to the colon, which was effectively treated with combination chemotherapy.

Chlamydia trachomatis proctitis.

A 19−year−old woman was admitted to our hospital with a 3−month history of bloody diarrhea and abdominal pain. On examination, she had some tenderness of the lower abdomen. Routine stool culture was negative. Blood tests showed that the white blood cell count was normal (7600/ L), but that the neutrophils were slightly increased (71.9 %); the C−reactive protein was 4.49 mg/dL. Barium enema revealed a small area of nodular (granule−like) mu− cosa in the lower rectum (Figure 1). There was no inflammation and no nodular le− sions from the cecum to the upper rec− tum. Colonoscopy also showed an erythe− matous nodular mucosa in the lower rec− tum (Figure 2). Microscopic examination of the rectal biopsy specimens showed well−formed lymphoid follicles and dif− fuse inflammation in mucosa and lamina propria, with cryptitis. Enzyme immu− noassay of chlamydial antigens in the rec− tal biopsies and specific serum immuno− globulin G antibodies revealed the pres− ence of a Chlamydia trachomatis infection. The diagnosis was therefore proctitis caused by C. trachomatis. She was found to be HIV−negative. She was treated with oral minocycline and tetracyline and her symptoms and rectal inflammation im− proved after 1 month.

Increase in Endoscopic and Laparoscopic Surgery Regarding the Therapeutic Approach of Gastric Cancer Detected by Cancer Screening in Saga Prefecture, Japan.

Objective Despite recent advances in endoscopic treatment and laparoscopic surgery for gastric cancers, an increase in the uptake of these therapeutic approaches has not yet been fully demonstrated. Therefore, the present study aimed to investigate the change in therapeutic approaches regarding the treatment of gastric cancers detected by cancer screening in Saga Prefecture, Japan between April 2002 and March 2011. Methods Gastric cancer screening by X-ray was performed on 311,074 subjects between April 2002 and March 2011. In total, 534 patients were thereafter diagnosed with gastric cancer. Eighteen subjects were excluded because precise details of their treatment were not available. To evaluate the changes in the therapeutic approach, the observation period was divided into three 3-year intervals: Period I: April 2002 to March 2005; Period II: April 2005 to March 2008; Period III: April 2008 to March 2011. Results The use of open laparotomy for the treatment of gastric cancer decreased, and laparoscopic surgery and endoscopic treatment increased markedly in a time-dependent manner. A 2.5-fold increase in endoscopic treatment, and a 18.4-fold increase in laparoscopic surgery were observed in Period III compared with Period I (after adjusting for age and tumor characteristics). Conclusion Endoscopic treatment and laparoscopic surgery for gastric cancer increased during the investigation period (2002-2011), although the tumor characteristics of the gastric cancers detected through cancer screening in Saga Prefecture, Japan did not show any changes.