Masayuki Arashiro

Long-term Outcome of Patients With Obscure Gastrointestinal Bleeding Investigated by Double-Balloon Endoscopy

BACKGROUND & AIMS It is often difficult to determine the cause of obscure gastrointestinal bleeding (OGIB). We evaluated the diagnostic yield and long-term outcome of patients with OGIB by using double-balloon endoscopy (DBE). METHODS In this large, retrospective cohort study, DBE was performed in 200 consecutive patients with OGIB. Follow-up data were available from 151 patients for 29.7 months (range, 6-78 months), and clinical outcome was assessed. RESULTS DBE detected bleeding sources in 155 of 200 patients (77.5%). The most frequent source detected was small intestine ulcers/erosions (64 patients). Patients who underwent DBE within 1 month after the last episode of overt bleeding had a better yield of positive findings than those who did not (84%, 107/128 patients vs 57%, 24/42; P = .002). The overall rate of control of OGIB was 64% (97/151 patients). Patients with vascular lesions of the small intestine had a significantly lower rate of control of OGIB than those with other small intestine lesions (40%, 12/30 patients vs 74%, 52/70; P = .001). A requirement for a large transfusion before DBE (P = .012), multiple lesions (P = .010), and suspicious (not definite) lesions (P = .038) each significantly increased the likelihood of overt rebleeding in patients with vascular lesions of the small intestine. CONCLUSIONS DBE is useful for the diagnosis of patients with OGIB and should be performed as soon as possible after overt OGIB. Patients with vascular lesions of the small intestine should be followed with particular care.

Safety and efficacy of double-balloon enteroscopy in pediatric patients

BACKGROUND Although double-balloon enteroscopy (DBE) is performed increasingly often in adults, few findings are available on the use of DBE in pediatric patients in the published literature. OBJECTIVES The aim of our study was to evaluate the safety and efficacy of DBE in pediatric patients. DESIGN A retrospective database review. SETTING AND PATIENTS A database analysis was performed on all pediatric patients (18 years old or younger) who underwent DBE at the Jichi Medical University Hospital between September 2000 and October 2008 selected from a total of 825 patients. MAIN OUTCOME MEASUREMENTS Clinical utility and safety of DBE in pediatric patients. RESULTS A total of 92 procedures were performed in 48 patients (27 male, 21 female) with a median age (range) of 12.2 (4-18) years. DBE was performed with the patients under general anesthesia in 43 procedures and under moderate sedation in 49 procedures. The most common indication for DBE was treatment of a stricture of a biliary anastomosis after living-donor liver transplantation with establishment of Roux-en-Y hepaticojejunostomy (23 patients). Endoscopic retrograde cholangiography using DBE was performed, and endoscopic therapy could be performed successfully in 13 (56%) patients. The second most common indication was obscure GI bleeding (10 patients); the lesions responsible for the bleeding were found in 7 (70%) patients. Other indications included surveillance and treatment of hereditary polyposis syndromes (5 patients), abdominal pain (4 patients), and inflammatory bowel disease (2 patients). The overall diagnostic yield was 65% (31 of the 48 patients). Postpolypectomy bleeding occurred in 1 case, but no other complications such as perforation and pancreatitis were observed. LIMITATIONS Small number of patients, participation bias, and single centers experience. CONCLUSIONS DBE is a safe and clinically useful endoscopic procedure in pediatric patients.

Double balloon endoscopy in two hundred fifty cases for the diagnosis and treatment of small intestinal disorders.

Abstract.Double balloon endoscopy is based on a new insertion mode in which two balloons at the distal ends of both an endoscope and an overtube are operated in combination. We have performed 419 enteroscopic examinations in 250 patients using the Fujinon double balloon endoscopy system between September 2000 and October 2005. Total enteroscopy was successfully achieved by the combination of both oral and anal approaches in 55 out of 71 cases in whom total enteroscopy was intended. Of 250 patients, ulcerative and/or erosive lesions were found in 49 cases and tumors/polyps were found in 49 cases. We also found 26 cases of vascular lesion, including angiodysplasia. Endoscopic treatments, including hemostasis using either clipping devices or electro coagulation, polypectomy, endoscopic mucosal resection, balloon dilation, and stent placement was successfully carried out. Double balloon enteroscopy is both feasible and useful technique for the diagnosis as well as treatment of small intestinal disorders.

Nonsteroidal anti-inflammatory drug-induced small-bowel lesions identified by double-balloon endoscopy: endoscopic features of the lesions and endoscopic treatments for diaphragm disease

BackgroundNonsteroidal anti-inflammatory drugs (NSAIDs) occasionally induce small-bowel injury. However, the clinical features have only been partially clarified. The aim of this study was to clarify the clinical features of the disease and evaluate the effectiveness of endoscopic balloon dilation therapy for diaphragm disease, using double-balloon endoscopy (DBE).MethodsThis is a retrospective case study using our DBE database. Our inclusion criteria required patients to meet all the following criteria: (1) history of NSAID use; (2) endoscopic findings of erosion and/or ulcer and/or typical diaphragm-like strictures; (3) improvement in clinical findings (signs and symptoms) and/or endoscopic findings by cessation of NSAIDs, except for diaphragm disease; and (4) exclusion of other causes (e.g., malignant tumor, inflammatory bowel disease, and infectious disease). The clinical records of patients were investigated.ResultsEighteen patients were included. Sixteen patients showed ulcerative lesions, and the remaining 2 patients showed diaphragm diseases. For localized lesions, 12 patients evidenced lesions in the ileum, 5 patients had lesions in the duodenum and/or jejunum, and 1 had lesions in both intestines. The ulcerative lesions were multiple with various morphologies that were located unrelated to mesenteric or antimesenteric sides. The endoscopic balloon dilations were performed safely, and all patients improved with regard to their symptoms.ConclusionsSymptomatic NSAID-induced small-bowel injuries exhibit a variety of patterns of ulcerative lesions as observed in the ileum in many cases. The endoscopic balloon dilation appears to be a safe and effective treatment for diaphragm disease.

Reduction of ileoileal intussusception by using double-balloon endoscopy in Peutz-Jeghers syndrome (with video)

Until only a few years ago, primary surgical resection and intraoperative endoscopy with polypectomy were the only means available for treating polyps in the small intestine in patients with Peutz-Jeghers syndrome (PJS). With the introduction of double-balloon endoscopy 1-2 (DBE), however, endoscopic polypectomy has become available. However, in the case of intussusception in PJS, surgical intervention is still usually required. We describe our experience with successful reduction of an ileoileal intussusception followed by endoscopic resection of the responsible polyp by using DBE in a patient with PJS.

Endoscopic submucosal dissection using sodium hyaluronate, a new technique for en bloc resection of a large superficial tumor in the colon

Abstract.En bloc resection of superficial tumors in the colon is challenging but beneficial for the precise diagnosis and treatment. We have been using a novel technique of endoscopic submucosal dissection with a viscous substance, sodium hyaluronate, and a needle knife in combination with a small-caliber-tip transparent hood and succeeded in the endoscopic en bloc resection of large superficial tumors in the colon. We endoscopically treated superficial tumors larger than 20 mm in diameter of the colon in 166 patients between June 1998 and March 2005. All the lesions were successfully resected endoscopically and en bloc resection was achieved in 77 % of them. Even large superficial tumors in the colon can be resected in one piece by using this technique.

NEW TECHNIQUE FOR DIRECT PERCUTANEOUS ENDOSCOPIC JEJUNOSTOMY USING DOUBLE-BALLOON ENDOSCOPY AND MAGNETIC ANCHORS IN A PORCINE MODEL

Direct percutaneous endoscopic jejunostomy (D-PEJ) is not yet globally carried out because of two technical difficulties in the procedure.The first is difficulty in reaching the jejunum with good maneuverability by conventional endoscopy. The second involves the anatomical features of the jejunum. The jejunal lumen is much smaller than that of the stomach. In addition, the location of the jejunal loop is not stable in relation to the abdominal wall. To solve these problems, we developed a new technique for D-PEJ using double-balloon endoscopy (DBE) and magnetic anchors. DBE was used for the access to the jejunum.Two magnetic anchors were prepared for the inside and outside anchors. The inside anchor was tied to the tip of the endoscope. Two anchors were used to fix the jejunal wall to the abdominal wall. Puncture was carried out from the abdominal wall beside the outside anchor without fluoroscopy. The jejunal wall was fixed to the abdominal wall by suturing the fixing thread. Percutaneous endoscopic gastrostomy (PEG) tube was placed through the overtube of DBE (Fig. 1). To evaluate the feasibility and safety, placement of D-PEJ using DBE and magnetic anchors was carried out on eight pigs with survival. Procedure of the animal experiments was investigated and permitted by The Judging Committee of Experimental Animal Ethics of Jichi Medical University. D-PEJ was successfully placed in all eight pigs. DBE and magnetic anchors were useful for stabilization of the maneuvers. PEG tube placement through the overtube was useful for preventing contamination of the tube and trauma of the intestinal wall. The mean procedure time was 89 min. There were no complications. D-PEJ using DBE and magnetic anchors was feasible and safe in the porcine model.

Endoscopic submucosal dissection of esophageal lymphangioma: a case report with a review of the literature

Esophageal lymphangioma is a very rare disease. We report a case of esophageal lymphangioma successfully treated with endoscopic submucosal dissection (ESD), which yielded definitive histological diagnosis and symptom relief. ESD offers a better option for definitive diagnosis as well as complete resection of large esophageal lymphangiomas with flat configuration.

Successful Conservative Treatment of a Cholecystoduodenal Fistula Caused by a Cytomegalovirus-associated Duodenal Ulcer.

An 87-year-old woman on oral prednisolone was diagnosed with a cholecystoduodenal fistula (CDF) caused by a cytomegalovirus-associated duodenal ulcer (DU) and was managed conservatively. A CDF caused by a DU is extremely rare. Although surgical repair is recommended for the treatment of a CDF caused by cholecystolithiasis, appropriate treatment for CDF caused by a DU remains controversial. This case report of a CDF caused by a DU suggests that conservative treatment is feasible in the absence of DU-associated complications, such as an untreatable hemorrhage or obstruction; this finding is compatible with previously reported cases that were conservatively treated.