Michiko Iwamoto

Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases.

BACKGROUND & AIMS A specialized system for a new method for enteroscopy, the double-balloon method, was developed. The aim of this study was to evaluate the usefulness of this endoscopic system for small-intestinal disorders. METHODS The double-balloon endoscopy system was used to perform 178 enteroscopies (89 by the anterograde approach and 89 by the retrograde approach) in 123 patients. The system was assessed on the basis of the rates of success in jejunal and ileal insertion and the entire examination of the small intestine, diagnostic yields, ability to perform treatment, and complications. RESULTS Insertion of the endoscope beyond the ligament of Treitz or ileocecal valve was possible in all 178 procedures. It was possible to observe approximately one half to two thirds of the entire small intestine by each approach, and observation of the entire small intestine was possible in 24 (86%) of 28 trials. The source of bleeding was identified in 50 (76%) of 66 patients with GI bleeding, scrutiny of strictures was possible in 23 patients, and a tumor was examined endoscopically in 17 patients. Two complications (1.1%) occurred. Endoscopic therapies in the small intestine including hemostasis (12 cases), polypectomy (1 case), endoscopic mucosal resection (1 case), balloon dilation (6 cases), and stent placement (2 cases) were performed successfully. CONCLUSIONS Double-balloon endoscopy permits the exploration of the small intestine with a high success rate of total enteroscopy. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.

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.

Gastrointestinal stromal tumor in the jejunum: diagnosis and control of bleeding with electrocoagulation by using double-balloon enteroscopy.

A 43-year-old man presented with gastrointestinal bleeding. A tumor with central ulceration was observed in the jejunum, with the use of a new enteroscopy system called “double-balloon enteroscopy”. Bleeding after biopsy sampling of the tumor was controlled endoscopically by using electrocoagulation. Histological findings of the biopsy specimens were consistent with gastrointestinal stromal tumor, and this was surgically resected. Double-balloon enteroscopy was useful for the diagnosis as well as the control of bleeding in this patient.

Successful treatment with balloon dilatation using a double‐balloon enteroscope for a stricture in the small bowel of a patient with Crohn's disease

The requirement for endoscopic access to a stricture is a major limitation of the endoscopic dilatation for the treatment of strictures in the gastrointestinal tract. We have developed the double‐balloon enteroscopy method that enables visualization of the entire small bowel. In addition, double‐balloon enteroscopy has a potential for the interventional therapy including dilatation of strictures. We present here a case of jejunal strictures in a 47‐year‐old woman with Crohns disease successfully treated with a balloon catheter in combination with double‐balloon enteroscopy. Balloon dilation with double‐balloon enteroscopy is a promising method for the treatment of small bowel strictures in Crohns disease.

Endoscopic observation of Meckel's diverticulum by double balloon endoscopy: Report of five cases

Background and Aim:  Most cases of Meckels diverticula are asymptomatic, however, some cases presented with gastrointestinal (GI) bleeding. It is often difficult to determine whether Meckels diverticulum is a source of obscure GI bleeding. Double balloon endoscopy allows endoscopic access to the entire small intestine. The aim of this study was to compare endoscopic findings of three hemorrhagic and two non‐hemorrhagic Meckels diverticula in patients with obscure GI bleeding using this novel technique.

Endoscopic submucosal dissection using sodium hyaluronate for large superficial tumors in the colon

Endoscopic submucosal dissection is becoming popular for large superficial gastric cancer in Japan. However, it is considered difficult in the colon because the colonic wall is much thinner than the gastric wall. We use several devices to overcome this difficulty and have made it feasible in the colon as well. Submucosal injection of sodium hyaluronate is used to maintain sufficient thickening of the submucosal tissue and a small‐caliber‐tip or regular cylindrical transparent hood is used to open up the incised mucosa as a substitute for countertraction. In this method, not only the lateral margin, but the vertical margin of the resection can also be determined precisely because submucosal incision is carried out under direct visualization of the submucosal tissue.

Direct Observation with Double-Balloon Enteroscopy of an Intestinal Intramural Hematoma Resulting in Anticoagulant Ileus

Ileus induced by an intramural hematoma due to exces-sive anticoagulant therapy, namely, anticoagulant ileus, was first described by Hafner et al. (1) in 1962. Warfarin is responsible for 98% of the reports of anticoagulant ileus (2), but there is no relationship between the duration of an-ticoagulation and this disease (2, 3). Most anticoagulant ileus occurs in the jejunum (2, 4). Features of anticoag-ulant ileus in the small bowel have been described using gastrointestinal radiograph series (2, 5-10), computed to-mography (CT) (9, 10), ultrasound (8, 11), and angiog-raphy (8). However, enteroscopic findings of intramural hematoma in the small bowel have not previously been reported because of the difficulty in accessing the small in-testine. We have developed a new double-balloon method of enteroscopy (12, 13). This new enteroscopy facilitates deep insertion of an enteroscope into the small bowel. Using this new method, we were able to identify a hematoma in the small intestine of a patient with anticoagulant ileus.

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.

Nuclear accumulation of β-catenin occurs commonly in the epithelial cells of juvenile polyps

In the two conditions juvenile polyps (JPs) and juvenile polyposis coli (JPC), colonic polyps may have overlapping histologic and phenotypic appearance, but JPC confers a significant risk for colon adenocarcinoma. Although not thought to contain adenomatous polyposis coli (APC) mutations, the status of β-catenin and full-length APC protein expression in JPs is not known. We evaluated β-catenin and full-length APC protein expression in JPs from children with JPs and JPC. Cases were identified through endoscopic procedure records. Immunohistochemistry was performed for β-catenin and full-length APC protein. Loss of heterozygosity at the APC gene locus on chromosome 5 was assessed using two APC-linked microsatellite markers. Polyp and normal colonic tissue were analyzed from 36 children with JPs and 9 with JPC. Both APC and β-catenin immunoreactivity were present in epithelial cells from all samples but in different patterns. In all normal colon and polyp samples, APC expression was cytoplasmic with maximal immunoreactivity in the goblet cells. In contrast, β-catenin immunoreactivity in epithelial cells was limited to the plasma membrane in normal colon but was both cytoplasmic and nuclear in all 45 JPs. No evidence of APC gene loss of heterozygosity was found. In polyps from children with JPs and JPC, nuclear β-catenin accumulation is a consistent feature, and it is not due to APC gene mutation or loss of full-length APC protein expression. Thus, β-catenin accumulation may be intrinsic to the formation of juvenile-type polyps through an as-yet-undefined mechanism.

Technical modification of the double-balloon endoscopy to access to the proximal side of the stenosis in the distal colon.

BACKGROUND The inability to pass endoscopes beyond strictures is a considerable problem in patients with a colonic stricture. METHODS In patients with bowel obstruction, we have modified the insertion method for double-balloon endoscopy with a long, transnasal decompression tube. OBSERVATIONS We have succeeded in reaching the proximal side of the stricture from the oral approach across the entire small bowel in a patient. CONCLUSIONS This modified double-balloon enteroscopy is useful for patients with bowel obstruction in whom a long decompression tube is already placed.