Munehiro Tanaka

Preoperative diagnosis and staging of gallbladder carcinoma by EUS

BACKGROUND EUS has recently been shown to be efficacious for the preoperative assessment of depth of invasion of gallbladder carcinoma. This study assessed the value of EUS for determining T stage (International Union Against Cancer). METHODS Preoperative EUS findings in 41 patients with gallbladder carcinoma were analyzed retrospectively. EUS images were classified according to the shape of the tumor and the adjacent gallbladder wall structure as follows: type A, pedunculated mass with preserved adjacent wall structures; type B, sessile and/or broad-based mass with a preserved outer hyperechoic layer of the gallbladder wall; type C, sessile and/or broad-based mass with a narrowed outer hyperechoic layer; type D, sessile and/or broad-based mass with a disrupted outer hyperechoic layer. EUS and histopathologic findings were compared, including the depth of invasion of the tumor in the resection specimen. RESULTS The 4 categories of EUS images of gallbladder carcinoma correlated with the histologic depth of invasion and T stage. Accuracies for the EUS classification as type A corresponding to pTis, type B to pT1, type C to pT2, and type D to pT3-4 were, respectively, 100%, 75.6%, 85.3%, and 92.7%. CONCLUSIONS Preoperative EUS imaging accurately depicts T stage of gallbladder carcinoma and allows for effective therapeutic decision making.

Endosonography probe-guided endoscopic mucosal resection of gastric neoplasms

the stomach following endoscopic volvulus reduction in a poor surgical candidate. This novel approach resulted in persistence of normal gastric position as documented by UGI series 1 year later. Further data is needed on the long-term follow-up of patients with various types of symptomatic volvulus managed endoscopically in regards to the significance and frequency of recurrence. In conclusion, we have described a new maneuver, the alpha-loop technique, for endoscopic reduction of gastric volvulus. We used this technique to successfully reduce gastric volvulus in 7 out of 8 patients with no procedural complications. The major benefit of endoscopic volvulus reduction was to allow time for elective surgical repair of abdominal pathology (paraesophageal hernia) predisposing to volvulus formation. The role of the alpha-loop technique as a definitive therapy in poor surgical candidates and in patients with idiopathic volvulus requires further evaluation.

Dual therapy for third-line Helicobacter pylori eradication and urea breath test prediction.

We evaluated the efficacy and tolerability of a dual therapy with rabeprazole and amoxicillin (AMX) as an empiric third-line rescue therapy. In patients with failure of first-line treatment with a proton pump inhibitor (PPI)-AMX-clarithromycin regimen and second-line treatment with the PPI-AMX-metronidazole regimen, a third-line eradication regimen with rabeprazole (10 mg q.i.d.) and AMX (500 mg q.i.d.) was prescribed for 2 wk. Eradication was confirmed by the results of the ¹³C-urea breath test (UBT) at 12 wk after the therapy. A total of 46 patients were included; however, two were lost to follow-up. The eradication rates as determined by per-protocol and intention-to-treat analyses were 65.9% and 63.0%, respectively. The pretreatment UBT results in the subjects showing eradication failure; those patients showing successful eradication comprised 32.9 ± 28.8 permil and 14.8 ± 12.8 permil, respectively. The pretreatment UBT results in the subjects with eradication failure were significantly higher than those in the patients with successful eradication (P = 0.019). A low pretreatment UBT result (≤ 28.5 permil) predicted the success of the eradication therapy with a positive predictive value of 81.3% and a sensitivity of 89.7%. Adverse effects were reported in 18.2% of the patients, mainly diarrhea and stomatitis. Dual therapy with rabeprazole and AMX appears to serve as a potential empirical third-line strategy for patients with low values on pretreatment UBT.

Short- and long-term outcomes of endoscopic resection of rectal neuroendocrine tumours: analyses according to the WHO 2010 classification.

Abstract Objective Although the World Health Organisation (WHO) defined a novel classification of gastroenteropancreatic neuroendocrine tumours (NETs) in 2010, indications for endoscopic resection of rectal NETs in the guidelines were based on evidence accumulated for carcinoid tumours defined by a previous classification. This study was designed to clarify indications for endoscopic resection of rectal NETs corresponding to the new WHO classifications. Material and methods One hundred-seventy rectal NETs resected endoscopically from April 2001 to March 2012 were histologically re-classified according to the WHO 2010 criteria. The clinicopathological features of these lesions were analysed, and the short- and long-term outcomes of endoscopic resection were evaluated. Results Of the 170 rectal NETs, 166 were histopathologically diagnosed as NET G1 and four as NET G2. Thirty-eight tumours (22.4%) were positive for lymphovascular invasion, a percentage higher than expected. Although the curative resection rate was low (65.3%), en bloc (98.8%) and complete (85.9%) resection rates were high. Modified endoscopic mucosal resection (88.0%) and endoscopic submucosal dissection (92.2%) resulted in significantly higher complete resection rates than conventional endoscopic mucosal resection (36.4%). No patient experienced tumour recurrence, despite the low curative resection rate. Conclusion Despite the low curative resection rate, prognosis after endoscopic resection of rectal NETs was excellent. Prospective large-scale, long-term studies are required to determine whether NET G2 and tumours >1 cm should be included in the indication for endoscopic resection and whether tumours with lymphovascular invasion can be followed up without additional surgery.

Steroid-induced osteonecrosis in refractory ulcerative colitis.

We report a case of steroid-induced osteonecrosis in a patient with refractory ulcerative colitis. A 31 year-old woman presented suffering from refractory ulcerative colitis. She had been treated by prednisolone for ten years. Sharp pain and swelling appeared suddenly in her right knee. Conventional radiography revealed neither osteoporosis nor a fracture. However, magnetic resonance imaging by T1-, T2 and T2*-weighted images revealed irregular heterogeneous areas of low- and high-intensity in her right femur and tibia. For a precise early diagnosis of osteonecrosis, bone magnetic resonance imaging was found to be an excellent diagnostic tool.

Characteristics of Hemorrhagic Peptic Ulcers in Patients Receiving Antithrombotic/Nonsteroidal Antiinflammatory Drug Therapy

Background/Aims Antithrombotic/nonsteroidal antiinflammatory drug (NSAID) therapies increase the incidence of upper gastrointestinal bleeding. The features of hemorrhagic peptic ulcer disease in patients receiving antithrombotic/NSAID therapies were investigated. Methods We investigated the medical records of 485 consecutive patients who underwent esophagogastroduodenoscopy and were diagnosed with hemorrhagic gastroduodenal ulcers. The patients treated with antithrombotic agents/NSAIDs were categorized as the antithrombotic therapy (AT) group (n=213). The patients who were not treated with antithrombotics/NSAIDs were categorized as the control (C) group (n=263). The clinical characteristics were compared between the groups. Results The patients in the AT group were significantly older than those in the C group (p<0.0001). The hemoglobin levels before/without transfusion were significantly lower in the AT group (8.24±2.41 g/dL) than in the C group (9.44±2.95 g/dL) (p<0.0001). After adjusting for age, the difference in the hemoglobin levels between the two groups remained significant (p=0.0334). The transfusion rates were significantly higher in the AT group than in the C group (p=0.0002). However, the outcome of endoscopic hemostasis was similar in the AT and C groups. Conclusions Patients with hemorrhagic peptic ulcers receiving antithrombotic/NSAID therapies were exposed to a greater risk of severe bleeding that required transfusion but were still treatable by endoscopy.

Pedunculated Duodenal Lipoma Treated with Endoscopic Polypectomy with a Detachable Snare

We report endoscopic polypectomy with a detachable snare in a patient with a hemorrhagic pedunculated duodenal lipoma. A 67-year-old man with a history of spinal canal stenosis was admitted to our hospital because of recurrent tarry stools and anemia. Esophagogastroduodenoscopy revealed a pedunculated submucosal tumor measuring approximately 4 cm, in the second part of the duodenum. The tumor had a slightly yellowish coloration, and longitudinal erosion was noted on the surface of the tumor. There were no significant findings in the esophagus, stomach and bulbs. Barium study revealed a pedunculated submucosal tumor measuring 40 x 12 mm in the second portion of the duodenum. We judged that the submucosal tumor may have been the hemorrhagic source, and removed it by endoscopic snare polypectomy with a detachable snare. No complications occurred during endoscopic procedures. Histopathological examination revealed that the tumor was composed of mature adipose tissue in the submucosa, which was consistent with a diagnosis of lipoma In our experience, endoscopic polypectomy with a detachable snare is useful for the treatment of hemorrhagic pedunculated duodenal lipoma.

Endoscopic ultrasonographic findings in rectal leiomyoma

Abstract A 35 year old man visiting a hospital for his annual check‐up in August 1992 was found to have a large rectal tumour on digital examination. Colonoscopy revealed a bulging lesion with normal mucosa. Endoscopic biopsy showed only normal tissue. Endoscopic ultrasonography demonstrated a large hypo‐echoic submucosal tumour in the fourth layer (muscularis propria) of the rectal wall. Based on this endoscopic ultrasonographic finding, we diagnosed the tumour as leiomyoma pre‐operatively. The tumour was excised by a trans‐sacral local excision. The histological diagnosis of the resected specimen was cellular leiomyoma.

Effective hemostasis with hypertonic saline‐epinephrine solution for uncontrolled bleeding during endoscopic submucosal dissection of the stomach

Bleeding is a common complication of endoscopic submucosal dissection (ESD) and can be treated immediately by endoscopy. Soft coagulation using hemostatic forceps has been reported to be effective in gastric ESD, but locating the bleeding vessel(s) may be difficult due to continuous bleeding. Hemoclips are also used to stop bleeding, but they must be deployed with care to prevent their getting in the way and interfering with subsequent steps. Injection of hypertonic saline-epinephrine solution (HSE) is known to be effective for hemostasis in the gastrointestinal tract. Therefore, we attempted the use of HSE injection for hemostasis during ESD and observed that injection of HSE is highly effective in the cases where it was used. Nine patients with gastric bleeding during ESD procedures underwent hemostasis with HSE injection in our hospital between September 2010 and October 2011. In all cases, hemostatic forceps failed to stop bleeding that was successfully treated with injection of HSE. Bleeding was located in the middle third (four cases), in the lower third (distal; two cases) and in the upper third of the stomach (three cases) (Fig. 1). Seven of the nine cases were intramucosal lesions whereas two showed submucosal invasion. The average size of the resected specimen was 43 mm in diameter. HSE (1–2 cm; containing 3.6% sodium chloride and 0.005% epinephrine) was injected around the vessel, then stopped to see if the bleeding had arrested; if not, another 1–2 cm was injected and re-evaluated (Fig. 2). The average amount of injected HSE was 7.5 cm. All of the nine lesions were removed en bloc endoscopically. HSE is a simple procedure and will not impede later steps. Thus, when visibility and detection of a bleeding vessel is obscured as a result of continuous or massive bleeding, injection of HSE is an effective and expedient treatment for hemostasis.

Pedunculated gastric carcinoma demonstrating a gastric foveolar phenotype

We report a case of gastric cancer complicated with very well differentiated adenocarcinoma containing signet ring cells. An endoscopic examination revealed a pedunculated polyp in the fornix of the stomach. A surgical operation was performed and the pathological findings showed very well differentiated adenocarcinoma mimicking gastric foveolae with a poorly differentiated component containing signet ring cells. This is the first case of pedunculated gastric cancer complicated with very well differentiated adenocarcinoma containing signet ring cells and also demonstrating a gastric foveolar phenotype.