Naomi Higuchi

Improved techniques for double-balloon-enteroscopy-assisted endoscopic retrograde cholangiopancreatography

AIM To investigate the clinical outcome of double balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (DB-ERCP) in patients with altered gastrointestinal anatomy. METHODS Between September 2006 and April 2011, 47 procedures of DB-ERCP were performed in 28 patients with a Roux-en-Y total gastrectomy (n = 11), Billroth II gastrectomy (n = 15), or Roux-en-Y anastomosis with hepaticojejunostomy (n = 2). DB-ERCP was performed using a short-type DBE combined with several technical innovations such as using an endoscope attachment, marking by submucosal tattooing, selectively applying contrast medium, and CO₂ insufflations. RESULTS The papilla of Vater or hepaticojejunostomy site was reached in its entirety with a 96% success rate (45/47 procedures). There were no significant differences in the success rate of reaching the blind end with a DBE among Roux-en-Y total gastrectomy (96%), Billroth II reconstruction (94%), or pancreatoduodenectomy (100%), respectively (P = 0.91). The total successful rate of cannulation and contrast enhancement of the target bile duct in patients whom the blind end was reached with a DBE was 40/45 procedures (89%). Again, there were no significant differences in the success rate of cannulation and contrast enhancement of the target bile duct with a DBE among Roux-en-Y total gastrectomy (88 %), Billroth II reconstruction (89%), or pancreatoduodenectomy (100%), respectively (P = 0.67). Treatment was achieved in all 40 procedures (100%) in patients whom the contrast enhancement of the bile duct was successful. Common endoscopic treatments were endoscopic biliary drainage (24 procedures) and extraction of stones (14 procedures). Biliary drainage was done by placement of plastic stents. Stones extraction was done by lithotomy with the mechanical lithotripter followed by extraction with a basket or by the balloon pull-through method. Endoscopic sphincterotomy was performed in 14 procedures with a needle precutting knife using a guidewire. The mean total duration of the procedure was 93.6 ± 6.8 min and the mean time required to reach the papilla was 30.5 ± 3.7 min. The mean time required to reach the papilla tended to be shorter in Billroth II reconstruction (20.9 ± 5.8 min) than that in Roux-en-Y total gastrectomy (37.1 ± 4.9 min) but there was no significant difference (P = 0.09). A major complication occurred in one patient (3.5%); perforation of the long limb in a patient with Billroth II anastomosis. CONCLUSION Short-type DBE combined with several technical innovations enabled us to perform ERCP in most patients with altered gastrointestinal anatomy.

Impact of double-balloon endoscopy on the diagnosis of jejunoileal involvement in primary intestinal follicular lymphomas: a case series.

In recent years, primary gastrointestinal follicular lymphoma has been increasingly detected in the duodenum on esophagogastroduodenoscopy (EGD). Primary gastrointestinal follicular lymphomas are frequently distributed to multiple sites in the gastrointestinal tract. Therefore, investigation into the spread of follicular lymphomas in the small bowel is important in order to determine the most appropriate treatment strategy. The performance of double-balloon endoscopy (DBE) in the diagnosis of jejunoileal follicular lymphoma lesions has not been fully evaluated. We aimed to investigate the value of DBE in addition to computed tomography (CT) and (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG-PET) in the diagnosis of jejunoileal follicular lymphoma. DBE with biopsy was performed in seven patients with primary duodenal follicular lymphoma diagnosed by EGD, in order to investigate jejunoileal involvement. Jejunoileal follicular lymphoma lesions were detected by DBE in six out of the seven patients (three in the jejunum and three in the jejunum and ileum), whereas CT and (18)F-FDG-PET failed to detect the existence of these lesions. Endoscopic findings of the jejunoileal lesions revealed multiple white nodules and white villi, which were similar to those of duodenal lesions. DBE was more useful for the diagnosis of jejunoileal involvement in primary intestinal follicular lymphoma than CT and (18)F-FDG-PET. The use of DBE will become important for determining the most appropriate treatment for gastrointestinal follicular lymphoma.

Endoscopic submucosal dissection by using a grasping-type scissors forceps: a preliminary clinical study (with video).

BACKGROUND Endoscopic submucosal dissection (ESD) with a knife is a technically demanding procedure associated with a high complication rate. The shortcoming of this method is the difficulty of fixing the knife to the target lesion. It can lead to an unexpected incision and result in major complications, such as perforation and bleeding. To reduce the risk of complications related to ESD, we developed a new grasping-type scissors forceps (GSF), which can grasp and incise the targeted tissue by using electrosurgical current. OBJECTIVE To evaluate the efficacy and safety of ESD by using GSF for the removal of gastric neoplasms in human beings. DESIGN Prospective, uncontrolled, single center. SETTING Department of Gastroenterology, Aso Iizuka Hospital, Iizuka, Japan. PATIENTS Four patients with early gastric neoplastic lesions. INTERVENTIONS After marking and injection of a solution into the submucosa, the lesion was separated from the surrounding normal mucosa by complete incision around the lesion by using the GSF. A piece of submucosal tissue was grasped and cut with the GSF by using electrosurgical current to achieve submucosal excision. MAIN OUTCOME MEASUREMENT Technical success and complications. RESULTS All lesions were treated easily and safely, without any unexpected incisions. No delayed hemorrhage and perforation occurred. An en bloc resection and a negative resection margin was obtained in all cases. LIMITATIONS The small number of patients and an uncontrolled study. CONCLUSIONS ESD with GSF appeared to be an easy, safe, and technically efficient method for resecting GI neoplasms.

ENDOSCOPIC SUBMUCOSAL DISSECTION USING A GRASPING-TYPE SCISSORS FORCEPS FOR EARLY GASTRIC CANCERS AND ADENOMAS

Aim:  To reduce the risk of complications related to endoscopic submucosal dissection (ESD) using knives, we developed a new grasping‐type scissors forceps (GSF) that can grasp and incise the target tissue using electrosurgical current. The aim of the present study was to evaluate the efficacy and safety of ESD using GSF for the removal of early gastric cancers and adenomas.

Gastric emptying in diabetic patients by the 13C-octanoic acid breath test: role of insulin in gastric motility

BackgroundImpairment of gastric emptying is well recognized in patients with diabetes mellitus (DM), especially long-standing insulin-dependent diabetes mellitus (IDDM). The aim of this study was to evaluate the cause of delayed gastric emptying in DM patients.MethodsIn 16 controls, 16 non-insulin-dependent diabetes mellitus (NIDDM) patients and 23 IDDM patients, gastric emptying was studied using the 13C octanoic acid breath test. Breath samples were taken before a test meal labeled with 100 mg of 13C octanoic acid, and at 15-min intervals over a 300-min period postprandially.ResultsIn all DM patients, the gastric emptying coefficient was lower than that in the controls (P < 0.05), and lag time and half-emptying time were significantly longer (P < 0.05). Both NIDDM and IDDM patients showed delayed 13CO2 excretion compared with the controls, but IDDM patients showed more delayed gastric emptying than NIDDM patients (P < 0.05). There were no significant differences in sex, HbA1c level, or the rate of neuropathy between the two groups.ConclusionsIDDM patients showed delayed gastric emptying compared with NIDDM patients, and the 13C octanoic acid breath test is useful for evaluating DM patients with delayed gastric emptying.

Preserved gastric motility in patients with early gastric cancer after endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is now accepted as a minimally invasive treatment for early gastric cancer (EGC). To our knowledge, however, the functional effects of ESD have not been determined in patients with EGC. We therefore investigated whether gastric motility was affected by ESD.

W1250 Effect of Nutritional Supplementation with Zinc and Vitamin C in Acute Hemorrhagic Rectal Ulcer Patients: A Randomized Clinical Trial

Introduction: Green tea polyphenols, particularly -(-) epigallocatechin 3-gallate (EGCG), have sparked considerable interest as potential therapeutic agents for chronic inflammatory diseases due to their anti-oxidant and anti-inflammatory effects. Aim: Analyze the ability of EGCG to inhibit production of pro-inflammatory cytokines in human peripheral blood mononuclear cells (PBMCs) In Vitro to gauge its anti-inflammatory effects in immune cells from IBD patients. Methods: PBMCs were obtained from 4 colitis patients and 4 normal controls and enriched for monocytes or lymphocytes by plastic adherence. CD14+ macrophages, CD4+CD45+RO+ and CD4+CD45+RA+ T cells were isolated respectively by microbead technology. Three experiments were performed: 1) Lipopolysaccharide (LPS) stimulated CD14+ macrophages alone, 2) co-cultured with CD4+CD45+RO+ or CD4+CD45+RA+ T cells, or 3) anti-CD3 Ab stimulated CD4+CD45+RO+ T cells were incubated in the presence of EGCG (0-10 ng/μl) for 3 and 6 days. Supernatants were collected for cytokine analysis by ELISA. Results: LPS stimulated CD14+ macrophages, or CD4+CD45+RO+ T cells co-cultured with LPS stimulatedmacrophages experienced a dose-dependent reduction in pro-inflammatory cytokine production as shown in table 1. Co-culture of CD14+ macrophages with CD4+CD45+RO+ T cells resulted in a 92% reduction of IL-17 production. There was no change in IL-17 production when CD4+CD45+RA+ T cells were substituted. When evaluated in LPS stimulated CD14+ macrophages alone, EGCG elicited a similar reduction in cytokine production. Reduced cytokine levels were not due to loss of cell viability. Discussion: These results reveal that EGCG produces a significant anti-inflammatory effect by reducing the production of the pro-inflammatory cytokines TNFα, IL-1β, IL-6, and IFNγ. The ability of EGCG to increase apoptosis in lymphocytes from colitis patients, but not from healthy controls, suggests that it may offer a clinical benefit by this mechanism, as well. We are currently conducting a clinical trial in patients with ulcerative colitis to evaluate the clinical correlation of these findings. Table 1

Hepatobiliary and pancreatic: Spontaneous cystogastric fistula

A man, aged 52 years, with known chronic pancreatitis induced by alcohol was admitted to another hospital with increasing abdominal pain. He also had a fever and an elevated white cell count. An abdominal computed tomography (CT) scan revealed a large pancreatic pseudocyst in the region of the lesser sac. He was initially treated with antibiotics and with non-steroidal anti-inflammatory drugs. He was subsequently referred to our hospital because of the development of melena that required a blood transfusion. Upper gastrointestinal endoscopy revealed extrinsic compression on the posterior wall of the body of the stomach that was attributed to the pseudocyst. At the site of compression, there were three shallow gastric ulcers with the flow of pus from the base of one of the ulcers (Fig. 1). Subsequently, the opening of a cystogastric fistula was found in the ulcer bed (Fig. 2). The patient was diagnosed with a ruptured and infected pseudocyst and two pigtail stents (7 French) were inserted through the fistula into the cyst cavity. This was followed by a progressive reduction in the size of the pseudocyst and eventually by resolution of the cyst. In the case described above, it seems likely that there was spontaneous rupture of the pseudocyst into the stomach followed by infection within the cyst cavity. An alternative possibility is the development of an infection within a pseudocyst followed by rupture of an abscess into the stomach. However, the development of an infection within a pseudocyst is uncommon in the absence of diagnostic or therapeutic procedures such as endoscopic retrograde pancreatography or attempts at percutaneous drainage. The frequency of spontaneous rupture of pancreatic pseudocysts has been estimated at approximately 5%. Most of these cysts rupture into the stomach or duodenum and this may result in a spontaneous cure. A minority rupture into the peritoneal cavity and may result in pancreatic ascites. Endoscopic visualization of the opening of a cystogastric fistula appears to be rare. If the fistula is relatively wide, it may be reasonable to adopt a ‘wait and see’ policy. However, in patients with small fistulas, drainage can be facilitated by multiple endoscopic stents. These stents will need to be left in place for at least 6 weeks, particularly in the presence of infection.

Gastric emptying in diabetic patients by the 13

BackgroundImpairment of gastric emptying is well recognized in patients with diabetes mellitus (DM), especially long-standing insulin-dependent diabetes mellitus (IDDM). The aim of this study was to evaluate the cause of delayed gastric emptying in DM patients.MethodsIn 16 controls, 16 non-insulin-dependent diabetes mellitus (NIDDM) patients and 23 IDDM patients, gastric emptying was studied using the 13C octanoic acid breath test. Breath samples were taken before a test meal labeled with 100 mg of 13C octanoic acid, and at 15-min intervals over a 300-min period postprandially.ResultsIn all DM patients, the gastric emptying coefficient was lower than that in the controls (P < 0.05), and lag time and half-emptying time were significantly longer (P < 0.05). Both NIDDM and IDDM patients showed delayed 13CO2 excretion compared with the controls, but IDDM patients showed more delayed gastric emptying than NIDDM patients (P < 0.05). There were no significant differences in sex, HbA1c level, or the rate of neuropathy between the two groups.ConclusionsIDDM patients showed delayed gastric emptying compared with NIDDM patients, and the 13C octanoic acid breath test is useful for evaluating DM patients with delayed gastric emptying.