Noriaki Matsui

T helper 1‐inducing property of IL‐27/WSX‐1 signaling is required for the induction of experimental colitis

Background: WSX‐1, a component of the interleukin (IL)‐27 receptor, is a novel class I cytokine receptor with homology to the IL‐12 receptor &bgr;2 chain. Initially, WSX‐1 signaling was reported to play an important role in the promotion of T helper‐1 responses, but recent reports have revealed an anti‐inflammatory property in WSX‐1 signaling. In the present study, we investigated the role of IL‐27/WSX‐1 signaling in a murine colitis model, dextran sulfate sodium (DSS) colitis, by using WSX‐1 knockout (KO) mice. Methods: First, we observed whether WSX‐1 KO mice developed colitis spontaneously. Second, we induced DSS colitis in WSX‐1 KO and wild‐type (WT) mice. Results: WSX‐1 KO mice were observed not to develop colitis spontaneously. The severity of DSS colitis was decreased in WSX‐1 KO mice in comparison with WT mice in association with a reduced production of interferon‐&ggr;, IL‐6, and tumor necrosis factor‐&agr; by lamina propria mononuclear cells from WSX‐1 KO mice and the absence of T‐bet expression in the colon from WSX‐1 KO mice. Conclusions: This study revealed the inflammatory property of IL‐27/WSX‐1 signaling in intestinal inflammation. As a result, IL‐27/WSX‐1 signal pathway may thus be a promising candidate for the therapeutic intervention of human inflammatory bowel diseases such as Crohns disease and ulcerative colitis.

Endoscopic submucosal dissection for removal of superficial gastrointestinal neoplasms: A technical review

Endoscopic submucosal dissection (ESD) is now the most common endoscopic treatment in Japan for intramucosal gastrointestinal neoplasms (non-metastatic). ESD is an invasive endoscopic surgical procedure, requiring extensive knowledge, skill, and specialized equipment. ESD starts with evaluation of the lesion, as accurate assessment of the depth and margin of the lesion is essential. The devices and strategies used in ESD vary, depending on the nature of the lesion. Prior to the procedure, the operator must be knowledgeable about the treatment strategy(ies), the device(s) to use, the electrocautery machine settings, the substances to inject, and other aspects. In addition, the operator must be able to manage complications, should they arise, including immediate recognition of the complication(s) and its treatment. Finally, in case the ESD treatment is not successful, the operator should be prepared to apply alternative treatments. Thus, adequate knowledge and training are essential to successfully perform ESD.

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.

Prospective comparative study on the acceptability of unsedated transnasal endoscopy in younger versus older patients

Goals The aim of this prospective study was to compare the acceptance and tolerance for unsedated transnasal esophagogastroduodenoscopy (EGD) between younger and older patients. Background Little information is available on comparisons of younger and older patients with regard to acceptance and tolerance of transnasal EGD. Study A total of 260 patients were referred for unsedated transnasal EGD and divided into 2 groups according to their age: less than 60 years of age (group A, n=160) and 60 years of age and older (group B, n=100). A questionnaire for tolerance was completed by each patient (a validated 0 to 10 scale where “0” represents no discomfort/well tolerated and “10” represents severe discomfort/poorly tolerated). Results In 94.4% of group A and 95.0% of group B, insertions were successfully completed (P>0.05). Between groups A and B, discomfort during nasal anesthesia (1.7±0.2 vs. 1.6±0.2) and overall tolerance during procedure (1.7±0.2 vs. 1.5±0.2) were similar (P>0.05). However, discomfort during insertion was significantly greater in group A than in group B (2.5±0.2 vs. 1.9±0.2, P=0.02). Of all, 97.4% of group A and 94.7% of group B were willing to undergo unsedated transnasal EGD in the future (P>0.05). Conclusions There was no significant difference in acceptability between younger and older patients for unsedated transnasal EGD. Otherwise, younger patients experienced significantly more discomfort during insertion than did older patients.

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.

Large area of walled-off pancreatic necrosis successfully treated by endoscopic necrosectomy using a grasping-type scissors forceps.

Endoscopic necrosectomy (EN) for walled‐off pancreatic necrosis (WOPN) is less invasive than surgical treatment and has become the first choice for pancreatic abscess. EN is usually carried out with several devices including snares, baskets, and grasping forceps. Occasionally, we have encountered cases in which EN has not been satisfactorily carried out, and there is pressure for further innovation in EN. Here, we describe a case of a large area of WOPN that was successfully treated by EN with endoscopic submucosal dissection and associated techniques, which facilitated removal of necrotic tissues. A 60‐year‐old man was referred to our hospital for WOPN as a complication of necrotizing pancreatitis. As a result of his complicating conditions including ischemic heart disease, uncontrollable arrhythmia, chronic renalfailure, and persistent pleural effusion, he was deemed a poor surgical candidate. Although EN with conventional devices was carried out for five sessions, we could not remove the dense and massive necrotic tissues. At the sixth EN session, the Clutch Cutter device (Fujifilm, Tokyo, Japan) was used to remove the necrotic tissues, without major complications. This is believed to be the first report of EN using the Clutch Cutter for successful treatment of WOPN.

SUCCESSFUL ENDOSCOPIC ULTRASOUND‐GUIDED FINE‐NEEDLE ASPIRATION OF THE PELVIC LESION THROUGH THE SIGMOID COLON

Endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) is a useful modality when the target is a lymph node located in the mediastinum, perigastric area or perirectum. Although it is difficult to carry out EUS‐FNA of the colon using an oblique view linear scope, we report two cases of successful EUS‐FNA of the lesions via the proximal sigmoid colon using a recently available new convex type EUS scope. Case 1 was a 77‐year‐old Japanese woman noted to have multiple lymph node swelling in the para‐aortic area and in the pelvis. Case 2 was a 60‐year‐old Japanese woman noted to have a large mass in the left lower abdomen. In case 1, oral EUS showed no lymph node swelling. In both cases, EUS with forward‐viewing radial echoendoscope was carried out via the anus, and multiple lymph‐node swelling or a large mass was observed near the proximal sigmoid colon. In the EUS‐FNA for these cases, we used a new convex‐type EUS scope that has an oblique view, but with a wide‐angled optical device giving a view similar to a forward one. EUS‐FNA was successfully carried out on the lesions. The pathological specimen revealed diffuse large B‐cell lymphoma in case 1 and gastrointestinal stromal tumor (GIST) in case 2.

Newly developed all in one EUS system: one cart system, forward-viewing optics type 360 degrees electronic radial array echoendoscope and oblique-viewing type convex array echoendoscope.

Most endosonographers use radial scanning instruments for diagnostic imaging, and use longitudinal scanning instruments primarily for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). The use of two separate instruments for radial and longitudinal scanning means 2 different echoendoscopes are required, each with its own dedicated US processing unit. Currently available electronic radial echoendoscopes and linear instruments made by the same company require the same other brand US unit. Furthermore, no forward-viewing optics type 360 degrees electronic radial echoendoscope currently exists. We have developed an all-in-one one cart EUS system that saves space and is available for both the forward-viewing type 360 degrees radial electronic echoendoscope and the oblique-viewing type convex echoendoscope. These scopes have a transducer with variable frequency (5.0, 7.5, 10.0, 12.0 MHz) and color and power Doppler flow mapping capabilities. We performed a clinical development test for thirteen patients with sixteen lesions (Radial EUS on 8 lesions and EUS-FNA on 8 lesions) using this new EUS system. These new instruments provided satisfactory US and endoscopic images. The forward-viewing optics of the prototype enhanced intubation and instrument advancement. The radial scanning prototype provided an adequate diagnosis in 8 (100%) out of 8 lesions for EUS. The convex type achieved successful puncture in 8 (100%) out of 8 lesions and collection of adequate specimen for diagnosis of EUS-FNA in 4 (50%) out of 8 lesions. There were no complications in this series. This new system appears to be an attractive alternative for efficient EUS.

Complete response of early gastric cancer to uracil and tegafur

Abstract: A 74-year-old Japanese woman with early gastric cancer was successfully treated with uracil and tegafur (UFT). She was diagnosed by endoscopy (including endoscopic biopsy and endosonography) with an early gastric cancer, type IIa + IIc, on the greater curvature of the angulus. Surgical procedures or endoscopic therapy could not be performed because the patient had severe ischemic heart disease. Therefore, chemotherapy with UFT was administered at 300 mg/day for 15 months. Follow-up endoscopy, endosonography, and biopsy showed disappearance of the gastric cancer. To our knowledge, this is the first case report of the complete response of an early gastric cancer to UFT in the English-language literature.

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.