Noriyuki Isohata

Gastrografin as an alternative booster to sodium phosphate in colon capsule endoscopy: safety and efficacy pilot study.

Background and study aims: Sodium phosphate is a key component of bowel preparation regimen for colon capsule endoscopy (CCE), but may cause serious complications. The aim of this study is to evaluate the use of Gastrografin, substituted for sodium phosphate, in CCE bowel preparation. Patients and methods: In total, 29 patients (median age 64 years; 23 females) underwent CCE, covered by the national health insurance system of Japan. All had a history of laparotomy and/or previously incomplete colonoscopy. On the day before examination, patients ingested 1 L of polyethylene glycol + ascorbic acid with 0.5 L of water in the evening, and again the same laxative on the morning of examination. After capsule ingestion, 50 mL of Gastrografin diluted with 0.9 L of magnesium citrate was administered, and then repeated after 1 hour. Results: The capsule excretion rate was 97 % (28/29). The median colon transit time was 2 hours 45 minutes and rapid transit (< 40 minutes) through the colon occurred in one patient (3.4 %). Bowel cleansing level was adequate in 90 % of patients. The polyp (≥ 6 mm) detection rate was 52 %. Diluted Gastrografin was well tolerated by patients. No adverse events occurred. Conclusion: Gastrografin can be an alternative to sodium phosphate in CCE bowel preparation regimen.

Double‐balloon colonoscopy carried out by a trainee after incomplete conventional colonoscopy

It has been reported that double‐balloon colonoscopy (DBC) is useful for patients after failed colonoscopy. In most cases previously reported, expert colonoscopists have carried out DBC. However, DBC may not require significant expertise. The objective of the present study is to assess DBC carried out by an inexperienced colonoscopist in patients referred after previously incomplete colonoscopy.

Blue laser imaging endoscopy system for the early detection and characterization of colorectal lesions: a guide for the endoscopist

Blue laser imaging is a new system for image-enhanced endoscopy using laser light. Blue laser imaging utilizes two monochromatic lasers (410 and 450 nm) instead of xenon light. A 410 nm laser visualizes vascular microarchitecture, similar to narrow band imaging, and a 450 nm laser provides white light by excitation. According to three recently published reports, the diagnostic ability of polyp characterization using blue laser imaging compares favorably with narrow band imaging. No published data are available to date regarding polyp detection with blue laser imaging. However, blue laser imaging has the possibility to increase the detection of colorectal polyps by depicting brighter and clearer endoscopic images, even at a distant view, compared with first-generation image-enhanced endoscopy. A clinical trial to compare the detection between blue laser imaging and xenon light is warranted.

A novel retrieval technique for large colorectal tumors resected by endoscopic submucosal dissection: tumor extraction by defecation

Background and study aims: Endoscopic submucosal dissection (ESD) has been developed to facilitate en bloc resection of large lesions. However, it is laborious to retrieve the large colorectal specimens. We propose a novel retrieval technique using a Valsalva maneuver, known as Tumor Extraction by Defecation (TED). Case series: A total of nine lesions (median size 88 mm, maximum 225 mm; proximal colon three, rectum six) that could not be easily retrieved using net forceps were subsequently removed by TED. The rectum was filled with water through the colonoscope. The patient then strained to evacuate the specimen, facilitated by an almost straight anorectal angle. All specimens were retrieved without fragmentation, within minutes. Histology was assessed appropriately, including an adenoma in two and mucosal cancer in seven. All cut margins were verified to be negative. No adverse events occurred. Conclusions: TED is a promising technique for retrieving large colorectal specimens after ESD.

Pseudocirrhosis caused by regorafenib in an advanced rectal cancer patient with multiple liver metastases

A 70-year-old man who was diagnosed with unresectable advanced rectal cancer with multiple liver metastases, received oxaliplatin-based treatment with bevacizumab as first-line chemotherapy and irinotecan-based treatment with bevacizumab as second-line chemotherapy for a total of 17 months. The patient was treated with regorafenib (160 mg/day for 3 weeks) as third-line chemotherapy. Following completion of one course of regorafenib treatment, the patient complained of abdominal distension. Computed tomography (CT) examination identified liver atrophy and massive ascites, while no such symptoms were observed prior to the regorafenib treatment. Blood testing revealed increases in the aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP) levels. The patient was admitted to the Aizu Medical Center (Aizuwakamatsu, Japan). Approximately 2,000 ml of ascitic fluid were aspirated daily for 1 week by abdominal puncture. The patient was administered oral diuretics, including 20 mg/day of furosemide and 25 mg/day of spironolactone. Albumin was administered to correct the albumin deficit. The levels of AST, ALT and ALP were decreased from the peak value reported on admission and the patient was discharged from our hospital 16 days following treatment initiation. The CT examination after 1 month revealed that the volume of the liver had been restored and the ascites had disappeared. Furthermore, almost all the liver metastases were reduced in size. The carcinoembryonic antigen level, which was elevated prior to regorafenib treatment, also decreased to normal.

Topical lidocaine inhibits spasm during colonoscopy: a double-blind, randomized controlled trial (with video)

Background and study aims  Topical peppermint oil prevents intestinal spasm, but can cause rebound spasm. Lidocaine hydrochloride, a local anesthetic, may work as an antispasmodic by blocking Na + channels. The aim of this study was to investigate the effect of topical lidocaine on the inhibition of colonic spasm during colonoscopy, compared with peppermint oil. Patients and methods  A randomized, controlled double-blind trial was conducted in an academic endoscopy unit. Patients requiring endoscopic resection were randomly allocated to colonoscopy with topical administration of lidocaine (n = 30) or peppermint oil (n = 30). Similar vials containing different solutions were randomly numbered. Allocation was made based on the vial number. The solution used and the vial number were not revealed during the study. Two endoscopists performed all procedures using midazolam, without anticholinergic agents. When a pre-selected lesion was identified, the solution in the assigned vial was dispersed and the bowel observed for 5 minutes. The primary endpoint was the duration of spasm inhibition, and a secondary endpoint was the occurrence of rebound spasm stronger than before dispersion. Results  There were no significant differences in patient demographics. Spasm was inhibited in almost all patients in both groups, with a similar median duration (lidocaine 227 sec vs. peppermint 212.5 sec, P  = 0.508). In contrast, rebound spasm occurred less frequently in the lidocaine group (lidocaine 7 % vs. peppermint 47 %, P  = 0.001). There were no adverse events or symptoms associated with administration of the solutions. Conclusions  The inhibitory effect of lidocaine is not superior to peppermint oil. However, lidocaine significantly decreases the frequency of rebound spasms.

Ultrathin versus pediatric instruments for colonoscopy in older female patients: A randomized trial.

Small‐caliber endoscopes such as gastroscopes or pediatric colonoscopes are occasionally required to negotiate fixed or angulated colons. However, the use of a new ultrathin instrument (diameter 7.0 mm) narrower than other conventional colonoscopes has not been evaluated. The aim of the present study was to compare the use compare the use of an ultrathin colonoscope (UTC) with a pediatric colonoscope (PDC) for colonoscopy in older female patients.

Colonoscopy in Patients Aged 85 Years or Older: An Observational Study

Objectives: Colonoscopy is the first-line modality to examine the colon even in the very elderly but may have an increased risk of complications. This study aimed to evaluate the efficacy and safety of colonoscopy in the very elderly. Methods: Patients ≥85y old, who underwent colonoscopy between September 2010 and August 2012 in two tertiary-care hospitals in Japan were enrolled. Main outcome measures were cecal intubation rate, detection rate of adenomas and cancers, treatment, adverse events, and long-term outcomes. Results: A total of 207 colonoscopies were performed in 177 patients (females 72, males 105; maximum age 95 years). Of these, 202 attempted to reach the cecum, with success in 92%. Excluding patients with known colorectal neoplasms, invasive cancers were detected in 12%, including T1 lesions in 2% and T2 or deeper in 9%. No cancers were detected in patients referred for surveillance or mild abdominal symptoms. Cancers were found in 25% of patients with positive fecal immunochemical tests, 22% with altered bowel habits, 21% with anemia, and 18% with hematochezia. Treatment of 29 patients with cancer included surgery in 22, endoscopic resection in two and no treatment (due to comorbidities) in five. There were no complications. During 730 days (mean) of follow up, 27 patients died but only three died from recurrent colorectal cancer. Conclusions: Colonoscopy for patients aged ≥85 years is safe. A relatively high detection rate of cancers was found, and most were treatable and even curable. (UMIN000018575)

Morphometric study of the blood supply of pedunculated colon polyps: What is the optimal position on the stalk for snare resection?

Background and study aims: Bleeding after colonoscopic resection of pedunculated polyps cannot be easily predicted. The aims of this study were to evaluate the blood supply in pedunculated polyps and to clarify the optimal position on the polyp stalk for snare placement to prevent post-polypectomy hemorrhage. ]Patients and methods: In one institution, 11 pedunculated polyps from 11 patients were studied prospectively. All polyps were resected at the base of the stalk using a snare wire with electrocautery. Histologic axial sections from the apex and base of the stalk were examined with hematoxylin eosin and elastica stains. Elastica stains were used to identify blood vessels. The cross-sectional area of the stalk, total vessel area, maximum diameter of artery/arteriole lumen, number of thick (≥ 0.1 mm) vessels, and number of arteries/arterioles were measured in each section with image processing software. Wilcoxon signed-ranks test was used for comparison. Results: The median polyp diameter was 16 mm (range 7 to 24 mm) and median length of the stalk was 11 mm (range 7 to 23 mm). Two invasive cancers (T1) were included. The maximum diameter of the arterial/arteriolar lumen was greater at the base (P = 0.0044), whereas the ratio of the vessel area to the cross-section area was greater at the apex (P = 0.016). The number of thick vessels and arteries/arterioles were equivalent between apex and base. Conclusions: Morphometric study of the blood supply of pedunculated polyps confirmed that the optimal site for the excision of pedunculated polyps is in the middle of the stalk.