Sayo Ito

A prospective randomized study on the benefits of a new small-caliber colonoscope

BACKGROUND AND STUDY AIMS We compared the performance efficiency of a newly developed small-caliber colonoscope (PCF-PQ260 L) with passive bending, high force transmission, and an outer diameter of 9.2 mm with that of a standard colonoscope, in female and male patients, particularly with regard to passage through acute angulations or into the proximal colon. PATIENTS AND METHODS A total of 330 patients were randomly allocated to undergo small-caliber (n = 164) or standard (n = 166) colonoscopy. The patients were assessed for pain using a visual analogue scale (0 = none, 100 = extremely painful), and for cecal intubation, withdrawal time, difficulty of colonoscopy, dosage and level of sedation used, and any complications. RESULTS Median maximum pain and overall pain during colonoscopy were significantly lower in the small-caliber group than in the standard group in women (25 vs. 45, P < 0.001 and 15 vs. 26, P = 0.001, respectively), whereas no significant differences were seen in men (8 vs. 10, P = 0.103 and 16 vs. 20, P = 0.166, respectively). Furthermore, no significant differences were seen between groups in cecal intubation rate or time to cecum in all patients or by sex. CONCLUSIONS Use of the small-caliber colonoscope reduced pain in female patients, but offered no advantage over standard colonoscopy in male patients. The performance of the small-caliber colonoscope was equivalent to that of the standard colonoscope in terms of cecal intubation rate and time to cecum, regardless of the sex of the patient.

Favorable long-term clinical outcome of uncovered D-weave stent placement as definitive palliative treatment for malignant colorectal obstruction.

BACKGROUND: Most self-expandable metallic stents for colorectal placement are uncovered because of the high migration rate of covered stents. However, the optimal stent design for colorectal use remains unclear. OBJECTIVE: The purpose of this study was to evaluate the efficacy and safety of a double-wire woven uncovered stent for definitive palliative treatment of malignant colorectal obstruction. DESIGN: This study was a prospective, single-arm, observational clinical study of patients enrolled between December 2005 and September 2010. SETTINGS: This study was conducted at a referral hospital in Japan. PATIENTS: Twenty-four consecutive patients with malignant colorectal obstruction were included in the study. INTERVENTIONS: A double-wire woven uncovered stent was placed by use of a standard through-the-scope endoscopic placement technique. MAIN OUTCOME MEASURES: Technical, initial clinical, and long-term clinical success were measured. Long-term clinical success was defined as sustained relief of obstructive symptoms without reintervention until the patient’s death. RESULTS: The Karnofsky performance status score before stent placement was 60 (median, interquartile range, 42.5–67.5). Twenty of 24 patients had primary colorectal cancer, and 4 had extracolorectal malignancies. The site of obstruction was the ascending colon in 10 patients, descending colon in 4 patients, sigmoid colon in 7 patients, and rectum in 3 patients. Technical, initial, and long-term clinical success rates were 100%, 100%, and 83%. Median stent patency time was 149 days (interquartile range, 45–198 days). Median survival time after stent placement was 155 days (interquartile range, 68–231 days). Four patients (17%) had negative outcomes including stent occlusion by tumor ingrowth (8%) and stent migration (8%). The highest Karnofsky performance status score after stent placement was 70 (median; interquartile range, 50–70). The Karnofsky performance status score improved after stent placement (p = 0.002). LIMITATIONS: This study was limited because it was a single-arm, single-center study, and it had a small sample size. CONCLUSIONS: Endoscopic placement of double-wire woven uncovered stents is effective and safe as definitive palliative treatment for patients with malignant colorectal obstruction.

Preliminary Experience Using Full-Spectrum Endoscopy for Colorectal Cancer Screening: Matched Case Controlled Study

Background/Aim. High-quality colonoscopy is needed to reduce the morbidity and mortality of colorectal cancer. Full-spectrum endoscopy (FUSE) has recently shown potential in improving adenoma detection during colonoscopy. This study aimed to evaluate the feasibility and utility of FUSE colonoscopy. Methods. From April 2015 to February 2016, 130 patients underwent FUSE colonoscopy for screening at a tertiary cancer center. Cecal intubation rate (CIR), procedure time, polyp/adenoma detection rate (PDR/ADR), and mean number of adenomas per colonoscopy (APC) were compared in matched-control patients (n = 260) who underwent standard colonoscopy (SC). Accordingly, endoscopists subjectively evaluated the utility of FUSE colonoscopy. Results. The CIR of FUSE colonoscopy was 94.6%. Cecal intubation time (8.8 min versus 5.1 min, P < 0.001) and total procedure time (21.6 min versus 17.3 min, P < 0.001) in the FUSE group were significantly longer than those in the SC group. PDR (68.3 versus 71.2%, P = 0.567), ADR (63.4% versus 58.5%, P = 0.355), and APC (1.4 versus 1.4, P = 0.917) were not significantly different between the two groups. The wide view of FUSE colonoscopy was superior to that of SC based on the questionnaires. Conclusions. FUSE colonoscopy did not demonstrate superiority to SC in a clinical setting.

Factors associated with delayed gastric emptying in patients with stent placement for malignant gastric outlet obstruction

Background and study aims: Delayed gastric emptying (DGE) is an important factor in determining the clinical outcome in patients with stent placement for malignant gastric outlet obstruction but the factors associated with DGE remain unclear. The aim of this study was to investigate whether clinicopathologic data could be used to identify the factors for DGE in such patients. Patients and methods: A prospective, single-arm, observational clinical study was performed in a referral hospital in Japan. A total of 54 patients with stent placement for malignant gastric outlet obstruction were enrolled. A gastric emptying scintigraphy test was performed 1 week after stent placement. The relationship between DGE and clinicopathologic factors was investigated, and also the relationship between DGE and stent patency time, eating period (when the patient was able to maintain oral intake), and survival time. Results: A total of 38.9 % (21 /54) of patients had DGE. The following were identified as independent predictive factors of DGE: opioid use (odds ratio, 5.32; 95 % confidence interval [95 %CI], 1.07 – 26.41; p = 0.04), chemotherapy before stent placement (odds ratio, 8.03; 95 %CI, 1.85 – 34.95; p = 0.006), and smaller stent diameter (odds ratio, 13.59; 95 %CI, 1.72 – 107.41; p = 0.01). No relationship was found between DGE and the level of oral intake, stent patency time, eating period, and survival time. Conclusions: The factors associated with DGE after stent placement include those associated with the patient’s tumor as well as factors relating to their treatment, including stenting. The clinical and functional results after stent placement appear to be unrelated to the gastric emptying findings.

Characteristics and risk factors for sporadic non-ampullary duodenal adenocarcinoma.

Abstract Objectives: Despite the gradual increase in the incidence of non-ampullary duodenal adenocarcinoma (NADAC), the associated characteristics and risk factors remain poorly understood. The aim of this study was to clarify the clinical characteristics and risk factors of sporadic NADAC. Materials and methods: In this retrospective case-control study, we enrolled 156 Japanese NADAC patients with 160 lesions from our hospital’s cancer registry over 13 years. The patient demographics and clinical findings were compared to 468 age- and sex-matched controls selected from our medical health checkup recipients. Results: The ratio of men to women among the NADAC patients was 2:1, the median age was 64 years (range 31 to 90 years), the majority of the lesions were located in the second portion of the duodenum, and well-differentiated adenocarcinoma was the dominant histology. A univariate analysis revealed that smoking was a common risk factor for both men and women, whereas Helicobacter pylori (HP) infection and a history of colorectal cancer (CRC) were risk factors for the men. The multivariate analysis revealed that smoking, a history of CRC, and HP positivity were also individual risk factors for NADAC. Conclusions: Smoking, a history of CRC, and HP positivity were identified as risk factors for NADAC.

A simple endoscopic scoring system to differentiate between duodenal adenoma and carcinoma

Background and study aims  Diagnosis of nonampullary duodenal low grade adenoma (Vienna classification category 3, VCL 3) and high grade adenoma/carcinoma (VCL 4 or higher) is important for clinical management decisions. However, there are no criteria based on which endoscopic diagnosis can differentiate between VCL3 and VCL4 or higher. This study aimed to establish simple diagnostic criteria to differentiate between VCL3 and VCL4 or higher. Patients and methods  This retrospective study included patients with superficial nonampullary duodenal epithelial tumors (NADETs) who underwent tumor resection between June 2004 and November 2016 at a single cancer center hospital. Using patient demographics and endoscopic findings from 2004 to 2013, variables related to the final histology of VCL4 or higher were analyzed, and a predictive model was developed. Validation analysis was performed on patients treated between 2014 and 2016. Results  A total of 150 lesions in 134 patients were included. Lesion diameter, reddish color, depression, heterogeneous or no nodularity, and mixed or depressed macroscopic types were significantly predictive of VCL4 or higher. A predictive score model was developed and a score of 3 points was defined as an appropriate cutoff for predicting VCL4 or higher. In the validation analysis, the accuracy rate of VCL4 or higher diagnosis was 86 % when the score was ≥ 3 points. Scores between patients with VCL3 and VCL4 or higher were significantly different ( P  = 0.0004). Conclusions  A simple and useful endoscopic scoring system was developed to preoperatively differentiate between VCL3 and VCL4 or higher among superficial NADETs.

Use of a novel shorter minimum caliber needle for creating endoscopic tattoos for preoperative localization: a comparative ex vivo study

BACKGROUND AND STUDY AIMS  In colorectal cancer surgery, inadvertent deep injections during endoscopic tattooing can cause India ink leakage into the peritoneum, leading to complications or to poor visualization of the surgical plane. This ex vivo animal study compared the use of novel shorter, minimum caliber needles versus conventional injection needles for endoscopic tattooing. ANIMALS AND METHODS  Four endoscopists used the novel needles and conventional needles to make ten endoscopic tattoos (five tattoos/needle type/endoscopist) in harvested porcine rectum using a saline test-injection method. India ink leakage and the success of the tattoo (i. e. visible, < 40 mm, plus no India ink leakage) were compared. RESULTS India ink leakage was observed for 30 % (6/20) of the conventional needle tattoos but for none of the novel needle tattoos ( P  = 0.02). Tattoos created using the novel needles were more successful than those made with the conventional needles: 18/20 (90 %) vs. 11/20 (55 %); P  = 0.01. CONCLUSIONS The use of novel shorter minimum caliber needles may be safe and effective for endoscopic tattooing for preoperative localization prior to colorectal cancer surgery.

Underwater endoscopic mucosal resection for complete R0 removal of a residual adenoma at a perforated scar in a patient with colostomy.

Endoscopic mucosal resection (EMR) of residual polyps is technically challenging, as submucosal fibrosis from the initial resection makes it difficult to lift the lesion during submucosal injection and to snare the entire tumor [1]. Endoscopic submucosal dissection (ESD) enables complete removal of such residual polyps [2] but presents some technical difficulties and is time-consuming [3]. An 82-year-old man with permanent sigmoidostomy was referred to our unit because of a residual polyp in the descending colon, seen at the 18-month surveillance test after EMR at another hospital. Perforation had occurred during EMR, and clip closure had been performed. Colonoscopy through the sigmoidostomy showed a 12-mm polyp surrounded by multiple widespread scars on the dorsal side 20 cm proximal to the colostomy (▶Fig. 1). The lesion was diagnosed as an adenoma (▶Fig. 2 a, b). Complete removal by ESD was considered difficult [4]. First, there was the possibility of severe and widespread submucosal fibrosis because of multiple deep ulcer scars. Second, traction would have to be limited, since it is difficult to change the position of a patient with a colostomy. Third, the polyp was difficult to visualize because of a collapsed colon wall caused by gas leakage through the colostomy. We therefore performed underwater EMR (▶Fig. 3 and ▶Fig. 4, ▶Video1) [5]. En bloc resection without complications was achieved within 15 minutes. Histopathological examination showed an adenoma with negative resection margins (▶Fig. 5). There were three advantages to using water immersion in the underwater EMR. First, water immersion allowed us to “float” the lesion away from the muscularis layer, allowing wide-field resection of the entire polyp and scars (▶Fig. 4). Second, underwater EMR eliminated the E-Videos

A novel wide viewing endoscope for upper gastrointestinal screening: a pilot study

The feasibility of full-spectrum endoscopy (FUSE) esophagogastroduodenoscopy (EGD), providing a 245-degree field of view with double imagers on the front and left side of the endoscope was evaluated. Twenty-one healthy individuals (15 male, median age, 35 years) underwent upper gastrointestinal screening using FUSE-EGD. The primary end point was the rate of successful visualization of Vater’s papilla. Secondary end points were visualization of the squamo-columnar junction (SCJ) and the anal side of the pyloric ring, and the endoscopists’ subjective evaluation of usability based on maneuverability and imaging of FUSE-EGD. The mean procedure time was 6.5 min, with a median of 91 images captured. The rate of successful visualization of Vater’s papilla was 90 % (19/21). The whole circumference of the SCJ was observed with two video monitors in all cases. The anterior anal side of the pyloric ring was observed in 29 % (6/21) of cases. However, the general impression of the usability of FUSE-EGD was that it was rather inferior to that of a standard front viewing endoscope. Although the usability requires further modification, FUSE-EGD provided excellent results for imaging Vater’s papilla and the SCJ.

Treatment strategy for local recurrences after endoscopic resection of a colorectal neoplasm

Background and AimEndoscopic salvage treatment for recurrent or residual neoplasms is sometimes technically challenging, and information in choice of treatment methods is lacking. This study aimed to clarify the appropriate treatment strategy for local recurrence after endoscopic resection (ER).MethodsSeventy-four patients with 74 lesions who received endoscopic treatment for local recurrence after ER for colorectal epithelial neoplasms between January 2010 and December 2016 were enrolled. Patients with hyperplastic polyp, sessile-serrated adenoma/polyp, and submucosal invasive cancer in their initial ER were excluded. Treatment methods, treatment outcomes, and recurrence rate were evaluated for each recurrence based on the preoperative endoscopic diagnosis (adenomatous or cancerous).ResultsForty-nine of the 74 patients diagnosed with adenomatous recurrence were treated using cold polypectomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD) in 15, 26, and 8 patients, respectively. Cold polypectomy was applied only to diminutive lesions. EMR and ESD en bloc resection rates were 53.8 and 100%, respectively (p = 0.030). Two patients (7.7%) in the EMR group developed local recurrence, but an additional ER achieved complete resection. Meanwhile, the remaining 25 patients diagnosed with cancerous recurrence were treated via EMR and ESD for 7 and 18 patients, respectively. EMR and ESD en bloc resection rates were 28.6 and 83.3%, respectively (p = 0.017). Three patients (42.9%) in the EMR group developed recurrence.ConclusionsSelecting appropriate treatment methods for adenomatous recurrence could be decided based on estimated pathology and lesion size. ESD was effective for cancerous recurrence to achieve complete disease control.