Shigeto Koizumi

Large Brunner’s Gland Hyperplasia Treated with Modified Endoscopic Submucosal Dissection

Brunner’s glands are mucosal and submucosal alkalinesecreting glands that are most commonly located in the duodenum, especially in the first part of the duodenum, although they are rarely found in the pylorus and jejunum. Hyperplasia of these glands is normally seen in 2% of upper gastrointestinal (GI) endoscopies [1]. Five percent to 10% of benign duodenal tumors are caused by lesions of Brunner’s gland [2]. They are usually asymptomatic and lesions are discovered incidentally but they can occasionally cause symptoms such as GI hemorrhage and obstruction when they reach sizes >2 cm [3, 4]. In this paper, we report a case of large hyperplasia of Brunner’s gland successfully treated by modified endoscopic submucosal dissection (ESD) technique.

Successful Treatment of Refractory Duodenal Crohn’s Disease with Infliximab

Since the introduction of the anti-tumor necrosis factor (TNF) monoclonal antibody infliximab 1997, the treatment of Crohn’s disease has changed dramatically [1]. Duodenal Crohn’s disease is rare and unique in that its clinical response to medical therapy is universally poor and usually requires surgical therapy such as gastrojejunal bypass [2]. We present one case of duodenal Crohn’s disease with severe stricture that was resolved by treatment with infliximab. In March 2004, a 17-year-old man presented with abdominal pain and diarrhea; he was diagnosed as having Crohn’s disease in the colon. He was treated with corticosteroid (predonisolone, 40 mg/day) and mesalazine (Pentasa, 3.0 g/day). His symptoms and colonic lesions resolved and he was discharged in June 2004. He was maintained on mesalazine (Pentasa, 3.0 g/day) and corticosteroid (predonisolone, 10 mg/day) to prevent recurrence. Also, he was on enteral nutrition therapy using an elemental diet. In August 2004, he suddenly developed severe upper abdominal pain, abdominal distension, nausea, and vomiting. Abdominal CT scan showed marked wall thickness of duodenum. An upper GI X-ray showed a stricture of duodenum (Fig. 1). Endoscopic examination revealed a stricture with a large ulceration and mucosal edema in the duodenum bulb. Histologically, the biopsy specimen of the duodenal mucosa revealed marked active chronic inflammation with

Salvage endoscopic submucosal dissection for the esophagus-localized recurrence of esophageal squamous cell cancer after definitive chemoradiotherapy

1. Kawai K, Akasaka Y, Murakami I, et al. Endoscopic sphincterotomy of the ampulla of Vater. Gastrointest Endosc 1974;20:148-51. 2. Classen M, Demling L. Endoskopische sphincterotomie der papilla vateri und steinextraktion aus dem ductus choledochus [In German]. Dtsch Med Wochenschr 1974;99:469-76. 3. Geenen JE, Vennes JA, Silvis SE. Resume of a seminar on endoscopic retrograde sphincterotomy (ERS). Gastrointest Endosc 1981;27:31-8. 4. Soehendra N, Grimm H, Berger B, et al. Endoskopische behandlungsmogglichkeiten [In German]. 1988;1:2-9. 5. Cotton PB. Nonoperative removal of bile duct stones by duodenoscopic sphincterotomy. Br J Surg 1980;67:1. 6. Sievert CE, Silvis SE. Evaluation of electrohydraulic lithotripsy on human gallstones. Am J Gastroenterol 1985;80:854. 7. Leung JWC, Chung SSC. Electrohydraulic lithotripsy with peroral choledochoscopy. Br J Med 1989;299:595-8. 8. Siegel JH, Ben Zvi JS, Pullano WE. Electrohydraulic lithotripsy. Gastrointest Endosc 1990;36:134-6. 9. Kozarek RA, Low DE, Ball TJ. Tunable dye laser lithtripsy: in vitro studies and in vivo treatment of choledocholithiasis. Gastrointest Endosc 1988;34:418-21. 10. Ell C, Lux G, Hochberger J, et al. Laserlithotripsy of common bile duct stones. Gut 1988;29:746-51. 11. Cotton PB, Kozarek RA, Shapiro RH, et al. Endoscopic laser lithotripsy of large bile duct stones. Gastroenterology 1990;99:1128-33. 12. Ponchon T, Gagnon P, Valette PJ, et al. Pulsed dye laser lithotripsy of bile duct stones. Gastroenterology 1991;100:1730-6.

Advanced feasibility of endoscopic submucosal dissection for the treatment of gastric tube cancer after esophagectomy

The incidence of esophageal cancer is increasing worldwide. However, progress in surgical techniques and the development of novel therapeutic modalities such as adjuvant chemoradiation therapy combined with surgery have improved the postoperative survival up to 34% to 51% at 5 years. Therefore, long-term survival cases are no longer rare. Generally, gastric tubes are substituted for the reconstitution after the esophagectomy for the treatment of esophageal cancer. In association with the increase in the number of long-term follow-up cases after esophagectomy, the occurrence of secondary malignancies such as adenocarcinoma arising in gastric tubes has been reported. Until a decade ago, repeat surgery was considered for the treatment of adenocarcinoma in gastric tubes. However, this did not achieve satisfactory clinical outcomes because of its high operative risks. Recently, the use of EMR has been emphasized for treatment in patients with superficial lesions. Although the clinical risks of EMR associated with gastric tube cancer (GTC) treatment are significantly lower than those associated with surgery, EMR cannot always be used to resect GTC completely because of its technical limitations regarding the tumor sizes. Therefore, endoscopic submucosal dissection (ESD) is currently used as a therapeutic option for treating GTC. However, ESD for GTC also carries limitations with respect to the anatomical features of gastric tubes, particularly the suture line and staples with the possibility of fibrosis. We therefore investigated the feasibility of

The feasibility of endoscopic submucosal dissection for superficial esophageal cancer in patients with cirrhosis (with video)

Endoscopic submucosal dissection (ESD) was initially developed for gastric cancer and is currently accepted as an established procedure for superficial cancer of the esophagus. The most important advantage of ESD compared with EMR is that it can provide a high en bloc resection rate and precise histologic assessment even for large lesions. On the other hand, the disadvantage of ESD is a higher risk of bleeding and perforation than for EMR. Previous reports described that esophageal ESDrelated adverse events, such as postoperative bleeding and perforation, are considerably serious risks. However, ESD for patients with cirrhosis may carry a higher risk of these adverse events because of the low platelet count, coagulopathy, and portal hypertensive gastroenteropathy, including esophageal varices, in these patients. As a result, endoscopists have been hesitant to apply ESD for the treatment of esophageal cancer in patients with cirrhosis.

Rapid Regression of Multiple Gastric Carcinoid Tumors with Hypergastrinemia and Atrophic Gastritis after Renal Transplantation

To the Editor Gastric carcinoid tumors are rare. Nevertheless, when they occur, they are often found in patients diagnosed as having type A gastritis [1]. In patients with type A gastritis, the development of carcinoids and the widespread hyperplasia of enterochromaffin-like cells are related to atrophic changes of fundic mucosa and the trophic action of subsequently raised serum gastrin levels. In the past gastrectomy was the treatment of choice for carcinoid tumors; however, recent reports have shown that multiple gastric carcinoid tumors associated with type A gastritis are indolent and recommend that patients should receive more conservative treatment [1, 2]. We herein present one case where multiple gastric carcinoid tumors with hypergastrinemia and type A gastritis regressed after renal transplantation. In November 2000, a 51-year-old woman presented with epigastric pain and she received upper gastrointestinal endoscopy in our hospital. Endoscopic examination revealed multiple gastric polyps in the body and funds (Fig. 1). The polyps, measuring between 1 and 15 mm, were covered by intact mucosa identical to the surrounding tissue. The intervening gastric mucosa appeared atrophic with a pale shiny lining and visible submucosal vessels. Biopsies were taken for a histopathology of the polyps. Biopsies of the polyps showed gastric carcinoid tumors (Fig. 2), cells were positive for chromogranin A, synaptophysin, and neuron-specific enolase. Serum gastrin level was over 3,000 pg/ml (normal 0–90). Serum serotonin and urine 5-HIAA levels were normal. Antiparietal cell antibody was negative. Helicobacter pylori serology was negative. The patient was diagnosed as having multiple type I gastric carcinoid tumors. The question was how to manage this case. The patient did not want to receive surgical treatment, such as a total gastrectomy or antrectomy, because she had already received hemodialysis treatment for chronic renal failure. Therefore,with agreement of the patient, we decided to do an endoscopic follow-up. We performed endoscopic examination at six-month intervals. Between 2000 and 2004, follow-up endoscopy showed that the polyps had the same size as on the initial picture, and a histological examination of biopsies specimens revealed a residual carcinoid tumor in the mucosal layer. In December 2004, she received renal transplantation. After renal transplantation, she was treated with corticosteroid ( prednisolone, 10 mg/day) and Tacrolimus (Prograf, 4 mg/day) to prevent kidney graft rejection. The endoscopic examination at three months after renal transplantation showed marked regression of the carcinoid tumors. Furthermore, the endoscopic examination at six months after renal transplantation showed complete regression of the disease, though the serum gastrin level was still high (over 3,000 pg/ml) (Fig. 3). The endoscopic examination showed no progression of tumors at the end of the follow-up. Gastric carcinoid tumors fall under the broad classification of foregut carcinoid tumors. However, it is well known that these tumors are clinically and biologically distinct from the carcinoid tumors involving the rest of the gastrointestinal tract. In 1993, Rindi et al. classified gastric carcinoid tumor into three subtypes, based on pathogenesis [3]: type I and type II gastric carcinoids develop under the trophic influence of gastrin, whereas type III carcinoids are M. Odashima (&) M. Otaka M. Jin Y. Horikawa T. Matsuhashi R. Ohba N. Mimori S. Koizumi N. Kinoshita T. Takahashi S. Watanabe Department of Gastroenterogy, Akita University School of Medicine, 1-1-1, Hondo, Akita city, Akita 010-8543, Japan e-mail: odashima@doc.med.akita-u.ac.jp

True Primary Enterolith Treated by Balloon-assisted Enteroscopy

Primary enterolith is a rare condition that can induce ileus and intestinal perforation. We report the first case of a true primary enterolith treated by balloon-assisted enteroscopy. The patient presented with a small intestinal ileus. After its improvement following the insertion of an ileus tube, radiography with amidotrizoate sodium meglumine detected a round, movable defect in the ileum measuring 42 mm diameter. The patient was diagnosed with a primary enterolith based on her past history. The enterolith was fractured and removed using balloon-assisted enteroscopy. This case suggests that balloon-assisted enteroscopy may be an effective non-invasive treatment option for enteroliths.

Successful treatment with infliximab for refractory para-ileostomal ulceration in a patient with Behҫet’s disease

Behҫet’s disease (BD) is a chronic disorder involving multiple organ systems including the small and large intestines. A 46-year-old female diagnosed with intestinal BD presented with ileocecal perforation and diffuse peritonitis and subsequently underwent ileocolic resection with ileostomy. After surgery, she suffered from refractory para-ileostomal ulceration associated with BD. Most importantly, however, treatment with infliximab was significantly effective in healing the ulceration. This is the first report of para-ileostomal ulceration associated with BD successfully treated with infliximab, suggesting the possible use of infliximab as a therapeutic option for para-stomal ulcers related to BD.

Chronological Changes in the Gastric Cancer Subsite in Akita, Japan: The Trends from the Data of a Hospital-Based Registration System

With the decreasing global trend in the Helicobacter pylori infection rate, compositional changes in the gastric cancer subsites have occurred worldwide. However, the compositional changes in Asian countries, including Japan, remain to be clarified. The aim of this study is to investigate the latest chronological changes in the gastric cancer subsite using a hospital-based registration system in Akita prefecture in Japan. From 2007-2015, subsites of gastric cancers were coded according to the International Classification of Diseases for Oncology (ICD-03). The nine-year registration period was divided into the three 3-year periods: 2007-2009, 2010-2012, and 2013-2015. A total of 10,804 cases of gastric cancer were registered. The proportion of cardiac cancer among total gastric cancer slightly but significantly declined from 12.1% in 2007-2009 to 9.2% in 2013-2015 (P < 0.01). Among non-cardia cancer, the proportion of corpus cancer significantly increased from 41.3% to 50.2% during the study period (P < 0.01), while that of antropylorus cancer significantly decreased from 37.6% to 34.3% (P < 0.05). Such compositional changes in the gastric cancer subsite were observed largely in men, regardless of the histologic subtype of cancer. With the decreasing H. pylori infection rate, compositional changes in the gastric cancer subsite are occurring in Japan. While the proportion of cardia and antropylorus cancer is declining, that of corpus cancer is increasing, indicating diverse etiology of gastric carcinogenesis depending on the subsites. Identifying the most common sites of occurrence, may help to improve the efficiency of screening for gastric cancer.

Mesenteric lymph node abscess due to Yersinia enterocolitica : case report and review of the literature

Abstract We describe the case of a 74-year-old female with a mesenteric lymph node abscess caused by a Yersinia enterocolitica infection. She had been administered an immunosuppressive drug and was admitted to the hospital due to a high fever, right lower abdominal pain and advanced leukocytosis. We initially diagnosed her with lymphadenitis based on the symptoms and the imaging studies. However, conservative treatment with antibiotics did not yield any improvement, and abscess formation was suspected. Surgical treatment was performed, and the culture from the drainage fluid grew Y. enterocolitica. The histological findings suggested that an ulcerative lesion of the terminal ileum was the entry port of Y. enterocolitica. The pathogen infected the mesenteric lymph nodes and spread along the ileocecal lymphatic vessels, resulting in the formation of an abscess. We also provide a review of the previously published literature on lymph node abscesses due to Y. enterocolitica infections.