Shoryoku Hino

Combined use of a magnifying endoscope with a narrow band imaging system and a multibending endoscope for en bloc EMR of early stage gastric cancer.

BACKGROUND En bloc EMR is performed in Japan as a curative treatment for early stage gastric cancer. However, current methods of EMR are technically difficult and require proficiency in determining the extent of the cancer. This study assessed the feasibility of a new method to obviate these problems and to facilitate en bloc EMR. METHODS The new method uses two types of endoscopes: a magnifying endoscope with a narrow band imaging system to enhance the definition of mucosal and microcirculatory structure, and an endoscope with multibending tip deflection to maintain orientation during EMR. Forty-two consecutive cases of mucosal gastric cancer treated by EMR were reviewed retrospectively. In 12 of these patients, 12 lesions that fulfilled guideline criteria for EMR were treated by the modified, en bloc EMR method of circumferential incision and snare resection by using the two endoscopes. RESULTS The rate of complete en bloc resection with the new method of EMR was 91.7%, (11/12). There was no major complication. CONCLUSIONS The new en bloc resection method for EMR with two endoscopes described here is feasible and may be a safe and a reliable technique for curative treatment of mucosal gastric cancer.

New approach to diagnosing ampullary tumors by magnifying endoscopy combined with a narrow-band imaging system

BackgroundA newly developed narrow-band imaging (NBI) system, which uses modified optical filters, can yield clear images of microvessels and surface structure in gastric and colonic diseases. In the present study, we investigated the ability of magnifying endoscopy with NBI (MENBI) to diagnose and differentiate between benign and malignant ampullary tumors.MethodsFourteen patients, whose ampullas were noted to be significantly enlarged or protruding with conventional endoscopy, were enrolled in the study. Specimens, which were obtained by forceps biopsy, endoscopic papillectomy, and/or surgery, were retrieved for histopathological examination. The correlation between MENBI images and histopathological findings was investigated. MENBI findings were classified as I, oval-shaped villi; II, pinecone/leaf-shaped villi; or III, irregular/nonstructured. In addition, tortuous, dilated, and network-like vessels noted on the ampullary lesions with MENBI were defined as abnormal vessels.ResultsIn 6 of 14 patients, the ampullary changes were proven to be inflammatory in forceps biopsy specimens, without any evidence of malignancy after more than 1 year of follow-up. In five patients, ampullary lesions were treated by endoscopic papillectomy, and in three, by pancreatoduodenectomy. All adenomas and adenocarcinomas had type II and/or type III surface structures, and patients whose ampulla had a type I surface structure had only inflammatory or hyperplastic changes. In addition, abnormal vessels were seen only in adenocarcinomas and never in adenomas.ConclusionsMENBI has the ability and potential to predict histological characteristics of ampullary lesions.

Novel quantitative perfusion analysis with contrast-enhanced harmonic EUS for differentiation of autoimmune pancreatitis from pancreatic carcinoma

Abstract Objective. Autoimmune pancreatitis (AIP) is often misdiagnosed as pancreatic carcinoma (PC) despite recent advances in imaging tests. The aim of the study was to evaluate whether the quantitative perfusion analysis using software “Time intensity curve” with contrast-enhanced harmonic EUS (CH-EUS) facilitate the differentiation of AIP from PC. Methods. Consecutive patients with focal AIP and pancreatic carcinoma who underwent CH-EUS from January 2009 to September 2010 were analyzed. CH-EUS was performed with intravenous administration of an ultrasonographic contrast (Sonazoid) and electronic radial echoendoscope. The graph of time intensity curve (TIC) for pancreatic mass was generated to depict the changes in signal intensity over time within the region of interest (ROI). ROI was placed to cover an area with a pancreatic mass lesion. Based on the analysis of TIC, base intensity before injection (BI), peak intensity (PI), time to peak, and maximum intensity gain (MIG: PI-BI) were calculated. Results. Eight patients with focal AIP and twenty-two patients with PC were evaluated by TIC. PI and MIG of mass lesion of AIP were significantly higher than that of PC (21.4 dB vs. 9.6 dB, 17.5 vs. 6.6). Receiver operating characteristics analysis yielded an optimal MIG cutoff value of 12.5 with high sensitivity and specificity. Conclusion. Pancreatic mass lesions of AIP and PC exhibited markedly different patterns with the TIC. This novel diagnostic modality using TIC generated by CH-EUS might offer an opportunity to improve accuracy in the differential diagnosis between pancreatic mass lesion of AIP and PC.

Color Doppler endoscopic ultrasonography in identifying groups at a high-risk of recurrence of esophageal varices after endoscopic treatment

BackgroundOur preliminary study indicated that either a high hepatofugal flow velocity in the left gastric vein (LGV) or an anterior branch dominant pattern seen under color Doppler EUS (CD-EUS) were possible contributing risk factors for variceal recurrence after endoscopic treatment. However, the sample size was too small, and in this study we aimed to validate the results of the preliminary study.MethodsSixty-eight patients treated for moderate or large esophageal varices between 2001 and 2004 at a single university hospital were enrolled in this study. CD-EUS was followed by endoscopic variceal ligation and sclerotherapy.ResultsPatients were classified into either a high-risk group, which exhibited anterior branch dominance and flow velocity of 12 cm/s or more, or a low-risk group, which included all other patients. Half of the patients in the high-risk group exhibited a recurrence within half a year, whereas it took almost 2 years for half of the patients in the other group to exhibit a recurrence (P = 0.0044). Using the Cox proportional hazard model with multivariate analysis, only the features of the high-risk group were significant in triggering recurrence of varices (hazard ratio [HR], 3.00; 95% confidence interval [CI], 1.35–6.65; P < 0.001).ConclusionsThese results suggest that patients showing anterior branch dominance and rapid hepatofugal flow velocity in the LGV on CD-EUS examination may have a high risk of an early recurrence of esophageal varices.

A double-blind, block-randomized, placebo-controlled trial to identify the chemical assistance effect of mesna submucosal injection for gastric endoscopic submucosal dissection

BACKGROUND Previous animal studies and a pilot clinical trial demonstrated that submucosal injection of a thiol compound called mesna could chemically soften connective tissues and thus facilitate endoscopic submucosal dissection (ESD). OBJECTIVE To evaluate whether mesna injection could reduce procedural times for gastric ESD. DESIGN Double-blind, block-randomized, controlled trial. SETTING University hospital. PATIENTS A total of 101 patients with superficial gastric cancer indicated for ESD were enrolled and randomly assigned to either the mesna or control (saline solution) group. INTERVENTION Traditional ESD was performed with a single bolus injection of mesna or saline solution. MAIN OUTCOME MEASUREMENTS Time for submucosal dissection (TSD). RESULTS En bloc resection was achieved for all lesions in the mesna group (53/53) and 51 of 52 lesions (98.08%) in the control group. TSD was not statistically different between the groups (18.62 ± 13.9 [mean ± SD] minutes for the mesna group and 24.58 ± 24.55 [mean ± SD] minutes for the control group; P = .128), and there were fewer time-consuming cases (times over 30 minutes) in the mesna group compared with controls (7/53 vs 15/52; P = .049). Multivariate regression analysis demonstrated that use of mesna, specimen size, and the presence of fibrous scars were significantly correlated with TSD (P < .05). LIMITATIONS Single-center study. CONCLUSION TSD was not significantly different between the mesna and control injection groups, but multivariate analysis indicated that mesna injection reduced procedural challenges associated with the submucosal dissection. ( CLINICAL TRIAL REGISTRATION NUMBER UMIN000003786.).

Diode-laser ablation therapy for submucosal gastric cancer using indocyanine-green solution injection to the submucosa

A 805-nm diode laser ablation therapy with indocyanine green (ICG) was studied for the endoscopic treatment of early gastric cancer. The ICG solution with 1mg/ml was administrated to the submucosa of the resected porcine and anesthetized canine stomach for the purpose of enhancing the tissue absorption to the laser light. We established complete removal of the mucosa and the submucosa with laser power of 12 or 25 watts. The proper muscle was intact because the ICG solution prevents the laser light penetration to the proper muscle. An ablated depth could be easily recognized by observing the ablated surface color. Our results showed that the combination of the 805 nm diode laser irradiation and the submucosal injection of the ICG solution might provide selective and controllable endoscopic treatment for early gastric cancer.

A comparison of electronic radial and curvilinear endoscopic ultrasonography in the detection of pancreatic malignant tumor

Abstract Objective. There is no comparative study of electronic radial endoscopic ultrasonography (ER-EUS) and electronic curvilinear EUS (EC-EUS). The aim of this study was to compare the accuracy of ER-EUS and EC-EUS for detecting pancreatic malignancies. Methods. This was a retrospective review of the patients who had EUS assessment from September 2008 to December 2011 for suspicious pancreatic tumors. Sensitivity, specificity, and area under the ROC curve to detect pancreatic malignancies were calculated and compared between the ER-EUS and EC-EUS cohort. The final diagnosis of pancreatic malignancy was based on pathology, or the consensus of patients clinical course and multimodal imaging tests. Results. Two hundred twenty-one patients were included and divided into two cohorts: ER-EUS (n = 139) and EC-EUS (n = 82) cohorts. With propensity score matching method, 70 cases in each cohort were selected for the comparison. There was no significant difference in sensitivity, specificity, and area under the ROC curve to detect pancreatic malignancy between ER-EUS and EC-EUS cohort (88.5 vs. 100%, 88.6 vs. 90.9%, 0.8855 vs. 0.9545). Conclusion: ER-EUS and EC-EUS provided similar accuracy for the detection of pancreatic malignancies. In view of similar diagnostic results of ER-EUS and EC-EUS for the detection of pancreatic malignancy, and the advantage of being able to perform FNA with EC-EUS, EC-EUS may be the preferred choice.

A pilot study of the novel offset-tip papillotome for selective biliary cannulation in ERCP

Abstract Introduction: We developed a new offset-tip papillotome to facilitate biliary cannulation and reduce the incidence of unintended contrast injection into the pancreatic duct during ERCP. The aim of the present retrospective cohort study was to evaluate the utility of the novel offset-tip papillotome in achievement of biliary cannulation, and prevention of unintended contrast injection into the pancreatic duct during ERCP, compared with a standard straight-tip catheter. Material and methods: Patients with native papilla who required biliary ERCP were retrospectively reviewed. Biliary ERCPs were performed by two experienced endoscopists using either the offset-tip papillotome or a standard catheter. Patients in whom ERCP involved fellows in training were excluded. Results: Eighty-five patients were included and divided into two cohorts: The offset-tip papillotome (OT; n = 40) and the standard straight-tip cohort (ST; n = 45). Biliary cannulation success rates in OT and ST cohort were 92.5% and 88.9%, respectively. The frequency of unintended contrast injection into the pancreatic duct and time to biliary cannulation of the OT cohort during biliary cannulation were significantly less than those of the ST cohort (0.56 vs. 1.65 times and 103.3 vs. 287.9 seconds). Conclusion: The novel offset-tip papillotome could reduce the incidence of unintended contrast injection into the pancreatic duct and the time to biliary cannulation.

4525 Impact of left gastric vein hemodynamics using color doppler eus in the treatment of esophageal varices.

Background: Endoscopic Variceal Ligation (EVL) is a widely used and accepted prophylactic treatment for esophageal varices (EV)Θ. EVL is often associated with early recurrence of EV, but the recurrence rate appeared to be decreased by repeated endoscopic treatment. However, the hemodynamic changes associated with recurrent EVL treatment are poorly understood. Aim: To analyze changes of hemodynamics and anatomy of LGV caused by the endoscopic treatment for EV. Methods: 48 patients (Pts) with with cirrhosis (Group A: 18 Pts had >1 year follow up after eradication of EV: Group B: 30 Pts with no previous variceal treatment) were enrolled in this study.We used curved linear array echoendoscope (Pentax FG36UX) and Processing Unit (Hitachi EUB655). We analyzed 1) The diameter and blood velocity of trunks of LGV 2) Type of branches of LGV 3) The size of paraesophageal vein (PEV) 4)The detection rate of perforating vein (PV). We classified the types of branches into three groups; Type AD (anterior branch dominant), Type B (bilateral), Type PD (posterior branch dominant).We classified the size of PEV into four grades; Grade 1 (