Shouichi Tanaka

Endoscopic papillary balloon dilation and endoscopic sphincterotomy for bile duct stones: long-term outcomes in a prospective randomized controlled trial

BACKGROUND Little is known about the long-term outcome of endoscopic papillary balloon dilation for removal of bile duct stones. A randomized trial that compared long-term outcomes after endoscopic papillary balloon dilation and endoscopic sphincterotomy was conducted. METHODS Thirty-two patients with bile duct stones were randomized to endoscopic papillary balloon dilation or endoscopic sphincterotomy, with 16 patients in each group. Endoscopic papillary balloon dilation was performed by using an 8-mm-diameter balloon; endoscopic sphincterotomy was performed in the standard manner. The success rates for stone removal, as well as the frequency and types of early (<15 days), mid-term (<1 year), and long-term (1-6 years) post-procedure complications were evaluated. RESULTS The success rates for stone removal and early complication rates were similar for both groups. The frequency of stone recurrence was approximately 4-fold higher in the endoscopic papillary balloon dilation group (25%) vs. the endoscopic sphincterotomy group (6.3%) at mid-term evaluation. However, over the long term, Kaplan-Meier estimated probability of stone recurrence tended to be higher in the endoscopic sphincterotomy group vs. the endoscopic papillary balloon dilation group; recurrent stones were found in, respectively, 26.7% vs. 6.3%. Complications occurred in 7 patients in each group. CONCLUSIONS Long-term outcome of endoscopic papillary balloon dilation for bile duct stone removal is satisfactory, provided that consideration is given to recurrence of stones by early follow-up evaluation.

EMR of mucosa-associated lymphoid tissue lymphoma of the rectum

There are numerous reports of mucosa-associated lymphoid tissue (MALT) lymphoma involving the large intestine. Several studies have reported that anti-Helicobacter pylori treatment induced regression of colorectal MALT lymphoma, regardless of the presence or absence of H pylori.1-4 Here, a case is reported of rectal MALT lymphoma (negative for H pylori) diagnosed 7 years after surgical resection of MALT lymphoma of the sigmoid colon. The new lesion was treated by EMR.

Polypoid colonic hamartomatous inverted polyp

We herein present a unique polyp diagnosed as polypoid colonic hamartomatous inverted polyp. Colonoscopic examination revealed a clover‐like submucosal tumor about 30 mm in size with a long stalk at the mid‐transverse colon. The polyp consisted of elongated crypts with cystic dilatation located in the submucosal layer. To the best of our knowledge, there have been no previous reports of the same type of pedunculated colonic polyp, similar in appearance to inflammatory myoglandular polyps but covered with a layer of normal mucosa possessing the muscularis mucosae at the uppermost surface of the polyp.

Colorectal Manifestation of Follicular Lymphoma

OBJECTIVE Due to their rarity, the endoscopic features and clinical backgrounds of colorectal follicular lymphoma lesions have not yet been fully investigated. The aim of this study was to reveal the characteristics of this disease entity. METHODS A database search performed at the Department of Pathology of our institute identified 12 follicular lymphoma patients with involvement in the cecum, colon, and/or rectum. Data regarding the endoscopic, radiological, biological, and pathological examinations performed were retrospectively reviewed from their clinical records. RESULTS The mean age of the patients (5 men, 7 women) was 58.7 years. Five patients were classified as being Lugano system stage I, while the other seven patients were stage IV. In all of the patients, colorectal follicular lymphoma presented with papular (n=4), polypoid (n=4), and flat elevated lesions (n=4). No erosions or ulcers were seen in any of the lesions. The initial pathological diagnoses included extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (n=2) and colitis/proctitis with infiltration of inflammatory cells (n=3), in addition to the correct diagnosis of follicular lymphoma (n=7). CONCLUSION Colorectal involvement of follicular lymphoma shows no erosions or ulcers. These lesions could be macroscopically observed as papular, polypoid and flat elevated lesions. Making a correct diagnosis of this disease based on the findings of biopsied samples is sometimes challenging. In such cases, multiple biopsies and/or endoscopic mucosal resection is required, in addition to appropriate consultation with pathologists.

Gastric ulcer after prophylactic balloon-occluded retrograde transvenous obliteration

A 74-year-old man with compensated hepatitis C virus-related liver cirrhosis was admitted for the treatment of small hepatocellular carcinoma (HCC) by radiofrequency ablation therapy (RFA). As a routine pretreatment examination, gastrointestinal endoscopy was performed, and large nodular varices were observed in the gastric fornix, with telangiectasia on top of the varices. As soon as the RFA was completed, prophylactic balloon-occluded retrograde transvenous obliteration (B-RTO) was performed. Seven days after the B-RTO, the patient complicated of upper abdominal pain. Gastrointestinal endoscopy was performed, and a deep ulcer, located at the top of the tumor-shaped gastric varices, was found. The ulcer showed rapid healing after 1-week administration of a proton pump inhibitor (PPI). A severe ulcer after a B-RTO procedure, is extremely rare, because sclerosing agents rarely flow into the gastric mucosa. The ulcer in this patient was deep and large, and it may have been due to direct mucosal damage caused by the sclerosing agent, because mucosal telangiectasia on top of the varices was observed before the B-RTO. It is likely that, in this patient, the mucosal vessels communicated with the submucosal large varices, and ethanolamine oleate (EOI) flowed into the gastric mucosa via this communication. Based on our experience, we recommend periodic follow-up endoscopy.

Assessment of UDP-galactosyl-transferase activity in gastric mucosa of patients with chronic liver disease using an enzyme-linked peanut agglutinin binding assay

Gastric mucin plays an important role in protecting mucosa from irritants such as acids and pepsin, and UDP-galactosyltransferase is a key enzyme in mucin synthesis. In order to study the synthesis of gastric mucin in patients with chronic liver disease, we developed a new assay using a peanut agglutinin lectin to measure this enzyme in human gastric mucosa obtained by endoscopic biopsy. Enzyme activity correlated well with that determined with a previous method using radiolabeled galactose. The enzyme activity in gastric mucosa of cirrhotic patients was significantly lower than in patients with chronic hepatitis or in normal controls and correlated with the amount of mucin in surface epithelial cells. Our findings suggest that the synthesis of gastric mucin is impaired in patients with liver cirrhosis.

Triamcinolone injection and filling method to prevent stricture after esophageal endoscopic submucosal dissection

Esophageal endoscopic submucosal dissection (ESD) for large lesions has a risk of post-ESD stricture.1,2 Local triamcinolone injection3 or filling4 are reportedly useful to reduce the incidence of post-ESD stricture, but strictures requiring balloon dilation can occur3,4 Although oral prednisolone may be more effective than local triamcinolone,5 it raises concerns regarding adverse effects. We considered that a combination of triamcinolone injection and filling can enhance the stricture-prevention effect. Therefore, we assessed this method for two large defects. This article is protected by copyright. All rights reserved.

Localized Amyloid Deposition at the Ampulla of Vater.

A 77-year-old man presented at our hospital with general fatigue. He underwent an endoscopic examination to check for any malignancies. Esophagogastroduodenoscopy revealed a submucosal tumor-like elevated lesion at the ampulla of Vater. The surface of the lesion was whitish and smooth without any depressions (Picture 1A, arrows). A magnifying endoscopic examination with narrow-band imaging revealed a nonstructural surface pattern with telangiectasia (Picture 1B). An endoscopic biopsy revealed the deposition of an eosinophilic nonstructural substance in the mucosa (Picture 2A, oval), with a reddish-brown appearance on direct fast scarlet (DFS) staining and an apple-green appearance