Shyun Yamamoto

A new water instillation method for colonoscopy without sedation as performed by endoscopists-in-training

BACKGROUND Colonoscopy may be associated with discomfort when performed without sedation. A study was conducted to determine whether instillation of water into the colon at the beginning of the procedure reduces intubation time as well as patient discomfort and pain. METHODS Colonoscopy was performed in 259 patients by 3 endoscopists-in-training with limited experience. Patients were randomly allocated to 2 groups. In one, a technique was used in which 500 to 1000 mL of water is instilled into the colon by enema at the beginning of the procedure (instillation group, n = 130). In the other, patients underwent a conventional colonoscopy (control group, n = 129). Intubation time was measured and compared between the groups, and subjective discomfort experienced by the patients was measured upon completion of the examination. RESULTS Success rates for insertion to the cecum were similar, (95.4%, instillation group; 96.1%, control group). Detection rates for any colorectal diseases were not different between the groups (30.0% vs. 32.6%). Mean time to cecal intubation was 10.5 minutes in the instillation group and 16.2 minutes in the control group (p < 0.0001). The proportion of patients who complained of abdominal pain during the procedure was 17.1% in the instillation group and 33.3% in the control group (p < 0.001). CONCLUSIONS When used by endoscopists-in-training, the water-instillation colonoscopy technique was associated with less discomfort and faster cecal intubation with no decrease in the rate of detection of colorectal diseases.

Lymphoepithelial cyst of the pancreas.

A case of lymphoepithelial cyst (LEC) of the pancreas is presented. A 48-year-old man complaining of general fatigue was found to have a heterogeneous water-dense mass protruding from the surface of the pancreas on plain computed tomography (CT). Dynamic CT disclosed septa within the mass. Magnetic resonance imaging (MRI) showed a hypoiintense mass on T1-weighted imaging, and a hyperintense mass on T2-weighted imaging. MRI with gadolinium enhancement revealed septa within the mass. Endoscopic ultrasonography showed septa and fine echogenic structures within the cystic echoic lesion. Endoscopic retrograde pancreatecraphy showed a normal duct system. Distal pancreatectomy with splenectomy was performed, with a suspected diagnosis of cystic neoplasms of the pancreas. Histopathologic examination disclosed LEC of the pancreas. Our case suggests that LEC should be considered in the differential diagnosis of cystic neoplasms of the pancreas.

Prognosis following endoscopic injection sclerotherapy for esophageal varices in adults: 20-year follow-up study

Objective. Endoscopic injection sclerotherapy (EIS) is beneficial in the management of active hemorrhaging and prevention of recurrent bleeding from esophageal varices. However, its long-term efficacy and safety are poorly defined. The aim of this study was to determine long-term cumulative survival and clarify negative predictive factors for survival following EIS in patients with esophageal varices. Material and methods. Between 1981 and 1987, 72 patients were prospectively enrolled in a post-EIS follow-up program. Variceal rebleeding, recurrence, and survival were recorded in follow-up examinations conducted for up to 20 years. Results. The mean follow-up period was 86.9 months. The cumulative survival rates were 65.2%, 53.6%, 26.1%, and 11.6% at 36, 60, 120, and 240 months, respectively, with liver failure the most common cause of death. Esophageal varices were eradicated in 93.1% of the patients following EIS and no recurrence of varices was seen beyond 7 years. Significant negative predictive factors for survival rate shown by Coxs proportional multivariate hazard model analysis were older age, advanced liver damage, presence of hepatocellular carcinoma, and occurrence of rebleeding. Conclusions. Long-term survival, rebleeding, and recurrence rates following EIS were clarified. Furthermore, our results clearly demonstrate negative predictive factors for survival after EIS.

[Investigation of autopsy cases of patients who had endoscopic injection sclerotherapy performed, classified by their age at the time of initial therapy].

We performed endoscopic injection sclerotherapy (EIS) for esophageal varices on approximately 214 patients between October 1981 and July 1994 at our hospital. Of the 214 patients 114 have died, and we divided them into two groups according to their age when EIS was first performed: (i) group 1, less than 70 years old; and (ii) group 2, more than 70 years old. We investigated the efficacy of EIS for the group 2 patients with esophageal varices by comparing the two groups. EIS was considered effective in the group 2 patients because there was no difference between the two groups in the period of observation after EIS, but the time to re-therapy in the autopsy cases of this age group was significantly less. As a result of investigating the surgical outcome and the direct cause of death, it was suggested that; in future, prevention of death by hepatocellular carcinoma and hepatic failure was necessary for both groups.

Studies on acid protease fractions and gastric mucosal atrophy

SummaryA modified simple method applicable for clinical purpose for separate determination of “pepsin” and “gastricsin” by alkali treatment is reported. The method includes dialysis against 0.1 M acetate buffer, pH 5.3 and incubation in an equal volume of 0.1 M phosphate buffer, pH 7.8 to give a final pH of 7.25, at 25°C for 20 minutes, and has a good reproducibility. N-acetyl-L-phenylalanyl-L-diiodotyrosine (APDT) hyprolysing activity and alkali labile pepsin activity are correlated very well. Nevertheless the former cannot completely be destroyed by the treatment.

Studies on acid protease fractions and gastric mucosal atrophy. 3. Special reference to peptic ulcers.

SummaryIn combination with routine gastric secretion test and endoscopic congo red test, alkali labile pepsin (ALP) and alkali stable pepsin (ASP) were separately determined in total of 41 patients with peptic ulcer including 20 gastric (GU), 12 duodenal (DU) and 9 gastroduodenal ulcers (GDU), and in 10 normal controls.In both of basal and tetragastrin stimulated states, percent of ASP in total acid protease (%ASP) was increased in the order of GU, GDU, normal control and DU with a close relation to the dimension of acid secreting area determined by endoscopic congo red test. Percent ASP was decreased after tetragastrin provocation in all disease groups. GU had high %ASP and low maximal acid output (MAO), GDU had high %ASP and high MAO, and DU showed low %ASP and high MAO.