Sumio Fujinuma

A Study of Malignant Bile Duct Stenosis Using Percutaneous Transhepatic Cholangioscopy

Abstract: From June, 1987 to November, 1989, 11 patients with malignant bile duct stenosis, which was later confirmed by surgery or autopsy, were examined by percutaneous transhepatic cholangioscopy (PTCS) and by an endoscopic biopsy. The endoscopic findings obtained with the usual observation methods and methylene blue staining and the histological findings of the biopsy specimens were compared. A fine vascular proliferation was seen in all of the patients and a granular appearance was noted in patients with carcinoma of the major papilla. The papillary appearance was noted in one case each of pancreatic carcinoma, bile duct carcinoma and carcinoma of the major papilla. Marginal protrusion was not noted in patients with pancreatic carcinoma. A distorted narrow segment was seen only in cases of pancreatic carcinoma. The presence of a granular appearance indicated that the carcinoma was exposed on the surface. A high degree of fine vascular proliferation and a papillary appearance tended to indicate a carcinoma which invaded mainly into the fibromuscular layer without invasion of the mucosa. The methylene blue staining method was simple and effective for better visualization of the surface structure of the abnormal area, normal mucosa and the border zone.

MAGNIFYING COLONOSCOPY FOR THE DIAGNOSIS OF INFLAMMATORY CHANGES IN ULCERATIVE COLITIS

Background:  Endoscopic observation is the most effective method for the evaluation of staging in ulcerative colitis (UC). However, in cases with very mild inflammatory activity, histopathological diagnosis may also be required. Unfortunately, biopsy‐related accidents are not uncommon. As an alternative, we have used a magnifying colonoscope commonly used for tumor diagnosis to examine in detail the colon mucosa of UC patients in clinical remission, and then compared these findings relative to conventional endoscopy using histopathological diagnosis.

COMPARATIVE STUDY OF BACTERIAL IDENTIFICATION BY COLORECTAL TISSUE CULTURE AND FLUID CULTURE AFTER COLONOSCOPIC WASHING

Background:  Inflammation of the colon is often found during colonoscopy. In order to confirm the pathogenesis of the lesion, bacterial cultures are applied. Biopsied tissue specimens are used for bacterial culture, and fluid culture after colonoscopic washing also has been used for bacterial identification. In the latter method, sterile saline solution is sprayed over the area and then is collected with the fluid. The two methods have not been compared with each other.

SUCCESSFUL PLACEMENT OF SELF-EXPANDABLE METALLIC STENTS FOR DOUBLE COLORECTAL CANCERS

Stent placement for the palliation of unresectable colon cancer is an alternative to surgical treatment that has recently become popular. A dedicated stent for colorectal cancer is not available in Japan. We report a patient with two colonic obstructions who underwent a successful palliative treatment using two stents. He was admitted to Toho University Ohashi Medical Center because of ileus. A colonoscopy revealed two advanced lesions with stenosis in the sigmoid and transverse colon. Because he had multiple liver metastases and severe Alzheimer dementia, we selected palliative stent placement for the treatment of both strictures. We placed a covered stent in the sigmoid colon stricture and subsequently attempted to place a second stent in the transverse colon stricture. However, the second stent could not be placed in the transverse colon because the modified delivery system could not pass through the first stent in the sigmoid colon. This probably led to a twisting of the stent in the sigmoid colon. We next used the 24 F introducer sheath that is included in Keller‐Timmermans Introducer Sets. This strategy allowed the modified delivery system to be easily passed through the initial stent in the sigmoid colon and then advanced into the transverse colon stricture, enabling both stents to be positioned properly.

EVALUATION OF THE LOOPING FORMATION AND PAIN DURING INSERTION INTO THE CECUM IN COLONOSCOPY

Introduction:  One of the causes of pain during insertion of the colonoscope is stretching of the mesenterium by loop formation. The degree of pain differs according to the type of loop formation. Our aims were to study the accuracy of the colonoscopist’s assessment of the presence and type of loop formation and to study the degree of pain in relation to the type of loop by administering the visual analog scale (VAS).

ENDOSCOPIC ULTRASONOGRAPHY FINDINGS AND CLINICAL BACKGROUNDS IN CASES WITH EARLY RECURRENCE OF ESOPHAGEAL VARICES AFTER ENDOSCOPIC INJECTION SCLEROTHERAPY

Aims:  To investigate the factors affecting early recurrence of esophageal varices after endoscopic injection sclerotherapy (EIS).

Study of superficial type colorectal neoplasms with central depression.

Superficial lesion with central depression obtained by endoscopic resection (23 carcinomas limited in the mucosa and 40 adenomas) were studied morphologically and histologically. These lesions were calculated concerning the height from the muscularis mucosa, depth of depressed central portions and the height of circumferential mucosa. Then, using the image analyzer, followings were determined with two-dimensional analysis: (1) the size of neoplasms and also (2) the size of whole mucosal lesions which was calculated by drawing a perpendicular from the border of the neoplasms; and thus, the ratio of each area was calculated. Little difference was found between the adenomas and carcinomas. The sizes of carcinomas were found to be of 8.8 ± 4.7 mm and the adenomas of 5.1 ± 2.3 mm (p < 0.01). As for the depth of depression, it was found to be of 352 ± 147 μm in the carcinomas and 277 ± 93 μm in the adenomas (p < 0.05). Concerning the ratio of carcinomatous area in the mucosa, it was found to be 78 ± 10% in the carcinomas, while in the adenomas, it was found to be 70 ± 10% (p < 0.05). Accordingly, it was found that compared with the adenomas, carcinomas showed significantly larger in size, deeper depression in configuration and the ratio of their size in the mucosa is rather high.

PRELIMINARY STUDY ON BACTERIAL INFLUENCE IN ISCHEMIC COLITIS

Background:  It is necessary to exclude infectious colitis by fecal culture for diagnosis of ischemic colitis. But even if pathogenic bacteria are excluded, it is expected that the population of normal bacterial flora of the lesion is probably changing. We have performed bacterial culture using colonoscopic sampling in order to detect more important bacteria, when we diagnose ischemic colitis on colonoscopy.

Clinicopathological characteristics of superficial type colorectal adenomas obtained by endoscopic resection.

Colorectal adenomas may be either protruding type or superficial type lesions. To delineate the clinicopathological characteristics of the latter, 153 superficial type adenomas (including the surrounding mucosa) obtained by endoscopic resection were studied morphologically. Superficial type adenomas were defined as flat or flat depressed adenomas with a height of ≤3 mm; histologically, the tubules proliferated horizontally without vertical overlap. The location of tubules in the mucosa was classified as: involvement of the surface layer only (m1), deeper invasion not reaching the muscularis mucosae (m2), or invasion to the muscularis mucosae (m3). The results of analysis indicated: 1) there was no relationship between atypia and size; 2) although macroscopic features (depression, etc.) were associated with the grade of atypia, a closer association was obtained for the location in the mucosa; 3) based on our classification system for tubule location, (m2) and (m3) adenomas had a significantly higher frequency of depressed type lesions than did m1 lesions; and 4) the height of superficial type adenomas was 295 to 413 μm. Height was lowest in the m3 group followed by, in ascending order, the m2 and m1 groups. These morphological and histological characteristics are expected to contribute to improved diagnosis of superficial type adenomas.