Takahiro Wakamatsu

Sclerosing Esophagitis with IgG4-positive Plasma Cell Infiltration: A Case Report

The patient was a 76-year-old woman who had noticed slight difficulty in swallowing in the 3 years prior to this presentation. Her dysphagia progressed while she was hospitalized following cervical cancer surgery. Esophagogastroduodenoscopy and an esophagram showed circumferential erosion and a stricture of the thoracic esophagus. Esophageal resection was performed; the resected specimens showed a stricture and wall thickening. Histologically, transmural hyperplasia, which consisted of inflammatory granulation tissue with the abundant infiltration of IgG4-positive plasma cells and lymphocytes, was observed. The patient was diagnosed with probable IgG4-related disease. IgG4-related esophageal disease presenting as esophageal lesions alone is a very rare condition.

Evaluation of performance of the Omni mode for detecting video capsule endoscopy images: A multicenter randomized controlled trial

Background and study aims: Olympus recently developed a new algorithm called Omni mode that discards redundant video capsule endoscopy (VCE) images. The current study aimed to demonstrate the non-inferiority of the Omni mode in terms of true positives (TPs) and the superiority of the Omni mode with regard to reading time against a control (ordinary ES-10 system). Patients and methods: This multicenter prospective study included 40 patients with various small bowel diseases. VCE images were evaluated by 7 readers and 3 judging committee members. Two randomly allocated readers assessed the VCE images obtained using the 2 modalities for each patient. The order of the modalities was switched between the 2 readers and the interval between readings by the same reader was 2 weeks. The judging committee predefined clinically relevant lesions as major lesions and irrelevant lesions as minor lesions. The number of TPs for major and minor lesions and the reading times were compared between the modalities. The predefined non-inferiority margin for the TP ratio of the Omni mode compared with the control was 0.9. Results: The estimated TP ratios and 95 % confidence intervals for total, major, and minor lesions were 0.87 (0.80 – 0.95), 0.93 (0.83 – 1.04), and 0.83 (0.74 – 0.94), respectively. Although non-inferiority was not demonstrated, the rate of detection of major lesions was not significantly different between the modalities. The reading time was significantly lower when using the Omni mode than when using the control. Conclusions: The Omni mode may be only appropriate for the assessment of major lesions.

A retrograde-viewing device or a transparent hood for improving colorectal adenoma detection

We read with interest the articles by DeMarco et al1 and Waye et al2 regarding a retrograde-viewing device, the Third Eye Retroscope (TER) (Avantis Medical Systems; Sunnyvale, CA), for improving detection of colorectal adenomas behind folds. After cecal intubation, the TER was inserted through the colonoscope instrument channel, and the forward and retrograde images were observed during withdrawal. The additional detection rates with the TER for polyps and adenomas were 17% and 25%, respectively, in 298 patients1 and 13% and 11%, respectively, in 249 patients.2 We believe that simple device can detect more adenomas behind folds. Colonoscopy is believed to be the best available method or evaluating the colon and rectum. Because most colorectal ancers are considered to arise from adenomas, the detection nd removal of adenomas by colonoscopy has been recomended for the prevention of subsequent colorectal caners.3 However, some adenomas and even cancers may be missed during colonoscopy because they hide either behind folds or at flexures.1-4 We and others have previously shown that the use of a transparent hood attached to the tip of a conventional colonoscope significantly detects more adenomas behind folds and at flexures by depressing the folds and flexures.3-7 Although the value of colonoscopy depends argely on the ability of the endoscopist,4 this technique equires less experience of endoscopists.4-6 When adenomas are detected, the TER is withdrawn from the colonoscope and is reinserted after adenoma removal. This procedure is troublesome and lengthens the colonoscope withdrawal time.8 The TER is also special equipment, requires two endoscopy system units, and is not available in most institutions. The transparent hood is simple, inexpensive, and readily available in most institutions. We believe that this simple device allows inspection of the blinded areas behind folds and is an effective and more practical alternative for the detection of adenomas behind folds.

Excessive length of a tube in the stomach: a risk factor for a tangled or knotted tube.

1. Caldera F, Selby L. The Fellows’ Corner: how to avoid common pitfalls with bowel preparation agents. Gastrointest Endosc 2011;73:346-8. 2. Wexner SD, Beck DE, Baron TH, et al. A consensus document on bowel preparation before colonoscopy: prepared by a task force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Gastrointest Endosc 2006;63:894-909. 3. Mamula P, Adler DG, Conway JD, et al. ASGE technology status evaluation report. Colonoscopy preparation. Gastrointest Endosc 2009;69:1201-9. doi:10.1016/j.gie.2011.02.012

Peri-Appendiceal Red Patch and Pathogenesis of the Appendix in Ulcerative Colitis

To the Editor,We read with interest the article by Rubin and Roth [1]on the peri-appendiceal red patch (PARP) in ulcerativecolitis (UC). In 367 UC patients with distal colitis, 29(7.9%) patients had PARP. In the 29 patients, 23 (79%)were male, none had prior appendectomy, 20 of 30 (67%)biopsy findings showed that the parallel histologic activityin the PARP and the distal colitis, and 11 of 21 patients(52%) with endoscopic follow-up progressed to moreextensive disease. We believe that the pathogenesis of theappendix in UC patients should be highlighted.Although UC is characterized by continuous and diffuseinflammation extending proximally from the rectum, PARPhas been increasingly recognized in 48–86% patients withdistal UC [2–4], as in the study of Rubin and Rothe [1].Patients with PARP experience a more aggressive andrelapsing disease courses compared with patients withoutPARP [3]. Many case–control studies suggest that previousappendectomy is rare in UC patients [2, 3]. Patients withprevious appendectomy have a delayed onset of UC, areduced need for immunomodulators and proctocolectomy,and a reduced relapse rate and extent of UC [5]. Moreover,we and several investigators have reported the improve-ment of UC after appendectomy, especially in youngpatients with PARP [2, 6].The pathogenesis of UC has not been determined, but anabnormal mucosal immune response plays a major role inthe occurrence and pathophysiology of UC [2, 4]. Extensiveinfiltration of lymphocytes, especially CD4? T cells, hasbeen observed in the inflamed mucosa of UC patients.Activated CD4? T cells exhibit increased cytotoxic activityand secrete cytokines that enhance the inflammatory state,resulting in tissue injury. We have disclosed that the pro-portion of CD4? early-but-not-mature-activated T cells issignificantly increased in the appendix of UC patients [4, 7],and suspect that the appendix may be a priming site in theoccurrence of UC. We therefore believe that the appendixshould no longer be considered an evolutionary redundancy,especially in UC patients with PARP.References

Detection of ileal carcinoid tumor needs further investigations for other lesions.

To The Editor: We read with interest the article by Yarze et al. ( 1 ) on the detection of asymptomatic ileal carcinoid tumors during routine ileal intubation at screening colonoscopy. Th ey diagnosed six patients with a carcinoid tumor in the terminal ileum. Aft er surgical resection, metastatic lymph nodes were observed in those with the lesion ≥ 1 cm in size (four pateints). Although they recommended the routine ileal intubation at the time of screening colonoscopy, we believe that the detection of an ileal carcinoid tumor needs further investigations of small bowel for the possibility of multiple carcinoid tumors. Small bowel carcinoid tumors account for 15 – 29 % of all gastrointestinal carcinoid tumors, and account for 17 – 46 % of all malignant small bowel tumors ( 2 ). Although carcinoid tumors are slowly progressive and usually clinically silent, small bowel carcinoid tumors have a high rate of transmural invasion and are more likely to metastasize than carcinoid tumors in the rectum or appendix ( 3 ). Multicentricity has been reported as low as 2 – 4 % for rectal carcinoid tumors, but as high as 40 % for small bowel carcinoid tumors ( 4 ). Patients with multiple ileal carcinoid tumors are younger, have a greater risk of developing carcinoid syndrome, and have a poorer prognosis than patients with solitary tumors ( 5 ). Although carcinoid tumors of the rectum, stomach, and duodenum generally are found by endoscopy at an early stage, carcinoid tumors of the small bowel are diffi cult to be diagnosed by conventional imaging techniques, such as double-contrast barium study, computed tomography, and ultrasonography ( 2 ). Small bowel carcinoid tumors usually are discovered aft er resection of the small bowel in patients with obstructive symptoms, or during exploration of the small bowel for search of a primary tumor in patients with distant metastases ( 2 ). Multiple carcinoid tumors of the small bowel are extremely diffi cult to diagnose and localize before surgery ( 2 ). With the widespread use of capsule endoscopy and balloon-assisted endoscopy, management of small bowel lesions has become easier ( 2,4 ). Aft er failed detection with conventional imaging techniques, capsule endoscopy ( 4,6 ) and balloon-assisted endoscopy ( 2 ) can identify multiple carcinoid tumors in the small bowel. We therefore believe that the detection of a carcinoid tumor in the terminal ileum needs further investigations of the small bowel by capsule endoscopy or balloon-assisted endoscopy in the early diagnosis of multiple carcinoid tumors.

Colonoscopy with a transparent hood: simple technique for improved quality of colonoscopy.

To the Editor: We read with interest the article by Radaelli et al. (1) on the factors that influence the technical performance of colonoscopy. In nationwide quality improvement programs of colonoscopy in Italy, researchers set out to identify the factors in clinical practice. They concluded that the sedation/analgesic use, bowel preparation quality, endoscopist experience, and colonoscopy volume of centers influenced the quality of colonoscopy. We believe that a simple technique can improve the quality of colonoscopy.

Improved polyp detection: narrow-band imaging colonoscopy with a transparent retractable extension device.

Improved Polyp Detection: Narrow-Band Imaging Colonoscopy With a Transparent Retractable Extension Device

Complete endoscopic resection of large sessile or flat colorectal polyps with high-magnification chromoendoscopy or endoscopic submucosal dissection.

TO THE EDITOR: We read with interest the article by Arebi et al. [1] on endoscopic mucosal resection (EMR) of large sessile or flat colorectal polyps. Because all the polyps were 20 mm or larger in size, all resections were performed in a piecemeal fashion. During follow-up, 60 (40.3%) of the 149 polyps recurred, and 7 of the 60 polyps required surgery because of persistent recurrence of 4 benign polyps or incomplete resection of 3 invasive cancers. The recurrence was significantly related to the larger polyp size. Although the investigators concluded that a stricter follow-up is necessary for larger polyps because of a higher risk of recurrence, we believe that the recurrence rate could be reduced with the use of a novel technique. Large sessile or flat colorectal polyps have a greater malignancy potential [2,3]. Although, traditionally, these polyps are treated surgically, endoscopic resection is preferable to surgery because of its lower cost and lower morbidity [2]. EMR is a useful therapeutic technique because it permits en bloc resection [4,5], thereby providing a complete specimen for histological evaluation [4,6]. Based on the size and the location of the polyps, endoscopic resection can be performed en bloc or piecemeal [5]. The piecemeal technique is used most frequently in large sessile or flat polyps [5] as in the study by Arebi et al. [1]. In our previous study of EMR for gastric tumors, piecemeal resection directly influenced incomplete therapy [7]. The piecemeal resection of large colorectal polyps is also more likely to result in incomplete therapy compared with en bloc resection [4], and may be associated with a higher rate of recurrence [2,6]. This is presumably because of the residual adenomatous tissue that is not recognized with conventional colonoscopy [2,8]. The delay in providing adequate treatment also brings the risk of malignant changes in the residual polyps. Moreover, histological definition of the tumor margin is difficult on the multiple tissue specimens [2]. Argon plasma coagulation (APC) is suitable for treating a large mucosal area with a limited and predictable depth of tissue coagulation [2]. Whereas application of APC to the margins treated after piecemeal resection is reported to reduce the recurrence rate of large sessile or flat colorectal polyps [2], another study has shown that the recurrence rate is similar regardless of whether APC is added to complete the EMR [6]. The intense submucosal desmoplasia after APC also makes further resection difficult. Although Arebi et al. [1] applied APC to the residual adenomatous tissue, 40.3% of the polyps recurred after piecemeal resection. Endoscopic submucosal dissection (ESD) enables en bloc resection, regardless of tumor size, with a higher rate of radical cure than EMR [5]. Before ESD had been positively applied for early gastric cancers in Japan, we had performed endoscopic resection of gastric tumors after circumferential incision of the normal mucosa surrounding the tumors in order to avoid incomplete resection [7]. Although ESD is not a commonly used technique for large colorectal tumors because of the technical