Takahisa Murao

Successful application of laparoscopic and endoscopic cooperative surgery (LECS) for a lateral-spreading mucosal gastric cancer

In the current era of endoscopic submucosal dissection (ESD) for early gastric cancer, which carries a negligible risk of lymph node metastasis, local resection of the stomach remains an option for these lesions. This is particularly so for a large intramucosal lesion or a lesion with a strong ulcer scar, for which ESD becomes a difficult option. Here, we describe a case of lateral-spreading intramucosal gastric cancer of 6-cm diameter located at the fornix of the stomach, which was successfully treated by laparoscopic and endoscopic cooperative surgery (LECS) because of the expected risk of complications during ESD. In the LECS procedure, the resection margin was appropriately determined by the endoscopic evaluation in detail and by the ESD technique. If early gastric cancer fits the criteria for endoscopic resection but would present difficulty if performing ESD, this is a good indication for the LECS procedure.

Use of an external real‐time image viewer coupled with prespecified actions enhanced the complete examinations for capsule endoscopy

Background and Aim:  The clinical utility of capsule endoscopy (CE) is often limited by incomplete small‐bowel transit. The aim was to determine whether the use of an external real‐time viewer could reduce delays caused by delayed gastric emptying of the capsule or delayed intestinal transit and also improve the rate of positive findings.

Safety of gastrointestinal endoscopic biopsy in patients taking antithrombotics

Current Japanese gastrointestinal (GI) endoscopic guidelines permit endoscopic biopsy without cessation of antiplatelet agents and warfarin in patients with a therapeutic range of prothrombin time–international normalized ratio (PT‐INR) levels, although the evidence levels are low. We evaluated the safety of endoscopic biopsy in patients currently taking antithrombotics.

Evaluation of RAPID® 5 Access software for examination of capsule endoscopies and reading of the capsule by an endoscopy nurse

BackgroundSince capsule endoscopy (CE) is time consuming, one possible cost-effective strategy could be the use of an expert endoscopic assistant and available software to select images. Aims were to examine the clinical utility of RAPID® 5 Access software and find the optimum setting mode for reading. We also evaluated whether a nurse could preview the CE video and detect significant lesions accurately.MethodsThe capsule images in 14 volunteers with known mucosal injury induced by low dose aspirin and in 30 patients who were known to have a variety of significant lesions were selected. Using three setting modes of RAPID® 5 Access software, the detection rate and reading time for CE images by two well-trained physicians and one expert nurse were compared.ResultsThere was no significant difference in detection rate among the three readers. The detection rate using Quickview RAPID® 5 Access was significantly higher than that using RAPID® Reader version 4.1. Comparison among the three modes of RAPID® 5 Access showed that auto mode as well as displaying a single image at 12 fps was superior in the detection rate of denuded redness, while its reading time was longer compared to the other modes. Some significant lesions were not detected by using Quickview and Quadview modes.ConclusionsRAPID® 5 Access improves diagnostic yield, reducing reading time; however, it is still unacceptable because of the diagnostic miss rate and may be useful as an ancillary reading tool. Developing further improved software and training expert assistants for reading capsule images are necessary.

Combination of low-dose aspirin and thienopyridine exacerbates small bowel injury.

Abstract Objective. Antithrombotics is increasingly being used for cardiovascular prevention. In more recent studies, small bowel injury and enteropathy associated with low-dose aspirin are increasingly being recognized. Aim of this study was to evaluate small bowel injury using video capsule endoscopy (VCE) in obscure gastrointestinal bleeding (OGIB) patients taking low-dose aspirin including other antithrombotics. Material and methods. This is a retrospective review of chronic users of antithrombotics who underwent VCE for suspected small bowel bleeding. Small bowel mucosal injury was evaluated using VCE findings. Results. Fifty-four OGIB patients (36 men and 18 women, mean age 72.4 years) underwent VCE from January 2007 to May 2009. Twenty-two patients were taking 100 mg of enteric-coated aspirin (aspirin group), 8 taking thienopyridine, (ticlopidine or clopidogrel, thienopyridine group), 13 taking aspirin combined with thienopyridine (combined group), and 11 taking warfarin (warfarin group). The mucosal injury, especially ulcers were most frequently detected in the combined group (46.2%, p = 0.01) among the four groups. The median number of redness lesions in the combined group was the highest among the four groups and was significantly higher than that in the warfarin group. The lesions of redness or small erosions in the aspirin and the combined groups tended to exist in the proximal part of small bowel. Conclusions. Combination of low-dose aspirin therapy and thienopyridine may exacerbate small bowel injury, and the preventive strategies should be established.

Long-Term Outcome after Double-Balloon Endoscopy in Patients with Obscure Gastrointestinal Bleeding

Background and Aims: There are limited data concerning the clinical outcome of patients with obscure gastrointestinal bleeding (OGIB) after double-balloon endoscopy (DBE). The aim of the present study was to evaluate the long-term outcome of patients with OGIB after DBE. Patients and Methods: Eighty-seven consecutive patients with OGIB (47 men and 40 women; mean age 65.3 years) underwent DBE between July 2006 and December 2009. The criteria for assessment included documented iron deficiency anemia/occult or obscure small intestinal bleeding, and overt small intestinal bleeding. They were followed for a mean period of 41.4 months after DBE, and were divided into two groups according to their outcome, that is a good clinical course group (GC group) and a poor clinical course group (PC group). The clinical characteristics associated with rebleeding after DBE were analyzed by comparison of these two groups. Results: The source of bleeding was identified in 40 patients (46.0%) and endoscopic treatment was required in 21 of them (52.5%). The most frequent source of bleeding was ulcers/erosions (18.4%). During the follow-up period, 39 patients (44.8%) experienced bleeding and/or persistent iron deficiency anemia after DBE, while 48 patients did not. There were no significant differences of clinical characteristics between the two groups. However, there were more patients with diverticular bleeding in the GC group than the PC group, and there were significantly more patients with treatable small intestinal tumors/polyps in the GC group. There were also more patients with normal DBE findings in the GC group. Conclusion: This study demonstrated that the rebleeding rate after DBE varies depending on the source of bleeding.

Association of SLCO1B1*1b with peptic ulcer amongst Japanese patients taking low-dose aspirin

BACKGROUND In the recent case-control study, we showed an inverse association between peptic ulcer and angiotensin type 1 receptor (AT1R) blockers (ARBs) or HMG-Co A reductase inhibitors (statins). The aim was to evaluate whether the genotypes of uptake and efflux transporters of ARBs and statins relate to the presence of peptic ulcer and/or ulcer bleeding associated with aspirin use. METHODS Patients taking 100mg of enteric-coated aspirin for cardiovascular diseases who also participated in endoscopic surveillance were studied. SLCO1B, ABCC2, ABCG2, and MDR1 genotypes were determined by PCR or PCR-RFLP. RESULTS 492 patients enrolled including 78 with peptic ulcer. The frequencies of the SLCO1B1 521TT genotype were significantly higher in the ulcer group (p=0.006) compared to the controls. After adjustment for significant factors, the SLCO1B1 1b haplotype was significantly associated with peptic ulcer (OR, 3.64; 95% CI, 1.81-7.29). CONCLUSIONS SLCO1B1 1b haplotype may identify patients at increased risk for aspirin-induced peptic ulcer.

Novel Single Nucleotide Polymorphism Markers for Low Dose Aspirin-Associated Small Bowel Bleeding

Background Aspirin-induced enteropathy is now increasingly being recognized although the pathogenesis of small intestinal damage induced by aspirin is not well understood and related risk factors have not been established. Aim To investigate pharmacogenomic profile of low dose aspirin (LDA)-induced small bowel bleeding. Methods Genome-wide analysis of single nucleotide polymorphisms (SNPs) was performed using the Affymetrix DMET™ Plus Premier Pack. Genotypes of candidate genes associated with small bowel bleeding were determined using TaqMan SNP Genotyping Assay kits and direct sequencing. Results In the validation study in overall 37 patients with small bowel bleeding and 400 controls, 4 of 27 identified SNPs: CYP4F11 (rs1060463) GG (p=0.003), CYP2D6 (rs28360521) GG (p=0.02), CYP24A1 (rs4809957) T allele (p=0.04), and GSTP1 (rs1695) G allele (p=0.04) were significantly more frequent in the small bowel bleeding group compared to the controls. After adjustment for significant factors, CYP2D6 (rs28360521) GG (OR 4.11, 95% CI. 1.62 -10.4) was associated with small bowel bleeding. Conclusions CYP4F11 and CYP2D6 SNPs may identify patients at increased risk for aspirin-induced small bowel bleeding.

Rebamipide Improves Chronic Inflammation in the Lesser Curvature of the Corpus after Helicobacter pylori Eradication: A Multicenter Study

Background and Aim. Although many epidemiologic studies have shown that Helicobacter pylori eradication has prophylactic effects on gastric cancer, it does not completely eliminate the risk of gastric cancer. We aimed to investigate the changes in histological gastritis in patients receiving rebamipide treatment after H. pylori eradication. Methods. 206 patients who had undergone H. pylori eradication were evaluated. Of these, 169 patients who achieved successful eradication were randomly allocated to 2 groups: the rebamipide group (n = 82) and the untreated group (n = 87). The primary endpoints were histopathological findings according to the updated Sydney system at the start of the study and after 1 year. Results. Final assessment for histological gastritis was possible in 50 cases from the rebamipide group and 53 cases from the untreated group. The activity and atrophy improved in both the rebamipide and untreated groups, and no significant intergroup differences were observed. Chronic inflammation affecting the lesser curvature of the corpus was significantly improved in the rebamipide group compared to in the untreated group (1.12 ± 0.08 versus 1.35 ± 0.08; P = 0.043). Conclusions. Rebamipide treatment after H. pylori eradication alleviated chronic inflammation in the lesser curvature of the corpus compared to that in the untreated group. This trial is registered with UMIN000002369.

Usefulness of Ultrasonography for Diagnosis of Small Bowel Tumors: A Comparison Between Ultrasonography and Endoscopic Modalities

AbstractUltrasonography is a standard, noninvasive modality used to evaluate patients with gastrointestinal diseases. This study assessed the usefulness of ultrasonography in the detection of small bowel tumors.This study enrolled 558 consecutive patients (295 males, 263 females; mean age 71.1 years) who underwent ultrasonography before capsule endoscopy and/or balloon-assisted endoscopy. Ultrasonographic detection of small bowel tumors was compared with detection by capsule endoscopy and/or balloon-assisted endoscopy. In addition, factors affecting small bowel tumor detection by ultrasonography and clinical characteristics of patients with small bowel tumors undetected by ultrasonography were evaluated.Ninety-seven tumors (52 benign, 45 malignant) detected by capsule endoscopy and/or balloon-assisted endoscopy were retrospectively analyzed. The sensitivity and specificity of ultrasonography in the detection of small bowel tumors were 50.5% (47/93) and 100% (465/465), respectively. If we restricted patients to those with a tumor >20 mm in size, its detection ratio would become higher (91.7%): the ratio of submucosal tumor >20 mm in size was 85.7% (6/7) and that of partial and circumferential ulcerative tumors >20 mm in size was 96.9% (31/32), respectively. Small bowel tumors detected by ultrasonography (mean 33.2 mm) were significantly larger than those undetected by ultrasonography (mean 8.7 mm). The percentage of small bowel tumors located in the ileum detected by ultrasonography (70.6%) was significantly higher than those undetected by ultrasonography (29.4%). Of the 46 small bowel tumors undetected by ultrasonography, 42 (91.3%) were benign tumors with good clinical prognosis.Ultrasonography is a useful modality for detecting larger small bowel tumors and ulcerative lesions. Ultrasonography should be considered a first-line modality for patients suspected of having small bowel tumors, because most small bowel tumors undetected by ultrasonography were benign tumors with good clinical prognosis.