Takashi Hisabe

JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection

Colorectal endoscopic submucosal dissection (ESD) has become common in recent years. Suitable lesions for endoscopic treatment include not only early colorectal carcinomas but also many types of precarcinomatous adenomas. It is important to establish practical guidelines in which the preoperative diagnosis of colorectal neoplasia and the selection of endoscopic treatment procedures are properly outlined, and to ensure that the actual endoscopic treatment is useful and safe in general hospitals when carried out in accordance with the guidelines. In cooperation with the Japanese Society for Cancer of the Colon and Rectum, the Japanese Society of Coloproctology, and the Japanese Society of Gastroenterology, the Japan Gastroenterological Endoscopy Society has recently compiled a set of colorectal ESD/endoscopic mucosal resection (EMR) guidelines using evidence‐based methods. The guidelines focus on the diagnostic and therapeutic strategies and caveat before, during, and after ESD/EMR and, in this regard, exclude the specific procedures, types and proper use of instruments, devices, and drugs. Although eight areas, ranging from indication to pathology, were originally planned for inclusion in these guidelines, evidence was scarce in each area. Therefore, grades of recommendation were determined largely through expert consensus in these areas.

White opaque substance within superficial elevated gastric neoplasia as visualized by magnification endoscopy with narrow-band imaging: a new optical sign for differentiating between adenoma and carcinoma

BACKGROUND The microvascular pattern (MVP) as visualized by magnification endoscopy (ME) is a reliable marker for differentiating between benign and malignant gastric flat lesions. However, in cases of gastric neoplasia of 0-IIa type, it is sometimes impossible to visualize the MVP because a white opaque substance (WOS) obscures the subepithelial MVP. OBJECTIVE To investigate whether the morphology of the WOS could be a useful optical sign for discriminating between adenoma and carcinoma. SETTING Single tertiary referral center. MATERIALS Forty-six gastric neoplasias of only 0-IIa type (18 adenomas and 28 early carcinomas) were evaluated. INTERVENTION The prevalence and the morphology of the WOS as visualized by ME with narrow-band imaging (NBI) according to histologic type (adenoma vs carcinoma). MAIN OUTCOME MEASUREMENTS The WOS is more frequently present in adenomas than in carcinomas. With regard to the morphology of the WOS, 100% of the examples of WOS within adenomas demonstrated a regular distribution; in contrast, 83% of the examples of WOS within carcinomas showed an irregular distribution. RESULTS In cases in which a neoplasia of 0-IIa type showed either WOS with a regular distribution or a regular MVP, the sensitivity and specificity for discriminating adenoma from carcinoma were 94% and 96%, respectively. LIMITATIONS The number of cases was limited. The WOS has not yet been characterized by chemical analysis. CONCLUSION In cases in which the WOS is observed, rather than assessing the MVP, morphologic analysis of the WOS could be an alternative new optical sign for discriminating adenoma from carcinoma when using ME with NBI.

Local Recurrence After Endoscopic Resection for Large Colorectal Neoplasia: A Multicenter Prospective Study in Japan

OBJECTIVES:Conventional endoscopic resection (CER) is a widely accepted treatment for early colorectal neoplasia; however, large colorectal neoplasias remain problematic, as they necessitate piecemeal resection, increasing the risk of local recurrence. Endoscopic submucosal dissection (ESD) can improve the en bloc resection rate. This study aimed to evaluate local recurrence and its associated risk factors after endoscopic resection (ER) for colorectal neoplasias ≥20 mm.METHODS:A multicenter prospective study at 18 medium- and high-volume specialized institutions was conducted in Japan. Follow-up colonoscopy was performed after 12 months in cases of complete resection and after 3–6 months in cases of incomplete resection. Local recurrence was confirmed by endoscopic findings and/or pathological analysis.RESULTS:Follow-up colonoscopy was performed in 1,524 of 1,845 enrolled colorectal neoplasias (mean age, 65 years; 885 men; median tumor size, 32.8 mm). The local recurrence rates were 4.3% (65/1,524), 6.8% (55/808), and 1.4% (10/716) for the entire cohort, for CER, and for ESD, respectively. The relative risks of local recurrence were 0.21 (95% confidence interval, 0.11–0.39) with ESD compared with CER, 0.32 (95% confidence interval, 0.11–0.92) with en bloc ESD compared with en bloc CER, and 0.90 (95% confidence interval, 0.39–2.12) with piecemeal ESD compared with piecemeal CER. Significant factors associated with local recurrence were piecemeal resection, laterally spreading tumors of granular type, tumor size ≥40 mm, no pre-treatment magnification, and ≤10 years of experience in CER, and piecemeal resection only in ESD.CONCLUSIONS:En bloc ESD reduces the local recurrence rate for large colorectal neoplasias. Piecemeal resection is the most important risk factor for local recurrence regardless of the ER method used.

Adverse reactions to azathioprine cannot be predicted by thiopurine S-methyltransferase genotype in Japanese patients with inflammatory bowel disease

Background and Aims:  Azathioprine (AZA) is associated with a high frequency of adverse reactions. We examined polymorphism of the thiopurine S‐methyltransferase (TPMT) gene to determine whether the TPMT genotype would be a predictive marker for the development of adverse reactions to AZA.

Long-term outcome of endoscopic balloon dilation for small bowel strictures in patients with Crohn's disease.

Endoscopic balloon dilation (EBD) is an alternative to surgery for small bowel strictures of patients with Crohns disease (CD). However, little is known about the long‐term efficacy of EBD. The aim of the present study was to clarify the long‐term outcome of EBD for small bowel strictures in patients with CD.

Carbon dioxide insufflation compared with air insufflation in double-balloon enteroscopy: a prospective, randomized, double-blind trial

BACKGROUND Few studies have evaluated the degree of pain, the amount of retained gas, and the safety of carbon dioxide (CO(2)) insufflation in patients undergoing double-balloon enteroscopy (DBE). OBJECTIVE To clarify the usefulness and safety of CO(2) insufflation during DBE. DESIGN Single-center, prospective, randomized, double-blind, controlled trial. SETTING University hospital. PATIENTS Forty eligible patients with small-bowel disease for whom DBE was indicated were randomized to a CO(2) insufflation (CO(2)) group or an air insufflation (air) group by means of sealed envelopes. INTERVENTION DBE with insufflation of CO(2) or air. MAIN OUTCOME MEASUREMENTS Efficacy evaluation was based on the degree of pain as assessed by use of a visual analog scale (VAS) and the amount of residual gas retention within the small and large bowels on radiography. The safety of CO(2) insufflation was evaluated by arterial blood gas analysis. RESULTS Significantly fewer patients in the CO(2) group had severe pain of ≥ 50 mm on the VAS during DBE than in the air group (P = .02). Significantly less gas was retained in the small bowel just after and at 3 hours after DBE in the CO(2) group than in the air group (P = .003, P = .01, respectively). There was significantly less residual gas retention in the large bowel at 3 hours after DBE in the CO(2) group than in the air group (P = .02). There was no significant difference in pre-DBE and post-DBE partial pressure of oxygen in the blood (PaO(2)) and partial pressure of carbon dioxide in the blood (PaCO(2)) between groups. LIMITATIONS Small sample size. CONCLUSION CO(2) insufflation is a safe and useful procedure when performed during DBE.

CURRENT STATUS OF COLORECTAL ENDOSCOPIC SUBMUCOSAL DISSECTION IN JAPAN AND OTHER ASIAN COUNTRIES: PROGRESSING TOWARDS TECHNICAL STANDARDIZATION

Aim:  The primary purpose of this questionnaire survey study was to determine the current status of colorectal endoscopic submucosal dissection (ESD) in specialized Japanese referral centers before and after introduction of a government‐approved advanced medical treatment system; and, secondly, to determine the current status of colorectal ESD in other Asian specialized referral centers.

Anti-Saccharomyces cerevisiae antibodies in Japanese patients with inflammatory bowel disease: diagnostic accuracy and clinical value

Background: The diagnostic accuracy of the determination of anti-Saccharomyces cerevisiae antibodies (ASCA) and its clinical significance in Crohns disease (CD) have been reported in Western countries, but scarcely reported in Japan, where the dietary habits of people differ markedly from those of Western countries. Th present study was undertaken to examine the diagnostic accuracy and clinical significance of ASCA determination in Japanese patients with CD or ulcerative colitis (UC). Methods: Seventy-five serum samples obtained from 68 patients with CD, 34 serum samples obtained from 30 patients with UC, 35 serum samples from 35 patients with liver cirrhosis, and 31 serum samples from 31 healthy controls were examined. The optical density of each sample was measured by an enzyme-linked immunosorbent assay (ELISA) method to quantify ASCA IgA and IgG. Results: The cutoff level, as determined by discriminant analysis of the data, was 0.1502 for ASCA IgA and 0.156 for ASCA IgG. Of the 68 patients with CD, 31 (45.6%) were ASCA-positive, and of the 30 patients with UC, 4 (13.3%) were ASCA-positive according to these cutoff levels. The sensitivity and specificity of ASCA determination for the differential diagnosis of CD from UC were 45.6% and 86.7%, respectively. When the relationship between ASCA and the clinical features of CD was analyzed, ASCA positivity was found to be correlated with duration of illness. Conclusions: The specificity of ASCA was high; however, the sensitivity was not. ASCA titers were generally low in the Japanese population examined. It would be desirable to determine cutoff levels for ASCA tailored to the Japanese people for the diagnosis of inflammatory bowel disease.

Natural history of small colorectal protuberant adenomas.

Most previous studies of the natural history of small colorectal adenomas showed no increase in size, no changes that would have necessitated treatment within a couple of years and that malignant transformation is rare. Using endoscopic follow up for a mean period of 43.1 months we assessed the development and progression of 408 protuberant adenomas that were under 10 mm in diameter. Of the 408 lesions, 22 (5.4%) underwent morphological changes. There were 12 lesions (2.9%) whose final tumor diameter had reached 10 mm or more. There were three lesions (0.7%) that developed and progressed into intramucosal cancer. We concluded from the literature and from our own results that small colorectal protuberant adenomas do not grow to advanced adenomas within 5 years.

Improvement in the visibility of colorectal polyps by using blue laser imaging (with video)

BACKGROUND Fujifilm developed blue laser imaging (BLI) via a laser light source with a narrow-band light observation function. It has a brighter BLI bright mode for tumor detection. OBJECTIVE To investigate whether the BLI bright mode can improve the visibility of colorectal polyps compared with white light (WL). DESIGN We studied 100 colorectal polyps (protruding, 42; flat, 58; size, 2-20 mm) and recorded videos of the polyps by using the BLI bright mode and WL at Kyoto Prefectural University of Medicine and Fukuoka Chikushi University Hospital. The videos were evaluated by 4 expert endoscopists and 4 nonexperts. Each endoscopist evaluated the videos in a randomized order. Each polyp was assigned a visibility score from 4 (excellent visibility) to 1 (poor visibility). SETTING Japanese academic units. MAIN OUTCOME MEASUREMENTS The visibility scores in each mode and their relationship to the clinical characteristics were analyzed. RESULTS The mean visibility scores of the BLI bright mode were significantly higher than those of WL for both experts and nonexperts (experts, 3.10 ± 0.95 vs 2.90 ± 1.09; P = .00013; nonexperts, 3.04 ± 0.94 vs 2.78 ± 1.03; P < .0001). For all nonexperts, the visibility scores of the BLI bright mode were significantly higher than those of WL; however, these scores were significantly higher in only 2 experts. For experts, the mean visibility scores of the BLI bright mode was significantly higher than those of WL for flat polyps, neoplastic polyps, and polyps located on the left side of the colon and the rectum. LIMITATIONS Small sample size and review of videos. CONCLUSIONS Our study showed that polyps were more easily visible with the BLI bright mode compared with WL. ( CLINICAL TRIAL REGISTRATION NUMBER UMIN000013770.).