Taro Ikumoto

NBI and NBI Combined with Magnifying Colonoscopy

Although magnifying chromoendoscopy had been a reliable diagnostic tool, narrow-band imaging (NBI) has been developed in Japan since 1999 and has now replaced the major role of chromoendoscopy because of its convenience and simplicity. In this paper, we principally describe the efficacy of magnifying chromoendoscopy and magnifying colonoscopy with NBI for detection, histological prediction, estimation of the depth of early colorectal cancer, and future prospects. Although some meta-analyses have concluded that NBI is not superior to white light imaging for detection of adenomatous polyps in screening colonoscopy, NBI with magnification colonoscopy is useful for histological prediction, or for estimating the depth of invasion. To standardize these diagnostic strategies, we will focus on the NBI International Colorectal Endoscopic (NICE) classification proposed for use by endoscopists with or without a magnifying endoscope. However, more prospective research is needed to prove that this classification can be applied with satisfactory availability, feasibility, and reliability. In the future, NBI might contribute to the evaluation of real-time histological prediction during colonoscopy, which has substantial benefits for both reducing the risk of polypectomy and saving the cost of histological evaluation by resecting and discarding diminutive adenomatous polyps (resect and discard strategy).

The addition of high magnifying endoscopy improves rates of high confidence optical diagnosis of colorectal polyps

Background and study aims: The real-time optical diagnosis of colorectal polyps with high confidence predictions can achieve high levels of accuracy. Increasing the rates of high confidence optical diagnosis can improve the clinical application of real-time optical diagnosis in routine practice. The primary aim of this prospective study was to evaluate whether high magnifying endoscopy improves the rates of high confidence narrow-band imaging (NBI) – based optical diagnosis for differentiating between neoplastic and non-neoplastic colorectal lesions according to the NBI international colorectal endoscopic (NICE) classification. Patients and methods: Consecutive adult patients undergoing colonoscopy with a high magnifying (maximum, × 80) colonoscope between April and August 2012 were recruited. The optical diagnosis for each polyp was evaluated during colonoscopy in two consecutive stages by the same endoscopist, who first used NBI with non-magnifying endoscopy (NBI-NME), then NBI with magnifying endoscopy (NBI-ME). A level of confidence was assigned to each prediction. Results: The analysis included 124 patients (mean age, 56.4 years; male-to-female ratio, 72:52) with 248 polyps smaller than 10 mm. Of the 248 polyps, 210 were 1 to 5 mm in size and 38 were 6 to 9 mm in size; 77 polyps were hyperplastic, 4 were sessile serrated adenomas/polyps, 160 were low grade adenomas, 5 were high grade adenomas, and 2 were deep submucosal invasive carcinomas. The rate of high confidence optical diagnosis when NBI-ME was used was significantly higher than the rate when NBI-NME was used for diminutive (1 – 5 mm) polyps (92.9 % vs 79.5 %, P < 0.001) and for small (6 – 9 mm) polyps (94.7 % vs 84.2 %, P = 0.048). Conclusion: High magnifying endoscopy significantly improved the rates of high confidence NBI-based optical diagnosis of diminutive and small colorectal polyps. Study registration: UMIN 000007608

Prospective evaluation of the proportion of sessile serrated adenoma/polyps in endoscopically diagnosed colorectal polyps with hyperplastic features

Background and study aims: Sessile serrated adenoma/polyps (SSA/Ps) are considered precursors of colorectal cancers with microsatellite instability. However, it is still difficult to differentiate SSA/Ps from hyperplastic polyps endoscopically; therefore, the prevalence of SSA/Ps remains uncertain in clinical practice. This study aimed to clarify the proportion of SSA/Ps in endoscopically diagnosed colorectal polyps with hyperplastic features (E-HPs). Patients and methods: Patients aged ≥ 40 years undergoing colonoscopy for standard clinical indications at our center were prospectively enrolled between June 2013 and May 2014. During colonoscopy, 0.05 % indigo carmine dye was sprayed throughout the colorectum to highlight lesions. All detected lesions were diagnosed by high definition magnifying narrow-band imaging and were resected endoscopically or surgically, apart from rectosigmoid E-HPs ≤ 5 mm. The number of rectosigmoid E-HPs ≤ 5 mm was recorded, and some were resected for use as tissue samples. Results: A total of 343 patients (male: 42.9 %; mean age: 61.5 years) were included. Among 3838 E-HPs (distal: 96.4 %) detected in 294 patients, 792 were resected and analyzed. All of 21 SSA/Ps identified in 17 patients were included in E-HPs, and the overall proportion of SSA/Ps in E-HPs was 2.7 %. However, this proportion increased with the size of E-HPs (≤ 5 mm: 0.7 %; 6 – 9 mm: 29.0 %; ≥ 10 mm: 70 %) and was higher in the proximal colon than in the distal colorectum (10.9 % vs. 0.9 %). In addition, no SSA/P was found in the rectum, and no SSA/P had cytological dysplasia. Conclusions: The overall proportion of SSA/Ps in E-HPs was 2.7 %, although this proportion was higher in the proximal colon and increased with the size of E-HPs. SSA/Ps were common in routine colonoscopy, with a prevalence of at least 5.0 %. Study registration: UMIN000010832.

Feasibility of single-incision laparoscopic cholecystectomy for acute cholecystitis

AIM To assess the safety of single-incision laparoscopic cholecystectomy (SILC) for acute cholecystitis. METHODS All patients who underwent SILC at Sano Hospital (Kobe, Japan) between January 2010 and December 2014 were included in this retrospective study. Clinical data related to patient characteristics and surgical outcomes were collected from medical records. The parameters for assessing the safety of the procedure included operative time, volume of blood loss, achievement of the critical view of safety, use of additional trocars, conversion to laparotomy, intraoperative and postoperative complications, and duration of postoperative hospital stay. Patient backgrounds were statistically compared between those with and without conversion to laparotomy. RESULTS A total of 100 patients underwent SILC for acute cholecystitis during the period. Preoperative endoscopic treatment was performed for suspected choledocholithiasis in 41 patients (41%). The mean time from onset of acute cholecystitis was 7.7 d. According to the Updated Tokyo Guidelines (TG13) for the severity of cholecystitis, 86 and 14 patients had grade I and grade II acute cholecystitis, respectively. The mean operative time was 87.4 min. The mean estimated blood loss was 80.6 mL. The critical view of safety was obtained in 89 patients (89%). Conversion laparotomy was performed in 12 patients (12%). Postoperative complications of Clavien-Dindo grade III or greater were observed in 4 patients (4%). The mean duration of postoperative hospital stay was 5.7 d. Patients converted from SILC to laparotomy tended to have higher days after onset. CONCLUSION SILC is feasible for acute cholecystitis; in addition, early surgical intervention may reduce the risk of laparotomy conversion.

Manganese superoxide dismutase plays an important role in the inflammatory process and predicts disease severity and activity in patients with ulcerative colitis

The aim of this study was to investigate the expression pattern of manganese superoxide dismutase (MnSOD) in relation to inflammatory factors in ulcerative colitis (UC) and characterize this enzyme as a newly identified biomarker potentially linked to disease pathogenesis of UC. MnSOD expression was analyzed immunohistochemically in 48 formalin‐fixed and paraffin‐embedded specimens from patients with UC who had undergone endoscopical biopsy. MnSOD expression was observed in vascular endothelium, macrophages, and polymorphonuclear leukocytes within lamina propria of inflamed mucosa. The patients who did not express MnSOD tended to have stabilization of symptoms, but accompanied with status of inflammation. The MnSOD expression pattern was strongly correlated with disease type. MnSOD was expressed in polymorphonuclear leukocytes of all disease types, but cases of chronically counting and exacerbation type had particularly high frequency of immunopositive cells. MnSOD expression in macrophages was frequently observed in cases of symptom remaining type. The cases with MnSOD expression in the vascular endothelium showed a tendency to express in relapse‐remission and exacerbation of symptoms. Immunohistochemical evaluation for MnSOD expression may be useful for predicting disease severity and activity in patients with UC.

Gastrointestinal: Sessile serrated adenoma/polyps with a minute T1 colorectal carcinoma: Education and Imaging

An 80-year-old woman with no family history of cancer presented with abdominal pain and anemia. Colonoscopy revealed Campylobacter enterocolitis, and a 12 mm flat elevated lesion with VI pit pattern was incidentally detected in the ascending colon (Figure 1A). Magnifying narrow band imaging (NBI) revealed type IIIA capillary pattern (Figure 1B). Based on these endoscopic findings, submucosal invasive carcinoma was suspected. Endoscopic mucosal resection, by which the lesion was completely removed, was performed for histological evaluation. Histological examination revealed a serrated lesion with irregular branching crypts and/or L-shaped crypts as well as tumor invasion into the submucosa (Figures 2, arrow A, arrows: B). The patient was discharged after resolution of the colitis. At two years of follow-up, the patient has had neither recurrence of colitis nor evidence of metastasis. Serrated polyps belong to a heterogeneous group of lesions that are generally characterized morphologically. This type of lesion is thought to be a precursor of sporadic carcinomas with microsatellite instability, and is probably also a precursor of CpG islandmethylated microsatellite-stable carcinomas. We have previously reported that sessile serrated adenoma/ polyps (SSA/P) show a significantly higher proliferative activity as compared to hyperplastic polyps, according to the diagnostic criteria for SSA/P established by the research project “Potential of Cancerization of Colorectal Serrated Lesions” by the Japanese Society for Cancer of the Colon and Rectum, which also indicate that SSA/P have crypt dilation, irregular branching crypts and horizontally arranged basal crypts (inverted T-and/or L-shaped crypts). Further, malignant transformation of SSA/P arises predominantly in the right side of the colon. Recently, in Japan as well as other countries, the incidence of advanced cancer in the right side of the colon has increased in elderly persons. The pathogenic and cancerization factors of SSA/P are of great clinicopathological importance.

Gastrointestinal: Sessile serrated adenoma/polyps with a minute T1 colorectal carcinoma

An 80-year-old woman with no family history of cancer presented with abdominal pain and anemia. Colonoscopy revealed Campylobacter enterocolitis, and a 12 mm flat elevated lesion with VI pit pattern was incidentally detected in the ascending colon (Figure 1A). Magnifying narrow band imaging (NBI) revealed type IIIA capillary pattern (Figure 1B). Based on these endoscopic findings, submucosal invasive carcinoma was suspected. Endoscopic mucosal resection, by which the lesion was completely removed, was performed for histological evaluation. Histological examination revealed a serrated lesion with irregular branching crypts and/or L-shaped crypts as well as tumor invasion into the submucosa (Figures 2, arrow A, arrows: B). The patient was discharged after resolution of the colitis. At two years of follow-up, the patient has had neither recurrence of colitis nor evidence of metastasis. Serrated polyps belong to a heterogeneous group of lesions that are generally characterized morphologically. This type of lesion is thought to be a precursor of sporadic carcinomas with microsatellite instability, and is probably also a precursor of CpG islandmethylated microsatellite-stable carcinomas. We have previously reported that sessile serrated adenoma/ polyps (SSA/P) show a significantly higher proliferative activity as compared to hyperplastic polyps, according to the diagnostic criteria for SSA/P established by the research project “Potential of Cancerization of Colorectal Serrated Lesions” by the Japanese Society for Cancer of the Colon and Rectum, which also indicate that SSA/P have crypt dilation, irregular branching crypts and horizontally arranged basal crypts (inverted T-and/or L-shaped crypts). Further, malignant transformation of SSA/P arises predominantly in the right side of the colon. Recently, in Japan as well as other countries, the incidence of advanced cancer in the right side of the colon has increased in elderly persons. The pathogenic and cancerization factors of SSA/P are of great clinicopathological importance.

Education and Imaging. Gastrointestinal: sessile serrated adenoma/polyps with a minute T1 colorectal carcinoma.

An 80-year-old woman with no family history of cancer presented with abdominal pain and anemia. Colonoscopy revealed Campylobacter enterocolitis, and a 12 mm flat elevated lesion with VI pit pattern was incidentally detected in the ascending colon (Figure 1A). Magnifying narrow band imaging (NBI) revealed type IIIA capillary pattern (Figure 1B). Based on these endoscopic findings, submucosal invasive carcinoma was suspected. Endoscopic mucosal resection, by which the lesion was completely removed, was performed for histological evaluation. Histological examination revealed a serrated lesion with irregular branching crypts and/or L-shaped crypts as well as tumor invasion into the submucosa (Figures 2, arrow A, arrows: B). The patient was discharged after resolution of the colitis. At two years of follow-up, the patient has had neither recurrence of colitis nor evidence of metastasis. Serrated polyps belong to a heterogeneous group of lesions that are generally characterized morphologically. This type of lesion is thought to be a precursor of sporadic carcinomas with microsatellite instability, and is probably also a precursor of CpG islandmethylated microsatellite-stable carcinomas. We have previously reported that sessile serrated adenoma/ polyps (SSA/P) show a significantly higher proliferative activity as compared to hyperplastic polyps, according to the diagnostic criteria for SSA/P established by the research project “Potential of Cancerization of Colorectal Serrated Lesions” by the Japanese Society for Cancer of the Colon and Rectum, which also indicate that SSA/P have crypt dilation, irregular branching crypts and horizontally arranged basal crypts (inverted T-and/or L-shaped crypts). Further, malignant transformation of SSA/P arises predominantly in the right side of the colon. Recently, in Japan as well as other countries, the incidence of advanced cancer in the right side of the colon has increased in elderly persons. The pathogenic and cancerization factors of SSA/P are of great clinicopathological importance.

Observational cohort study focused on treatment continuity of patients (pts) treated with XELOX plus bevacizumab (BV) for previously untreated metastatic colorectal cancer (mCRC).

661 Background: Systemic chemotherapy for unresectable mCRC has remarkably progressed as a results of wide spread use of irinotecan, oxaliplatin, anti-VEGF antibody and anti-EGFR antibody. It is important to continue treatment combined with these drugs and prolong progression-free survival so as to improve overall survival. Methods: We planned and conducted the prospective observational cohort study of 40 pts treated with XELOX + BV for previously untreated mCRC to investigate the treatment continuity of XELOX + BV. Endpoints were time to treatment-failure (TTF), overall response rate, resection rate, liver resection rate, progression-free survival (PFS), overall survival (OS) and safety. Eligibility criteria were (1) histologically confirmed mCRC, (2) with lesions evaluable by imaging, (3) previously untreated (except for surgery), (4) with condition enough to receive XELOX + BV, (5) written informed consent. Forty pts were planned to be enrolled during 2 years and followed up to 2 years. Results: Betwee...