Tomohiko Moriyama

Long-term effect of Helicobacter pylori eradication on the development of metachronous gastric cancer after endoscopic resection of early gastric cancer.

BACKGROUND A prospective, randomized trial proved that Helicobacter pylori eradication significantly reduces the incidence of metachronous gastric cancer during a 3-year follow-up. OBJECTIVE To investigate the long-term effect of H pylori eradication on the incidence of metachronous gastric cancer after endoscopic resection of early gastric cancer. DESIGN Retrospective, multicenter study. SETTING Kyushu University Hospital and 6 other hospitals in Fukuoka Prefecture, Japan. PATIENTS AND INTERVENTIONS Follow-up data for 268 H pylori-positive patients who had undergone endoscopic resection of early gastric cancer were retrospectively investigated. A total of 177 patients underwent successful H pylori eradication (eradicated group), whereas 91 had persistent H pylori infection (persistent group). MAIN OUTCOME MEASUREMENTS The incidence of metachronous gastric cancer was compared in these 2 groups. RESULTS When the follow-up period was censored at 5 years, the incidence rate in the eradicated group was lower than that observed in the persistent group (P = .007). During the overall follow-up period ranging from 1.1 to 11.1 years (median 3.0 years), metachronous gastric cancer developed in 13 patients (14.3%) in the persistent group and in 15 patients (8.5%) in the eradicated group (P = .262, log-rank test). Based on a multivariate logistic regression analysis, baseline severe mucosal atrophy and a follow-up of more than 5 years were found to be independent risk factors for the development of metachronous gastric cancer. LIMITATIONS Retrospective study. CONCLUSIONS H pylori eradication does not reduce the incidence of metachronous gastric cancer. H pylori eradication should be performed before the progression of gastric mucosal atrophy.

Changes in Helicobacter pylori status in patients with rheumatoid arthritis under non‐steroidal anti‐inflammatory drugs

Background: The role of Helicobacter pylori infection in rheumatoid arthritis (RA) patients during treatment with non‐steroidal anti‐inflammatory drugs (NSAID) is still unclear. Methods: By means of endoscopy and biopsy, gastroduodenal lesions and H. pylori status were repeatedly examined in 88 RA patients at intervals ranging from 26 to 49 months. Histology and culture were applied to determine H. pylori status. Serial changes in gastroduodenal lesions and histologic score for mucosal atrophy were compared among groups classified by initial and second H. pylori status. Results: There were 28 patients with continuously positive H. pylori infection (CP group), 33 patients with continuously negative H. pylori infection (CN group), 7 patients in whom H. pylori status became negative (PN group), and 20 patients in whom H. pylori status could not be determined (UD group). Age, duration and species of NSAID, disease activity of RA, gastroprotective drugs applied and the prevalence of gastroduodenal mucosal lesions were not different among the groups at either the initial or the second examination. In the PN group, the score for mucosal atrophy at the second examination was significantly lower than at the initial examination, whereas no difference was found for the CP, CN and UD groups. Overall, histologic score for mucosal atrophy was higher in H. pylori‐positive patients than in H. pylori‐negative patients at both initial and second examination. Conclusions: In RA patients using NSAIDs, H. pylori infection may not affect the course of gastroduodenal lesions and activity of RA, but the infection contributes to mucosal atrophy.

Hypermethylation of p14ARF May Be Predictive of Colitic Cancer in Patients with Ulcerative Colitis

PurposeThe microsatellite instability and CpG island hypermethylation of p14ARF and p16INK4a are related to the pathogenesis of neoplasia in ulcerative colitis. This study was designed to assess the significance of those genetic or epigenetic alterations for cancer surveillance in ulcerative colitis.MethodsDuring surveillance colonoscopy in 39 patients with ulcerative colitis, biopsy specimens were obtained from the cecum and the rectum as well as from any other areas suspected of being neoplasia by chromoscopy. Using DNA extracts, the methylation status of p14ARF and p16INK4a and the microsatellite status were determined.ResultsMicrosatellite instability was positive in one of five dysplasias, but it was negative in the cecum and the rectum. The incidence of hypermethylation of p14ARF was 0 percent in the cecum, 26 percent in the rectum, and 100 percent in dysplasia, whereas that of p16INK4a was 10, 10, and 0 percent, respectively. Patients who were positive for the hypermethylation of p14ARFin the rectum had a longer duration of ulcerative colitis than those who were negative for such hypermethylation. Two of 10 patients who were positive for p14ARF hypermethylation in the rectum and 1 of 29 patients who were negative for the hypermethylation had dysplasia. During the subsequent surveillance of 36 patients, dysplasia was detected in 2 of 8 patients with p14ARF hypermethylation and in none of 28 patients without hypermethylation (P = 0.044).ConclusionsIn patients with ulcerative colitis, hypermethylation of p14ARF seems to be associated with an early stage of dysplasia. The hypermethylation may be one of candidates for potential biomarker to identify patients at a high risk of dysplasia.

Familial fundic gland polyposis with gastric cancer

We read with interest the article by Worthley et al 1 regarding a new autosomal dominant syndrome characterised by fundic gland polyposis (FGP) and gastric cancer, which was not associated with familial adenomatous polyposis (FAP). We have experienced two similar cases of gastric adenocarcinoma occurring in pedigrees with familial FGP without FAP. A 56-year-old woman was referred to our institution for further investigation of her multiple gastric polyps. On admission, serology and 13C urea breath test yielded negative results for Helicobacter pylori . Upper gastrointestinal endoscopy revealed numerous fundic gland polyps covering the …

A novel extra-wide-angle-view colonoscope: a simulated pilot study using anatomic colorectal models.

BACKGROUND A major factor that may contribute to a higher adenoma miss rate during colonoscopy is undetected lesions located behind haustral folds, flexures, or rectal valves. OBJECTIVE To assess the efficacy of a prototype, novel, extra-wide-angle-view colonoscope that provides a simultaneous lateral-backward view that complements the forward view lens. DESIGN A simulated pilot study of two anatomic colorectal models, each prepared with 8 polyps positioned in obvious locations and 8 polyps placed behind folds. Thirty-two endoscopists with different levels of experience performed examinations on models in a random order by using the extra-wide-angle-view colonoscope and a standard colonoscope. MAIN OUTCOME MEASUREMENTS The detection rates of simulated polyps. RESULTS The mean detection rate for all simulated polyps with the extra-wide-angle-view colonoscope was significantly higher than that with the standard colonoscope (68% vs 51%; P < .0001). The detection rate for polyps behind folds was significantly higher in the extra-wide-angle-view colonoscope than in the standard colonoscope (61.7% vs 46.9%; P = .0009). LIMITATIONS Not a clinical study. CONCLUSION The novel, extra-wide-angle-view colonoscope may represent an advancement in colorectal polyp detection. The value of the colonoscope for clinical use awaits further study.

Feasibility of a novel colonoscope with extra-wide angle of view: A clinical study

BACKGROUND AND STUDY AIMS Lesions may be missed during colonoscopy because of anatomical features such as mucosal folds. This feasibility study assessed the safety and efficacy of a novel colonoscope with extra-wide angle of view, which provides a simultaneous lateral-backward view to complement the forward view. PATIENTS AND METHODS Consecutive patients undergoing colonoscopy using the prototype colonoscope were enrolled in this multicenter, single-arm study. The number of adverse events, and the first detection of adenomas during withdrawal by the lateral-backward view and the forward view were evaluated. RESULTS A total of 47 patients underwent colonoscopy examination to the cecum. The mean insertion and withdrawal times were 6.4 ± 4.9 minutes and 8.6 ± 4.2 minutes, respectively. Of 47 detected polyps, 28 adenomatous polyps were found (mean size 3.3 ± 3.1 mm). A total of 29 polyps (61.7 %) and 16 adenomatous polyps (57.1 %) were first detected with the lateral-backward view. The lateral-backward view first detected 5/6 adenomatous polyps (83.3 %) in the ascending colon and all (2/2) adenomatous polyps in the sigmoid colon. No adverse events occurred during the study. CONCLUSIONS This exploratory study suggested that a novel colonoscope with extra-wide angle of view is safe and feasible, and has the potential to improve colorectal adenoma detection. TRIAL REGISTER UMIN000016450.

Helicobacter pylori status and esophagogastroduodenal mucosal lesions in patients with end-stage renal failure on maintenance hemodialysis

ObjectivesThe aim of this study was to elucidate the impact of Helicobacter pylori infection on esophagogastroduodenal mucosal lesions in patients with end-stage renal failure on maintenance hemodialysis (HD).MethodsAn upper endoscopy and the 13C-urea breath test were performed in 198 patients on maintenance HD. Clinical features, serum pepsinogen levels and esophagogastroduodenal mucosal lesions were compared between H. pylori-positive and H. pylori-negative patients. Risk factors associated with esophagogastroduodenal mucosal lesion were determined by multivariate analyses.ResultsThe upper endoscopy revealed that gastric erosion was the most frequent (58%) type of esophagogastroduodenal mucosal lesion, followed by duodenal erosion (18%), gastric ulcer (14%), gastroesophageal reflux disease (10%), and duodenal ulcer (7%). Of the 198 patients enrolled in the study, 81 were positive and 117 patients were negative for H. pylori infection. The time duration after the introduction of HD was significantly longer and serum pepsinogen I/II ratio was significantly higher in H. pylori-negative patients than in H. pylori-positive patients. Multivariate analyses revealed that the H. pylori infection was an independent, protective factor for gastric erosion (odds ratio 0.38; 95% confidence interval 0.21–0.70), while the infection was unrelated to other mucosal lesions.ConclusionsThe most common mucosal lesion observed in our study cohort, all of whom were patients on maintenance HD, was gastric erosion. The high prevalence of this type of lesion may be explained partly by the cure of H. pylori infection during the clinical course of maintenance HD.

Improved visibility of colorectal flat tumors using image-enhanced endoscopy.

Colonoscopy is considered the gold standard for detecting colorectal tumors; however, conventional colonoscopy can miss flat tumors. We aimed to determine whether visualization of colorectal flat lesions was improved by autofluorescence imaging and narrow‐band imaging image analysis in conjunction with a new endoscopy system. Eight physicians compared autofluorescent, narrow‐band, and chromoendoscopy images to 30 corresponding white‐light images of flat tumors. Physicians rated tumor visibility from each image set as follows: +2 (improved), +1 (somewhat improved), 0 (equivalent to white light), −1 (somewhat decreased), and −2 (decreased). The eight scores for each image were totalled and evaluated. Interobserver agreement was also examined. Autofluorescent, narrow‐band, and chromoendoscopy images showed improvements of 63.3% (19/30), 6.7% (2/30), and 73.3% (22/30), respectively, with no instances of decreased visibility. Autofluorescence scores were generally greater than narrow‐band scores. Interobserver agreement was 0.65 for autofluorescence, 0.80 for narrow‐band imaging, and 0.70 for chromoendoscopy. In conclusion, using a new endoscopy system in conjunction with autofluorescent imaging improved visibility of colorectal flat tumors, equivalent to the visibility achieved using chromoendoscopy.

Advanced technology for the improvement of adenoma and polyp detection during colonoscopy

Early detection and removal of adenomatous polyps reduces colorectal cancer death. However, many studies have reported that up to 20% of adenomas can be missed during colonoscopy. To improve visualization and reduce the blind spot of the colonic mucosa for an increase in the adenoma detection rate, many endoscopic techniques and technologies have been developed. The benefit of the high‐definition endoscope for improving adenoma and polyp detection is marginal. Wide‐angle colonoscope has failed to improve adenoma detection compared to standard colonoscopy. Although the cap‐assisted colonoscope can reduce cecal intubation times, it does not seem to improve adenoma and polyp detection. The diagnostic accuracy of the colon capsule endoscope is low compared to the conventional colonoscope. Third Eye® retroscope®, which provides additional retrograde viewing, has revealed significant improvement in adenoma and polyp detection compared to standard colonoscopy. However, this device increases procedural times. Recently developed full‐spectrum endoscopy colonoscope and extra‐wide‐angle‐view colonoscope have demonstrated a significantly lower miss rate of polyps. However, clinical trials are mandatory to determine the efficacy of these novel technologies for cancer screening. In addition, education and training for these novel techniques and technologies should seriously be considered to improve adenoma and polyp detection.

Is Small-Bowel Radiography Necessary Before Double-Balloon Endoscopy?

OBJECTIVE Small-bowel radiography may be replaced by enteroscopy in the diagnosis of small-intestine lesions. We retrospectively elucidated the diagnostic yield of small-bowel radiography performed before double-balloon endoscopy. MATERIALS AND METHODS One hundred twenty-four patients who underwent double-balloon endoscopy during the period 2004-2006 were classified into those with abnormal radiographic findings (n = 45), normal radiographic findings (n = 31), and no small-bowl radiographs (n = 48). The classification was based on the use of small-bowel radiography and the diagnosis before double-balloon endoscopy. The indications for, approaches to, and diagnostic yields of double-balloon endoscopy were compared for the three groups. The diagnostic yield of small-bowel radiography was considered positive when any sign of pathologic change in the small bowel was identified. The diagnostic yield of double-balloon endoscopy was considered positive when endoscopic or biopsy findings explained the clinical manifestations. RESULTS The group with abnormal findings on small-bowel radiography was younger (15-86 years) and less frequently had obscure bleeding (8.9%) than the group with normal findings on small-bowel radiography (age, 17-84 years; frequency of obscure bleeding, 45.2%) (p = 0.01) or the group without small-bowel radiographs (age, 15-91 years; frequency of obscure bleeding, 64.6%) (p < 0.0001). The positive diagnostic yield of double-balloon endoscopy was highest in the group with abnormal findings on small-bowel radiography (71.1%), followed by the group with no small-bowel radiographs (45.8%) and the group with normal findings on small-bowel radiography (35.5%) (p = 0.0002). Among patients who did undergo small-bowl radiography, the accuracy of the technique was 68.4%, the positive predictive value was 71.1%, and the negative predictive value was 64.5%. The positive diagnostic yields of small-bowel radiography and double-balloon endoscopy were not statistically different (59.2% for small-bowel radiography, 56.6% for double-balloon endoscopy; p > 0.1). CONCLUSION The diagnostic accuracy of double-balloon endoscopy seems to improve if the procedure is preceded by small-bowel radiography.