Tomoyoshi Shibuya

Endoscopic submucosal dissection of large colorectal tumors by using a novel spring-action S-O clip for traction (with video)

BACKGROUND Endoscopic submucosal dissection (ESD) allows en bloc resection of large GI neoplasms, regardless of their size; however, technical difficulties associated with ESD in the colorectum make it less widely applied in the treatment of tumors in this region. To address this difficulty, we designed a rubber strip-based traction device, called the S-O clip (Sakamoto-Osada clip) and reported previously that ESD with this device was effective for complete resection of large, superficial colorectal neoplasms. In this report, we describe a novel spring-action version of the S-O clip (spring S-O clip) that improves the facility of clip use during ESD of colorectal tumors. OBJECTIVE To evaluate the efficacy and safety of the spring S-O clip for ESD of colorectal neoplasms. DESIGN Case series. SETTING Juntendo University Hospital. MAIN OUTCOME MEASUREMENTS The efficacy and safety of the spring S-O clip traction device during ESD of colorectal tumors. RESULTS In 3 cases, a large, superficial neoplasm in the right side of the colon was removed safely and successfully en bloc without complication. Procedure times for the 3 cases were 44, 27, and 49 minutes, with resected specimens measuring 40, 24, and 35 mm, respectively. LIMITATION Uncontrolled study. CONCLUSION This limited case series demonstrates that spring S-O clip-assisted ESD is safe and effective for en bloc resection of large superficial neoplasms in the right side of the colon.

Correlations among total colonoscopic findings, clinical symptoms, and laboratory markers in ulcerative colitis

Background and Aim:  Colonoscopy plays an integral role in the diagnosis, management and surveillance of ulcerative colitis (UC). In the present study we assessed the relationship between endoscopic and histological findings, clinical symptoms, and laboratory data.

Comparison of several activity indices for the evaluation of endoscopic activity in UC: inter- and intraobserver consistency.

Background: This study evaluated inter‐ and intraobserver agreement in the assessment of ulcerative colitis (UC) activity using 4 established indices and a newly designed Modified 6‐point Activity Index. Method: In all, 279 endoscopic pictures of inflammatory lesions from 93 UC patients were displayed twice to 4 expert and 4 trainee endoscopists, at an interval of 1 month. Each picture was assessed for inflammatory changes using established indices (Matts, Schroeder [a.k.a. Mayo Score], Baron, and Blackstone) and our new Modified 6‐point Activity Index. Weighted kappa statistics were used to estimate intra‐ and interobserver variation. Results: The Matts and Schroeder indices gave a “good” degree of concordance for expert endoscopists in terms of inter‐ and intraobserver agreements (0.74–0.78); this was not so evident with the Baron and Blackstone indices (0.61–0.73). For trainee endoscopists, all scores for inter‐ and intraobserver weighted kappa values using established indices (0.41–0.51) were lower than for the experts. The degree of concordance using the Modified 6‐point Activity Index was rated as “good” for inter‐ and intraobserver agreements for expert endoscopists (0.65 and 0.79), and as “moderate” for trainee endoscopists (0.54 and 0.64). Conclusions: Accurate assessment of UC disease activity from endoscopic findings benefited from experience. For expert endoscopists, the Matts and Schroeder indices proved the most reliable of the 4 established indices. Current endoscopic technologies may be adequate for assessing UC activity, particularly if modified to permit a finer classification of disease severity based on 6 grades, as with our newly developed Modified 6‐point Activity Index. (Inflamm Bowel Dis 2009;)

Overexpression of a 60-kDa heat shock protein enhances cytoprotective function of small intestinal epithelial cells.

AIMS With the advancement of small intestinal (double balloon and capsule) endoscopy technology, incidence of small intestinal lesion caused by nonsteroidal anti-inflammatory drugs (NSAIDs) has been known to be high. However, therapy for small intestinal mucosal lesion has not yet been developed. Previous studies have shown that heat shock proteins (HSPs) are involved in cytoprotection mediated by their function as a molecular chaperone. In this study, we examined the effect of HSP60 or HSP70 overexpression on hydrogen peroxide-induced (H2O2) or indomethacin-induced cell damage in the small intestinal epithelial cells. MAIN METHODS cDNA of human HSP60 or HSP70 was transfected to rat small intestinal (IEC-6) cells, and HSP60- or HSP70-overexpressing cells were cloned. IEC-6 cells transfected with vector only were used as control cells. These cells were treated with H2O2 (0-0.14mM) or indomethacin (0-2.5mM). The cell viability was determined by MTT-assay. Cell necrosis was evaluated by LDH-release assay. Further, apoptosis was evaluated by caspases-3/7 activity and TUNEL assay. KEY FINDINGS Cell viability after H2O2 or indomethacin treatment was significantly higher in HSP60-overexpressing cells compared with that in control cells and HSP60-overexpressing cells. Apoptotic cells were also reduced in HSP60-overexpressing. CONCLUSION These results indicate that HSP60 plays an important role in protecting small intestinal mucosal cells from H2O2-induced or indomethacin-induced cell injury. HSP70-overexpressing cells did not show anti-apoptotic ability. SIGNIFICANCE These findings possibly suggest that function of each HSP is different in the small intestine. Therefore, for the therapy of small intestinal mucosal lesion, HSP60-induction therapy could be a new therapeutic strategy.

MAIT cells are activated and accumulated in the inflamed mucosa of ulcerative colitis

Ulcerative colitis (UC) is a chronic, relapsing and remitting, inflammatory disorder of the large intestine. Mucosal associated invariant T (MAIT) cells are a member of innate‐like lymphocytes found abundantly in the mucosal tissue. The contribution of MAIT cells in the pathogenesis of UC is still unclear; therefore, this study aimed at investigating the role of these cells in patients with UC.

Factors associated with incomplete colonoscopy at a Japanese academic hospital

AIM To evaluate significant risk factors for incomplete colonoscopy at a Japanese academic hospital. METHODS A total of 11812 consecutive Japanese people were identified who underwent a colonoscopy at an academic hospital. A multiple logistic regression model was used to evaluate retrospectively the significant risk factors for incomplete colonoscopy. RESULTS The cecal intubation rate was 95.0%. By univariate analysis, age, female sex, poor bowel cleansing, and a history of abdominal or pelvic surgery were significant risk factors for incomplete colonoscopy (P < 0.001). Moreover, age- and sex-adjusted analysis showed that significant risk factors for incomplete colonoscopy were female sex (OR = 1.38, 95%CI: 1.17-1.64, P = 0.0002), age ≥ 60 years old (OR = 1.44, 95%CI: 1.22-1.71, P < 0.0001), a history of prior abdominal or pelvic surgery (OR = 1.55, 95%CI: 1.28-1.86, P < 0.0001), poor bowel cleansing (OR = 4.64, 95%CI: 3.69-5.84, P < 0.0001), and inflammatory bowel disease (IBD) (OR = 1.48, 95%CI: 1.13-1.95, P = 0.0048). In Japanese men, by age-adjusted analysis, IBD (OR = 1.69, 95%CI: 1.18-2.43, P = 0.005) was an independent risk factor for incomplete colonoscopy. CONCLUSION Several characteristics in the Japanese population were identified that could predict technical difficulty with colonoscopy.

Usefulness of flexible spectral imaging color enhancement for the detection and diagnosis of small intestinal lesions found by capsule endoscopy

Abstract Objective. Capsule endoscopy (CE) is an established technique for the detection and diagnosis of obscure gastrointestinal bleeding (OGIB). Flexible spectral imaging color enhancement (FICE) is a software feature of RAPID 6.5. This study assessed the value of FICE for accurate identification of red lesions during CE. Methods. We randomly selected 10 patients who underwent CE for OGIB at Juntendo University. The CE images were read by five endoscopists. Small bowel videos, which were recorded by regular CE devices (PillCam SB2, Given Imaging), were evaluated on RAPID 6.5. We standardized the reading condition to a dual view, at a speed of 20 frames/s in manual mode. This interpreted FICE-CE images obtained at settings 1–3. Both conventional and FICE images were read at random. We defined a conventional image as standard and investigated the potential of FICE in detecting small intestinal lesions by the Steel–Dwass test. Results. We considered that conventional images represented baseline (100). On this basis, detection rates for FICE images were as follows: FICE1 = 266.4 ± 33.1 (p < 0.0001); FICE2 = 255.4 ± 25.6 (p < 0.0001); and FICE3 = 117.0 ± 12.3 (p = 0.9447). Detection rates using FICE1 and FICE2 images were significantly higher than conventional CE images. FICE1 and FICE2 were more useful in detecting erosions than conventional CE (p < 0.0001) and FICE3 (p < 0.0001). Conclusions. FICE-CE has a high level of visibility by transparentizing bile or enhancing the color difference associated with reddish mucosa. We found that FICE-CE images were useful in the diagnosing of small intestinal lesions.

Metastatic renal cell carcinoma diagnosed by capsule endoscopy and double balloon endoscopy

Summary Background Renal cell carcinoma commonly metastasizes to lung, liver, and bone. Small intestinal metastases are exceedingly rare. Case Report A 75-year-old man presented at our hospital with tarry stools. He had undergone a right nephrectomy for renal cell carcinoma (RCC) 6 years previously; in addition, he had received antiplatelet treatment for ischemic heart disease. Esophagogastroduodenoscopy, total colonoscopy, and computed tomography did not identify any cause for the gastrointestinal bleeding. He underwent capsule endoscopy (CE), which revealed an ulcerated submucosal tumor in the jejunum. We performed a double-balloon endoscopy (DBE), and histological findings identified a clear cell carcinoma. We diagnosed metastasis from the RCC. We performed a jejunectomy to resect the tumor and thus eliminate the source of the bleeding. Conclusions CE and DBE are useful diagnostic tools. We recommend investigating the possibility of small intestinal metastases in cases of intestinal bleeding or anemia in patients with a history of malignant tumor.

Correlation of Heat Shock Protein Expression to Gender Difference in Development of Stress-Induced Gastric Mucosal Injury in Rats

Recent studies have indicated that heat shock proteins (HSPs), which function as molecular chaperones, play important roles in cellular responses to stress-related events. However, the gender difference in the expression of HSP in the gastric mucosa remains unclear. In order to understand the mechanism of gender difference in the prevalence or severity of gastric mucosal lesions, the expression level of HSP and the correlation of estrogen to HSP induction in the gastric mucosa were evaluated in this study. The basal expression levels of HSP60 and HSP90 in the gastric mucosa were significantly higher in females than those in males. The gastric ulcer index was significantly higher in male rats compared to female rats observed after 12 h water immersion stress exposure. At this time point, the expression levels of HSP60 and HSP90 in the gastric mucosa were significantly higher in females than those in males. An estrogen-treatment significantly induced the expression of HSP60, HSP70 and HSP90 in the gastric mucosa. Inversely, an ovariectomy dramatically reduced the expression of HSP60, HSP70 and HSP90 in the gastric mucosa. Our results suggested that estrogen might play an important role in gastric mucosal protection with the induction of gastric mucosal HSPs.

Optimal timing for resuming antithrombotic agents and risk factors for delayed bleeding after endoscopic resection of colorectal tumors.

Aim. To examine optimal timing for resuming antithrombotic agents and risk factors for delayed bleeding after endoscopic resection of colorectal tumors. Method. Of 1,970 polyps larger than 10 mm removed by polypectomy, endoscopic mucosal resection, or endoscopic submucosal dissection, delayed bleeding, which was designated as bleeding that occurred 6 or more hours after endoscopic treatment, occurred in 52 cases (2.6%); 156 nonbleeding cases matched for age and gender were controls in this single-institution retrospective case-control study. We investigated (1) patient-factors: resuming antithrombotic agents within 5 days following endoscopic resection, hypertension, and diabetes mellitus; and (2) tumor-factors: morphology, size, location, and resection technique by conditional logistic regression. Results. By multivariate analysis resumption of anticoagulants within 5 days was a significant risk factor for delayed bleeding (OR 10.2; 95% CI = 2.7–38.3; P = 0.0006). But resuming a thienopyridine within 5 days was not (OR 0.9; 95% CI = 0.1–2.6; P = 0.40). Other patient- and tumor-factors were not significant. Conclusion. Resuming anticoagulants within 5 days after endoscopic treatment was associated with delayed bleeding whereas resuming thienopyridines was not.