Toshihiko Higashizawa

A novel method of endoscopic mucosal resection using sodium hyaluronate.

BACKGROUND Saline-assisted endoscopic mucosal resection is an established therapeutic method. However, it is sometimes difficult to maintain a desired level of tissue elevation after injection of saline. Therefore we decided to use a mucinous substance such as sodium hyaluronate instead of saline. METHODS Two resected porcine stomachs and five dogs were used for the study. The elevations, made by submucosal injections of sodium hyaluronate, were compared with those produced with normal saline. Sodium hyaluronate-assisted mucosal resections were compared with the saline-assisted resections. RESULTS Mucosal elevations created by submucosal injections of sodium hyaluronate remained for a longer time with a clearer margin compared to those made by saline injection. Endoscopic mucosal resections were performed safely with the assistance of sodium hyaluronate. CONCLUSIONS Use of sodium hyaluronate instead of saline for endoscopic mucosal resection could make the procedure easier and more reliable.

Biliary guidewire facilitates bile duct biopsy and endoscopic drainage

Background: The introduction of a guidewire through bile duct strictures may facilitate transpapillary bile duct biopsy and subsequent biliary drainage.

Epinephrine irrigation for the prevention of pancreatic damage after endoscopic balloon sphincteroplasty

Background and Aim: Endoscopic balloon sphincteroplasty (EBS) is an alternative to sphincterotomy for the treatment of bile duct stones. The purpose of this study was to determine if epinephrine irrigation of the papilla can prevent the pancreatic damage associated with EBS.

Comparison of intraductal ultrasonography with percutaneous transhepatic cholangioscopy for the identification of residual bile duct stones during lithotripsy

Background: An imaging modality that can be used to identity small stones after a biliary lithotripsy is required. Intraductal ultrasonography was evaluated by using percutaneous transhepatic cholangioscopy as the gold standard.

A patient with sarcoidosis who developed heterochronic involvements in different organs from initial organs during 7 years

A 59-year-old woman, who was given a diagnosis of sarcoidosis by supraclavicular lymph node biopsy 5 years previously, was admitted for further examination following abnormal radiologic findings. Nodular pulmonary and abdominal lesions were observed by computed tomography, and liver biopsy was performed and showed epithelioid cell granulomas. She was asymptomatic and was followed up with no therapy. At 1 year follow-up, the pulmonary and abdominal lesions had nearly complete resolution. Nodular pulmonary and abdominal lesions in patients with sarcoidosis can mimic metastatic disease, lymphoma, and infection, and can reappear during disease activity. Therefore, differential diagnosis and continual follow-up are important.

Looping technique for transpapillary selective biopsy of the left hepatic duct

Purpose. Because biopsy forceps tend to turn towards the right hepatic duct during endoscopic retrograde cholangiopancreatography (ERCP), selective access to the left hepatic duct is difficult. Methods. In this study, we managed to insert biopsy forceps selectively into the left hepatic duct, by using a looping technique, in three patients. Biopsy forceps were inserted into the right hepatic duct by the conventional method. The elevator of the endoscope was kept down, and the shaft of the biopsy forceps was then advanced to the duodenal cavity until it formed a loop between the endoscope and the papilla. During the procedure, the tip of the forceps was kept at the hepatic hilus. Results. In this condition, we were able to slowly rotate the tip of the forceps and direct the forceps towards the left. Sufficient material from the left hepatic duct was obtained in all patients. Conclusions. The looping technique was useful for selective access to the left hepatic duct.

Percutaneous recanalization of the bile duct along an endoscopic naso-biliary catheter.

Abstract: Percutaneous recanalization of the bile duct is essential for placing biliary stents and carrying out other interventions. This prospective study was performed to establish safe approaches for percutaneous recanalization of the bile duct when it had previously resulted in failure. Between July 1995 and July 1999, percutaneous recanalization of the bile duct was attempted in 58 patients with a malignant biliary stenosis. When recanalization failed, an endoscopic naso-biliary drainage (ENBD) catheter was placed across the stenosis. The procedure was again attempted along the ENBD catheter. In the period of the study, four patients underwent successful recanalization after ENBD, although attempts prior to ENBD had been unsuccessful. As a result, the success rate of recanalization in the period was 100% (58/58). When recanalization fails, the use of an ENBD catheter may provide access to the biliary tree, and the biliary stenosis can be recanalized safely.

7223 Peripheral venous endotoxin levels in patients with esophageal varices during the course of a new form of endoscopic variceal ligation.

Purpose: This study mainly investigated the following: (1) comparison of peripheral venous endotoxin levels in cirrhotic patients with varices before modified endoscopic esophageal variceal ligation (EVL) (“intensive ligation” method: a radical obliterative approach to the treatment of esophageal varices); (2) whether modified EVL affected peripheral venous endotoxin levels in these patients during the course of this therapy. Methods: Twenty patients were treated with modified EVL. The endotoxin level was detected using a new modification of a chromogenic substrate assay (Endospec-SP test) before and after EVL therapy. The normal range of endotoxin was considered 3.0 pg/dl or less. Students t test was used. The level of significance was p

2215 Endoscopic mucosal resection using sodium hyaluronate: Development of new devices for a more reliable single-step resection.

Purpose We developed a new method of endoscopic mucosal resection (EMR) using a mucinous substance of sodium hyaluronate. Its clinical application was started in June 1998. The details of this method were introduced in the 3rd ASGE video forum. This time, we developed new devices to establish a more reliable method, which enables a single-step resection of lesions larger than 4 cm in diameter.We tried this method on a large superficial gastric cancer of 4 cm in diameter. The new method will be presented on video. Methods The new devices we developed this time are incision forceps and a flat-ended transparent hood. The incision forceps can grasp a piece of tissue and cut the tissue with high frequency currents. The transparent hood on the tip of the scope plays two roles. One is the correction of the opening direction of the forceps, and the other is the opening and visualization of the submucosal layer at the incision line. After submucosal injections of sodium hyaluronate and a circumferential incision of the elevated mucosa with a needle knife, the thickened submucosal layer is cut with these devices instead of using a polypectomy snare. A large mucosa can be stripped off in one piece by this method. After several trials on dogs, in October 1999, we performed this method on a 71 year-old man with a large superficial gastric cancer located on the anterior wall of the antrum. The lesion arose from a pre-pylorus region and reached the angle. It also spread from the lessor curvature to the greater curvature. Results The cutting of the submucosal layer could be performed safely because the submucosal layer was maintained thick by the local injections of sodium hyaluronate. The tumor was resected in one piece. The pathological findings showed a complete resection of well differetiated intramucosal adenocarcinoma that measured 40 mm by 35 mm in diameter. The resected specimen measured 58 mm by 52 mm. The margin of the specimen was free of neoplasm along its circumference. There was no apparent vascular or lymphatic invasion. Conclusions From our experience, the main reason of failure in a single-step resection is the slipping of a part of the tumor out of the snare. It becomes almost impossible to hold an entire tumor with a snare if the tumor is large enough to locate in a round shape. The new method of EMR using sodium hyaluronate with assistance of the new devices can overcome the problems that are related to snareing. The new method enables a single-step resection of a large flat lesion greater than 4 cm in diameter.