Yasutaka Hijikata

ENDOSCOPIC SUBMUCOSAL DISSECTION WITH SHEATH-ASSISTED COUNTER TRACTION FOR EARLY GASTRIC CANCERS

Aim:  Endoscopic submucosal dissection (ESD) is associated with frequent complications, such as bleeding and perforation. The procedure is technically difficult, requires considerable skill and is longer than conventional endoscopic mucosal resection (EMR). Thus, non‐invasive tools and methods are needed to facilitate direct visualization of the submucosal layer during ESD.

Usefulness of a Slow Nutrient Drinking Test for Evaluating Gastric Perception and Accommodation

Background/Aim: An implication of the drinking test for gastric function is controversial. We evaluated the usefulness of a nutrient drinking test for examining gastric function by comparing it with a gastric barostat study. Methods: We investigated perceived pressure of an intragastric bag with stepwise distension and postprandial peak gastric volume (accommodation volume) with a consistent pressure after drinking a liquid meal (200 ml, 300 kcal) in 18 volunteers. Drinking a similar liquid meal on a different day at a continual rate of 15 ml/min was performed to score satiety and bloated sensations at 5-min intervals. An additional 10 volunteers performed the drinking test before and after administration of mosapride citrate or a placebo in a double-blind crossover study. Results: Pressure to induce severe discomfort correlated positively with maximum satiety volume in the drinking test (r = 0.60, p = 0.02). Accommodation volume in the barostat study showed a significant correlation (r = 0.59, p = 0.03) with threshold volume to induce bloating in the drinking test. Mosapride tended to increase the volume inducing the first bloated sensation as compared to the placebo. Conclusion: The present drinking test may be useful for evaluating the threshold to induce severe discomfort and accommodation volume.

Long-term survival and improved quality of life after chemoradiotherapy to treat esophageal small cell carcinoma: a report of two cases.

In case 1, endoscopy revealed a submucosal tumor with central ulceration in the esophagus of a 54- year-old man. A biopsy specimen revealed small cell carcinoma without metastasis and the stage of the cancer was stage I (T2N0M0). Two cycles of concurrent cisplatin, etoposide and radiotherapy resulted in an incomplete response/stable disease. The tumor recurred and had metastasized to the brain, lung, liver, lymph nodes of the mediastinum, abdomen and bones after six cycles. Two cycles of irinotecan and cisplatin then elicited a complete response in the primary esophageal lesion. However, progressive disease was identified in the metastatic bone tumors. Despite two further cycles of therapy, he died 447 days after the initial course. In case 2, a biopsy specimen of a tumor with central ulceration in the esophagus of a 77-year old man with swallowing difficulty indicated small cell carcinoma. The stage of the cancer was diagnosed as stage II (T3N0M0). Two cycles of irinotecan, cisplatin and concurrent radiotherapy elicited a complete response. However, the tumor metastasized to the brain and the liver 644 days after starting treatment. Two cycles of carboplastin plus irinotecan elicited a partial response in the metastatic tumors, but he died 988 days after starting chemotherapy.

Endoscopic submucosal dissection with sheath-assisted counter traction using a novel sheath for early gastric cancers.

BACKGROUND/AIMS Endoscopic submucosal dissection (ESD) is technically demanding and requires considerable skill. We previously described sheath-assisted counter traction ESD that uses simple materials and methods to improve cutting line visualization. We recently improved counter-traction of the submucosal layer using a novel chemically treated sheath that reduces slippage and maintains traction, and investigated the utility of the novel sheath for ESD. METHODOLOGY Forty-three and 25 consecutive patients with early gastric carcinomas were treated by standard ESD and traction ESD assisted with novel sheaths, respectively. The mean duration of procedures relative to tumor size and location, as well as complications after ESD between the two groups were compared. RESULTS The mean duration of ESD procedures for lesions =20mm in diameter was significantly reduced using the novel sheath. The mean duration of procedures for all locations of resected tumors in the stomach was significantly reduced using the novel sheath. However, no perforation and delayed bleeding developed after treatment with the novel sheath. CONCLUSIONS Sheath-assisted counter traction ESD by the novel sheath was technically simpler and thus less time-consuming regardless of the location of lesions, especially when =20mm in diameter. The traction ESD with the novel sheath is safe and not invasive, and it can be universally applied to standard ESD.

Treatment Adherence in Patients with Ulcerative Colitis Is Dependent on the Formulation of 5-Aminosalicylic Acid

Background/Aims: It is unclear whether 5-aminosalicylic acid (5-ASA) formulation is associated with treatment adherence in ulcerative colitis (UC). Thus, we aimed to investigate the adherence rate after switching from 5-ASA tablets to granules. Methods: This prospective study included 121 UC outpatients treated using 5-ASA tablets. They were grouped based on choice: Group 1 (continued with tablets) and Group 2 (switched to granules without regimen change). Group 2 was further divided into Group 3 (returned to tablets) and Group 4 (continued with granules). The patients completed a self-administered questionnaire regarding the treatment. The primary endpoint was change in adherence after switching to granules. Results: Seventy-nine patients continued with tablets, while 42 patients switched to granules. The adherence rate to the tablet was not significantly different between Group 1 and 2 before switching. In Group 2, switching to granules did not affect adherence. However, in Group 4, adherence significantly improved after switching to granules. Group 3 showed no significant change in adherence before and after switching from tablets. Full-time work and difficulty taking tablets were significant predictors of continuing with granules in Group 4. Conclusion: Patients who continued with 5-ASA granules showed significantly increased adherence, suggesting that patient-tailored drug formulations improved treatment adherence.

A Small Bowel Ulcer due to Clopidogrel with Cytomegalovirus Enteritis Diagnosed by Capsule and Double-Balloon Endoscopy

We report the first case of small bowel ulcers due to clopidogrel in a 74-year-old man. He presented with diarrhea and melena after having been taking low-dose aspirin (LDA) and clopidogrel. There was no evidence of bleeding in the stomach, duodenum, or colon. Capsule endoscopy showed multiple ulcers and erosions in the small intestine. Double-balloon endoscopy revealed multiple ulcers throughout the ileum. Examination of the biopsy specimen showed cytomegalovirus infection. His LDA was discontinued and he was prescribed ganciclovir. However, the small bowel ulcers were aggravated. Therefore, clopidogrel was discontinued. The small bowel ulcers subsequently healed completely, forming scars.

A gastric glomus tumor resected using non-exposed endoscopic wall-inversion surgery

Gastric glomus tumors are extremely rare, constituting approximately 1% of gastric mesenchymal tumors. We report the case of a 45-year-old female patient in whom upper gastrointestinal endoscopy revealed a 3-cm submucosal tumor with a bridging fold in the posterior wall of the antrum of the stomach. Contrast-enhanced computed tomography revealed the tumor to be hypervascular in the arterial phase and exhibit continuous enhancement in the post-venous phase. Dynamic contrast-enhanced magnetic resonance imaging showed that the tumor was hypervascular in the early phase and persistently enhanced in the late phase. Endoscopic ultrasonography revealed a mosaic echo pattern. Endoscopic ultrasound-guided fine-needle aspiration biopsy was performed. Immunohistochemical examination revealed that the tumor was positive for α-smooth muscle actin and synaptophysin, but negative for CD56, chromogranin A and C-kit. Furthermore, 1–2% of the tumor cell nuclei were Ki-67-positive. Thus, the preoperative diagnosis was a benign glomus tumor. The patient then underwent non-exposed endoscopic wall-inversion surgery (NEWS), and the tumor was completely resected. In conclusion, NEWS is an effective method for the treatment of gastric glomus tumors.

Tu1622 Evaluation of Relationship Between Gastroesophageal Reflux Disease (GERD) and Laryngopharyngeal Reflux Disease (LPRD)

Evaluation of Relationship Between Gastroesophageal Reflux Disease (GERD) and Laryngopharyngeal Reflux Disease (LPRD) Yoshihiro Kondo*, Makoto Sasaki, Naotaka Ogasawara, Yasushi Funaki, Mari Mizuno, Akihito Iida, Naohiko Kawamura, Kentaro Tokudome, Yasutaka Hijikata, Shinya Izawa, Ryuta Masui, Yoshitsugi Ito, Yasuhiro Tamura, Hisatsugu Noda, Kunio Kasugai Gastroenterology, Aichi Medical University, Nagakute, Japan Introduction: Gastroesophageal reflux disease (GERD) is defined as a condition that develops when reflux of the stomach contents involving gastric acid juice causes troublesome symptoms. GERD typically presents heartburn and regurgitation, but it can also present atypically as chronic cough, throat pain, and asthma. Atypical symptoms such as chronic cough, throat pain, and asthma are considered to be associated with laryngopharyngeal reflux disease (LPRD). Currently, LPRD is associated with laryngeal irritation such as laryngitis caused by reflux of the gastric acid juice. However, the accurate relationship between GERD, especially endoscopic positive esophagitis (EE) and LPRD is still unknown. In this study, we examined the grades of EE and the larynx findings using esophago-gastroendoscopy, and investigated the relationship between GERD and LPRD. Methods: Four hundred two patients except gastrointestinal malignant tumors, gastrointestinal ulcer, esophageal varices, and usage of proton pump inhibitor or H2-blocker underwent esophago-gastroendoscopy for examining the findings of gastro-esophageal junction, cardiac position of the stomach, and larynx at the Department of Gastroenterology, Aichi Medical University School of Medicine between January 2007 and December 2008. Three otorhinolaryngologists and three gastroendoscopists blindly evaluated the findings of laryngopharyngeal area (edema of inferior position of larynx, redness of aryepiglottic fold, thickness of interarytenoid mucosa, and presence of vocal fold granuloma) and gastro-esophageal junction, respectively. Independent and significant predictive factors of EE (background of patients, symptoms, the laryngopharyngeal findings, presence of esophageal hernia) were determined by multivariate analysis. Results: Thirty patients (7.5%) were diagnosed as EE. Of all patients, 114 (28.4%), 230 (57.2%), 271 (67.4%), and 7 (1.7%) patients harbored edema of inferior position of larynx, reddness of aryepiglottic fold, thickness of interarytenoid mucosa, and granuloma of vocal fold, respectively. One hundred fifteen patients (28.6%) complained of laryngopharyngeal reflux symptoms, but there was no relationship between laryngopharyngeal reflux symptoms, the grades of EE, and the findings of larynx. However, esophageal hernia [odds ratio (OR), 2.6], and thickness of interarytenoid mucosa (OR, 4.9), were independent predictive factors of EE. Conclusion: Although laryngopharyngeal reflux symptoms possessed no statistical relation to the findings of both EE and laryngitis, the thickness of interarytenoid mucosa which might be initially affected by the reflux of stomach contents involving gastric acid juice was exceedingly related to EE.

Sa2052 Putative IBD Prophylaxis in Addition to Metabolic Syndrome by Oligosaccharide Synthesize Enzyme

Introduction: Obesity and metabolic disorders are linked to inflammation via gut flora and/ or gut permeability. Gut derived endotoxin triggers inflammation leading to metabolic syndrome (MetS) and contributing to oxidative stress. Aim: To investigate the effect of Lactobacillus casei Shirota on gut permeability, presence of endotoxin and neutrophil function in MetS. Patients and Methods: Patients with MetS were randomized to receive 3 x 6.5x109 CFU Lactobacillus casei Shirota (probiotic group) or not for 3 months. Gut permeability was assessed by a differential sugar absorption method, endotoxin by an adapted limulus amoebocyte lysate assay, neutrophil function and toll-like receptor (TLR) expression by flow cytometry and ELISA was used to detect lipopolysaccharide binding protein (LBP) and sCD14 levels. Results: Twenty-eight patients and 10 healthy controls were included. Gut permeability was significantly increased in MetS compared to controls but did not differ between patient groups. None of the patients were positive for endotoxin. LBP and sCD14 levels were not significantly different from healthy controls. C-reactive protein and LBP levels slightly but significantly increased after 3 months within the probiotics group. Neutrophil function and TLR expression did not differ from healthy controls or within the patient groups. Discussion: Gut permeability of MetS patients was increased before markers of low grade inflammation were measurable, most likely because only a minority of patients had morbid obesity normally leading to inflammation. Lactobacillus casei Shirota did not have any influence on any parameter tested possibly due to too short study duration or underdosing of Lactobacillus casei Shirota.

Hepatocellular Carcinoma 11 and a Half Years after the Resolution of Chronic Hepatitis C Virus Infection Successfully Treated with Interferon

A 41-year-old Japanese man had received successful interferon (IFN) therapy against chronic hepatitis C in 1994. Since then, serum hepatitis C virus (HCV) RNA had been negative, and aminotransferase levels had been continuously normal. He had abstained from alcohol. However, his serum aminotransferase levels showed slight elevation as his body weight increased gradually. He was diagnosed as having fatty liver and diabetes mellitus. In January 2006, 11 and a half years after the resolution of HCV infection, he was found to have a hepatic nodule 4.0 cm in diameter at liver S4/8 region by plain abdominal CT at an annual follow-up examination. He was diagnosed as having hepatocellular carcinoma (HCC) by angiography. The tumor was curatively resected and its histological diagnosis was moderately differentiated HCC. Noncancerous lesion of the liver revealed fibrosis of stage F2 and mild inflammation of grade A1 with mild steatosis. This case suggests that all patients with chronic HCV infection should be followed as long as possible for the potential development of HCC even after clearance of the virus.