Yoshihide Tatsumi

Initial experience with a new peroral electronic pancreatoscope with an accessory channel

BACKGROUNDnA peroral electronic pancreatoscope was previously developed to improve visualization of the pancreatic duct, but this instrument had no accessory channel.nnnMETHODSnA new peroral electronic pancreatoscope (2.6-mm external diameter) with an accessory channel (0.5 mm) was developed. Peroral pancreatoscopy or cholangioscopy was performed with this new instrument in 11 patients with various pancreatobiliary diseases. The clinical utility of the new peroral electronic pancreatoscope was assessed, and visualization with this new instrument was compared with that of the prototype.nnnRESULTSnThe resolution of the two instrument systems was nearly equal, with that provided by the new peroral electronic pancreatoscope being slightly better. The new peroral electronic pancreatoscope was inserted successfully into the pancreatic or bile duct in 9 of the 11 patients (82%). Observation of a predetermined target and juice collection with direct visualization was successful in 8 of the 9 patients (89%).nnnCONCLUSIONSnThe new peroral electronic pancreatoscope with an accessory channel was useful for clinical diagnosis of various pancreatobiliary diseases. Visualization is excellent. Pancreatic juice and other samples can be collected under direct visualization.

Pancreatoscopy for the next generation: development of the peroral electronic pancreatoscope system

BACKGROUNDnTo improve visualization of the pancreatic duct with a pancreatoscope, we have developed the smallest known electronic endoscope, that is, the peroral electronic pancreatoscope.nnnMETHODSnThis instrument (2.1 mm, external diameter) was developed with a 50k-pixel interline charge coupled device. A peroral fiberoptic pancreatoscope was used as control, connected to a video converter. The visibility of both systems was studied with a test chart. The model pancreatic duct, the oral mucosa, and the pancreatic ducts of a healthy control subject and patients with chronic pancreatitis were examined with both systems.nnnRESULTSnThe smallest visible interval (with a 5 mm distance between the object and the distal end of the endoscope) was 0.07 mm with the peroral electronic pancreatoscope and 0.2 mm with the peroral fiberoptic pancreatoscope. The electronic instrument produced better images of the model pancreatic duct than the fiberoptic endoscope. A clear image of the small vessels of the oral mucosa was obtained with the electronic but not with the fiberoptic instrument. The fine vessel network of the pancreatic duct was visualized only with the electronic instrument; pancreatic duct stones and rough-surfaced pancreatic duct were shown more precisely with the electronic endoscope.nnnCONCLUSIONSnThe peroral electronic pancreatoscope provides images of the fine detail of the pancreatic duct and will contribute to the diagnosis of pancreatic diseases.

Electronic pancreatoscopy for the diagnosis of pancreatic diseases

OBJECTIVES:Diagnostic pancreatoscopy was performed in 56 patients using the newly developed peroral electronic pancreatoscope (PEPS). The diagnostic value of the PEPS for pancreatic diseases was evaluated.METHODS:The PEPS (external diameter = 2.1 mm, bidirectional tip deflection) was developed with a minute 50,000-pixel interline charge-coupled device. Pancreatoscopy was performed by means of an endoscopic retrograde approach without sphincterotomy. The cases examined were normal (three), chronic pancreatitis (32), pancreatic cancer (eight), and intraductal papillary mucinous tumors (13).RESULTS:Of the 56 cases, 42 (75%) were adequately seen. In normal cases, fine capillary vessels were clearly visualized on the smooth whitish-pink mucosa. Findings in chronic pancreatitis included protein plugs, calcified stones, rough whitish mucosa, scar formation, edema, erythema, and indistinct capillary appearance. All the stenoses of chronic pancreatitis could be differentiated from those of pancreatic cancer with the PEPS. In the pancreatic cancer cases, all patients had stenoses or duct cutoffs; most cases had friable mucosa with erythema and erosive changes, and a single patient had a compressed pancreatic duct wall covered with normal epithelium. In the cases of intraductal papillary mucinous tumors, papillary tumors were visualized with extreme clarity. In the case of adenocarcinoma, the PEPS revealed oval-shaped tumors with spotty redness or villous tumors with dilation of capillary vessels. Moderate acute pancreatitis was recognized after pancreatoscopy in one of the 56 cases (1.8%).CONCLUSIONS:Electronic pancreatoscopy with the PEPS is feasible in most patients and technically safe, and improves diagnostic yield over conventional pancreatoscopy.

Direct cholangioscopy and pancreatoscopy.

Direct cholangiopancreatoscopy has played a minor role in the diagnosis and treatment of pancreaticobiliary disorders, initially because of instrument fragility and suboptimal imaging, and later because of improvements in noninvasive and semi-invasive imaging techniques. Digital scopes provide superior images and hold the promise of increased application and improved durability.

Effect of Helicobacter pylori eradication on gastroesophageal function

Background:u2002 To elucidate the cause of possible occurrence of reflux esophagitis after Helicobacter pylori eradication, gastric and esophageal function among H. pylori infected Japanese patients were evaluated both before and after eradication therapy.

Feasibility and tolerance of 2-way and 4-way angulation videoscopes for unsedated patients undergoing transnasal EGD in GI cancer screening

BACKGROUNDnThe differences between 2-way and 4-way angulation endoscopes for use in unsedated patients undergoing transnasal EGD have not been elucidated.nnnOBJECTIVEnOur purpose was to evaluate the feasibility and tolerance of 2- and 4-way angulation endoscopes for unsedated transnasal EGD in GI cancer screening of elderly people.nnnDESIGNnA total of 291 patients were randomized to receive unsedated transnasal EGD with a 5.2-mm diameter 2-way angulation endoscope (GIF-N260, Olympus, Tokyo, Japan) (n = 146) or 5.5-mm diameter 4-way angulation endoscope (XGIF-XP240N2, Olympus) (n = 145). The transnasal insertion success rate and incidence of epistaxis were compared. The following parameters were evaluated: overall quality of the examination, ease of passing the endoscope through the pylorus, intubation of the second portion of the duodenum, ability to observe the entire upper GI tract and perform target biopsy, and examination time. Patient tolerance and acceptance were also assessed with regard to nasal pain, choking, gagging, abdominal discomfort, and overall pain and discomfort.nnnSETTINGnMatsushita Health Care Center, Moriguchi, Japan.nnnPATIENTSnA total of 291 patients had unsedated transnasal EGD as part of a gastric cancer screening program.nnnRESULTSnUse of the pediatric 4-way angulation endoscope significantly shortened the examination time when biopsy was performed compared with the 2-way angulation instrument, whereas the examination time without biopsy was not significantly different. Other parameters were not significantly different between the 2 endoscopes.nnnCONCLUSIONnFor unsedated transnasal EGD with biopsy, the 5.5-mm 4-way angulation videoscope shortens examination time while providing easy transnasal insertion and improved patient tolerance.

Analysis of the 13C‐urea breath test for detection of Helicobacter pylori infection based on the kinetics of Δ‐13CO2 using laser spectroscopy

We have previously reported on laser spectroscopy as a simple alternative to mass spectrometry. To validate a simplified 13C‐urea breath test (UBT) with laser spectroscopy for the detection of Helicobacter pylori in clinical use, we evaluated the optimal time of breath sample collection. The 13C‐UBT was carried out on each of 102 infected and 70 non‐infected subjects (32 without eradication and 38 after eradication therapy). Breath samples were taken at five time points within 60 min followed by 100 mg of 13C‐urea administration. The ratio of 13CO2 to 12CO2 was measured using laser spectroscopy and the recovery of tracer in the exhaled breath was calculated. Results were compared with histological and culture examinations of gastric biopsies to establish the infection status. For statistical evaluation of 13C‐UBT, the optimal timing of breath sample collection was examined on the basis of the kinetics of Δ‐13CO2. In 32 H. pylori‐negative patients (without therapy), the mean ± 2SD of Δ‐13CO2 was at its minimum 20 min after urea ingestion whereas in H. pylori‐positive patients, the mean ± SD Δ‐13CO2 was maximum at 20 min. In addition, receiver operating characteristic (ROC) curve analysis showed that the cut‐off value was estimated between 2.5–3.0 per mil (‰) at 20 min before therapy. Based on the histology and culture results, the sensitivity, specificity and positive and negative predictive values were 98.0%, 100%, 100% and 94.1%, respectively. In conclusion, 13C‐UBT with laser spectroscopy is a non‐invasive, simple, sensitive and specific test to determine H. pylori status. Our findings suggest that in clinical use, measurements made at 20 min after substrate administration could be recommended for most sensitive and specific 13C‐UBT results.

REGRESSION OF ATYPICAL LYMPHOID HYPERPLASIA AFTER ERADICATION OF HELICOBACTER PYLORI

A rare case of endescopic and histological regression of a gastric lymphoid mucosal lesion after eradication ofHelicobacter pylori is reported. A 72-year-old man was suspected of having a low-grade B-cell gastric mucosa-associated lymphoid tissue (MALT) lymphoma by endoscopic and histological findings. Histology of biopsy specimens showed massive infiltration of atypical lymphocytes and lymphoepithelial lesions. Immunohistochemical staining revealed kappa light chain expression in the infiltrated atypical lymphocytes to be twofold that of lambda light chain. The above diagnosis was thus highly suspected but not confirmed. Antibiotic therapy was given on the basis of evidence ofH. pylori infection. Successful eradication ofH. pylori resulted in remarkable improvement of endoscopic and histological findings. Follow-up studies were carried out 8 months after eradication, with no evidence of relapse. The eradication ofH. pylori appears to be an effective alternative therapy for B-cell lymphoproliferative disease, although longer follow-up and further studies are needed before this treatment can be establisted.

Ischemic hepatitis induced by mesenteric volvulus in a patient with chronic obstructive lung disease

Abstract: A 66-year-old man with chronic obstructive lung disease was admitted to our hospital, presenting with mesenteric volvulus and mild liver injury. A superior mesenteric angiogram revealed that the arteries supplying the small intestine were twisted in the arterial phase, while the portal vein was not visualized in the late phase. A celiac angiogram demonstrated that portal blood flow from the splenic venous return was maintained. The patients symptoms had almost resolved the day after admission, and his serum transaminases level had gradually decreased to normal with conservative therapy. A superior mesenteric angiogram on the 13th hospital day showed a normal arteriogram and the portal vein demonstrated blood flow from the superior mesenteric vein. Liver biopsy revealed hemorrhagic necrosis around the central veins, which was compatible with ischemic hepatitis. Since the patients O2 saturation level on admission was not low enough to have caused ischemic hepatitis by itself, we suspect that a sudden decrease in portal blood flow was the additional factor that allowed the threshold for the initiation of ischemic liver damage to be reached.

Analysis of cardiopulmonary stress during endoscopy: Is unsedated transnasal esophagogastroduodenoscopy appropriate for elderly patients?

BACKGROUNDnTransnasal esophagogastroduodenoscopy (EGD) without sedation has been reported to be safe and tolerable. It has recently been used widely in Japan for the detection of upper gastrointestinal disease. Alternatively, transoral examination using a thin endoscope has also been reported to be highly tolerable.nnnOBJECTIVEnTo examine the cardiocirculatory effects of transoral versus transnasal EGD in an attempt to determine the most suitable endoscopic methods for patients ≥75 years of age.nnnMETHODSnSubjects who underwent monitoring of respiratory and circulatory dynamics without sedation during endoscopic screening examinations were enrolled at the New Ooe Hospital (Kyoto, Japan) between April 2008 and March 2009. A total of 165 patients (age ≥75 years) provided written informed consent and were investigated in the present study. Patients were randomly divided into three subgroups: UO group--thin endoscope; SO group--standard endoscope; and UT group--transnasal EGD. Percutaneous arterial blood oxygen saturation, heart rate and blood pressure were evaluated just before EGD and at five time points during EGD. After transnasal EGD, patients who had previously been examined using transoral EGD with a standard endoscope were asked about preferences for their next examination.nnnRESULTSnThere were no statistical differences in the characteristics among the groups. Percutaneous oxygen saturation in the UT group showed a transient drop compared with the SO and UO groups at the beginning of the endoscopic procedure. Heart rate showed no significant differences among the SO, UO and UT groups; Systolic blood pressure in the UO group was lower immediately after insertion compared with the SO and UT groups. The rate pressure product in the UO group was comparable with that in the UT group during endoscopy, and the SO group showed a continuously higher level than the UO and UT groups. More than one-half (54.4%) of patients were willing to choose transnasal EGD for next examination.nnnCONCLUSIONSnFor elderly patients, unsedated transnasal EGD failed to show an advantage over unsedated standard endoscopy. Transoral thin EGD was estimated to be safe and tolerable.