Yoshiko Nakayama

Prospective randomized comparison of cold snare polypectomy and conventional polypectomy for small colorectal polyps.

Background and Aim: The ideal method to remove small colorectal polyps is unknown. We compared removal by colon snare transection without electrocautery (cold snare polypectomy) with conventional electrocautery snare polypectomy (hot polypectomy) in terms of procedure duration, difficulty in retrieving polyps, bleeding, and post-polypectomy symptoms. Methods: Patients with colorectal polyps up to 8 mm in diameter were randomized to polypectomy by cold snare technique (cold group) or conventional polypectomy (conventional group). The principal outcome measures were abdominal symptoms within 2 weeks after polypectomy. Secondary outcome measures were the rates of retrieval of colorectal polyps and bleeding. Results: Eighty patients were randomized: cold group, n = 40 (101 polyps) and conventional group, n = 40 (104 polyps). The patients’ demographic characteristics and the number and size of polyps removed were similar between the two techniques. Procedure time was significantly shorter with cold polypectomy vs. conventional polypectomy (18 vs. 25 min, p < 0.0001). Complete polyp retrieval rates were identical [96% (97/101) vs. 96% (100/104)]. No bleeding requiring hemostasis occurred in either group. Abdominal symptoms shortly after polypectomy were more common with conventional polypectomy (i.e. 20%; 8/40) than with cold polypectomy (i.e. 2.5%; 1/40; p = 0.029). Conclusion: Cold polypectomy was superior to conventional polypectomy in terms of procedure time and post-polypectomy abdominal symptoms. The two methods were otherwise essentially identical in terms of bleeding risk and complete polyp retrieval. Cold polypectomy is therefore the preferred method for removal of small colorectal polyps.

Biliary stenting in the management of large or multiple common bile duct stones

BACKGROUND Endoscopic biliary stenting with a plastic stent is often performed to prevent impaction of common bile duct (CBD) stones. The therapeutic effect of a plastic stent placement in terms of reduction in stone size and number has not been established. OBJECTIVE The aim of this study was to study the effect of biliary stenting as therapy for CBD stones. DESIGN Retrospective study. SETTING Municipal hospital outpatients. INTERVENTIONS Patients with large (> or = 20 mm) and/or multiple (> or = 3) stones had placement of a 7F double-pigtail plastic stent without stone extraction at the initial ERCP. Approximately 2 months later, stone removal was attempted. The number and size of CBD stones before and after stent placement, stone clearance, complications, and 180-day mortality were evaluated. RESULTS Forty patients were studied. Stent placement averaged 65 days (range, 50-82 days). The median number (interquartile range) of stones per patient fell after stent placement (4.0 [3.0] before vs. 2.0 [1.0] after; P < .0001). Characteristically, larger stones became smaller and small stones disappeared (ie, the median stone index decreased from 4.6 [3.0] to 2.0 [1.5]; P < .0001). Stone clearance at the second ERCP was achieved in 37 out of 40 patients (93%). Complications included cholangitis (13%) and pancreatitis (5%) after the second ERCP. No 180-day mortality occurred. LIMITATIONS A retrospective, single-center study. CONCLUSIONS Stent placement for 2 months was associated with large and/or multiple CBD stones becoming smaller and/or disappearing without any complications. Stenting followed by a wait period may assist in difficult CBD stone removal.

Nasopharyngeal Decolonization of Methicillin-Resistant Staphylococcus aureus Can Reduce PEG Peristomal Wound Infection

OBJECTIVES:The aim of this study is to determine whether nasopharyngeal decolonization of methicillin-resistant Staphylococcus aureus (MRSA) can reduce peristomal wound infection shortly after percutaneous endoscopic gastrostomy (PEG) placement.METHODS:Of the 84 hospitalized patients referred for PEG, 72 were enrolled in a one-third observation (Group A) and two-thirds in a randomized trial (Groups B and C). Nasopharyngeal swabs were taken from a consecutive series of patients prior to PEG insertion. Based upon these results, they were classified into three groups: Group A, MRSA-negative (n = 24), Group B, MRSA-positive, but not eradicated (n = 24), Group C, MRSA-positive and eradicated with intranasal application of mupirocin, arbekacin inhalation, and oral sulfamethoxazole/trimethoprim (n = 24). The standard PEG pull-through insertion technique was performed on all 72 patients. All patients received prophylactic and concomitant antibiotics. Infections at the peristomal site were prospectively evaluated and defined as having at least two of the following conditions: peristomal erythema, induration, and purulent discharge. Bacterial culture using purulent discharge was performed.RESULTS:There was significant difference in the peristomal infection rates among the groups: Group A, 0% (0/0); Group B, 100% (24/24); Group C, 8% (2/24) (p≤ 0.0001). In Group C, nasopharyngeal decolonization of MRSA, which was achieved by the combination of intranasal mupirocin, arbekacin inhalation, and oral sulfamethoxazole/trimethoprim in all 24 patients, significantly reduced peristomal infections. Eighteen (16 in Group B and 2 in Group C) of these 26 infected patients had cellulitis and developed purulent discharge from which MRSA was isolated.CONCLUSIONS:Nasopharyngeal decolonization of MRSA can reduce peristomal infection shortly after the pull-through PEG insertion. MRSA appears to be a major pathogen in PEG peristomal infection while prophylactic and concomitant antibiotics are being used.

Low-Dose Propofol Sedation for Diagnostic Esophagogastroduodenoscopy: Results in 10,662 Adults

OBJECTIVE:The use of propofol sedation during endoscopic procedures has increased in recent years. The aim of this study was to evaluate the safety and effectiveness of nurse-administered low-dose propofol sedation for diagnostic esophagogastroduodenoscopy (EGD).METHODS:We prospectively assessed the outcome and complications of low-dose bolus propofol for endoscopic sedation for diagnostic EGD. Propofol was administered by bolus injection, with a standard protocol of 40 mg for patients <70 years old, 30 mg for patients 70–89 years old, and 20 mg for patients 90 years or older. When required for adequate sedation, additional doses were given, to a maximum of 120 mg. The primary outcome measure was respiratory depression, defined as oxygen desaturation (SpO2 <90%) that continued for more than 20 s. Secondary measures included successful procedures, full recovery within 60 min of the procedure, and complications.RESULTS:All procedures were successful; 8,431 of 10,662 patients (79.1%) completed diagnostic EGD with a single bolus of propofol. Only 0.26% (28 patients) required transient supplemental oxygen supply; neither mask ventilation nor endotracheal intubation was required. Full recovery occurred in 99.9% of patients 60 min after the procedure. Men and younger patients required significantly higher doses of propofol than did the women and older patients (men vs. women, 46.5±19 vs. 42.7±15 mg, P=0.0008; age 40–49 vs. age 50–59, 51.5±16 vs. 46.3±13 mg, P<0.0001). Of the 400 patients, 368 (92%) wanted to drive home or to their offices, and all did so without incident. A total of 99% were willing to repeat the same procedure again.CONCLUSIONS:Low-dose nurse-administered propofol sedation is safe and practical for diagnostic EGD.

Multicenter Comparison of Rapid Lateral Flow Stool Antigen Immunoassay and Stool Antigen Enzyme Immunoassay for the Diagnosis of Helicobacter pylori Infection in Children

Background and Aim.  The stool antigen enzyme immunoassay (EIA) methods are widely used for diagnosing Helicobacter pylori infection. Recently, a novel, rapid stool antigen test, the lateral flow immunoassay (LFI) method, has been developed. The primary purpose of this study was to compare the EIA method with the LFI method for the diagnosis of H. pylori infection in children.

Safety and Driving Ability following Low-Dose Propofol Sedation

Background and Aim: Automobile driving is prohibited after midazolam sedation because of the slow recovery of psychomotor function. This study prospectively assessed the safety of low-dose propofol sedation (study 1) and compared driving ability following propofol and midazolam sedation (study 2). Methods: Study 1: We prospectively investigated bolus injection of a low-dose of propofol (40–80 mg for <70 years and 30 mg for ≥70 years) for diagnostic esophagogastroduodenoscopy (EGD). Respiratory depression, time to full recovery, and overall patient satisfaction were evaluated and blood concentrations of propofol were measured. Study 2: A subset of subjects undergoing diagnostic EGD were randomized to receive 40 mg of propofol (n = 30), 4 mg of midazolam (n = 30) or no sedation controls (n = 20), and the residual effects of each drug were tested using a driving simulator. The primary outcome measure was driving ability. The second outcome measures were overall patient satisfaction and complications. Results: Study 1: Only 1.1% of 12,031 healthy subjects developed transient oxygen desaturation. Full recovery was present in 97.5% 30 min after the procedure; 99.8% were willing to repeat the same procedure. The blood levels of propofol (40–80 mg) at 60 min were <100 ng/ml. Study 2: Driving ability recovered to the basal level within 60 min of propofol administration but not with 120 min with midazolam. There were no complications; overall patient satisfaction was similar between propofol and midazolam (8.9 vs. 8.5, p = 0.34). Conclusion: Low-dose propofol sedation was safe and recovery including driving ability was with 60 min.

Usefulness of a small-caliber, variable-stiffness colonoscope as a backup in patients with difficult or incomplete colonoscopy.

OBJECTIVES:Although variable-stiffness colonoscopes have been developed, difficult or incomplete colonoscopies occasionally occur. The aim of this study was to evaluate the usefulness of a small-caliber, variable-stiffness colonoscope (scVSC) as a backup in patients with difficult or incomplete colonoscopies.METHODS:First, we retrospectively reviewed the cecal intubation rate of colonoscopies in which an adult standard colonoscope (AC) was immediately switched to an scVSC in all patients in whom a colonoscopy with an AC was incomplete. Second, 374 consecutive patients were randomized to undergo colonoscopy with a pediatric variable-stiffness colonoscope (PVSC, n = 123), AC (n = 125), or scVSC (n = 126). The scVSC was used by the same endoscopist to reattempt colonoscopy immediately after colonoscopy with a PVSC or an AC had been assessed as difficult or incomplete. The cecal intubation rate and time and the ancillary maneuvers used were evaluated.RESULTS:Fifty-two (2.5%) of the 2,056 attempted colonoscopies with an AC did not reach the cecum. Fifty-one of the 52 patients (98.1%) had complete colonoscopies after the switch from the AC to the scVSC. The initial intubation rate and time were not statistically different among the groups: PVSC, 95% and 6.8 min; AC, 91% and 7.5 min; and scVSC, 98% and 8.2 min. Cecal intubation was achieved in all five patients (100%) and in 10 out of 11 (91%) patients, respectively, after the PVSC or AC was switched to the scVSC.CONCLUSIONS:The completion rate markedly improved after switching from an AC or PVSC to an scVSC in difficult or incomplete colonoscopies, although the scVSC does not appear to offer any distinct advantage over the AC or PVSC for routine colonoscopies.

Results of triple eradication therapy in Japanese children: a retrospective multicenter study

BackgroundLarge-scale clinical trials in children are lacking concerning Helicobacter pylori eradication therapies. The purpose of this study was to assess the efficacy of proton pump inhibitor (PPI)-based triple therapies in Japanese children.MethodsThis was a retrospective analysis of the first- and second-line PPI-based triple therapies from pediatric gastrointestinal units between 1996 and 2003. Data collected included doses and duration of regimens, drug compliance, success or failure of eradication, ulcer healing, and symptom response of those with dyspepsia and no ulcers. The results of antibiotic susceptibility tests were also reported in cases where these were performed.ResultsA total of 149 pediatric patients (mean age, 12.6 years) were studied, including 123 patients who received first-line therapy: 115 received a PPI plus amoxicillin and clarithromycin (PAC) and 8 received a PPI plus amoxicillin and metronidazole (PAM). Overall eradication rates of the first-line PAC and PAM therapies were 77.4% and 87.5%, respectively (P = 0.68). All 14 patients with failed PAC therapy received the second-line PAM regimen, resulting in an eradication rate of 100%. Mild side effects were reported only in PAC regimens (13.8%). Primary resistance to amoxicillin, clarithromycin, and metronidazole was detected in 0%, 34.7%, and 12.5% of the strains, respectively. The PAC regimen showed a high eradication rate for clarithromycin-susceptible strains (91.7%), but was relatively ineffective for resistant strains (40.0%) (P < 0.01). Eradication of H. pylori was associated with ulcer healing and symptomatic improvement among those with gastritis only (both; P < 0.001). Among 17 patients with iron-deficiency anemia, post-treatment hemoglobin levels were higher than the pretreatment levels (P < 0.001).ConclusionsThe PAC regimen is effective in children. Clarithromycin resistance is associated with eradication failure. Metronidazole is a good substitute for clarithromycin as the second-line option for children.

Helicobacter pylori infection: diagnosis and treatment

Helicobacter pylori is one of the most common infections worldwide. Eradication of this important pathogen would lead to virtual elimination of the second most common cancer worldwide – gastric cancer. A variety of accurate diagnostic tests are available but current therapeutic regimens are generally unsatisfactory, with failure rates of between 20 and 40%. Difficulty in curing the infection has led to a three-step approach: diagnosis, therapy and confirmation of cure. Better studies, including head-to-head comparison of different drugs, drug formulations, dosing intervals, dosing in relation to meals, and duration of therapy are needed. The high rates of reinfection and the lack of improvements in standards of living in developing countries makes the development of a vaccine a high priority.

Acute Colorectal Obstruction Treated by Means of Transanal Drainage Tube: Effectiveness Before Surgery and Stenting

OBJECTIVES: The aim of this study was to clarify the usefulness of the management of acute colorectal obstruction using a transanal drainage tube before surgery or stenting.METHODS:Fifty-four patients (34 males and 20 females, aged 46–94 yr, mean = 69.7) treated between May 1998 and March 2004 for acute colorectal obstruction were identified in a colorectal obstruction database, and their clinical and radiological features were reviewed. Based on abdominal computed tomography findings, urgent colonoscopy was performed. Subsequently, endoscopic decompression using a Dennis® Colorectal Tube (DCT) was attempted.RESULTS:Endoscopic decompression using the DCT was technically successful in 52 of 54 patients (96.3%). The site of obstruction was the cecum in 4, the ascending colon in 2, the transverse colon in 7, the descending colon in 11, the sigmoid colon in 18, and the rectum in 12. The etiology of obstruction was primary colorectal carcinoma in 45, non-colonic metastatic carcinoma in 4, postoperative obstruction in 4, and retrograde intussusception in 1. Following adequate cleansing of the colon, 44 patients underwent a one-stage surgery after 7 ± 3 days (SD; range, 4–10 days). Stenting was successfully used as the final palliative treatment in 4. The use of the DCT alone relieved postoperative stenosis (3 patients) and retrograde intussusception (Prognosis in patients with obstructing colorectal carcinoma. Am J Surg 1982;143:742–7). During these treatments, perforation occurred in one patient with postoperative stenosis of the cecum.CONCLUSIONS:Management of acute colorectal obstruction using the DCT was found to be effective and safe, irrespective of the site or etiology of the obstruction. Therefore, this procedure should be considered as a primary method for decompression of the obstructed colon before considering surgery or stenting.