Yutaka Sekine

Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases.

BACKGROUND & AIMS A specialized system for a new method for enteroscopy, the double-balloon method, was developed. The aim of this study was to evaluate the usefulness of this endoscopic system for small-intestinal disorders. METHODS The double-balloon endoscopy system was used to perform 178 enteroscopies (89 by the anterograde approach and 89 by the retrograde approach) in 123 patients. The system was assessed on the basis of the rates of success in jejunal and ileal insertion and the entire examination of the small intestine, diagnostic yields, ability to perform treatment, and complications. RESULTS Insertion of the endoscope beyond the ligament of Treitz or ileocecal valve was possible in all 178 procedures. It was possible to observe approximately one half to two thirds of the entire small intestine by each approach, and observation of the entire small intestine was possible in 24 (86%) of 28 trials. The source of bleeding was identified in 50 (76%) of 66 patients with GI bleeding, scrutiny of strictures was possible in 23 patients, and a tumor was examined endoscopically in 17 patients. Two complications (1.1%) occurred. Endoscopic therapies in the small intestine including hemostasis (12 cases), polypectomy (1 case), endoscopic mucosal resection (1 case), balloon dilation (6 cases), and stent placement (2 cases) were performed successfully. CONCLUSIONS Double-balloon endoscopy permits the exploration of the small intestine with a high success rate of total enteroscopy. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.

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.

Gastrointestinal stromal tumor in the jejunum: diagnosis and control of bleeding with electrocoagulation by using double-balloon enteroscopy.

A 43-year-old man presented with gastrointestinal bleeding. A tumor with central ulceration was observed in the jejunum, with the use of a new enteroscopy system called “double-balloon enteroscopy”. Bleeding after biopsy sampling of the tumor was controlled endoscopically by using electrocoagulation. Histological findings of the biopsy specimens were consistent with gastrointestinal stromal tumor, and this was surgically resected. Double-balloon enteroscopy was useful for the diagnosis as well as the control of bleeding in this patient.

Successful treatment with balloon dilatation using a double‐balloon enteroscope for a stricture in the small bowel of a patient with Crohn's disease

The requirement for endoscopic access to a stricture is a major limitation of the endoscopic dilatation for the treatment of strictures in the gastrointestinal tract. We have developed the double‐balloon enteroscopy method that enables visualization of the entire small bowel. In addition, double‐balloon enteroscopy has a potential for the interventional therapy including dilatation of strictures. We present here a case of jejunal strictures in a 47‐year‐old woman with Crohns disease successfully treated with a balloon catheter in combination with double‐balloon enteroscopy. Balloon dilation with double‐balloon enteroscopy is a promising method for the treatment of small bowel strictures in Crohns disease.

Endoscopic submucosal dissection using sodium hyaluronate for large superficial tumors in the colon

Endoscopic submucosal dissection is becoming popular for large superficial gastric cancer in Japan. However, it is considered difficult in the colon because the colonic wall is much thinner than the gastric wall. We use several devices to overcome this difficulty and have made it feasible in the colon as well. Submucosal injection of sodium hyaluronate is used to maintain sufficient thickening of the submucosal tissue and a small‐caliber‐tip or regular cylindrical transparent hood is used to open up the incised mucosa as a substitute for countertraction. In this method, not only the lateral margin, but the vertical margin of the resection can also be determined precisely because submucosal incision is carried out under direct visualization of the submucosal tissue.

Direct Observation with Double-Balloon Enteroscopy of an Intestinal Intramural Hematoma Resulting in Anticoagulant Ileus

Ileus induced by an intramural hematoma due to exces-sive anticoagulant therapy, namely, anticoagulant ileus, was first described by Hafner et al. (1) in 1962. Warfarin is responsible for 98% of the reports of anticoagulant ileus (2), but there is no relationship between the duration of an-ticoagulation and this disease (2, 3). Most anticoagulant ileus occurs in the jejunum (2, 4). Features of anticoag-ulant ileus in the small bowel have been described using gastrointestinal radiograph series (2, 5-10), computed to-mography (CT) (9, 10), ultrasound (8, 11), and angiog-raphy (8). However, enteroscopic findings of intramural hematoma in the small bowel have not previously been reported because of the difficulty in accessing the small in-testine. We have developed a new double-balloon method of enteroscopy (12, 13). This new enteroscopy facilitates deep insertion of an enteroscope into the small bowel. Using this new method, we were able to identify a hematoma in the small intestine of a patient with anticoagulant ileus.

Technical modification of the double-balloon endoscopy to access to the proximal side of the stenosis in the distal colon.

BACKGROUND The inability to pass endoscopes beyond strictures is a considerable problem in patients with a colonic stricture. METHODS In patients with bowel obstruction, we have modified the insertion method for double-balloon endoscopy with a long, transnasal decompression tube. OBSERVATIONS We have succeeded in reaching the proximal side of the stricture from the oral approach across the entire small bowel in a patient. CONCLUSIONS This modified double-balloon enteroscopy is useful for patients with bowel obstruction in whom a long decompression tube is already placed.

Systemic cytomegalovirus infection with severe ileal bleeding associated with Crohn's disease.

wall of the cecum with punctate mucosal defect and adherent clot and normal surrounding mucosa. This defect fits the clinical description of Dieulafoy’s lesion. She was treated with injection of epinephrine followed by thermocoagulation. The patient was later discharged without complications. Follow-up after 6 months revealed a stable Hb of 10.5. Dieulafoy’s lesion accounts for ,2% of acute GI bleeding episodes (1). Colonic, rectal, and anal canal Dieulafoy’s lesions are rare (2). It can cause massive and recurrent lower GI hemorrhage with hemodynamic instability, as it did in our case (3, 4). The diagnosis may be easily overlooked because the entity is not well recognized. Traditionally, the surgical treatment of colonic Dieulafoy’s lesion has been resection of the involved segment (2). Endoscopic band ligation has been suggested as an alternative modality (5). Amaro et al. first reported a rectal Dieulafoy’s lesion treated successfully with endoscopic epinephrine injection followed by thermocoagulation, as was done in our case with good results (6). The follow-up of our patient with no evidence of recurrent bleeding confirms the efficacy of this therapeutic approach on a single case. Further awareness of this disease is required; it should be included in the differential diagnosis when a definitive source of bleeding is not found on routine investigations.

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.