Large colonic lipoma with a laterally spreading tumor treated by endoscopic submucosal dissection: A case report

BACKGROUND

Since fat does not transmit electrical energy well, delayed perforation and post-polypectomy syndrome due to electrical thermal injury are concerns in the endoscopic removal of colonic lipoma. The endoscopic submucosal dissection (ESD) technique concentrates electrical energy conducts to the submucosa, not the adipose tissue. This helps to minimize electrical thermal injury, especially in the case of large colonic lipomas. In rare cases, such as colonic lipomas accompanied by mucosal lesions, it is difficult for endoscopists to decide how to safely remove them.

CASE SUMMARY

A 78-year-old man underwent colonoscopy for colorectal cancer screening. During colonoscopy, a yellowish submucosal tumor with positive cushion sign was observed in the ascending colon measuring about 4.5 cm. A nodular mucosal lesion of about 2.5 cm was observed on the mucosal surface of the lipoma. The lipoma was so large that it occupied much of the inside of the colon, making it difficult to see the entire laterally spreading tumor (LST) at once. The LST was confined to the surface of the lipoma, which had a semipedunculated shape with a wide neck. The margin of the LST was not observed at the neck of the lipoma. ESD was performed and the colonic lipoma with the LST was successfully removed without complications. After 3 d of hospitalization, the patient was discharged without any symptoms. The final pathology report showed that the lesion consisted of submucosal lipoma and tubulovillous adenoma with low-grade dysplasia.

CONCLUSION

ESD is effective and safe for treating a large colonic lipoma with an LST by minimizing electrical thermal injury.

Selenobaculum gbiensis gen. nov. sp. nov., a new bacterium isolated from the gut microbiota of a patient with Crohn's disease

The human gut microbiota is a complex ecology comprising approximately 10 to 100 trillion microbial cells. Most of the bacteria detected by 16s rRNA sequencing have yet to be cultured, but intensive attempts to isolate the novel bacteria have improved our knowledge of the gut microbiome composition and its roles within human host. In our culturomics study, a novel gram-negative, motile, obligately anaerobic, rod-shaped bacteria, designated as strain ICN-92133T, was isolated from a fecal sample of a 26-year-old patient with Crohn's disease. Based on the 16s rRNA sequence of strain ICN-92133T, the phylogeny analysis placed the strain into the family Selenomonadaceae, showing 93.91% similarity with the closely related Massilibacillus massiliensis strain DSM 102838T. Strain ICN-92133T exhibited a genome size of 2,679,003 bp with a GC content of 35.5% which was predicted to contain 26 potential virulence factors and five antimicrobial resistance genes. In comparative genomic analysis, strain ICN-92133T showed digital DNA-DNA Hybridization and OrthoANI values lower than 21.9% and 71.9% with the closest type strains, respectively. In addition, comparing phenotypic, biochemical, and cellular fatty acids with those of closely related strains revealed the distinctiveness of strain ICN-92133T. Based on the taxonogenomic results, strain ICN-92133T is proposed as a novel species belonging to a new genus. Therefore, we suggest the name of the new genus Selenobaculum gen. nov. within the family Selenomonadaceae and strain ICN-92133T (= KCTC 25622T = JCM 36070T) as a type strain of new species Selenobaculum gbiensis sp. nov.

Activity of Lactobacillus crispatus isolated from vaginal microbiota against Mycobacterium tuberculosis

Tuberculosis, an infectious disease, is caused by Mycobacterium tuberculosis. It remains a significant public health issue around the globe, causing about 1.8 million deaths every year. Drug-resistant M. tuberculosis, including multi-drug-resistant (MDR), extremely-drug-resistant (XDR), and totally drug-resistant (TDR) M. tuberculosis, continues to be a threat to public health. In the case of antibiotic-resistant tuberculosis, the treatment effect of conventional antibiotics is low. Side effects caused by high doses over a long period are causing severe problems. To overcome these problems, there is an urgent need to develop a new anti-tuberculosis drug that is different from the existing compound-based antibiotics. Probiotics are defined as live microorganisms conferring health benefits. They can be potential therapeutic agents in this context as the effectiveness of probiotics against different infectious diseases has been well established. Here, we report that Lactobacillus crispatus PMC201 shows a promising effect on tuberculosis isolated from vaginal fluids of healthy Korean women. Lactobacillus crispatus PMC201 reduced M. tuberculosis H37Rv under co-culture conditions in broth and reduced M. tuberculosis H37Rv and XDR M. tuberculosis in macrophages. Lactobacillus crispatus PMC201 was not toxic to a guinea pig model and did not induce dysbiosis in a human intestinal microbial ecosystem simulator. Taken together, these results indicate that L. crispatus PMC201 can be a promising alternative drug candidate in the current tuberculosis drug regime. Further study is warranted to assess the in vivo efficacy and confirm the mode of action of L. crispatus PMC201.

Urinary Microbiome Characteristics in Female Patients with Acute Uncomplicated Cystitis and Recurrent Cystitis

Traditionally, the diagnostic mainstay of recurrent urinary tract infection has been urinary culture. However, the causative uropathogen of recurrent cystitis has not been well established. Urine DNA next-generation sequencing (NGS) can provide additional information on these infections. Herein, we compared urine NGS results and urine cultures in patients with acute uncomplicated cystitis (AUC) and recurrent cystitis (RC), and evaluated the difference in microbiome patterns in the NGS results. Patients who underwent urine culture and NGS due to AUC or RC were retrospectively reviewed. All urine samples were collected via a transurethral catheter and studied utilizing a type of NGS called 16S ribosomal RNA gene amplification and sequencing. The sensitivity of urine NGS was significantly higher than that of conventional urine culture (69.0% vs. 16.7%, p < 0.05). The detection rate of urine NGS was slightly lower in the RC group than in the AUC group (67.7% vs. 72.7%). Microbiome diversity was significantly higher in the RC group compared to the AUC group (p = 0.007), and the microbiome composition was significantly different between the AUC and RC groups. In the urine NGS results, Pseudomonas, Acinetobacter, and Enterobacteriaceae were found in the AUC group, and Sphingomonas, Staphylococcus, Streptococcus, and Rothia spp. were detected in the RC group. Urine NGS can significantly increase the diagnostic sensitivity compared to traditional urine culture methods, especially in RC patients. AUC and RC patients had significant differences in bacterial diversity and patterns. Therefore, recurrent cystitis might be approached from a different perspective.

Feasibility and response of helical tomotherapy in patients with metastatic colorectal cancer

Purpose

To investigate the treatment outcome and the toxicity of helical tomotherapy (HT) in patients with metastatic colorectal cancer (mCRC).

Materials and Methods

We retrospectively reviewed 18 patients with 31 lesions from mCRC treated with HT between 2009 and 2013. The liver (9 lesions) and lymph nodes (9 lesions) were the most frequent sites. The planning target volume (PTV) ranged from 12 to 1,110 mL (median, 114 mL). The total doses ranged from 30 to 70 Gy in 10-30 fractions. When the α/β value for the tumor was assumed to be 10 Gy for the biologically equivalent dose (BED), the total doses ranged from 39 to 119 Gy₁₀ (median, 55 Gy₁₀). Nineteen lesions were treated with concurrent chemotherapy (CCRT).

Results

With a median follow-up time of 16 months, the median overall survival for 18 patients was 33 months. Eight lesions (26%) achieved complete response. The 1- and 3-year local progression free survival (LPFS) rates for 31 lesions were 45% and 34%, respectively. On univariate analysis, significant parameters influencing LPFS rates were chemotherapy response before HT, aim of HT, CCRT, PTV, BED, and adjuvant chemotherapy. On multivariate analysis, PTV ≤113 mL and BED >48 Gy₁₀ were associated with a statistically significant improvement in LFPS. During HT, four patients experienced grade 3 hematologic toxicities, each of whom had also received CCRT.

Conclusion

The current study demonstrates the efficacy and tolerability of HT for mCRC. To define optimal RT dose according to tumor size of mCRC, further study should be needed.

Expanding indications for ESD: mucosal disease (upper and lower gastrointestinal tract)

Endoscopic resection is now considered a curative procedure for early gastric cancer. In Japan, it has increasingly replaced surgical resection for this indication, although in the West it has not been universally accepted as a first-line treatment. Recently, endoscopic submucosal dissection has been increasingly applied to colorectal disease, although it has not become a standard therapeutic procedure for early colorectal carcinoma because of its technical difficulty, the relatively long procedure time required, and the risk of complications, such as perforation and bleeding.

Endoscopic comparison of alendronate alone and the enteric-coated alendronate with calcitriol combination in postmenopausal Korean females

BACKGROUND/AIMS

This study was performed to compare the mucosal findings after esophagogastroduodenoscopy in two groups before and after the use of alendronate only and following administration of the enteric-coated alendronate (5 mg) and calcitriol (0.5 µg) combined drug (Maxmarvil, Yuyu Co.).

METHODS

The study population consisted of 33 postmenopausal healthy female volunteers, aged 50 to 70 years (mean age, 58 ± 5) without gastrointestinal symptoms and with normal baseline endoscopic findings. Esophagogastroduodenoscopy was performed at baseline and was repeated 2 weeks later after daily intake of Maxmarvil (n = 17 subjects) or alendronate only (n = 16 subjects). Mucosal injury scores were reported by an endoscopist after 2 weeks of treatment with each medication schedule.

RESULTS

Esophageal mucosal injuries developed in two of 16 subjects in the alendronate only group and 0 of 17 in the Maxmarvil group. Gastric mucosal injuries developed in eight subjects in the alendronate group and four subjects in the Maxmarvil group; this difference was statistically significant.

CONCLUSIONS

The mucosal damage scores for the alendronate group (total score 24) were significantly higher than those for the Maxmarvil group (total score 9) in the esophagus and stomach. Therefore, this study suggested that enteric-coated Maxmarvil is less harmful to gastrointestinal mucosa than alendronate, and may improve the tolerability of osteoporosis medication in clinical practice.

Correlation of narrow band imaging with magnifying colonoscopy and histology in colorectal tumors

BACKGROUND/AIMS

Narrow band imaging (NBI) is a new technique that uses optical filters for imaging of mucosal morphology. The aim of this study was to correlate findings of NBI with magnifying colonoscopy and histology for prediction of neoplastic colorectal lesion.

METHODS

Between September 2005 and December 2007, 107 colon polyps from 68 patients were detected by conventional colonoscopy and subsequently evaluated by NBI with magnifying colonoscopy and analyzed for a pit pattern and a capillary pattern. More analysis was done regarding thickness and irregularity of capillary features.

RESULTS

Pit pattern with NBI magnification to discriminate between neoplastic and non-neoplastic lesions had a sensitivity of 88.9% and a specificity of 87.5%; capillary pattern yielded test performance characteristics of 91.9% and 87.5%. In respect of capillary thickness, invisible capillaries were found significantly more often in hyperplastic lesions. All thick capillaries were found in neoplastic polyps, and found significantly more often in carcinomas with submucosal massive invasion (sm-m) (p<0.01). In respect of capillary irregularity, invisible capillaries were found significantly more often in hyperplasic lesions, and severely irregular capillaries were found significantly more often in sm-m lesions (p<0.01).

CONCLUSIONS

Observation of capillary thickness and irregularity by NBI magnification is useful for correlating histological grade with carcinoma, especially with depth of submucosal invasion.

Correlation of narrow band imaging with magnifying colonoscopy and histology in colorectal tumors

Background/Aims

Narrow band imaging (NBI) is a new technique that uses optical filters for imaging of mucosal morphology. The aim of this study was to correlate findings of NBI with magnifying colonoscopy and histology for prediction of neoplastic colorectal lesion.

Methods

Between September 2005 and December 2007, 107 colon polyps from 68 patients were detected by conventional colonoscopy and subsequently evaluated by NBI with magnifying colonoscopy and analyzed for a pit pattern and a capillary pattern. More analysis was done regarding thickness and irregularity of capillary features.

Results

Pit pattern with NBI magnification to discriminate between neoplastic and non-neoplastic lesions had a sensitivity of 88.9% and a specificity of 87.5%; capillary pattern yielded test performance characteristics of 91.9% and 87.5%. In respect of capillary thickness, invisible capillaries were found significantly more often in hyperplastic lesions. All thick capillaries were found in neoplastic polyps, and found significantly more often in carcinomas with submucosal massive invasion (sm-m) (p<0.01). In respect of capillary irregularity, invisible capillaries were found significantly more often in hyperplasic lesions, and severely irregular capillaries were found significantly more often in sm-m lesions (p<0.01).

Conclusions

Observation of capillary thickness and irregularity by NBI magnification is useful for correlating histological grade with carcinoma, especially with depth of submucosal invasion.

Prospective, randomized study of conventional versus HybridKnife endoscopic submucosal dissection methods for the esophagus: an animal study

BACKGROUND

Endoscopic submucosal dissection (ESD) increases en bloc and histologically complete resection rate of neoplastic mucosal tumors but is technically more demanding than EMR. Limited data are available comparing the efficacy and safety of a new ESD designed to overcome these limitations and conventional ESD (C-ESD) techniques.

OBJECTIVE

To compare the safety, efficacy, and operation time of the new HybridKnife ESD (HK-ESD) with C-ESD in the esophagus.

DESIGN

Prospective, randomized, controlled study.

SETTING

Animal research laboratory.

SUBJECTS

Seventeen anesthetized Yorkshire pigs.

INTERVENTIONS

Removal of a 4-cm length of half-circumference esophageal mucosa by C-ESD with Hook knife or Flexknife versus HK-ESD.

MAIN OUTCOME MEASUREMENTS

Procedure time, en bloc and complete resection rate, and complications (bleeding and perforation).

RESULTS

All resections were completed en bloc. Procedure time was shorter in C-ESD. However, it was similar after 12 procedures. Significantly more bleeding occurred during C-ESD (28 vs 12, P = .0007). Histological muscularis propria injuries occurred with equal frequency (16 vs 17) and were mostly seen during the first 11 procedures. There were 3 perforations (2 endoscopic, 1 histological), all with C-ESD.

LIMITATIONS

Nonsurvival study, use of 2 conventional knives, no training period for a new procedure.

CONCLUSIONS

The HK-ESD technique was equally effective as the C-ESD technique for successful en bloc resection and was safer with less bleeding and perforation. Although procedure time was longer in HK-ESD, the difference became nonsignificant after 12 procedures.

Outcome of palliative self-expanding metal stent placement in malignant colorectal obstruction according to stent type and manufacturer

BACKGROUND

Self-expandable metallic stents (SEMS) of varying designs and materials have been developed to reduce complications, but few comparative data are available with regard to the type of stent and the stent manufacturer. We analyzed the success rates and complication rates, according to stent type (uncovered vs. covered stent) and individual stent manufacturer, in malignant colorectal obstruction.

METHODS

From November 2001 to August 2008, 103 patients were retrospectively included in this study: four types of uncovered stents in 73 patients and two types of covered stents in 30 patients. The SEMS was inserted into the obstructive site by using the through-the-scope method.

RESULTS

Technical and clinical success rates were not different between stent type or among stent manufacturers: 100 and 100% (p = ns) and 100 and 96.6% (p > 0.05), respectively, in uncovered and covered stents. Stent occlusion and migration rates were 12.3 and 3.3% (p = 0.274) and 13.7 and 16.7% (p = 0.761), respectively, in uncovered and covered stents, and 11.1, 5, and 9% (p = 0.761) and 25.9, 15, and 0% (p = 0.037) in Wallstent, Niti-S, and Bonastent uncovered stents, respectively.

CONCLUSIONS

The placement of SEMS is an effective and safe treatment for patients with malignant colorectal obstruction. Although minor differences in outcome were detected according to the type and the manufacturer of the stents, no statistically significant difference was observed, except in stent migration among the stent manufacturer.

Effect of drug-eluting metal stents in benign esophageal stricture: an in vivo animal study

BACKGROUND AND STUDY AIMS

The aim of this study in canines was to investigate the effectiveness and safety of self-expandable metal stents, which were coated with paclitaxel to minimize the tissue response.

MATERIALS AND METHODS

14 dogs (5-10 kg) were randomly allocated to two groups. Drug-eluting stents (DES, n = 7) or nondrug-eluting stents (non-DES, n = 7) were endoscopically inserted and fixed in the esophagus of healthy dogs. Every 2 weeks, for a maximum period of 8 weeks, an endoscopic examination was performed to evaluate the status of stent insertion, the grade of tissue hyperplasia, and mucosal change at both ends of the stent.

RESULTS

One case of stent migration was observed after 4 weeks in the non-DES group. In this group, tissue reaction and hyperplasia remained for more than 4 weeks after stent insertion. By contrast, an endoscopic examination of the surrounding esophageal mucosa in the DES group showed very little tissue reaction, and the stent was easily separated from the esophageal tissue.

CONCLUSION

Although further studies are required to confirm our results, we suggest that these newly designed DES may provide an alternative tool to manage refractory benign esophageal stricture.

[Significance of microsatellite instability in early gastric cancer treated by endoscopic submucosal dissection]

BACKGROUND/AIMS

Microsatellite instability (MSI) is defined as a change of any length due to either insertion or deletion of repeating units, in a microsatellite within a tumor when compared to normal tissue. MSI is closely related with genetic instability, particularly in hereditary nonpolyposis colorectal cancer. MSI is found in 10-50% of all gastric cancers, suggesting that MSI may play an important role in carcinogenesis. The aim of this study was to investigate the relationship between microsatellite instability and clinicopathologic features in early gastric cancers (EGCs) treated by endoscopic submucosal dissection (ESD).

METHODS

We analyzed clinicopathological features of 95 specimens of EGCs including MSI, histologic type, mucin phenotype, p53, VEGF, location of cancer, depth of invasion, incidence of synchronous and metachronous cancer, age, and gender derived from 94 patients, treated by ESD during recent 19 months were analyzed in this study.

RESULTS

According to microsatellite stability, MSI was observed in 13 (13.7%) cases of 95 specimens. The incidence of MSI was increased in patients with cancer at lower part of stomach and female gender. There was no significant relation between MSI and clinicopathologic features including histologic type, mucin phenotype, p53, VEGF, and depth of invasion.

CONCLUSIONS

Our results demonstrate that there is no relationship between MSI and clinicopathologic features except tumor location and gender in ECGs treated by ESD. However, further studies are needed to evaluate the significance of MSI in EGCs.

Synchronous early gastric cancer resembling submucosal tumor at the fundus

Concern about detecting gastric carcinoma in its early stages has increased the incidence of detecting multiple synchronous gastric carcinomas. Although gastric carcinomas may present with various gross features, those showing the features of submucosal tumor (SMT) are rare. We report on a case of synchronous gastric carcinomas comprising one lesion with typical features of superficial early gastric carcinoma and the other with atypical features that mimicked SMT. Even though synchronous gastric carcinoma is rare, it may be worthwhile to make a pathological diagnosis of coexisting SMT using endoscopic-ultrasound-guided fine-needle aspiration or endoscopic mucosal resection.

Relevance of ineffective esophageal motility and hyperactive acid sensitization in patients with gastroesophageal reflux

BACKGROUND AND AIM

Esophageal motor abnormalities including ineffective esophageal motility (IEM) and visceral hypersensitivity have been frequently observed in patients with gastroesophageal reflux. The aim of this study was to observe the incidences of hypersensitivity to acid infusion and motor abnormalities in non-erosive reflux disease (NERD) compared with erosive esophagitis.

METHODS

We performed upper GI endoscopy, an acid perfusion test and esophageal manometry on 113 NERD patients and 37 erosive esophagitis patients.

RESULTS

The frequency of acid sensitization was 69.9% in NERD and 67.6% in erosive esophagitis. The frequency of esophageal motor abnormality in patients with erosive esophagitis (48.6%) was higher than in patients with NERD (25.7%, P = 0.014). The most frequent esophageal motor abnormality was IEM. The frequency of IEM was 15.9% in NERD patients, 42.9% in Los Angeles grade A, 53.8% in Los Angeles grade B and 66.7% in Los Angeles grade C esophagitis (chi(2) = 16.67, P < 0.0001).

CONCLUSION

Our results suggest that no difference exists between visceral hypersensitivity in patients with NERD and those with erosive esophagitis, and that IEM occurs in NERD as well as erosive esophagitis patients. The occurrence of IEM is associated with the endoscopic severity of gastroesophageal reflux disease.

EMR for early gastric cancer in Korea: a multicenter retrospective study

BACKGROUND

EMR has been accepted as a treatment modality for selected cases of early gastric cancer (EGC) in Japan. However, long-term outcomes after EMR for EGC have not been fully documented.

OBJECTIVES

We reviewed the experiences of EMR for EGC in Korea, with emphasis on the long-term outcome.

DESIGN

Multicenter, retrospective study.

METHODS

Data were collected retrospectively by use of the on-line database registry system. From January 2000 to December 2002, 514 EGCs in 506 patients were treated by EMR in 13 institutions in Korea. Median age of the patients was 60 years (range 45-83 years). The resection was regarded as incomplete if histopathologic examination revealed a positive resection margin or submucosal invasion or positive lymphovascular invasion or undifferentiated histologic diagnosis.

RESULTS

The most commonly used technique was circumferential precutting followed by snare resection (EMR-P, n = 269, 52.3%). Complete resection and incomplete resection after EMR were confirmed in 399 lesions (77.6%) and 103 lesions (20.0%), respectively. For completely resected mucosal cancers (n = 399), the median duration of follow-up was 23.5 months (range 5-70 months). In this group, local recurrence was detected in 24 cases (6.0%) with a median interval between EMR and recurrence of 17.9 months (range 3.5-51.7 months). There were 3 cases with perforation and 71 cases with bleeding. No deaths were related to recurrence of gastric cancer during the overall median follow-up period of 39 months.

LIMITATIONS

Multicenter retrospective design, no controls.

CONCLUSIONS

EMR is an effective therapeutic modality for selected cases of EGC in Korea.

[Eradication rate of first-line and second-line therapy for Helicobacter pylori infection, and reinfection rate after successful eradication]

BACKGROUND/AIMS

The increasing trend of antibiotic resistance emphasizes the need for the assessment of eradication rate of first and second-line therapy for Helicobacter pylori (H. pylori) infection. The reinfection rate depends on the geographical, national, or socioeconomic status of the patients. The aim of this study was to evaluate the recent 5-year changes of eradication rates and the reinfection rates after the successful eradication of Helicobacter pylori infection for 3-years follow-up in Bucheon, Korea.

METHODS

From February 2001 to August 2006, 3,267 patients with H. pylori-positive peptic ulcer disease received the first-line therapy for 7 days. The 317 patients who failed to the first-line therapy received the second-line therapy for 7 days. The 167 patients with 3-years follow-up after the successful eradication were included. 13C-urea breath tests or rapid urease tests and histologies were assessed to determine the H. pylori status after the eradication.

RESULTS

The eradication rate of first-line therapy was 83.7% in 2001, 83.4% in 2002, 83.7% in 2003, 85.9% in 2004, 87.2% in 2005, and 81.8% in 2006 by per protocol analysis (PP), respectively. The eradication rate of second-line therapy was 80.0% in 2002, 86.8% in 2003, 89.7% in 2004, 98.0% in 2005, and 78.8% in 2006 by PP. The cumulative reinfection rate was 6.0%. The annual reinfection rate was 2.0%. The recurrence rate of peptic ulcer was 17.2% in the patients without reinfection and 50% with reinfection.

CONCLUSIONS

The eradication rate for H. pylori have not changed in the recent 5-years. The annual reinfection rate was low. The successful eradication of H. pylori was effective for preventing the recurrence of peptic ulcers.

[Effectiveness and tolerance of duodenoscopic bowel preparation for colonoscopy]

BACKGROUND/AIMS

Bowel preparation for colonoscopy remains an unpleasant experience because oral solutions have unpleasant tastes and may provoke abdominal pain, nausea, vomiting, and sleep disturbance. Duodenoscopic bowel preparation is an alternative method for patients who are unwilling to take oral preparation solution or for those who are supposed to have both gastroscopic and colonoscopic examination on the same day. We assessed the effectiveness and tolerance of duodenoscopic bowel preparation.

METHODS

Patients in group OA (orally administered) ingested 45 mL of sodium phosphate (NaP) in the evening before the day of procedure and in the morning on the day of colonoscopy, whereas patients in group EA (endoscopically administered) were prepared for the procedure by duodenoscopic infusion of 90 mL of NaP diluted with 180 mL of water into the second portion of the duodenum. After 4 hours, we assessed the overall quality of colonic cleansing, using a range of excellent to inadequate. The patients completed a questionnaire on their preparation-associated symptoms, tolerance, and preference.

RESULTS

In group EA, sleep disturbance (p0.05) and nausea (p0.05) occurred less frequently than in group OA. Overall, the tolerance rating for preparation was higher in group EA. However, the quality of colonic cleansing and cecum intubation time was not different between the two groups. Patients in group EA who had ingested NaP in the past preferred duodenoscopic bowel preparation.

CONCLUSIONS

Duodenoscopic bowel preparation may play a role in colonic cleansing especially for patients who are scheduled to undergo gastroscopic and colonoscopic examination on the same day and for those who are unwilling to ingest NaP.

Effectiveness of sodium alginate as a submucosal injection material for endoscopic mucosal resection in animal

BACKGROUND/AIMS

Although various solutions are being tested for submucosal injection during endoscopic resection, ideal solution has not been established yet. We performed an animal study to evaluate the possibility of sodium alginate as an ideal submucosal injection solution for endoscopic mucosal resection (EMR).

METHODS

To compare the lesion-lifting properties of different solutions, injection was done to the submucosal layer of porcine stomach. Then the height of mucosal elevation was measured. In addition, EMR was performed after submucosal injection of sodium alginate solution in six dogs. Two were euthanized after 30 minutes of endoscopic observation while the others were euthanized after 1-4 weeks. Retrieved stomachs were examined microscopically.

RESULTS

Sodium alginate and sodium hyaluronate solutions maintained longer elevation of the submucosal layer than other solutions. There was no significant difference in the height between two solutions. A clear separation of the mucosal layer from the proper muscle layer was achieved by injecting sodium alginate solution. Histological examination of EMR-induced artificial ulcers revealed no apparent tissue damage and showed normal healing process.

CONCLUSIONS

Sodium alginate solution creates a sufficient submucosal fluid cushion without apparent tissue damage. It can be considered as an effective submucosal injection material.

[Long-term results of endoscopic histoacryl (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices--a 10-year experience]

BACKGROUND/AIMS

Gastric variceal bleeding is an infrequent but serious complication of portal hypertension. Endoscopic injection of Histoacryl (N-butyl-2-cyanoacrylate) has been approved as an effective treatment for gastric variceal bleeding. The aim of this study was to evaluate the long-term efficacy and safety of the endoscopic injection of Histoacryl for the treatment of gastric varices.

METHODS

Between January 1994 and January 2005, eighty-five patients with gastric varices received endoscopic injections of Histoacryl. Among these 85 patients, 65 received the procedure within 1 week after gastric variceal bleeding, and 13 received as a prophylactic procedure. According to the Sarin classification, 32 patients were GOV1 and 53 were GOV2. Most of the varices were large (F2 or F3, 75 patients). The average volume of Histoacryl per each session was 1.43 ml. Among 85 patients, 72 patients were followed-up and the median duration was 24.5 months.

RESULTS

The rate of initial hemostasis was 98.6% and recurrent bleeding occurred in 29.2% (21 of 72). When rebleeding occurred, 76.2% was within 1 year after the initial injection. Treatment failure-related mortality rate was 1.4% (1 of 85). Twenty-seven patients died, mostly due to hepatocelluar carcinoma or liver failure. Two patients experienced pulmonary embolism and one experienced splenic infarction. They recovered without specific treatment. Rebleeding rate had a tendency to increase in patients with hepatocelluar carcinoma (p=0.051) and GOV2 (p=0.061).

CONCLUSIONS

Histoacryl injection therapy is a effective treatment method for gastric varices with high initial hemostasis rate and low major complications.

[The expression of p53, p16, cyclin D1 in esophageal squamous cell carcinoma and esophageal dysplasia]

BACKGROUNDS/AIMS

p53 is known to play a central role in sensing and signaling for the growth arrest and apoptosis in cells with DNA damage. Mutation of p53 is a frequent event in esophageal squamous cell carcinoma (ESCC). p16 protein binds to cyclin dependent kinase 4 (CDK4) inhibiting the ability of CDK4 to interact with cyclin D1, and stimulates the passage through the G1 phase of cell cycle. We observed the expression patterns and frequencies of p53, p16, and cyclin D1 in esophageal dysplasia and in esophageal squamous cell carcinomas.

METHODS

In 15 patients of ESCC, 5 patients of esophageal dysplasia and 5 volunteers with normal esophagus, tissue specimens were taken from esophageal lesions during the operation or endoscopic examination. We used specific monoclonal antibodies for p53 protein, p16(INK4 ) protein and cyclin D1. Immunoreactivity was scored.

RESULTS

Mean age of all groups was 66 years old (range 47-93) and men to women ratio was 19:1. p53 mutation was observed in 87% (13/15) of ESCC, in 80% (4/5) of esophageal dysplasia, in 0% (0/5) of normal mucosa (p=0.001). p16 expression was seen in 40% (2/5) of esophageal dysplasia, 27% (4/15) of ESCC and 100% (5/5) of normal mucosa (p=0.016). Cyclin D1 expression was not significantly different among 20% (1/5) of esophageal dysplasia, 53% (8/15) of ESCC and 20% (1/5) of normal mucosa. Either the expression of p53 mutation or the loss of p16 occurred in 80% (4/5) of esophageal dysplasia and in 93% (14/15) of ESCC.

CONCLUSIONS

The expression of p53 mutation and the loss of p16 might play a central role in the pathogenesis of esophageal squamous cell carcinoma (ESCC), and contribute to the development of precancerous lesion such as dysplasia. In addition, there is a possibility that the mutations of p53 and p16 silencing would be the early events in ESCC development.

[Magnifying endoscopy in upper gastrointestinal tract]

For the diagnosis of upper gastrointestinal (GI) lesions, magnification method is usually used in conjunction with chromoscopy, enabling the endoscopist to view subtle mucosal patterns in exquisite detail. Recently published datas have shown that magnifying endoscopy might be a valuable adjunct for the diagnosis, detection, and characterization of inflammatory and neoplastic lesions of the upper GI tract. It is also proven to be an useful surveillance protocol in identifying dysplastic epithelium or early cancer within a segment of Barrett's esophagus. Possible indications for magnifying endoscopy in upper GI tract include screening and surveillance of Barrett's esophagus, defining the extent of esophageal and gastric adenocarcinoma, detecting synchronous/metachronous gastric and esophageal cancers, diagnosing Helicobacter pylori infection, and recognizing minimal mucosal changes in gastroesophageal reflux disease. By grading the quality of evidence for the currently published trials, it is clear that the majority are case series, case reports, and/or observational studies without randomization, control, or blinding. Moreover, other evidence-based criteria such as independent, blind comparisons of magnifying endoscopy with a standard method which evaluates this technology in an appropriate spectrum of patients to whom the test may be applicable, and standardizing methodology would be crucial before magnifying endoscopy becomes a standard procedure in clinical practice. In the future, a uniform classification system for staining and magnifying patterns should be devised and observer agreement should be tested. Futher studies then could be performed based upon consistent, validated, and standardized terminologies and criteria.

Variation in expression of gastric leptin according to differentiation and growth pattern in gastric adenocarcinoma

Leptin is an adipocyte-derived hormone that regulates body fat stores and feeding behavior. The presence of leptin in stomach epithelium was recently demonstrated in the rat and humans, and gastric leptin has been linked to the control of meal size, local inflammatory responses, and paracrine and autocrine functions through leptin receptors in the stomach. We compared the expression patterns of leptin and of the long variant of the leptin receptor (Ob-Rb) between areas with non-ulcerated mucosa and with hyperplastic polyps, adenoma, or adenocarcinoma to evaluate the expression relative to different disease states. Leptin and Ob-Rb were expressed in hyperplastic polyps, adenoma, and adenocarcinoma. In the gastric adenocarcinoma, leptin was expressed significantly less in the poorly differentiated and diffuse-type groups than in the well-differentiated and moderately differentiated groups or in the intestinal type. Based upon our findings, we suggest the possibility that leptin expression can have a pathophysiologic role about the differentiation or growth pattern of gastric adenocarcinoma. A further series of experiments is necessary to elucidate the pathophysiological role of leptin in the differentiation of gastric adenocarcinoma.

[The relationship between ineffective esophageal motility and gastro-esophageal reflux disease]

BACKGROUND/AIMS

Ineffective esophageal motility (IEM) is a distinct manometric entity characterized by a hypocontractile esophagus. Recently, IEM replaced the nonspecific esophageal motility disorder (NEMD), and its associations with gastro-esophageal reflux disease (GERD) and respiratory symptoms are well known. We evaluated the relationship of IEM with GERD, and the diagnostic value of IEM for GERD.

METHODS

We retrospectively analyzed recent 3-year (Jan. 1998-Sep. 2002) datas of esophageal manometry, acid perfusion test and simultaneous 24 hr-ambulatory pH-metry with manometry studies in 270 consecutive patients with esophageal and/or GERD symptoms. The prevalence of IEM in GERD group and non-GERD group, and the variables of pH-metry and manometry among esophageal motility disorders were compared. In addition, the sensitivity, specificity, positive predictive value, negative predictive value of IEM, esophageal symptom, and acid perfusion test for GERD were calculated.

RESULTS

There was no significant difference in IEM prevalence rate between GERD group and non-GERD group. In addition, there was no significant difference in GERD prevalence rate and esophageal acid clearance in variety of motility disorder groups. Total percent time of pH <4 in IEM group did not show any difference when compared with other groups except in the achalasia group. In regard of diagnostic value to detect GERD, all positive results showed high specificity (97%) in IEM with esophageal symptom and positive acid perfusion test.

CONCLUSIONS

The diagnosis of IEM using esophageal manometry in patients with various esophageal symptoms does not strongly suggest on association with GERD. However, IEM with concomitant esophageal symptoms and positive acid perfusion test has diagnostic values for GERD.

Management of malignant stricture of the esophagogastric junction with a newly designed self-expanding metal stent with an antireflux mechanism

BACKGROUND AND STUDY AIMS

When stents are placed across the esophagogastric junction for palliative treatment of malignant strictures, they may lead to esophagogastric reflux. The aim of this study was to compare the effectiveness of a newly designed antireflux stent with that of a standard open stent and a currently available antireflux stent (Dostent) in preventing gastroesophageal reflux symptoms in patients with inoperable cancer at the esophagogastric junction.

PATIENTS AND METHODS

Thirty-six consecutive patients with cancer at the esophagogastric junction were randomly assigned to undergo placement of a newly designed antireflux stent (n = 12), a Dostent (n = 12), or a standard open stent (n = 12). Technical and clinical success, dysphagia score, reflux symptoms, complications and ambulatory 24-h esophageal pH monitoring were assessed.

RESULTS

The technical success rates were 100 %. After 1 week, dysphagia had improved in all patient groups ( P < 0.05), but the degree of improvement did not differ between the three groups. The DeMeester score was significantly lower in the group with the newly designed antireflux stent than in the other groups. The fraction of the total recording time during which esophageal pH was below 4 was 3.14 +/- 5.78 % using the newly designed antireflux stent, in comparison with 29.25 +/- 15.41 % in the Dostent group and 15.01 +/- 11.72 % in the standard open stent group ( P < 0.001). Fewer reflux episodes occurred with the newly designed antireflux stent than with the Dostent or standard open stent. There were no complications with any of the three stents.

CONCLUSIONS

The newly designed antireflux stent is effective in relieving dysphagia caused by malignant cancer at the esophagogastric junction. The newly designed antireflux stent is significantly more effective in preventing gastroesophageal reflux than currently available antireflux stents.

Wire-guided endoscopic snare papillectomy for tumors of the major duodenal papilla

BACKGROUND

Endoscopic excision for adenoma of the major duodenal papilla was introduced as an alternative to surgery, but postprocedure pancreatitis is a serious drawback. This study assessed the feasibility and the safety of endoscopic papillectomy with a guidewire and pancreatic-duct stent insertion to prevent pancreatitis.

METHODS

Six patients were enrolled. The snare loop was passed over a guidewire that had been inserted into the pancreatic duct. Immediately after snare resection, a pancreatic stent was placed along the indwelling guidewire.

RESULTS

En bloc papillectomy and pancreatic stent insertion were performed successfully in all patients. Pancreatitis did not develop acutely in any patient. Complications included cholangitis (n = 1) and late-onset pancreatitis owing to the pancreatic stent (n = 1). Scant residual adenomatous tissue was present at resection margins in two patients and was treated endoscopically.

CONCLUSIONS

Wire-guided endoscopic snare papillectomy in selected patients is a useful technique that maintains pancreatic-duct access for stent placement. This appears to prevent pancreatitis and to improve the outcome for patients undergoing endoscopic resection of papillary tumors.

Endoscopic treatment of retained bile-duct stones by using a balloon catheter for electrohydraulic lithotripsy without cholangioscopy

BACKGROUND

Electrohydraulic lithotripsy is a highly effective method for fragmenting biliary stones, but direct visual control is required. The efficacy and the safety of electrohydraulic lithotripsy without cholangioscopy by using a balloon catheter were evaluated in patients with bile-duct stones that could not be extracted by using standard techniques.

METHODS

Nineteen patients with extrahepatic bile-duct stones that could not be extracted by using conventional endoscopic methods, e.g., mechanical lithotripsy, were selected to undergo electrohydraulic lithotripsy without peroral cholangioscopy. An electrohydraulic lithotripsy probe with a 3.0 F radio-opaque tip was inserted through a balloon catheter. Electrohydraulic lithotripsy was performed under fluoroscopy until the fragmented stone could be captured in a large basket for mechanical lithotripsy. Endoscopic removal of the fragments was attempted during the electrohydraulic lithotripsy session.

RESULTS

Stones were successfully fragmented in 17 of 19 patients. In 16 patients (84.2%), the bile duct was cleared of all stones. A mean of 1.8 endoscopic sessions was required for complete removal. Additional mechanical lithotripsy was performed in 9 (56.2%) of the 16 patients. Minor complications were noted in 4 patients (2 hemobilia, 1 pancreatitis, 1 cholangitis). There was no 30-day mortality.

CONCLUSIONS

For a selected group of patients with bile-duct stones not extractable by using standard techniques, fluoroscopically controlled electrohydraulic lithotripsy with a balloon catheter seems to be an effective method of fragmentation.

Management of malignant strictures of the cervical esophagus with a newly-designed self-expanding metal stent

Recently, the use of self-expanding metal stents has become a well-established method of palliative treatment for stenotic malignant diseases in the middle and distal esophagus. However, published results on the use of self-expanding metal stents in cervical esophageal cancer are somewhat limited by a paucity of clinical details and experience. A new self-expanding esophageal metal stent with a short upper flange 0.7 cm in length was studied prospectively in order to assess its efficacy for palliative treatment. This report presents experience in three patients in whom this new stent was used in the treatment of cervical esophageal cancers. Stent placement was successful in all three patients, with no serious complications such as esophageal perforation, hemorrhage, or foreign-body sensation. All of the patients experienced rapid improvement in dysphagia and clinical symptoms. The newly designed self-expanding stent can be of value in the treatment of stenotic cervical esophageal cancer.

Through-the-scope double colonic stenting in the management of inoperable proximal malignant colonic obstruction: a pilot study

BACKGROUND AND STUDY AIMS

Particularly in cases of proximal colonic obstruction, the long distance and tortuosity of the bowel make it difficult for gastroenterologists and radiologists to advance the stent to the point of the obstruction. The purpose of this study was to evaluate the clinical usefulness and efficacy in preventing stent migration and tumor ingrowth of a new self-expanding through-the-scope (TTS) double colonic stent in the palliative management of patients with inoperable proximal malignant colonic obstruction.

PATIENTS AND METHODS

A total of seven patients (four men, three women; mean age 62 years, range 57 - 68) underwent placement of a newly developed through-the-scope self-expanding double colonic stent. The etiologies of the obstructions at the time of stent insertion were colonic adenocarcinoma (no previous surgical resection) in five cases and metastatic adenocarcinoma from gastric carcinoma in two. The locations of the obstructions were the ascending colon in three cases, the hepatic flexure in two, and the transverse colon in two. To prevent tumor ingrowth and stent migration, an uncovered Niti-S stent (Taewoong Medical Co., Ltd., Seoul, South Korea) was inserted into the stenotic area; a partly membrane-covered Niti-S stent was then again inserted into the stenotic area inside the uncovered Niti-S stent.

RESULTS

The self-expanding TTS double colonic stents were placed in the colon in seven patients with acute malignant colonic obstruction. Double stenting was successful in traversing the lesion in six of the seven cases. In one patient, the stent was not successfully placed across the lesion due to a very acute angle at the hepatic flexure. There were no significant complications relating to the insertion, with no clinical or radiographic evidence of perforation or bleeding during or after the procedures, and there were no cases of stent migration or tumor ingrowth during the mean follow-up period of 13 months.

CONCLUSIONS

Placement of these new self-expanding through-the-scope double colonic stents for the management of inoperable proximal malignant colonic obstruction is a feasible, effective, and safe form of palliative treatment for the prevention of stent migration and tumor ingrowth.

[A case of hepatocellular carcinoma with metastasis to gingival mucosa]

Hepatocellular carcinoma is one of the most common causes of death in Koreans. Most cases of hepatocellular carcinoma are beyond the stage of curative resection at the time of diagnosis due to extrahepatic metastasis as well as wide distribution of tumor in the liver. The lung is the most common site of extrahepatic metastasis but metastasis to gingiva is very rare in hepatocellular carcinoma. We report a case hepatocellular carcinoma with gingival metastasis in a 59 year old male patient.

Wire-guided intraductal US in the assessment of bile duct strictures with Mirizzi syndrome-like features at ERCP

BACKGROUND

Mirizzi syndrome refers to common hepatic duct obstruction caused by extrinsic compression that is usually from a stone impacted in the cystic duct. The utility of transpapillary intraductal US for assessment of biliary strictures with radiographic features of Mirizzi syndrome was studied retrospectively.

METHODS

Intraductal US was performed in 16 patients with a common hepatic duct stricture caused by extrinsic compression and nonvisualization of the gallbladder by endoscopic retrograde cholangiography. An over-the-wire catheter US probe (20 MHz) was inserted into the bile duct. Intraductal US findings were compared with the final diagnoses at surgery.

RESULTS

Intraductal US was successful in all patients. The extraluminal cause of the common hepatic duct stricture was detected in 14 patients (87.5%). In 9 patients, intraductal US detected an impacted stone outside the common hepatic duct. Intraductal US demonstrated extraluminal lesions without evidence of a stone in 5 patients, including a mass in 4 and asymmetrical, irregular thickening of the bile duct wall in 1 patient. In the remaining 2 patients, intraductal US demonstrated only a distended gallbladder.

CONCLUSIONS

Transpapillary wire-guided intraductal US is useful for assessing biliary strictures with features that suggest Mirizzi syndrome and optimizes management of patients with these findings.

Use of detachable snares and elastic bands for endoscopic control of bleeding from large gastric varices

BACKGROUND

Bleeding from gastric varices larger than 2 cm in diameter represents a major limitation for endoscopic hemostasis.

METHODS

Endoscopic ligation of gastric varices was performed with detachable snares and elastic bands in 41 patients who had recent bleeding from gastric varices larger than 2 cm in diameter. Gastric varices larger than 2 cm were ligated with detachable snares, and then adjacent small gastric varices were ligated with elastic bands.

RESULTS

Among the 41 patients, 10 of 12 patients with active bleeding and 28 of 29 patients with red color signs at initial endoscopy were successfully treated by endoscopic ligation by using detachable snares and elastic bands. Bleeding recurred early (before variceal eradication) in 4 of 38 patients (10.5%). The overall hemostatic rate for endoscopic ligation was 82.9% (34/41). In 33 of 36 patients (91.7%) who underwent repeated ligation treatments, variceal eradication was nearly complete. Mean follow-up in 30 of 33 patients after eradication of varices was 16.4 months (3-32 months), and 29 of 30 did not have recurrent bleeding. During and after ligation there were no serious complications.

CONCLUSIONS

Endoscopic ligation therapy with large detachable snares and elastic bands is safe and effective for treatment of large bleeding gastric varices.

The role of percutaneous transhepatic papillary balloon dilation in percutaneous choledochoscopic lithotomy

BACKGROUND

When choledochoscopic lithotomy with basket and electrohydraulic lithotripsy is used to remove intrahepatic duct stones, fragments or small stones usually remain in the bile duct that are too small to be captured with a basket.

METHODS

An attempt was made to remove stone fragments in 16 patients with intrahepatic duct stones by antegrade balloon dilation of the sphincter of Oddi with a conventional balloon catheter. After balloon dilation, remnant stones and sludge were pushed through the papilla with the choledochoscope.

RESULTS

Bile duct stones were completely removed in 12 of 16 patients (75%); stones were removed in 1 session. There was no clinical evidence of procedure-related pancreatitis or fatal complications.

CONCLUSIONS

Percutaneous transhepatic papillary balloon dilation of the sphincter of Oddi and clearance of remnant bile duct stones and stone fragments with the tip of choledochoscope is simple and effective in patients undergoing percutaneous transhepatic choledochoscopic lithotomy.

Bacteremia with nontyphi Salmonella and therapeutic implication

OBJECTIVES

The recent decades witnessed the increased incidence of bacteremia with nontyphi Salmonella, especially in patients with underlying diseases. To evaluate clinically the patients with bacteremia by nontyphi Salmonella, we investigated the clinical records of the patients.

METHODS

Retrospective study was performed on 30 cases of bacteremia with nontyphi Salmonella admitted to Soon Chun Hyang University Hospital from 1987 to 1993, and we analyzed with regard to age distribution, underlying diseases, clinical presentation and fatality.

RESULTS

Children below 2 years of age were seven patients and patients over 55 years of age were 8 patients. The male to female ratio was 3:2. Only five cases were nosocomially acquired. More than two-thirds (21 patients) had no discernible other illness at the time of their bacteremia. A quarter of the patients presented without gastrointestinal manifestation. There were four deaths in the 30 patients with nontyphi Salmonella septicemia (13.3%).

CONCLUSIONS

We investigated the clinical characteristics of 30 cases of non-typhi Salmonella bacteremia, which has a relatively high incidence nowadays while, to the contrary, Salmonella typhi trends toward being on the decrease in Korea.