Selection of appropriate endoscopic therapies for duodenal tumors: An open-label study, single-center experience

AIM:To determine an appropriate compartmentalization of endoscopic submucosal dissection(ESD)or endoscopic mucosal resection(EMR)for duodenal tumors.METHODS:Forty-six duodenal lesions(excluding papillary lesions)from 44 patients with duodenal tumors treated endoscopically between 2005 and 2013 were divided into the ESD and EMR groups for retrospective comparison and analysis.RESULTS:The mean age was 65±9 years(35-79years).There were 24 lesions from men and 22 from women.The lesions consisted of 6 early cancers,31adenomas and 9 neuroendocrine tumors.Lesion location was the duodenal bulb in 15 cases and the descending part of the duodenum in 31 cases.The most common macroscopic morphology was elevated type in 21 cases(45.6%).Mean tumor diameter was 11.9±9.7 mm(3-60 mm).Treatment procedure was ESD(15 cases)vs EMR(31 cases).The examined parameters in the ESD vs EMR groups were as follows:mean tumor diameter,12.9±14.3 mm(3-60 mm)vs 11.4 ±6.7 mm(4-25 mm);en bloc resection rate,86.7%vs 83.9%;complete resection rate,86.7%vs 74.2%;procedure time,86.5±63.1 min(15-217 min)vs 13.2±17.0 min(2-89 min)(P<0.0001);intraprocedural perforation,3 cases vs none(P=0.0300);delayed perforation,none in either group;postprocedural bleeding,1 case vs none;mean postoperative length of hospitalization,8.2±2.9 d(5-16 d)vs 6.1±2.0 d(2-12 d)(P=0.0067);recurrence,none vs 1 case(occurring at 7 mo postoperatively).CONCLUSION:ESD was associated with a longer procedure time and a higher incidence of intraprocedural perforation;EMR was associated with a lower rate of complete resection.

Clinical investigation of 41 patients with ischemic colitis accompanied by ulcer

AIM: To investigate the relationship among the presence of ulcer lesions, underlying disease, and clinical course in patients with ischemic colitis. METHODS: The subjects were 41 patients (10 male and 31 female; mean age 70 years) with ischemic colitis who were admitted to and received treatment in our hospital from 2000 to 2006. We compared their characteristics and analyzed the mean lengths of admission and fast- ing for 9 patients with ulcer lesions (ulcer group) and 32 without (non-ulcer group). RESULTS: The groups with presence and absence of ulcer differed significantly only in white blood cell (WBC) count. Lengths of fasting and admission were 7.9 d and 17.9 d for the ulcer group and 4.4 d and 10.7 d for the non-ulcer group, respectively, and significantly longer in the ulcer group (P = 0.0057 and 0.0001). There was no correlation between presence of ulcer and presence of underlying diseases. CONCLUSION: Lengths of fasting and admission were significantly longer in patients with ischemic colitis with ulcer than for those without ulcer.

Results of mass endoscopic examination for gastric cancer in Kamigoto Hospital,Nagasaki Prefecture

AIM:To examine how the introduction of endoscopy to gastric cancer screening affected survival prognosis in a regional population. METHODS: The subjects comprised 4261 residents of Kamigoto,Nagasaki Prefecture,who underwent gastric X-ray examination for gastric cancer screening from 1991 to 1995,and all 7178 residents who underwent endoscopic examination for the same purpose from 1996 to 2003. The analysis evaluated trends in age-adjusted gastric cancer mortality rates and standard mortality ratios (SMRs) among the Kamigoto residents. RESULTS: According to demographic statistics,the 1995 and 2000 age-adjusted gastric cancer mortality rates in Nagasaki Prefecture (per 100 000 population) were 42.6 and 37.3 for males and 18.6 and 16.0 for females,while the corresponding rates in Kamigoto before and after the introduction of endoscopic screening were respectively 51.9 and 28.0,and 26.6 and 6.9. The data obtained in this study were divided into those for two periods,1990-1996 and 1997-2006,and SMRs were calculated separately for males and females. For the first period,the SMR was 1.04 (95% CI 0.50-1.58) for males and 1.54 (95% CI 0.71-2.38) for females,while for the second period the SMR was 0.71 (95% CI 0.33-1.10) for males and 0.62 (95% CI 0.19-1.05) for females. CONCLUSION: Following the introduction of endoscopic examination,gastric cancer death rates decreased in Kamigoto.

Risk factors for postoperative bleeding after gastric endoscopic submucosal dissection in patients under antithrombotics

AIM: To evaluate the risk factors for postoperative bleeding after gastric endoscopic submucosal dissection(ESD) based on the latest guidelines.METHODS: A total of 262 gastric neoplasms were treated by ESD at our center during a 2-year period from October 2012. We analyzed the data of these cases retrospectively to identify the risk factors for postESD bleeding.RESULTS: Of the 48(18.3%) cases on antithrombotic treatment, 10 were still receiving antiplatelet drugs perioperatively, 13 were on heparin replacement after oral anticoagulant withdrawal, and the antithrombotic therapy was discontinued perioperatively in 25 cases. Postoperative bleeding occurred in 23 cases(8.8%). The postoperative bleeding rate in the heparin replacement group was 61.5%, significantly higher than that in the non-antithrombotic therapy group(6.1%). Univariate analysis identified history of antithrombotic drug use, heparin replacement, hemodialysis, cardiovascular disease, diabetes mellitus, elevated prothrombin timeinternational normalized ratio, and low hemoglobin level on admission as risk factors for post ESD bleeding. Multivariate analysis identified only heparin replacement(OR = 13.7, 95%CI: 1.2-151.3, P = 0.0329) as a significant risk factor for post-ESD bleeding.CONCLUSION: Continued administration of antiplatelet agents, based on the guidelines, was not a risk factor for postoperative bleeding after gastric ESD; however, heparin replacement, which is recommended after withdrawal of oral anticoagulants, was identified as a significant risk factor.

Rebamipide enema therapy for left-sided ischemic colitis patients accompanied by ulcers:Open label study

AIM: To attempt rectal administration of rebamipide in the treatment of ischemic colitis patients with ulcers, and evaluate its effects. METHODS: We compared 9 ischemic colitis patients (2 men, 7 women) with ulcers treated by bowel rest only from 2000 to 2005 (conventional therapy group), with 6 patients (2 men, 4 women) treated by rebamipide enema therapy in 2006 (rebamipide enema therapy group) and analyzed the mean duration of fasting and hospitalization, degree of ulcer healing, and decrease in WBC count for the two groups. RESULTS: The mean duration of fasting and hos- pitalization were 2.7 ± 1.8 d and 9.2 ± 1.5 d in the rebamipide group and 7.9 ± 4.1 d and 17.9 ± 6.8 d in the control group, respectively, and signifi cantly re- duced in the rebamipide group (t = -2.915; P = 0.0121 and t = -3.054; P = 0.0092). As for the degree of ul- cer healing at 7 d after admission, the ulcer score was reduced by 3.5 ± 0.5 (points) in the rebamipide group and 2.8 ± 0.5 (points) in the control group (t = 1.975; P = 0.0797), while the decrease in WBC count was 120.0 ± 55.8 (× 102/μL) in the rebamipide group and 85.9 ± 56.8 (× 102/μL) in the control group (t = 1.006; P = 0.3360). CONCLUSION: In left-sided ischemic colitis patients with ulcers, rebamipide enema therapy significantly reduced the duration of fasting and hospitalization, recommending its use as a new and effective thera- peutic alternative.

Future directions of duodenal endoscopic submucosal dissection

Endoscopic therapies for lesions of the duodenum are technically more difficult than those for lesions of the other parts of the gastrointestinal tract due to the anatomical features of the duodenum, and the incidence rate of complications such as perforation and bleeding is also higher. These aforementioned trends were especially noticeable for the case of duodenal endoscopic submucosal dissection(ESD). The indication for ESD of duodenal tumors should be determined by assessment of the histopathology, macroscopic morphology, and diameter of the tumors. The three types of candidate lesions for endoscopic therapy are adenoma, carcinoma, and neuroendocrine tumors. For applying endoscopic therapies to duodenal lesions, accurate preoperative histopathological diagnosis is necessary. The most important technical issue in duodenal ESD is the submucosal dissection process. In duodenal ESD, a short needle-type knife is suitable for the mucosal incision and submucosal dissection processes, and the Small-caliber-tip Transparent hood is an important tool. After endoscopic therapies, the wound should be closed by clipping in order to prevent complications such as secondary hemorrhage and delayed perforation. At present, the criteria for selection between ESD and EMR vary among institutions. The indications for ESD should be carefully considered. Duodenal ESD should have limitations, such as the need for its being performed by experts with abundant experience in performing the procedure.

Case of acute pancreatitis associated with Campylobacter enteritis

A 25-year-old man was admitted with the chief complaints of right flank pain,watery diarrhea,and fever.Blood tests revealed high levels of inflammatory markers,and infectious enteritis was diagnosed.A stool culture obtained on admission revealed no growth of any significant pathogens.Conservative therapy was undertaken with fasting and fluid replacement.On day 2 of admission,the fever resolved,the frequency of defecation reduced,the right flank pain began to subside,and the white blood cell count started to decrease.On hospital day 4,the frequency of diarrhea decreased to approximately 5 times per day,and the right flank pain resolved.However,the patient developed epigastric pain and increased blood levels of the pancreatic enzymes.Abdominal computed tomography revealed mild pancreatic enlargement.Acute pancreatitis was diagnosed,and conservative therapy with fasting and fluid replacement was continued.A day later,the blood levels of the pancreatic enzymes peaked out.On hospital day 7,the patient passed stools with fresh blood,and Campylobacter jejuni/coli was detected by culture.Lower gastrointestinal endoscopy performed on hospital day 8 revealed diffuse aphthae extending from the terminal ileum to the entire colon.Based on the findings,pancreatitis associated with Campylobacter enteritis was diagnosed.In the present case,a possible mechanism of onset of pancreatitis was invasion of the pancreatic duct by Campylobacter and the host immune responses to Campylobacter.