[Show abstract][Hide abstract] ABSTRACT: A 66-year-old Japanese man consulted our institution due to paroxysmal and repetitive bouts of fever and abdominal pain that had persisted for more than one week. Capsule and double-balloon endoscopy (DBE) showed petal-shaped mucosal redness with white hemming in the jejunum and ileum, and histopathology of the biopsy specimens revealed villous atrophy and cryptitis with extensive severe neutrophil infiltration. A genetic examination disclosed compound heterozygous MEFV mutations (E84K, P369S), and familial Mediterranean fever was diagnosed. Treatment with colchicine and infliximab was very effective in inducing the complete disappearance of symptoms and normalization of the endoscopic findings. To the best of our knowledge, this is the first report to describe the findings of small intestinal endoscopic images obtained using capsule and DBE.
Internal Medicine 06/2015; 54(11):1343-7. DOI:10.2169/internalmedicine.54.3690 · 0.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The efficacy of 2nd-look esophagogastroduodenoscopy (EGD) with endoscopic hemostatic therapy (EHT) for the prevention of postendoscopic submucosal dissection (ESD) clinical bleeding remains controversial. The aim of this study was to estimate post-ESD bleeding rate using 2nd and 3rd-look strategy, and to determine risk factors for clinical bleeding, and for EHT at 2nd and 3rd-look EGDs.Three hundred forty-four consecutive patients with early gastric cancer or adenoma underwent ESD from January 2006 through March 2012. Second and 3rd-look EGDs were performed on day 1 (D1) and day 7 (D7), respectively, with EHT as needed.Post-ESD clinical bleeding rate was 2.6% (95% confidence interval [CI] 1.2%-4.9%). For clinical bleeding, adjusted odds ratios (ORs) for age <65 years and antithrombotic drug uses were 4.40 (95% CI 1.07-19.93) and 7.34 (95% CI 1.80-32.48), respectively. For D1 EHT, adjusted ORs of tumor location in the lower part of the stomach and maximum tumor diameter ≥60 mm were 2.16 (95% CI 1.35-3.51) and 2.20 (95% CI 1.05-4.98), respectively. For D7 EHT, adjusted OR of D1 EHT was 4.65 (95% CI 1.56-20.0).Post-ESD clinical bleeding rate was relatively low using 2nd and 3rd-look strategy. Age <65 years and antithrombotic drug use are significant risk factors for clinical bleeding. Regarding EHT, tumor location in the lower part of the stomach and maximum diameter of resected specimen ≥60 mm are significant predictors for D1 EHT. D1 EHT in turn is a significant risk factor for D7 EHT. The efficacy of sequential strategy for preventing post-ESD bleeding is promising.
Medicine 02/2015; 94(6):e491. DOI:10.1097/MD.0000000000000491 · 5.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
EUS-guided FNA (EUS-FNA) has a high diagnostic accuracy for pancreatic diseases. However, although most reports have typically focused on cytology, histological tissue quality has rarely been investigated. The effectiveness of EUS-FNA combined with high negative pressure (HNP) suction was recently indicated for tissue acquisition, but has not thus far been tested in a prospective, randomized clinical trial.
To evaluate the adequacy of EUS-FNA with HNP for the histological diagnosis of pancreatic lesions by using 25-gauge needles.
Prospective, single-blind, randomized, controlled crossover trial.
Seven tertiary referral centers.
Patients referred for EUS-FNA of pancreatic solid lesions. From July 2011 to April 2012, 90 patients underwent EUS-FNA of pancreatic solid masses by using normal negative pressure (NNP) and HNP with 2 respective passes. The order of the passes was randomized, and the sample adequacy, quality, and histology were evaluated by a single expert pathologist.
EUS-FNA by using NNP and HNP.
Main Outcome Measurements
The adequacy of tissue acquisition and the accuracy of histological diagnoses made by using the EUS-FNA technique with HNP.
We found that 72.2% (65/90) and 90% (81/90) of the specimens obtained using NNP and HNP, respectively, were adequate for histological diagnosis (P = .0003, McNemar test). For 73.3% (66/90) and 82.2% (74/90) of the specimens obtained by using NNP and HNP, respectively, an accurate diagnosis was achieved (P = .06, McNemar test). Pancreatitis developed in 1 patient after this procedure, which subsided with conservative therapy.
This was a single-blinded, crossover study.
Biopsy procedures that combine the EUS-FNA with HNP techniques are superior to EUS-FNA with NNP procedures for tissue acquisition. (Clinical trial registration number: UMIN000005939.)
[Show abstract][Hide abstract] ABSTRACT: This study aimed to evaluate the efficacy of gemcitabine-based chemoradiotherapy followed by surgery (gem-CRTS) for pancreatic ductal adenocarcinoma (PDAC) for borderline resectable (BR) and locally unresectable (UR) tumors.
One hundred patients with PDAC who underwent the gem-CRTS protocol were classified into 3 groups, namely, resectable (R; 14), BR (44), and UR (42). After chemoradiotherapy, the patients were reassessed for curative-intent resection.
At reassessment, distant metastases became apparent in 27% of R patients, in 12% of BR patients, and in 18% of UR patients. The multivariate analysis of preoperative factors indicated that the CA19-9 reduction rate was an independent prognostic factor in the BR group. Among reassessed patients, the resection rate was 63.6% in R, 83.7% in BR, and 50.0% in UR patients. In 63 patients that underwent curative-intent resection, the 3-year survival rate was 83.3% in R, 33.0% in BR, and 7.8% in UR patients. Using multivariate analysis, the independent prognostic factor was found to be the surgical margin in BR patients and human equilibrative nucleoside transporter 1 expression in UR patients.
We consider that our gem-CRTS protocol, even for locally UR PDAC, allows for the identification of candidates for aggressive resection at the time of reassessment and improved prognosis in the patients with positive human equilibrative nucleoside transporter 1 expression.
[Show abstract][Hide abstract] ABSTRACT: Background and study aims:
Only a few large cohort studies have evaluated the efficacy and safety of endoscopic necrosectomy for infected walled-off pancreatic necrosis (WOPN). Therefore, a multicenter, large cohort study was conducted to evaluate the efficacy and safety of endoscopic necrosectomy and to examine the procedural details and follow-up after successful endoscopic necrosectomy.
Patients and methods:
A retrospective review was conducted in 16 leading Japanese institutions for patients who underwent endoscopic necrosectomy for infected WOPN between August 2005 and July 2011. The follow-up data were also reviewed to determine the long-term outcomes of the procedures.
Of 57 patients, 43 (75 %) experienced successful resolution after a median of 5 sessions of endoscopic necrosectomy and 21 days of treatment. Complications occurred in 19 patients (33 %) during the treatment period. Six patients died (11 %): two due to multiple organ failure and one patient each from air embolism, splenic aneurysm, hemorrhage from a Mallory - Weiss tear, and an unknown cause. Of 43 patients with successful endoscopic necrosectomy, recurrent cavity formation was observed in three patients during a median follow-up period of 27 months.
Endoscopic necrosectomy can be an effective technique for infected WOPN and requires a relatively short treatment period. However, serious complications can arise, including death. Therefore, patients should be carefully selected, and knowledgeable, skilled, and experienced operators should perform the procedure. Further research into safer technologies is required in order to reduce the associated morbidity and mortality.
[Show abstract][Hide abstract] ABSTRACT: Pancreatic tumor metastasis from colorectal cancer is very rare. This study evaluated the significance of an endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) and surgical treatment. Case 1 was a 67-year-old male with a history of rectal cancer (6 years ago) and lung metastases (5 years ago) who had two masses in the pancreatic head and body. Case 2 was a 58-year-old male with the history of rectal cancer and simultaneous lung metastasis (7 years ago) who had a mass in the pancreatic body. Imaging studies showed stenosis of the pancreatic duct with distal dilatation in both cases, mimicking primary pancreatic cancer. An EUS-FNAB with immunohistochemical staining made a definitive diagnosis of pancreatic metastasis from rectal cancer. Both patients received margin-negative limited resection, middle-segment-preserving pancreatectomy and distal pancreatectomy, respectively, and were alive 16 and 6 months after pancreatectomy, respectively. An EUS-FNAB is helpful to make a definitive diagnosis of pancreatic metastasis and in determining the subsequent therapeutic approach.
Surgery Today 11/2012; 44(2). DOI:10.1007/s00595-012-0407-2 · 1.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The 13-year-old boy underwent tumor enucleation for pancreatic head insulinoma close to the pancreatic main duct after a preoperative endoscopic pancreatic stent placed by endoscopic retrograde cholangiopancreatography. The tumor was safely excised by identifying the indwelled pancreatic stent during the surgical procedure without pancreatic duct injury or postoperative complications.
Pediatric Surgery International 05/2012; 28(7):707-9. DOI:10.1007/s00383-012-3104-8 · 1.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Incomplete resection of gastric neoplasms by endoscopic treatment could lead to residual/local recurrence, which may be difficult to identify. This study aimed to evaluate the usefulness of magnifying endoscopy for identifying and demarcating residual/local recurrent gastric neoplasms after endoscopic treatment.
Between December 2004 and November 2010, magnifying endoscopy was performed in 15 patients with residual/local recurrent gastric neoplasms. All patients underwent conventional magnifying endoscopy (CME) and enhanced-magnification endoscopy with acetic acid instillation (EME) after conventional endoscopy (CE). Eleven patients additionally underwent magnifying endoscopy using narrow-band imaging (NBI-ME) and a combination of narrow-band imaging and acetic acid instillation (NBI-EME). For each procedure, it was recorded whether the location and circumferential demarcation of the lesions were identified. All lesions were resected by endoscopic submucosal dissection.
Eleven lesions were identified using CE. However, two and four additional lesions were identified using CME and EME, respectively. In 11 cases, NBI-ME and NBI-EME were performed and all lesions were identified. Three lesions, which were identified by CME, were not demarcated circumferentially. All 15 lesions were well demarcated by EME and 11 by NBI-ME and NBI-EME. Of the resected specimens, histopathology indicated that ten lesions were differentiated tubular adenocarcinomas and five lesions were adenomas. The histopathological diagnosis of the location and demarcation of all neoplasms corresponded to endoscopic findings.
Magnifying endoscopy techniques (CME, EME, NBI-ME, and NBI-EME) may be useful for identifying and demarcating residual/local recurrent gastric neoplasms after previous endoscopic treatment.
[Show abstract][Hide abstract] ABSTRACT: We aimed to determine the relationship between the intratumoral expression of human equilibrative nucleoside transporter (hENT1), the main gemcitabine transporter into cells, and the outcome of gemcitabine-based chemoradiotherapy (Gem-CRT) in patients with International Union Against Cancer (UICC) T3-T4 pancreatic adenocarcinoma.
The expressions of hENT1, thymidylate synthase (TS), and dihydropyrimidine dehydrogenase were immunohistochemically analyzed using the resected specimens from 55 patients (T3, 38 and T4, 17) who had received curative-intent resection after Gem-CRT.
The status of hENT1 expression (positive in 39 and negative in 16) was significantly associated with "clinical efficacy" (defined as more than 50% reduction of the serum carbohydrate antigen [CA] 19-9 level with stable disease [SD] or partial response [PR] according to the Response Evaluation Criteria in Solid Tumors [RECIST]) for Gem-CRT. The 1- and 3-year overall survival (OS) rates were significantly higher in the positive hENT1 expression group (82.9, 39.5%) than in the negative expression group (42.9, 14.3%) (p = 0.0037). According to combination analysis of hENT1 and TS expressions, the 1- and 3-year OS rates were significantly higher in the positive-low combination (89.1, 51.0%) group than in the negative-high group (66.7, 0%) (p = 0.023). Multivariate analysis revealed that positive hENT1 expression and R0 resection were significant prognostic factors for OS.
The hENT1 expression in pancreatic adenocarcinoma strongly influences the outcome of preoperative Gem-CRT treatment. This biomarker could become a useful predictor of therapeutic effect for gemcitabine-based therapy in pancreatic cancer patients.
[Show abstract][Hide abstract] ABSTRACT: Although the prognostic benefit of neoadjuvant chemoradiotherapy (NCRT) against pancreatic cancer has been indicated by several reports, it is controversial whether histological response is associated with prognosis. The objective was to explore the relationship between histological response and prognosis in T3 and T4 pancreatic adenocarcinoma.
We histologically examined the resected specimens obtained from 58 patients (T3, n = 40; and T4, n = 18) for whom we performed curative-intent resection after NCRT. Histological response was evaluated according to Evans's criteria to determine whether it influenced survival.
In T3 tumors, 13 (32.5%) belonged to high responders (tumor destruction of >50%) (R0, n = 13) and 27 (67.5%) belonged to low responders (tumor destruction of ≤50%) (R0, n = 22, R1, n = 3, R2, n = 2). Recurrence-free survival rate was significantly higher in high responders than in low responders (3-year recurrence-free survival rates: 71.3% vs 13.1%, P = 0.0095). In T4 tumors, however, only 1 (5.6%) was a high responder, and R0 resection was obtained only in 5 patients (27.8%).
In T3 tumors, histological response is considered a significant prognostic indicator, securing the surgical margin, whereas in T4 tumors, NCRT did not provide beneficial histological response, not securing the surgical margin.