Cold polypectomy is an excellent treatment for conventional polypectomy in terms of safety, convenience and cost, and this procedure is gradually spreading in Europe, the US and Japan.
The safety and treatment outcome of cold polypectomy have improved due to improvements in the procedure and the device.
Furthermore, the safety of cold polypectomy in patients who are taking antithrombotic drugs was recently reported.
However, cold polypectomy has a disadvantage in that histopathological stump evaluation is difficult and resection depth is shallow. In addition, the rate of recurrence and long-term prognosis in patients who underwent cold polypectomy are not clear.
It is important to understand these problems and to perform cold polypectomy for the appropriate lesions.
In the current guidelines in Japan, excision of lesions with a diameter of 5 mm or less by cold polypectomy is not recommended, because of the incidence of accidents with hot polypectomy. However, the resection of adenomatous lesions regardless of size by cold polypectomy is performed in Europe and the US, and may be recommended in Japan in the future.
The diagnosis of inflammatory bowel disease (IBD) including ulcerative colitis (UC) and Crohnʼs disease (CD) in the absence of typical endoscopic features is often challenging. In such cases, UC or CD cannot be definitively diagnosed, and these conditions are categorized as “inflammatory bowel disease-unclassified”. Recent technological advances have introduced balloon-assisted endoscopy and capsule endoscopy for the management of patients with chronic enteritis. These techniques enable the detection of mucosal lesions in the small intestine. Furthermore, these innovations have changed the diagnostic strategy of IBD and IBD-related diseases. In this review, we present an overview, as well as the clinical characteristics and endoscopic diagnosis of IBD-related diseases including intestinal Behçetʼs disease with simple ulcer, trisomy 8-associated enteritis, chronic enteropathy associated with the SLCO2A1 gene, and familial Mediterranean fever with enteritis.
A 58-year-old woman was referred to our department for dysphagia as a result of pharyngitis that occurred after bone marrow transplantation. Endoscopic examination revealed complete hypopharyngeal obstruction, and surgical gastrostomy was performed. Then, endoscopic incision and dilation were performed by using a Sato-type curved laryngoscope, transgastrostomic endoscope and oral endoscope under general anesthesia. After the treatment, swallowing became possible. A combined antegrade-retrograde endoscopic approach has low invasiveness and is useful.
A 51-year-old male exhibited multiple submucosal tumors (SMT) all over the gastric corpus on esophagogastroduodenoscopy (EGD). Pathologic examination of biopsy specimens of the SMT led to the diagnosis of neuroendocrine tumor (NET), grade 2 (G2), according to the 2010 World Health Organization (WHO) grading system. Moreover, EGD revealed extensive atrophic mucosa over the gastric corpus, and a blood test revealed hypergastrinemia and positivity for anti-parietal cell antibody. Dynamic computed tomography and positron-emission tomography/computed tomography revealed no abnormal findings. Thus, the patient was diagnosed with multiple gastric NETs (type 1, Rindi classification; the number of NETs, 8), accompanied by autoimmune gastritis. We were indecisive regarding whether to perform endoscopic treatment or surgical treatment. We discussed this with the patient, and he finally selected and underwent total gastrectomy with lymphadenectomy. The postoperative pathological examination revealed 14 NETs (maximum diameter, 7 mm) in the gastric corpus; most were NET G1, and small parts were NET G2. Although total gastrectomy was the chosen treatment for this case, reports of multiple gastric NETs (type 1) for which less invasive treatments (e.g., endoscopic resection or limited operation) were selected have recently been increasing. Here, we report our experience of a patient with multiple gastric NETs (type 1), along with a literature review and discussion primarily regarding the selection of treatment for this disease.
A 49-year-old woman was referred to our hospital for detailed examination of a gastric polyp. Gastric X-ray examination revealed a polyp in the fornix.
Esophagogastroduodenoscopy revealed a raspberry-like elevated lesion, 5 mm in diameter, in the fornix. The lesion resembled a gastric hyperplastic polyp on endoscopy. Magnified endoscopy with narrow band imaging revealed papillary microstructures of varying size, plus irregularly dilated microvessels within the widened intervening part. Based on biopsy examination, the diagnosis of a mild atypical ductal structure was made. Early gastric cancer was suspected, and endoscopic submucosal dissection of the lesion was performed.
Histopathological examination revealed that the lesion was a well-differentiated tubular adenocarcinoma with low-grade atypism. Immunohistochemical examination showed that the neoplasm was positive for MUC5AC, and negative for MUC6, CD10, and MUC2, indicating that the lesion was a foveolar-type gastric adenocarcinoma.
The patient had no history of Helicobacter pylori (H. pylori) eradication therapy, and she was not infected with H. pylori.
An 83-year-old man was scheduled to undergo upper gastrointestinal endoscopy. Past medical history revealed that the patient had been diagnosed with situs inversus totalis by x-ray examination 16 years previously. Upper gastrointestinal endoscopy was initially performed with the patient lying on his left side. Insufflation failed to inflate the gastric antrum sufficiently to allow observation, and air continued to flow toward the gastric body. As a result, the patient suffered from gastric mucosal laceration. Upper gastrointestinal endoscopy was therefore performed again with the patient lying on his right side. The gastric antrum was inflated sufficiently for observation. During this endoscopic examination and the subsequent endoscopic examination, the patient was found to have a total of three gastric lesions: a 0-Ⅱc lesion at the anterior wall, 20 mm in diameter; a 0-Ⅱc lesion at the greater curvature, 15 mm in diameter; and a 0-Ⅱa lesion at the greater curvature, 10 mm in diameter. Pathologic examination showed that the patient had triple early gastric cancer.
We performed endoscopic submucosal dissection with the patient lying on his right side, while the operator and endoscopic unit were positioned on the side opposite the side on which they would normally be positioned when the usual operation is being performed with the patient lying on his left side.
This setup enabled us to adequately perform endoscopic submucosal dissection, and curative resection of all three lesions was achieved endoscopically.
A 70-year-old male complained of abdominal pain during hospitalization for pneumonia. Plain abdominal computed tomography showed multiple enteroliths in the terminal ileum, and colonoscopy showed stenosis of Bauhinʼs ileocecal valve. Due to the failure to crush or retrieve enteroliths by the single balloon dilation (18mm) procedure, the double balloon dilation procedure was performed to obtain a larger expansion (15mm＋20mm). After double balloon valve dilation, seven true enteroliths were retrieved by a mechanical lithotripter. Our literature search did not reveal any study reporting double balloon dilation of Bauhinʼs ileocecal valve. In this paper, we report a case of incarcerated enteroliths treated successfully by double balloon dilation without surgery.
Double balloon endoscopy has been broadly accepted for patients with small bowel disease, patients with surgically altered intestines, and patients in whom conventional colonoscopy was unsuccessful. However, we often encounter difficult situations and incomplete insertion of the double balloon endoscope in cases with abdominal adhesion due to prior laparotomy. Heavy-handed maneuvers of the scope may lead to severe adverse events. On the other hand, several tips and knacks that endoscopists do not know can overcome these difficulties. Here, we describe the essential technique and several tips when difficult situations are encountered during double balloon endoscopy.
The endocytoscope (EC) is a brand-new endoscope that enables in vivo evaluation of cellular atypia with a magnification of 520 times. The prototype of the EC, which was developed in 2004, was a probe-type endocytoscope for viewing the esophageal epithelium (XEC-300, 450 times; XEC-120, 1,100 times). After further development for more than 10 years, the endocytoscope (CF-H290ECI) was launched in 2018, making it possible for use in clinical practice. There are two ways to diagnose colorectal lesions by using an EC: (1) endocytoscopic vascular pattern (EC-V) classification, in which vessel findings are evaluated in combination with findings of narrow band imaging (NBI), and (2) EC classification, which involves evaluation of the form of the glands and nuclei after methylene blue staining. The EC-V classification is very simple, and the EC classification can be performed by evaluating cell variants in addition to structural variants, making it possible to make a diagnosis approaching pathological diagnosis. In this paper, we describe techniques of using the EC from basic observation to diagnostic methods.
Background and Aim: Immunohistological evaluations are essential for diagnosing subepithelial tumors (SET). However, endoscopic ultrasound-guided sampling using fine-needle aspiration (FNA) needles is limited in its ability to procure core tissue for immunostaining. Fine-needle biopsy (FNB) needles may mitigate this limitation. The present study aimed to examine the efficacy of FNB needles for procuring samples that enable the diagnosis of SET.
Methods: One hundred sixty patients were included in the study and separated into those whose samples were obtained using FNB needles (FNB group) and those whose samples were procured using FNA needles (FNA group). Groups were compared regarding the conclusive diagnosis rate and unwarranted resection rate. Propensity score matching was introduced to reduce selection bias.
Results: Rates at which conclusive diagnoses were reached through adequate immunohistological evaluations were 82% and 60% in the FNB and FNA groups, respectively; this difference was significant (P=0.013). Unwarranted resection rate was significantly lower in the FNB group (2%) than in the FNA group (14%; P=0.032). Multivariate analyses showed that lesions ≤20mm were a significant risk factor for lower conclusive diagnosis rates following the use of FNB needles (P=0.017).
Conclusions: Fine-needle biopsy needles can be useful for obtaining samples that facilitate the diagnosis of SET and for avoiding unwarranted resections. However, FNB needles may be less advantageous for small SET.