Many incidents of infection of patients with microorganisms during endoscopic examinations have been reported. Recently, several guidelines for their prevention have been drawn up and updated by some medical societies. Standard precautions are essential, and endoscopes and apparatuses should be reprocessed according to Spaulding’s classification. Reprocessing of endoscopes requires high-level disinfection using glutaraldehyde, orthophthalaldehyde, or paracetic acid with an automatic re-processor. Apparatuses should be sterilized using autoclaves or ethylene oxide gas, or disposable equipment should be used. The endoscopy suite should be thought of as a very dirty place because of the release of patients’ blood and body fluids. Therefore, endoscopists must make efforts to prevent not only infection from patient to patient, but also infection from patient to endoscopic staff using personal protective equipment. Further, the endoscopist should always be aware of whether each piece of medical equipment is clean or dirty at all times during the endoscopic procedure so that the endoscopist can avoid becoming sources of contamination during endoscopic procedures. To achieve suitable infection control in endoscopy, the person who is responsible for the endoscopy suite should become the leader of infection control. The leader should establish an adequate reprocessing system of endoscopes and apparatuses according to the guidelines, and should educate the endoscopic staff concerning infection control in endoscopy.
Gastric and colon cancers are common causes of cancer deaths in Japan. The risk of death from these cancers can be markedly reduced by screening gastrointestinal endoscopy. Sedation improves the acceptability of endoscopy to patients and results in a better tolerated procedure. Achieving safe and effective sedation requires an understanding of the characteristics of the medication utilized. Medications used for sedation in endoscopy include midazolam, propofol and dexmedetomidine hydrochloride. Based on the guidelines for endoscopic procedures established by the Japan Gastrointestinal Endoscopy Society, we discuss how to utilize these drugs to obtain safe and effective sedation. In addition, we discuss allergy, adverse events, and safe use of sedative medicines during and after endoscopic procedures.
We report a case of gastric carcinoma coexisting with Epstein-Barr virus (EBV)-associated gastric carcinoma and early gastric adenocarcinoma. A 76-year-old man visited our hospital with epigastric pain of one month’s duration. Upper gastrointestinal endoscopy revealed a wide-range type 3 tumor crossing over the upper part of the lesser curvature and the posterior wall; moreover, there was a 0-Ⅱc lesion in the anterior wall of the antrum. Following biopsy, the type 3 tumor was diagnosed as poorly differentiated carcinoma with lymphoid stroma and the 0-Ⅱc lesion was diagnosed as adenocarcinoma. Total gastrectomy was performed. EBV-encoded RNA in situ hybridization (EBER-ISH) on both lesions revealed that the type 3 tumor was EBV-positive and the 0-Ⅱc lesion was EBV-negative. We should note that the prevalence of EBV-associated gastric carcinoma is higher in multiple gastric carcinomas than in simple gastric carcinomas.
A 62-year-old man was admitted to our hospital due to vomiting. Abdominal enhanced computed tomography (CT) showed a large retroperitoneal hematoma, and upper gastrointestinal endoscopy revealed stenosis of the horizontal portion of the duodenum. In addition to nasal gastric tube drainage, we started enteral nutrition after placing a nasal jejunal tube through the ligament of Treitz under fluoroscopic guidance. On hospital day 14, follow-up abdominal enhanced CT revealed a posterior inferior pancreaticoduodenal artery pseudoaneurysm; however, we continued conservative therapy because the hematoma had not increased in size. On hospital day 21, follow-up CT showed that the hematoma had shrunk somewhat. However, upper gastrointestinal endoscopy showed that the duodenal stenosis remained. We therefore performed endoscopic balloon dilation and removed the nasal tubes on hospital day 23. No recurrence of digestive symptoms was noted after he started oral consumption of food on hospital day 28. He was discharged on hospital day 34. In most cases, conservative therapy can improve duodenal stenosis due to retroperitoneal hematoma. However, in some cases, the duodenal stenosis does not improve due to fibrosis, even though the size of the hematoma decreases. Such cases often require surgical management. In our case, we successfully performed endoscopic balloon dilation, and the stenosis improved.
A 67-year-old woman developed palpitation four days after starting oral administration of ibuprofen for dental caries. She went to a local clinic where a blood test was performed. She was found to have anemia and was referred to our hospital. After detailed investigation of anemia was performed, she was emergently admitted to our hospital. A blood transfusion was administered on hospital day 1 and her anemia improved on hospital day 2. Findings of upper endoscopy performed on hospital day 1 and colonoscopy performed on hospital day 3 were normal. Her medical history and imaging findings did not indicate intestinal stenosis. However, capsule endoscopy (CE) performed on hospital day 6 revealed a stenotic region accompanied by an ulcer at the distal portion of the ileum, resulting in capsule retention. Abdominal pain and nausea developed two days after CE, and small bowel obstruction due to capsule retention was diagnosed. Two days after insertion of an ileus tube, the capsule was excreted spontaneously. She was discharged from the hospital on hospital day 16. Eighteen weeks after discontinuing ibuprofen, retrograde single-balloon enteroscopy revealed a healed ulcer and the patient was diagnosed with a small intestinal ulcer induced by a nonsteroidal anti-inflammatory drug (NSAID). Endoscopists should carefully consider whether to perform CE in patients who are taking an NSAID regardless of the duration of administration, since acute edematous small intestinal stenosis could be caused by the formation of an intestinal ulcer induced by short-term administration of NSAIDs.
A 73-year-old man presented at his local clinic with chief complaints of constipation, abdominal pain, and bloating. In the abdominal X-ray, sigmoid volvulus was suspected, and therefore he was referred to our hospital.
The absence of intestinal necrosis and perforation was validated by examination, blood sampling, and imaging findings at our hospital. Therefore, colonoscopic detorsion was chosen as the treatment method. A colonoscope was inserted into the sigmoid colonic loop deeper than the site of strangulation, and degasification was performed. Next, the scope was pushed forward to the descending colon; however, there was a poor visual field because of abundant stool. Hence, insufflation was needed, and with re-accumulation of gas in the sigmoid colonic loop, detorsion was difficult to perform. This required the insertion of a second scope for degasification, and upon performing degasification within the loop, detorsion was achieved. We report a case of sigmoid volvulus that was successfully treated by insertion of a second endoscope.
Liquid-based cytology (LBC) has been introduced mainly for cervical cytology, and is also widely used for the cytology of liquid specimens such as urine and ascites and punctured specimens such as breast and thyroid tumors. Recently, a number of papers on the usefulness of LBC for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) specimens of pancreatic lesions have been reported. In this article, we review the usefulness of LBC for EUS-FNA specimens and describe the practical procedure.
Background and study aim: This study aimed to assess the safety and feasibility of endoscopic submucosal dissection (ESD) using a scissors-type knife with prophylactic closure using over-the-scope clip (OTSC) for superficial non-ampullary duodenal epithelial tumors (SNADETs).
Patients and methods: Consecutive patients who underwent ESD for SNADETs＞10 mm between January 2009 and July 2019 were retrospectively enrolled. We performed ESD using either a needle-type knife (Flush Knife-ESD) or a scissors-type knife (Clutch Cutter-ESD). Mucosal defects were prophylactically closed using three methods: conventional clip, laparoscopic closure, or OTSC.
Results: A total of 84 lesions were resected using the Flush Knife-ESD and the Clutch Cutter-ESD (37 and 47 patients, respectively), and conventional clip, laparoscopic closure, and OTSC for mucosal defect closure after ESD were applied in 13, 13, and 56 lesions, respectively. The R0 resection rate was significantly higher in the Clutch Cutter-ESD than that in the Flush Knife-ESD (97.9％ vs 83.8％, respectively, P＝0.040). The intraoperative perforation rate was significantly lower in the Clutch Cutter-ESD than in the Flush Knife-ESD (0％ vs 13.5％, respectively, P＝0.014). Complete closure rates of conventional clip, laparoscopic closure, and OTSC were 76.9％, 92.3％, and 98.2％, respectively (P＝0.021); and delayed perforation rates were 15.4％, 7.7％, and 1.8％, respectively (P＝0.092）.
Conclusions: Endoscopic submucosal dissection using a scissors-type knife with prophylactic OTSC closure is safe and feasible for the low-invasive treatment of SNADETs.