Clinical usefulness of the hold-and-drag closure using the SB clip for large mucosal defects after colorectal endoscopic submucosal dissection.

BACKGROUND: Endoscopic clip closure of mucosal defects after colorectal endoscopic submucosal dissection (ESD) reduces the risk of postoperative adverse events, but achieving complete closure for large mucosal defects can be difficult. The aim of this study was to evaluate the effectiveness of the hold-and-drag closure using an SB clip compared with that of the conventional closure for mucosal defects after colorectal ESD. METHODS: Eighty-four consecutive colorectal lesions resected by ESD at the Hiroshima Asa Citizens Hospital were registered and randomly allocated to two groups (Group A: SB clip, Group B: EZ clip), and then endoscopic closures were performed. We crossed-over to the SB clip in situations where the initial closure using an EZ clip was unsuccessful in achieving complete closure. Outcomes were compared and analyzed. RESULTS: Forty-two lesions were randomly assigned to groups A and B. The complete closure rate was significantly higher in group A, especially in resected specimens with a diameter of 30 mm or more. Twelve lesions that failed complete closure in group B were changed to SB clips, and 95% of the whole of group B were successfully closed. There were no significant differences in procedural time, number of clips, and cost of clips between groups A and B. CONCLUSION: Compared with the conventional closure, the hold-and-drag closure using an SB clip is a more suitable method for complete closure, especially for large mucosal defects of 30 mm or more. Furthermore, this is a simpler and more economical compared to a zipper closure using EZ clips.

[Two rare cases of severe hyponatremia with consciousness disorder following bowel preparation and high fluid intake].

Symptomatic hyponatremia due to bowel preparation is extremely rare, but it can cause severe neurological symptoms and require hospitalization. We report our experience with two cases of symptomatic hyponatremia after bowel preparation. Our findings suggest that the cause of hyponatremia may be not only oral bowel cleansing agents but also high fluid intake. Adjusting the dose and pace of oral bowel cleansing agents and fluid intake;rehydration should be considered to prevent any recurrences.

Optimal candidates for early colonoscopy in the management of acute lower gastrointestinal bleeding.

BACKGROUND AND AIM: Early colonoscopy has not shown any advantages over elective colonoscopy in reducing the risk of early rebleeding (≤ 30 days) after acute lower gastrointestinal bleeding (ALGIB). Considering the heterogeneity among patients with ALGIB, we sought to evaluate appropriate candidates for early colonoscopy. METHODS: A total of 592 patients with ALGIB were enrolled, and the clinical outcomes of early colonoscopy were investigated. Thereafter, the participants were divided into two groups: the recent bleeding group (n = 445), with hematochezia 0-6 h before hospital arrival, and non-recent bleeding group (n = 147). The clinical outcomes yielded by early colonoscopy were assessed in each group. RESULTS: The multivariate analysis including the entire population revealed that early colonoscopy (< 24 h) did not reduce the risk of early rebleeding (adjusted odds ratio [AOR], 0.88; 95% confidence interval [CI], 0.55-1.39). However, in the subgroup analysis, early colonoscopy independently reduced the risk of early rebleeding in the recent bleeding group (AOR, 0.56; 95% CI, 0.33-0.94). Moreover, a reduction in the need for radiological or surgical intervention (AOR, 0.34), transfusion (AOR, 0.62), and prolonged hospitalization (AOR, 0.42), as well as improvement in diagnostic yield (AOR, 1.78) and endoscopic treatment rates (AOR, 1.66), were observed. Early colonoscopy did not improve the outcomes of the non-recent bleeding group. CONCLUSIONS: Early colonoscopy is not required for all patients with ALGIB. However, it may be suitable for those with hematochezia 0-6 h before hospital arrival, as it reduces early rebleeding and improves clinical outcomes.

A Case of Pyometra Caused by Achromobacter xylosoxidans and γ-Streptococcus in an Elderly Frail Woman.

Pyometra is an easily overlooked disease with nonspecific symptoms; however, a delayed diagnosis can lead to severe complications. An 80-year-old frail woman presented to our hospital with a chief complaint of persistent fever for 10 days. Her blood tests showed an elevated inflammatory response, and computed tomography showed a 10-cm cystic lesion in the pelvic floor compressing the bladder. A catheter was inserted from the vagina into the uterine cavity, resulting in pus drainage and pyometra diagnosis. A pus culture was subsequently performed, which detected Achromobacter xylosoxidans, a common cause of respiratory tract infections in cystic fibrosis and bloodstream infections, andγ-streptococcus. To the best of our knowledge, this is the first report of pyometra caused by Achromobacter xylosoxidans. The patient was treated with drainage and piperacillin-tazobactam administration. Pyometra is especially prevalent in older women with impaired activities of daily living and dementia. Although fever, lower abdominal pain, and increased discharge may occur, symptoms are often nonspecific, and half of such cases are asymptomatic. Furthermore, delayed diagnosis can lead to perforation of the uterus and consequent pan-peritonitis. Thus, the diagnosis of pyometra should be considered in older women presenting with unknown fever, and imaging studies and gynecological consultation should be requested promptly.

A pilot study to evaluate the effectiveness and safety of urgent endoscopy for gastroduodenal perforation.

BACKGROUND: Gastroduodenal perforation is potentially life threatening and requires early diagnosis and treatment. Urgent endoscopy facilitates detecting bleeding sites and achieving hemostasis. However, there is no consensus on urgent endoscopy for gastroduodenal perforation in Japan. METHODS: We evaluated the effectiveness and safety of urgent endoscopy for gastroduodenal perforation. We compared clinical characteristics between 140 patients who underwent urgent endoscopy (urgent endoscopy group) and 16 patients did not (no urgent endoscopy group) at Hiroshima City Asa Citizens Hospital between December 2005 and December 2018. RESULTS: Endoscopic diagnosis was possible in all urgent endoscopy group. In contrast, correct diagnosis of the perforation site was made on CT in 99 cases (63%). Furthermore, the proportion of cases with correct diagnosis of the perforation site by CT findings differed significantly between the urgent endoscopy group and the no urgent endoscopy group (66% vs. 38%, p < 0.05). No complications of urgent endoscopy were observed. Primary perforation site was gastric in 42 cases and duodenal in 114. In the 42 gastric perforation cases, 12 gastric perforation cases (29%) were managed conservatively, successfully in 9 (75%); 2 cases (17%) required delayed emergency surgery for worsening peritonitis. In the 114 duodenal perforation cases (duodenal ulcer in all cases), 52 cases (46%) were managed conservatively, successfully in 48 (92%); 3 cases (6%) required delayed emergency surgery for worsening peritonitis. A significantly higher proportion of gastric perforation cases than duodenal perforation cases required surgical treatment (76% vs. 57%, p < 0.05). Multivariate analysis revealed localized abdominal pain (no peritonism) (OR 0.25; 95% CI 0.08-0.75; p < 0.01) and perforation diameter ≤ 5 mm (OR 0.13; 95% CI 0.04-0.36; p < 0.01) as significant independent clinical factors for successful conservative management of duodenal ulcer perforation. CONCLUSIONS: Urgent endoscopy in gastroduodenal perforation enabled primary diagnosis and perforation site identification, and facilitated deciding the management strategy.

Step-clipping method can improve the detectability of the target lesion in colonic diverticular bleeding.

Background and study aims Despite the information regarding extravasation from contrast-enhanced computed tomography (CECT), the detectability of the target diverticulum by colonoscopy remains unsatisfactory in colonic diverticular bleeding (CDB). The lack of common signs recognizable on CT and endoscopic images makes it difficult to set a region of interest; however, this can be overcome with the "step-clipping" method, a strategic marking technique for revealing the target. We aimed to investigate the clinical performance of the step-clipping method in patients with CDB. Patients and methods Eighty-seven patients diagnosed with CDB with extravasation using CECT who underwent colonoscopy between August 2007 and February 2020 were included. Patients were divided into two categories: the traditional group (those who underwent colonoscopy from August 2007 to May 2017, n = 54) and the step-clipping group (those who underwent colonoscopy from June 2017 to February 2020, n = 33). Results The detection rate for the responsible diverticulum was significantly higher in the step-clipping group than in the traditional group (94 % vs 63 %; P  = .0013). The step-clipping group had a shorter average search time during colonoscopy (9.6 vs 40.5 minutes; P  < .0001) and lower re-bleeding rate after the initial colonoscopy (6 % vs 26 %; P  = .02) than the traditional group, which facilitated earlier hospital discharge (5.4 vs 6.8 days; P  = .027). Conclusions Colonoscopy using the step-clipping method can improve the detectability of the target lesion within a shorter time, thus leading to lower re-bleeding rates and earlier hospital discharge.

A Rare Case of Delayed Perigastric Abscess after Curative Resection of Early Gastric Cancer by Uncomplicated Endoscopic Submucosal Dissection: Successful Treatment with Endoscopic Ultrasound-guided Drainage.

A 72-year-old man had undergone uncomplicated endoscopic submucosal dissection (ESD) with en bloc resection of a localized 20-mm IIc lesion in the anterior wall of the gastric angle. Twenty-eight days later, he was re-admitted with epigastric pain of one-week duration. Contrast-enhanced computed tomography (CT) revealed a 60-mm mass bordered by viscera; repeat endoscopy confirmed a smooth elevated submucosal tumor at the greater curvature on the oral side of the post-ESD ulcer. We diagnosed him with a perigastric abscess as a complication of ESD and performed endoscopic ultrasound-guided drainage. Subsequently, the symptoms and blood inflammatory parameters improved, and follow-up CT showed the disappearance of the abscess.

Bile pigment in small-bowel water content may reflect bowel habits: a retrospective analysis of a capsule endoscopy imaging series.

BACKGROUND: Pigmented bile salts darken the small-bowel lumen and are present with bile acid, which is involved in the development of bowel habits. The small-bowel water content (SBWC) in the ileum could represent the colonic environment, but no studies have focused on this feature. However, measurement of crude SBWC can be challenging because of the technical difficulty of the endoscopic approach without preparation. Our aim was to evaluate optically active bile pigments in the SBWC of patients with abnormal bowel habits using capsule endoscopy (CE) to investigate the impact of bile acid on bowel habits. METHODS: The study population included 37 constipated patients, 20 patients with diarrhea, and 77 patients with normal bowel habits who underwent CE between January 2015 and May 2018. Patients with secondary abnormal bowel habits were excluded. In addition to conventional imaging, we used flexible spectral imaging color enhancement (FICE) setting 1 imaging, in which the effects of bile pigments on color are suppressed. Intergroup color differences of SBWC in the ileum (ΔE) were evaluated from conventional and FICE setting 1 images. Color values were assessed using the CIE L*a*b* color space. Differences in SBWC lightness (black to white, range 0-100) were also evaluated. RESULTS: The ΔE values from the comparison of conventional images between patients with constipation and with normal bowel habits and between patients with diarrhea and with normal bowel habits were 12.4 and 11.2, respectively. These values decreased to 4.4 and 3.3, respectively, when FICE setting 1 images were evaluated. Patients with constipation and diarrhea had significantly brighter (34.4 versus 27.6, P < .0001) and darker (19.6 versus 27.6, P < .0001) SBWC lightness, respectively, than patients with normal bowel habits. The FICE setting 1 images did not reveal significant differences in SBWC lightness between those with constipation and with normal bowel habits (44.1 versus 43.5, P = .83) or between those with diarrhea and with normal bowel habits (39.1 versus 43.5, P = .20). CONCLUSIONS: Differences in SBWC color and darkness in the ileum appear to be attributable to bile pigments. Therefore, bile pigments in SBWC may reflect bowel habits.

Successful Endoscopic Sclerotherapy Using Polidocanol for Small Bowel Hemangioma.

Small-bowel hemangiomas are a possible source of gastrointestinal bleeding for which there is no established treatment approach. In this report, we describe the case of a 58-year-old woman who presented with hematochezia and who was diagnosed with small bowel hemangioma. She was successfully treated using endoscopic sclerotherapy. Initial capsule endoscopy revealed bleeding in the ileum. Subsequent double-balloon enteroscopy showed a 2-cm, bluish-purple, ileal submucosal tumor with an overlying protrusion. The lesion was responsible for the hematochezia and was treated with intralesional injection of polidocanol. The hematochezia completely resolved and at 4 months after sclerotherapy, the size of the lesion was significantly reduced.

A new procedure combining local resection with endoscopic submucosal dissection for low rectal tumor: a four-case series.

Rectal tumors are traditionally resected by proctectomy to ensure the achievement of negative margins, an approach associated with an adverse impact on subsequent quality of life due to sequelae such as permanent stoma and urinary and sexual dysfunction. Many studies have now demonstrated that recurrence after local excision of early rectal tumors is significantly higher than would typically be expected. We have developed a new procedure, described herein, that combines local resection with endoscopic submucosal dissection for low rectal tumor. We report four consecutive cases (three submucosal tumors and one tumor with clinical deep submucosal invasion) treated at Hiroshima City Asa Citizens Hospital between January 2009 and March 2018. The mean duration of the procedure was 137 minutes. The en bloc resection and histologically complete resection rates were 100 %. Delayed bleeding and perforation rates were 0 %. Postoperative complications were fever and anal pain (one case each). All patients recovered with conservative therapy. No recurrence was found in any of the four patients during a follow-up period of 56 months. Our combined endoscopic and surgical procedure for low rectal tumors enabled definite negative vertical margins, reduced tumor volume, allowed for accurate pathological diagnosis, preserved rectal function, and aided the decision on additional therapy.

The 'step-clipping' method: a guide for identifying a previously bleeding colonic diverticulum.

Background and study aims Unsatisfactory detectability of a previously bleeding diverticulum by colonoscopy results from difficulty in precisely locating the target lesion, even with presence of an extravasation on contrast-enhanced computed tomography (CECT). This study aimed to evaluate the usefulness of the step-clipping method to overcome this limitation. Patients and methods Step-clipping was indicated for patients with colonic diverticular bleeding and presence of extravasation on CECT, but with absence of active bleeding on subsequent colonoscopy. The target diverticulum was identified by comparing computed tomography images before and after step clipping, which provided a positional relationship between each clip and the target lesion. Results Based on data from 21 consecutive cases meeting our inclusion criteria (14 men and 7 women; mean age, 73.2 years), the target diverticulum was endoscopically identified in 20 cases (95 %), in a median time of 5 minutes, and successfully treated. No adverse events were observed with the step-clipping method. Conclusion Step-clipping provided easy guidance to the target site for treatment in a short time, despite spontaneous cessation of bleeding at the diverticulum.

[A case of ruptured posterior superior pancreaticoduodenal artery aneurysm successfully treated by emergency transcatheter embolization].

A man in his 40s with no remarkable past medical history was referred to our hospital with acute exacerbation of nonspecific epigastric pain by another hospital on the morning of the day of presentation. Though vital signs were stable, tenderness and guarding were observed over the entire abdomen. Contrast-enhanced computed tomography (CT) revealed a giant retroperitoneal hematoma due to a ruptured aneurysm close to the superior mesenteric artery. Emergency angiography of the superior mesenteric artery detected a ruptured 2-mm pseudoaneurysm of the posterior superior pancreaticoduodenal artery, for which embolization was immediately performed. The postoperative course was good, with the patient complaining only of transient abdominal pain due to exclusion of the hematoma on hospital day 6. His clinical symptoms disappeared with conservative treatment, and the patient was discharged on hospital day 18. Complete occlusion of the aneurysm and reduction of the hematoma was confirmed on follow-up CT. Pancreaticoduodenal artery aneurysm is an uncommon visceral artery aneurysm, and ruptured aneurysms typically result in fatal hemorrhage and high mortality. We herein report a case of ruptured aneurysm of the posterior pancreaticoduodenal artery where emergency transcatheter arterial embolization was able to save the patient's life. We also review 116 cases of pancreaticoduodenal artery aneurysm reported in Japanese literature.

Management and risk factors for incomplete resection associated with jumbo forceps polypectomy for diminutive colorectal polyps: a single-institution retrospective study.

BACKGROUND: Cold forceps polypectomy is simple and widely used in clinical practice. However, there are concerns about the risk of incomplete resection using this technique. In recent years, it has been reported that polypectomy with jumbo forceps (JF) is an effective treatment modality for diminutive polyps (DPs) because JF are able to remove large tissue samples with the combined advantage of a higher complete histological resection rate for DPs than standard forceps. To our knowledge, no studies have evaluated the risk factors for incomplete resection when polypectomy with JF is performed for DPs. METHODS: From among 1129 DPs resected using JF at Hiroshima City Asa Citizens Hospital between November 2015 and December 2016, we retrospectively evaluated the clinical outcomes of 999 tumors with known histopathology and investigated the relationship between incomplete resection and clinicopathological factors. RESULTS: Most lesions [985 (87%)] were low-grade dysplasia and 14 (1%) were high-grade dysplasia. The en bloc resection rate was 92% (918/999) and the histological en bloc resection rate was 78% (777/999). Multivariate analysis showed that the significant independent predictors of incomplete resection were tumor size ≥ 4 mm [odds ratio (OR) 3.8; 95% confidence interval (CI) 2.65-5.37; p < 0.01], non-tangential direction of forceps in relation to the tumor (OR 1.73; 95% CI 1.21-2.45; p < 0.01), and lack of muscularis mucosae in the pathological specimen (OR 15.7; 95% CI 9.16-27.7; p < 0.01). CONCLUSIONS: This study identified significant independent predictors of incomplete resection of DPs which may be helpful when planning polypectomy with JF.

Effectiveness and safety of endoscopic radial incision and cutting for severe benign anastomotic stenosis after surgery for colorectal carcinoma: a three-case series.

Benign colonic anastomotic stenosis sometimes occurs after surgical resection and usually requires surgical or endoscopic dilation. Limited data are available on the effectiveness and safety of the endoscopic radial incision and cutting (RIC) method at sites other than the esophagus. The aim of this retrospective study was to investigate the effectiveness and safety of RIC dilation for severe benign anastomotic colonic stenosis. Subjects were 3 men (median age 72 years, range 65 - 76 years) who developed severe benign anastomotic stenosis after surgical resection for colorectal carcinoma and were subsequently treated by RIC dilation at Hiroshima City Asa Citizens Hospital between May 2014 and December 2016. Severe anastomotic stenosis was defined as a narrowed anastomosis through which a standard colonoscope could not be passed. The median interval from surgery to RIC was 21 months (range 9 - 29 months). RIC was successful in all 3 patients and reduced the severity of dyschezia postoperatively; 2 patients experienced improvement after a single RIC session and the other after 6 RIC sessions. No treatment-related adverse events or re-stenosis requiring repeat dilation was noted during a median follow-up of 27 months (range 8 - 37 months). Our findings indicate that the RIC technique can be applied safely and effectively to various sites in the colon, avoiding the need for reoperation.

Arteriosclerosis Is a Major Predictor of Small Bowel Vascular Lesions.

BACKGROUND: Most studies have focused on evaluating the association between the presence of small bowel vascular lesions (SBVLs) and patients' comorbidities. AIMS: We sought to uncover a more fundamental indicator that may predict the presence of SBVLs by considering atherosclerosis qualitatively and quantitatively. METHODS: We enrolled 79 consecutive patients with obscure gastrointestinal bleeding who had undergone computed tomography (CT) and capsule endoscopy or double-balloon endoscopy from January 2015 to June 2017. The SBVL frequency, type, and location, and the relationship between the presence of SBVLs and the patients' clinical characteristics were evaluated. Arterial wall calcification was assessed on unenhanced CT images, and a modified Agatston scoring system was used to determine the abdominal aorta calcium scores. RESULTS: Of the 27 (34%) patients with SBVLs, 15 (19%) had type 1a, 12 (15%) had type 1b, and 2 (3%) had type 2a SBVLs. Most of the lesions were located in the jejunum. Cardiovascular disease (P = .017), chronic kidney disease (P = .025), and arteriosclerosis (P = .0036) were associated with the presence of SBVLs. Subsequent multivariate analysis revealed that arteriosclerosis (odds ratio [OR] 7.29; 95% confidence interval [CI] 1.13-143.9) and superior mesenteric artery calcification (OR 16.3; 95% CI 3.64-118.6) were independent predictors of the presence of SBVLs. The modified Agatston score was significantly higher in SBVL cases than in non-SBVL cases (6384 vs. 2666, P = .0023). CONCLUSIONS: Arteriosclerosis, especially increased superior mesenteric artery calcification, is associated with an increased likelihood of SBVLs.