Long-term outcomes of endoscopic balloon dilation for intestinal strictures in patients with Crohn's disease during maintenance treatment with anti-tumor necrosis factor alpha antibodies.

BACKGROUND AND AIMS: Efficacy of endoscopic balloon dilation (EBD) for intestinal strictures in patients with Crohn's disease (CD) receiving anti-tumor necrosis factor alpha antibodies (anti-TNF) as maintenance therapy is unclear. We investigated the long-term efficacy and safety of EBD for intestinal strictures in patients with CD receiving anti-TNF. METHODS: We retrospectively analyzed data from patients with CD who received anti-TNF as maintenance therapy from 2008 to 2017, underwent EBD, and were followed up for ≥6 months. The primary endpoint was the cumulative surgery-free rate. The main secondary endpoints were technical success, repeat EBD rate, risk factors affecting surgical outcomes, and safety. RESULTS: Seventy-two patients with CD were assessed. The median observation period after EBD was 50 months. The technical success rate was 67%. The 3- and 5-year cumulative surgery-free rates were 81.1% and 73.5%, respectively. The repeat EBD rate was 74%. Multivariable analyses showed that risk factors affecting surgical outcomes were age at disease onset ≤16 years (hazard ratio 3.69; 95% confidence interval 1.36-10.01; P = 0.011). Serious complications requiring surgery developed in three patients. CONCLUSIONS: Endoscopic balloon dilation was an effective and safe short-term treatment and a useful long-term treatment for CD patients with intestinal strictures receiving anti-TNF as maintenance therapy.

Endoscopic submucosal dissection for superficial esophageal cancer in a diverticulum: A case report with literature review.

Superficial esophageal cancer (SEC) in a diverticulum is rare and has a high risk of perforation during endoscopic resection. Although endoscopic submucosal dissection (ESD) is a standard treatment option, it is challenging to perform. Here, we describe the case of a 79-year-old male patient with a history of ESD for SEC. Surveillance esophagogastroduodenoscopy identified a 20-mm-sized reddish depressed lesion in a diverticulum in the middle esophagus. The lesion was confirmed to be squamous cell carcinoma by biopsy. Magnification endoscopy with narrow-band imaging showed intraepithelial papillary capillary loops of type B1 according to the magnified endoscopic classification of the Japan Esophageal Society. Endoscopic ultrasonography revealed the presence of the muscular layer of the esophagus wall in the diverticulum. Therefore, the lesion was diagnosed as SEC, confined to the epithelium or lamina propria mucosae, in a Rokitansky diverticulum. Based on these findings, ESD was considered technically feasible. Traction-assisted ESD using clip with line was performed, and en bloc resection was achieved without adverse events. The resected specimen pathologically revealed a squamous cell carcinoma confined to the lamina propria mucosae without lymphovascular invasion, suggesting a curative resection. The patient recovered well, and no recurrence has been observed for 5 years after the ESD. Whether ESD is appropriate for the treatment of SEC in a diverticulum remains unclear. However, our case shows that it can be a treatment option in such cases due to its minimal invasiveness and good effectiveness.

Cancer risk in Japanese Crohn's disease patients: investigation of the standardized incidence ratio.

BACKGROUND AND AIM: There have been very few reported investigations on the standardized incidence ratio (SIR) of intestinal cancer and all cancers other than intestinal cancer with Crohn's disease (CD) by organ in Japan. This study examined the risk of developing cancer (i.e. SIR) that occurs in association with CD. METHODS: The subjects were 770 CD patients managed at our hospital department, which specializes in inflammatory bowel disease, during the approximately 25 years from July 1985 to August 2010. The number of expected cancer patients in a healthy population matched for sex and age with the CD patients in our hospital was then calculated. The relative risk, or SIR, was also calculated. RESULTS: The total observation period was 10,552 person-years, during which 19 cases (2.5%) of cancer were discovered in 770 subjects. The cancer cases included nine cases of colorectal cancer (CRC), one case of small bowel cancer, one case of stomach cancer, three cases of acute myeloid leukemia, two cases of endometrial cancer, one case of lung cancer, one case of skin cancer, and one case of thyroid cancer. The SIR for cancers in Japan in 2003 was 0.87 (95% confidence interval [CI] 0.52-1.35) for all cancers, 2.79 (95% CI 1.28-5.29) for CRC, and 6.94 (95% CI 1.43-20.3) for leukemia. CONCLUSIONS: Among the cancers in CD patients in our hospital, no significant difference was seen in the risk for all cancers in comparison with the standard population. However, the risks for CRC and leukemia were significantly higher than in the standard population.

Long-term outcomes after endoscopic submucosal dissection for colorectal epithelial neoplasms in patients with severe comorbidities.

Background and Aim: Long-term outcomes after endoscopic submucosal dissection (ESD) for colorectal epithelial neoplasms (CENs) in patients with severe comorbidities have not been clarified; the current study aimed to examine these long-term outcomes and compared them with those in patients with non-severe comorbidities. Methods: We included 231 patients with CENs who underwent ESD between April 2005 and March 2023. Patients with comorbidities were categorized according to the American Society of Anesthesiologists Physical Status (ASA-PS). We conducted a propensity score-matched analysis and compared long-term outcomes of the two groups after ESD for CENs. Results: Of the 156 patients enrolled in the study, 43 and 113 had severe (ASA-PS III) and non-severe (ASA-PS I/II) comorbidities, respectively. The 1:1 propensity score analysis matched 36 patients with severe comorbidities to 36 patients with non-severe comorbidities. After matching, there was no difference in the procedural outcomes of ESD between both groups. Regarding long-term outcomes, the 5-year overall survival rates after matching in the ASA-PS I/II and III groups were 100% and 73.5%, respectively, and patients in the ASA-PS III group exhibited significantly shorter overall survival than those in the ASA-PS I/II group (hazard ratio 7.209; 95% confidence interval 1.592-32.646; P = 0.010). No colorectal cancer-related deaths were noted in either group. Conclusion: Overall survival after ESD for CENs was shorter in patients with severe comorbidities than in those with non-severe comorbidities. Clinicians should carefully determine whether the benefits of CEN resection with ESD outweigh the procedural risks in patients with severe comorbidities.

A review on the current status and definitions of activity indices in inflammatory bowel disease: how to use indices for precise evaluation.

Many clinical trials have been conducted for inflammatory bowel disease (IBD), so various clinical indices (CIs) and endoscopic indices (EIs) have also been evaluated. However, recently, with the progress of IBD management, review of established indices from previous studies, and establishment of new indices, the landscape of the use of indices in clinical trials have changed. We investigated the number and frequency of the indices adapted in recent clinical trials for ulcerative colitis (CI and EI) and Crohn's disease (CI, EI, index related to magnetic resonance imaging, index for evaluating patient-reported outcomes, and health-related quality of life). Based on the results, we selected representative indices and further reviewed their content and characteristics. Moreover, various definitions, including clinical and endoscopic response or remission, have been described by means of representative indices in clinical trials.

Carbon dioxide insufflation compared with air insufflation in double-balloon enteroscopy: a prospective, randomized, double-blind trial.

BACKGROUND: Few studies have evaluated the degree of pain, the amount of retained gas, and the safety of carbon dioxide (CO(2)) insufflation in patients undergoing double-balloon enteroscopy (DBE). OBJECTIVE: To clarify the usefulness and safety of CO(2) insufflation during DBE. DESIGN: Single-center, prospective, randomized, double-blind, controlled trial. SETTING: University hospital. PATIENTS: Forty eligible patients with small-bowel disease for whom DBE was indicated were randomized to a CO(2) insufflation (CO(2)) group or an air insufflation (air) group by means of sealed envelopes. INTERVENTION: DBE with insufflation of CO(2) or air. MAIN OUTCOME MEASUREMENTS: Efficacy evaluation was based on the degree of pain as assessed by use of a visual analog scale (VAS) and the amount of residual gas retention within the small and large bowels on radiography. The safety of CO(2) insufflation was evaluated by arterial blood gas analysis. RESULTS: Significantly fewer patients in the CO(2) group had severe pain of ≥ 50 mm on the VAS during DBE than in the air group (P = .02). Significantly less gas was retained in the small bowel just after and at 3 hours after DBE in the CO(2) group than in the air group (P = .003, P = .01, respectively). There was significantly less residual gas retention in the large bowel at 3 hours after DBE in the CO(2) group than in the air group (P = .02). There was no significant difference in pre-DBE and post-DBE partial pressure of oxygen in the blood (PaO(2)) and partial pressure of carbon dioxide in the blood (PaCO(2)) between groups. LIMITATIONS: Small sample size. CONCLUSION: CO(2) insufflation is a safe and useful procedure when performed during DBE.

Efficacy of enteral nutrition in patients with Crohn's disease on maintenance anti-TNF-alpha antibody therapy: a meta-analysis.

Enteral nutrition (EN) is effective in Crohn's disease (CD) patients and has been shown to have an inhibitory effect on loss of response to anti-tumor necrosis factor (TNF)-alpha antibody therapy; however, the current level of evidence is not sufficient. The objective of this meta-analysis was to determine whether EN in combination anti-TNF-alpha antibody therapy is useful in maintaining remission. PubMed was used to identify all relevant studies. A total of nine articles were identified including one randomized control trial, two prospective cohort studies, and six retrospective cohort studies. We performed a meta-analysis on all these articles to assess the remission maintenance effect of EN (n = 857). The remission or response maintenance effect in the EN group was 203/288 (70.5%), which was higher than 306/569 (53.8%) in the non-EN group. The odds ratio for long-term remission or response using fixed effects model and random effects model were 2.23 (95% CI 1.60-3.10) and 2.19 (95% CI 1.49-3.22), respectively. The usefulness of EN was unclear in two prospective studies that were conducted immediately after remission induction with anti-TNF-alpha antibody therapy was detected. Differences in the definition of relapse and the observation period among articles were considered to be limitations. This analysis suggests that EN is effective for maintaining remission in patients already in remission or response as a result of anti-TNF-alpha antibody maintenance therapy.

Risk factors for severity of colonic diverticular hemorrhage.

BACKGROUND/AIMS: Colonic diverticular hemorrhage (DH) was a rare disease until the 1990s, and its incidence has increased rapidly since 2000 in Japan. In recent years, colonic DH has been the most frequent cause of lower gastrointestinal bleeding (LGIB). Nearly all cases of DH are mild, with the bleeding often stopping spontaneously. Some cases, however, require surgery or arterial embolization. In this study, using a cohort at Fukuoka University Chikushi Hospital, we investigated factors associated with severe colonic DH. METHODS: Among patients with LGIB who underwent colonoscopy at our hospital between 1995 and 2013, DH was identified in 273 patients. Among them, 62 patients (22.7%) were defined as having severe colonic DH according to recurrence of bleeding in a short period, and/or the necessity of transfusion, arterial embolization, or surgery. We then evaluated risk factors for severe DH among DH patients in this retrospective cohort. RESULTS: Among the 273 patients with DH, use of non-steroidal anti-inflammatory drugs (NSAIDs) (odds ratio [OR], 2.801; 95% confidence interval [CI], 1.164-6.742), Charlson Risk Index (CRI) ≥2 (OR, 3.336; 95% CI, 1.154-7.353), right-sided colonic DH (OR, 3.873; 95% CI, 1.554-9.653), and symptoms of cerebral hypoperfusion (such as light-headedness, dizziness, or syncope) (OR, 2.926; 95% CI, 1.310-6.535) showed an increased risk of severe DH even after controlling for other factors. CONCLUSIONS: Severe DH occurred in 23% of DH patients, and NSAID use, CRI ≥2, right-sided colonic DH, and symptoms of cerebral hypoperfusion are suggested to be predictors of severe DH.