Efficacy and safety of radial incision and cutting for nonsurgical refractory benign esophageal stricture.

Background and study aims Radial incision and cutting (RIC) was established to improve refractory esophageal anastomotic strictures but its efficacy and safety for nonsurgical refractory strictures remain unclear. To evaluate the usefulness of RIC in nonsurgical refractory strictures, we retrospectively compared outcomes between nonsurgical and surgical strictures. Patients and methods We retrospectively studied 54 consecutive patients who were initially treated with RIC for refractory benign esophageal stricture. The study variables included dysphasia score improvement rate, frequency of repeated RIC, cumulative patency rate, cumulative stricture improved rate, and adverse events(AEs), which were compared between nonsurgical (n = 21) and surgical (n = 33) stricture groups. Results Immediately after RIC, 90.5% of patients in the nonsurgical group and 84.8% of patients in the surgical group had improvement in dysphagia ( P = 0.69). The frequency of intervening repeated RIC was 42.9% in the nonsurgical group and 42.4% in the surgical group ( P = 0.98). During median follow-up of 22.3 months (range, 1.0-175.0), the cumulative patency rate ( P = 0.23) and cumulative stricture improvement rate ( P = 0.14) but there was not statistical difference between the two groups. Despite a low cumulative stricture improvement rate (9.5%) at 6 months after the first RIC in the nonsurgical group, 57.7% of patients no longer required endoscopic balloon dilatation at 2 years. The cumulative stricture improvement rate was significantly lower in patients with a history of radiation therapy. No severe AEs were observed in the nonsurgical group. Conclusions RIC for nonsurgical refractory benign esophageal stricture is an effective and safe treatment option.

Repeated talaporfin sodium photodynamic therapy for esophageal cancer: safety and efficacy.

BACKGROUND: Talaporfin sodium photodynamic therapy (tPDT) is an effective salvage treatment for local failure after chemoradiotherapy for esophageal cancer. Repeated tPDT could also be indicated for local recurrence or residue after the first salvage tPDT. However, the safety and efficacy of repeated tPDT have not been elucidated. METHODS: We reviewed 52 patients with esophageal cancer who were treated with the first tPDT at Kyoto University Hospital between October 2015 and April 2020. RESULTS: Among 52 patients, repeated tPDT after the first tPDT was indicated for 13 patients (25%), of which six had residual tumor, four had local recurrence after complete response (CR) after the first tPDT at the primary site, and six had metachronous lesion. The total session of repeated tPDT was 25; 16 were for primary sites and nine were for metachronous sites. Among them, six patients (46.2%) achieved local (L)-CR and nine lesions (56.3%) achieved lesion L-CR. By session, 10 sessions (40%) achieved L-CR. There were no severe adverse events except for one patient; this patient showed grade 3 esophageal stenosis and perforation after the third tPDT on the same lesion that was previously treated with porfimer sodium photodynamic therapy four times. CONCLUSION: Repeated tPDT could be an effective and safe treatment for local failure even after salvage tPDT for esophageal cancer.

A novel endoscopic imaging system for quantitative evaluation of colonic mucosal inflammation in patients with quiescent ulcerative colitis.

Background and study aims Mucosal healing (MH) is associated with clinical outcome in ulcerative colitis (UC) patients. In most clinical trials, a Mayo endoscopic subscore (MES) of 0 or 1 is defined as MH. However, several recent studies have reported that clinical outcome is different between UC patients with MES 0 and those with MES 1. In addition, the MES is subjective and may differ among endoscopists. Therefore, a repeatable and objective scoring system is required to distinguish MES 0 from MES 1, even in clinically quiescent UC. Here, we assessed the usefulness of new image-enhancing endoscopic technology, the i-scan TE-c, to quantitatively evaluate colonic inflammation in patients with quiescent UC. Methods We retrospectively reviewed the data from 52 UC patients in clinical remission who had undergone routine colonoscopy with standard white light. The white-light images were reassessed using the new system, and the degree of colonic mucosal inflammation was quantified according to the MAGIC (Mucosal Analysis of Inflammatory Gravity by i-scan TE-c Image) score. We used the i-scan TE-c system to investigate the association among the MAGIC score, MES, and histologic activity (Geboes score). Results The MAGIC score was significantly higher in the MES 1 group than in the MES 0 group ( P  = 0.0034). The MAGIC score significantly correlated with the Geboes score ( P  = 0.015). Conclusions Our novel image-enhancing endoscopic system was useful for objective and quantitative evaluation of MH in patients with quiescent UC. Further clinical studies using this imaging system are required to confirm its clinical benefit for the management of UC patients.

Diagnostic accuracy of endoscopic features of pediatric acute gastrointestinal graft-versus-host disease.

BACKGROUND AND AIM: Acute gastrointestinal graft-versus-host disease (GI-GVHD) is a major cause of morbidity and mortality after hematopoietic stem cell transplantation (HSCT). There are very few studies on specific endoscopic findings in pediatric acute GI-GVHD. The aim of this retrospective case-control study was to elucidate the characteristic endoscopic findings in pediatric acute GI-GVHD that improve the diagnostic accuracy of endoscopy. METHODS: All consecutive patients under 18 years of age who underwent allogeneic HSCT in Kyoto University Hospital from May 2003 to October 2014 were identified retrospectively. Patients who underwent GI endoscopy as a result of sustained GI symptoms were identified. Intestinal villous patterns were evaluated by magnification endoscopy with the water-immersion technique. The patients were diagnosed with acute GI-GVHD and non-GVHD on the basis of biopsy histology. Endoscopic findings of the two groups were compared. RESULTS: Of the 171 patients who underwent HSCT, 30 underwent GI endoscopy. Of these, 17 and nine were diagnosed with acute GI-GVHD and non-GVHD, respectively. Compared with non-GVHD, acute GI-GVHD was associated significantly more often with short blunt villi in the duodenum (P = 0.013), variable defect villi and short blunt villi in the ileum (P = 0.009 and 0.035, respectively), and edema, erosion, and tortoiseshell-like mucosae in the colon (P = 0.017, 0.023, and 0.017, respectively). CONCLUSION: Pediatric acute GI-GVHD was associated with several characteristic features on magnifying endoscopy with the water-immersion technique. These features will be useful for endoscopic diagnosis of pediatric acute GI-GVHD.

Endoscopic laryngo-pharyngeal surgery for superficial laryngo-pharyngeal cancer.

BACKGROUND AND STUDY AIMS: Narrow band imaging (NBI) combined with magnifying endoscopy enables us to detect superficial laryngo-pharyngeal cancers, which are difficult to detect by standard endoscopy. Endoscopic laryngo-pharyngeal surgery (ELPS) is a technique developed to treat such lesions and the purpose of this study is to evaluate the usefulness of ELPS for superficial laryngo-pharyngeal cancer. PATIENTS AND METHODS: Seventy five consecutive patients with 104 fresh superficial laryngo-pharyngeal cancers are included in this study. Under general anesthesia, a specially-designed curved laryngoscope was inserted to create a working space in the pharyngeal lumen. A magnifying endoscope was inserted transorally to visualize the field and a head & neck surgeon dissected the lesion using the combination of the orally-inserted curved grasping forceps and electrosurgical needle knife in both hands. The safely, functional outcomes, and oncologic outcomes of ELPS were evaluated retrospectively. RESULTS: Median operation time per lesion was 35 min. Post-operative bleeding occurred in 3 cases and temporal subcutaneous emphysema occurred in 10 cases. No vocal fold impairment occurred after surgery. The median fasting period was 2 days and all patients except one have a normal diet with no limitations. Local recurrence occurred in 1 case, and the 3-year overall survival rate and the 3-year disease specific survival rate was 90% and 100%, respectively. CONCLUSIONS: ELPS is a hybrid of head and neck surgery and gastrointestinal endoscopic treatment, and enjoys the merit of both procedures. ELPS makes it possible to perform minimally-invasive surgery, preserving both the swallowing and phonation functions.

Prior use of immunomodulatory drugs improves the clinical outcome of endoscopic balloon dilation for intestinal stricture in patients with Crohn's disease.

BACKGROUND: Endoscopic balloon dilation is a promising procedure to improve symptoms of intestinal stricture in patients with Crohn's disease (CD). However, the long-term efficacy of endoscopic balloon dilation combined with immunomodulatory drugs remains unclear. The aim of the present study is to investigate whether prior use of immunomodulatory drugs affects the clinical outcome of endoscopic balloon dilation for intestinal stricture in CD. PATIENTS AND METHODS: Between January 2004 and December 2011, 83 dilations were carried out in 25 patients with CD. Median follow-up period was 46 months. Patients were categorized into two groups based on their medications at the first endoscopic balloon dilation: early immunomodulatory drug-induction group (early IM-induction group) in which patients were already treated with immunomodulatory drugs before the dilation; and post-immunomodulatory drug-induction group (post-IM-induction group) in which patients were not yet treated withimmunomodulatory drugs before dilation. We compared the long-term cumulative non-surgical rate and the mean number of dilation procedures per patient between early and post-IM-induction groups to clarify the influence of prior use of immunomodulatory drugs on the clinical outcome of endoscopic balloon dilation. RESULTS: There was a significant difference in the mean number of dilation procedures per patient between the early IM-induction and post-IM-induction groups (P = 0.04), although no significant difference in the cumulative non-surgical rate was observed between the two groups (P = 0.14). CONCLUSION: Prior use of immunomodulatory drugs may improve the clinical outcome of endoscopic balloon dilation for intestinal stricture in CD.

The impact of adenosine pharmacologic stress combined with low-level exercise in patients undergoing myocardial perfusion imaging (BIWAKO adenosine-Ex trial).

BACKGROUND: The combination of adenosine infusion with low-level exercise has become a common approach for inducing stress during stress myocardial perfusion imaging (MPI). We investigated stress MPI performed by combined low-level exercise and adenosine infusion. This combined protocol can decrease adverse reactions and reduce the effect of scattered rays from the liver. METHODS AND RESULTS: Subjects were clinically referred for a 53-min rest-stress Tc-99m Sestamibi MPI procedure using BIWAKO PROTOCOL. Ninety-eight patients (44.5%) underwent adenosine infusion with ergometer exercise testing and 122 patients (55.5%) underwent adenosine infusion without exercise testing. We evaluated the liver/heart (L/H) uptake ratio, background activity in the upper mediastinum, and adverse reactions. RESULTS: The L/H ratio and background activity were lower in the adenosine-exercise group than in the adenosine-non-exercise group (1.8 ± 0.54 vs. 2.1 ± 0.62, P < 0.0056; 43.1 ± 12.2 vs. 61.5 ± 15.4, P < 0.0001). The adenosine-exercise group had fewer adverse reactions than the adenosine-non-exercise group (11.2 vs. 19.7%). All of the adverse reactions were minor, with the exception of severe back pain in one case. The incidence of adverse reactions in our study was lower than that in previous studies for unknown reason. CONCLUSION: Adenosine infusion in combination with low-level exercise seems to result in higher-quality images and fewer adverse reactions than adenosine infusion without exercise. The combined protocol decreases adverse reactions and improves the quality of myocardial perfusion images by decreasing background activity.

Differences of image enhancement in image-enhanced endoscopy: narrow band imaging versus flexible spectral imaging color enhancement.

BACKGROUND: Narrow band imaging (NBI) can emphasize images of the surface microvasculature of lesions, because the central wavelengths of the NBI filter are 415 and 540 nm and these wavelengths are well absorbed by hemoglobin. Flexible spectral imaging color enhancement (FICE) increases the contrast in depictions of mucosal lesions. However, quantitative evaluation of the image enhancement shown by NBI and FICE has not been reported. The aim of this study was to measure and compare the degrees of image enhancement in NBI and FICE. METHODS: We compared the visibility of human blood diluted with distilled water between that shown by white-light imaging (WLI) and that shown by NBI or FICE. One milliliter of human blood was plated onto a 12-well transparent plastic plate to set up doubling dilutions, from 1/2 to 1/2(23). High-definition endoscopes were used for each imaging method. A total of 11 endoscopists independently evaluated the visibility of the diluted blood. The median dilution was defined as the limit of visibility in each image. RESULTS: NBI enabled clearer visualization of the presence of blood compared with conventional WLI. NBI recognized blood contamination up to a 1/2(14) dilution, whereas conventional WLI recognized blood contamination up to a 1/2(11) dilution. In contrast, FICE did not improve the visualization of diluted blood and recognized blood contamination up to a 1/2(10) dilution. CONCLUSIONS: NBI more effectively enhanced images of diluted blood compared to conventional WLI, while FICE did not improve the visualization of the diluted blood. These data suggest the usefulness of NBI for the early detection of gastrointestinal neoplasia, which is accompanied by abundant neovascularization.

New protocol of myocardial SPECT imaging with technetium-99m sestamibi for reducing the time interval between rest and adenosine stress phases.

We have developed a new protocol of myocardial perfusion-gated single-photon emission computed tomography (SPECT), by use of technetium-99m sestamibi (MIBI), in which SPECT imaging at rest followed by SPECT imaging after adenosine with low level ergometer stress can be conducted by use of the Monzen position within a shortened total testing time of 1 h or less. The study group consisted of 137 patients who underwent this new imaging protocol. The diagnostic quality of the images was as good as that of images obtained with the conventional method (30-60 min after the injection of MIBI). The SPECT image quality for the 137 patients was evaluated, and the percentages of images rated as excellent, good, fair, and poor were 65.3, 27.4, 5.8, and 1.5% for the rest image, and 68.2, 21.9, 8.4, and 1.5% for the stress image, respectively. The shortened total testing time reduced the physical and mental burden on the patient compared with that of conventional myocardial perfusion imaging. Because this technique allows us to perform rest and stress myocardial imaging within a short period, it is expected to be very useful in the clinical setting.

French maritime pine bark extract inhibits viral replication and prevents development of viral myocarditis.

BACKGROUND: French maritime pine bark extract (Pycnogenol) revealed diverse anti-inflammatory actions by an inhibition of NF-kappaB-dependent gene expression. The aim of this study was to determine whether Pycnogenol had a beneficial effect on viral myocarditis in mice. METHODS AND MATERIALS: Four-week-old inbred male DBA/2 mice were inoculated intraperitoneally with 10 plaque-forming units (pfu) of the encephalomyocarditis (EMC) virus. Pycnogenol was administered orally at a dose of 1 or 10 mg/kg per day for the histologic study, and 10 or 100 mg/kg for the gene expression study, beginning on the day of viral inoculation. RESULTS: The area of myocardial infiltration and necrosis on day 7 was significantly smaller in the hearts of mice treated with Pycnogenol 10 mg/kg (16.2 +/- 8.9% and 19.2 +/- 9.7%, respectively, n = 10, mean +/- SEM) compared with controls (27.6 +/- 15.0% and 30.1 +/- 15.7%, respectively, n = 10, P < .05). There was a nonsignificant trend for less myocardial infiltration in the Pycnogenol 1 mg/kg group. Myocardial virus concentration on day 7 was 8.4 +/- 0.3 x 10(3) pfu/mg in mice treated with 1 mg/kg of Pycnogenol, and 2.7 +/- 0.6 x 10(4) pfu/mg in control mice, and the difference was statistically significant (P < .05). Gene expressions of tumor necrosis factor, type-I procollagen, stem cell factor, and mast cell tryptase were significantly suppressed in the hearts of mice treated with Pycnogenol 100 mg/kg. CONCLUSIONS: These results suggest that Pycnogenol exerts its beneficial effects on viral myocarditis by decreasing virus replication, and by suppressing expression of pro-inflammatory cytokines, genes related to cardiac remodeling, and mast cell-related genes in the hearts of mice.