Giant Brunner's gland hyperplasia of the duodenum successfully resected en bloc by endoscopic mucosal resection: A case report.

BACKGROUND: Duodenal Brunner's gland hyperplasia (BGH) is a therapeutic target when complications such as bleeding or gastrointestinal obstruction occur or when malignancy cannot be ruled out. Herein, we present a case of large BGH treated with endoscopic mucosal resection (EMR). CASE SUMMARY: An 83-year-old woman presented at our hospital with dizziness. Blood tests revealed severe anemia, esophagogastroduodenoscopy showed a 6.5 cm lesion protruding from the anterior wall of the duodenal bulb, and biopsy revealed the presence of glandular epithelium. Endoscopic ultrasonography (EUS) demonstrated relatively high echogenicity with a cystic component. The muscularis propria was slightly elevated at the base of the lesion. EMR was performed without complications. The formalin-fixed lesion size was 6 cm × 3.5 cm × 3 cm, showing nodular proliferation of non-dysplastic Brunner's glands compartmentalized by fibrous septa, confirming the diagnosis of BGH. Reports of EMR or hot snare polypectomy are rare for duodenal BGH > 6 cm. In this case, the choice of EMR was made by obtaining information on the base of the lesion as well as on the internal characteristics through EUS. CONCLUSION: Large duodenal lesions with good endoscopic maneuverability and no evident muscular layer involvement on EUS may be resectable via EMR.

Phlegmonous Colitis after Cold Snare Polypectomy in an Immunosuppressed Patient: A Case Report.

Introduction: Cold snare polypectomy (CSP) is a procedure with a low risk of complications. Here, we present our experience of a rare case of submucosal abscess following CSP in an immunosuppressed patient. Case Presentation: Seventy-eight-year-old man underwent CSP, developing a fever, chills, and right lower abdominal pain 8 days later. Ultrasound and computed tomography revealed wall thickening of the ascending colon, presenting as whitening and thickening of the same region, and excretion of pus was observed after biopsy. The diagnosis was made as phlegmonous colitis, for which antibiotic therapy was commenced. The patient was diagnosed with chronic myelomonocytic leukemia (CMML) during admission. We considered the following reasons as possible causes of infectious complications after CSP: (1) the patient had a highly immunosuppressed state with comorbidities such as CMML as well as diabetes mellitus and (2) disruption of the mucosal barrier occurred during endoscopic resection. Conclusion: Although CSP is generally considered safe, our case highlights the potential for serious complications in immunosuppressed patients. Therefore, the decision to perform CSP in such patients should be made with caution to avoid unnecessary interventions. In instances where treatment is essential, thorough bowel preparation and prophylactic antibiotic use may be necessary to mitigate the risks.

Systemic AL amyloidosis with multiple submucosal hematomas of the colon: a case report and literature review.

Amyloid light-chain (AL) amyloidosis rarely causes colorectal submucosal hematoma. A 76-year-old man presented with a complaint of bloody stool. An initial colonoscopy revealed ulcerative lesions in the descending colon, leading to a diagnosis of ischemic colitis. One month later, he presented with cardiac failure, suspected cardiac amyloidosis, and underwent a second colonoscopy. Although it revealed multiple ulcerative lesions from the ascending to transverse colon, biopsy samples did not confirm amyloid deposition. He underwent a third colonoscopy 3 weeks later due to recurrent bloody stool. It showed multiple submucosal hematomas from the ascending to descending colon concomitant with ulcerative lesions in the descending colon and multiple elevated lesions in the sigmoid colon. Biopsy samples confirmed amyloid deposition. Using a systemic search, multiple myeloma with AL amyloidosis was diagnosed. Colorectal submucosal or intramural hematomas are conditions usually encountered in trauma, antithrombotic use, or coagulation disorders. Based on our review of the literatures, we identified several differences between colorectal intramural hematoma caused by amyloidosis and those caused by other etiologies. We believe that amyloidosis should be considered when relatively small and multiple colorectal hematomas, not restricted to the sigmoid colon, and with concomitant findings of erosions and ulcers, are observed.

Exploration of predictors associated with bleeding in computed tomography-guided core needle splenic biopsy: A retrospective study.

Splenic diseases may be caused by infections and can be either malignant, such as lymphoma and lung cancer, or benign, such as hemangioma. In some cases, diagnostic uncertainty of imaging persists, and image-guided splenic needle biopsy is a useful diagnostic tool to avoid the disadvantages of incorrect diagnosis, including performing unnecessary splenectomy or not giving the necessary treatment. Splenic biopsies can be divided into ultrasound-guided, computed tomography (CT)-guided fine-needle aspiration, or core needle biopsy (CNB). However, few studies have focused exclusively on complications associated with CT-guided CNB of the spleen. Therefore, we assessed bleeding, the most common complication of CT-guided CNB of the spleen, and evaluated factors associated with the bleeding. Using the biopsy database maintained at the institution, all patients who underwent CT-guided CNB of the spleen between May 2012 and September 2022 were identified retrospectively. The 18 identified patients were divided into post-biopsy bleeding and non-bleeding groups for analysis. In total, 17 patients (94.4%) could be diagnosed accurately with CT-guided CNB. Bleeding complications occurred in 7 cases of CT-guided CNB; of these, 2 patients with Common Terminology Criteria for Adverse Events grade 4 disease required transcatheter arterial embolization. The bleeding group was characterized by diffuse spleen tumors in all cases, with significantly more diffuse spleen tumors than the non-bleeding group. CT-guided CNB is a useful option for neoplastic lesions of the spleen that are difficult to diagnose using imaging alone. However, consideration should be given to post-biopsy bleeding in patients with diffuse splenic tumors.

Comprehensive review on endoscopic ultrasound-guided tissue acquisition techniques for solid pancreatic tumor.

Pancreatic ductal adenocarcinoma is speculated to become the second leading cause of cancer-related mortality by 2030, a high mortality rate considering the number of cases. Surgery and chemotherapy are the main treatment options, but they are burdensome for patients. A clear histological diagnosis is needed to determine a treatment plan, and endoscopic ultrasound (EUS)-guided tissue acquisition (TA) is a suitable technique that does not worsen the cancer-specific prognosis even for lesions at risk of needle tract seeding. With the development of personalized medicine and precision treatment, there has been an increasing demand to increase cell counts and collect specimens while preserving tissue structure, leading to the development of the fine-needle biopsy (FNB) needle. EUS-FNB is rapidly replacing EUS-guided fine-needle aspiration (FNA) as the procedure of choice for EUS-TA of pancreatic cancer. However, EUS-FNA is sometimes necessary where the FNB needle cannot penetrate small hard lesions, so it is important clinicians are familiar with both. Given these recent dev-elopments, we present an up-to-date review of the role of EUS-TA in pancreatic cancer. Particularly, technical aspects, such as needle caliber, negative pressure, and puncture methods, for obtaining an adequate specimen in EUS-TA are discussed.

White gastric mucosa during endoscopy as a new endoscopic feature of chronic ischemic gastritis: A case report.

Chronic ischemic gastritis (CIG) requires early diagnosis and treatment as complications of thromboembolism can be fatal. Although computed tomography (CT) is useful in the diagnosis of CIG, it is difficult to diagnose from a patient's history, endoscopic findings, and tissue biopsy. Identification of the key findings that motivate computed tomography is an important issue. We report a case of CIG diagnosed by endoscopic findings of white patches of mucosa over time. A 63-year-old man presented with epigastric pain. He had a history of repeated gastric ulcers of an undetermined cause. We performed upper endoscopy and observed the appearance of multiple white patches on the gastric mucosa. Central vessel stenosis was considered, and aortic computed tomography revealed complete occlusion of the superior mesenteric artery and stenosis of the celiac artery. We carried out a surgical bypass and found no postoperative endoscopic mucosal changes or abdominal pain. White patch changes in the gastric mucosa over time during endoscopy may indicate CIG. This finding may help in the future diagnosis of CIG.

Effectiveness of early colonoscopy in patients with colonic diverticular hemorrhage: A single-center retrospective cohort study.

BACKGROUND: Current guidelines recommend colonoscopy within 24 h for acute lower gastrointestinal bleeding; however, the evidence in support for colonic diverticular hemorrhage (CDH) indications remains insufficient. AIM: To investigate the effectiveness of early colonoscopy on the length of hospital stay for CDH patients. METHODS: We conducted a single-center retrospective cohort study. Patients who underwent colonoscopy within 24 h of presentation (early group) were compared with those who underwent colonoscopy beyond 24 h of presentation (elective group). The primary outcome was the length of hospital stay, and secondary outcomes were the identification of stigmata of recent hemorrhage (SRH), rebleeding, red blood cell transfusion more than 4 units, and interventional radiology and abdominal surgery after colonoscopy. RESULTS: We identified 574 CDH cases. Patients were divided into the early (n = 328) and elective (n = 226) groups. After propensity score matching, 191 pairs were generated. The length of hospital stay did not significantly differ between the two groups (early group vs elective group; median, 7 vs 8 d; P = 0.10). The early group had a significantly high identification of SRH (risk difference, 11.6%; 95%CI: 2.7 to 20.3; P = 0.02). No significant differences were found in the rebleeding (risk difference, 4.7%; 95%CI: -4.1 to 13.5; P = 0.35), red blood cell transfusion more than 4 units (risk difference, 1.6%; 95%CI: -7.5 to 10.6; P = 0.82), and interventional radiology and abdominal surgery rate after colonoscopy (risk difference, 0.5%; 95%CI: -2.2 to 3.2; P = 1.00). CONCLUSION: Early colonoscopy within 24 h, on arrival for CDH, could not improve the length of hospital stay.

Clinical features and progress of ischemic gastritis with high fatalities: Seven case reports.

BACKGROUND: Ischemic gastritis is a clinically rare and highly fatal disease that occurs when the hemodynamics of a patient with vascular risk is disrupted. Early diagnosis and treatment are possible only with upper endoscopy after symptom appearance. We report seven cases of ischemic gastritis and its clinical features, prognosis, and indicators that may help in early detection. CASE SUMMARY: Of the seven patients, six had vascular risk and five died within 2 wk of diagnosis. Their symptoms included hematemesis and hypotension. Although surgery is a choice for radical treatment, not all patients were tolerant. For such patients, conservative treatment was selected, but all of them died. In contrast, patients who underwent repeat endoscopy showed improved mucosal findings, suggesting that this improvement may not affect prognosis. Some ischemic changes such as wall thickening, mural emphysema, and fluid retention in the stomach were observed before diagnosis through endoscopy and computed tomography (CT). The CT scan can be effective for early detection, and improvement in circulatory failure and aggressive treatment may save the lives of patients with this disease. CONCLUSION: The characteristic CT findings enable early detection of ischemic gastritis. Early diagnosis increases the chance of survival if early therapeutic intervention and improvement of circulatory dynamics can be achieved in this highly fatal disease.

Liver cyst with biliary communication treated with endoscopic ultrasound-guided drainage: A case report.

RATIONALE: Simple liver cysts are common, and usually benign and asymptomatic, requiring little to no treatment. Liver cysts with biliary communication, however, are rare and require effective treatment to avoid recurrence. PATIENT CONCERNS: A 70-year-old woman with breast cancer visited our hospital for treatment. Physical examination revealed abdominal distension and bilateral lower leg edema. DIAGNOSIS: Abdominal contrast-enhanced computed tomography revealed a giant liver cyst, inducing inferior vena cava compression that was causing her edema. INTERVENTIONS: Percutaneous transhepatic cyst drainage was performed. Since the bilirubin level in the drained fluid was high, the patient was diagnosed with a liver cyst with biliary communication. After the procedure, her symptoms improved and the cyst decreased in size. However, the drainage volume did not decrease after approximately 2 weeks. Sclerotherapy with minocycline was ineffective. Thus, endoscopic retrograde cholangiopancreatography was performed, and an endoscopic nasobiliary drainage tube was inserted. The percutaneous drainage tube was clamped, and the cyst showed increase in size. Therefore, endoscopic ultrasound-guided cyst drainage, which is less invasive than surgery, was performed. OUTCOMES: The cyst tended to decrease in size even after the percutaneous drainage tube had been removed. At 3years follow-up, the cyst has almost disappeared. LESSONS: Endoscopic ultrasound-guided drainage can treat liver cyst with biliary communication.

Advanced Colon Cancer after Curative Resection of Intramucosal Adenocarcinoma with Endoscopic Submucosal Dissection.

Endoscopic resection, particularly endoscopic submucosal dissection (ESD), for colorectal cancers enables a precise pathological diagnosis and safe R0 resection. The recurrence rate after ESD is generally extremely low, with annual surveillance colonoscopy recommended. However, surveillance may not be considered for super-elderly patients owing to their condition. This is a case report of an 85-year-old man in whom curative resection was achieved for an intramucosal adenocarcinoma with ESD. The patient presented with a hypoechoic mass located in his lower right abdomen, diagnosed via surveillance abdominal ultrasound. He had undergone curative ESD for intramucosal cecal cancer 2 years prior. Colonoscopy revealed a type 2 epithelial tumor at the proximal aspect of the ESD scar. Ileocolic resection with lymph node dissection was performed. An epithelial tumor and well-differentiated adenocarcinoma but not a submucosal tumor was detected in the mucosal layer. The lesion was diagnosed not as a local recurrence after ESD but as a newly emerged original advanced cancer. After ESD for colorectal cancer, a newly developed advanced cancer may occur at the site of the ESD scar in a shorter term than usual. Surveillance colonoscopy after ESD is necessary even for super-elderly patients.

Secondary Minimal Change Disease Due to Pancreatic Cancer Improved by Chemotherapy.

We herein describe an 82-year-old patient who presented with proteinuria and systemic edema. He was diagnosed with minimal change disease (MCD) and was found to have stage III pancreatic cancer. He could not undergo surgical resection due to invasion to the celiac artery and he was thus treated with chemotherapy. After a month of chemotherapy, his proteinuria improved to a normal level. After two months of chemotherapy, computed tomography indicated a partial response to the therapy. MCD can occur as paraneoplastic syndrome in patients with malignant disease, and chemotherapy can be effective for MCD associated with paraneoplastic syndrome.

A Targeted Biopsy during Menstruation for the Definitive Diagnosis of Rectovaginal Endometriosis: A Report of Two Cases.

We herein report the definitive diagnosis of rectovaginal endometriosis in two cases. Case 1 involved a 46-year-old woman with abdominal pain and hematochezia. The diagnosis after the first and second examinations using lower gastrointestinal (GI) endoscopy was unclear. Differential diagnoses included mucosa-associated lymphoid tissue and colorectal cancer. The third lower GI endoscopy with a targeted biopsy, performed during menstruation, confirmed rectovaginal endometriosis. Case 2 involved a 38-year-old woman with hematochezia. Lower GI endoscopy during menstruation revealed rectovaginal endometriosis. When rectovaginal or bowel endometriosis is suspected, lower GI endoscopy and a targeted biopsy during menstruation can prevent unnecessary surgery.

Surface Modification and Adhesion Mechanism of Isotactic Polypropylene with Low-Energy Electron-Beam Treatments.

Recently, smaller-size electron-beam (EB) accelerators have offered EB irradiation in laboratory systems. Therefore, polymer surface treatments with low-energy EB have been developed in the past years. For high adhesion strength, low-energy EB treatment is also a promising method in comparison to plasma surface treatment. In the plasma treatment, the mechanism of the effect on the adhesion properties has been proved and the excess treatments led to the formation of a weak boundary layer and reduction of adhesion strength. In contrast, the low-energy EB possesses high penetration ability. In this work, we focused on the surface treatments of isotactic polypropylene (it.PP) with low-energy EB irradiation for adhesion. The dependence of adhesion strength on the absorbed dose of electron beam was evaluated, and the mechanism of electron beam on the adhesion properties was investigated from various perspectives of surface properties and morphology. Compared to that of plasma-treated it.PP, the adhesion strength of it.PP with electron-beam irradiation increased drastically. We proved that the radical was generated in the substrates after electron-beam treatments and would form covalent bonds between adhesives and substrates, which achieved higher adhesion than plasma treatments. In addition, the electron beam reached effectively a deep region from the top surface of the substrates and provided larger adhesion strength.

Preparation and characterization of cellulose nanofiber cryogels as oil absorbents and enzymatic lipolysis scaffolds.

Cellulose nanofiber (CNF) materials have received much attention as sustainable "green" materials with high mechanical properties. Their application in oil absorption and enzymatic lipolysis makes them further attractive from the perspective of environmental issues including marine pollution preservation. Herein, we prepared CNF cryogels with various surface properties, evaluated their capacities as oil absorbents and applied them as lipase-lipolysis scaffolds. Their obtained cryogels consisted of various modified CNFs and their structure and properties were investigated. Moreover, lipase-supported CNF cryogels were prepared for enzymatic lipolysis. The cryogels of protonated TEMPO-oxidized CNF showed the highest absorption capacity for olive oil, while all the CNF cryogels possessed similar absorption abilities towards water. In enzymatic lipolysis with lipase, the TEMPO-oxidized CNF (TOCN-Na+) cryogel showed the highest specific activity. The specific activities of lipase in TOCN-Na+ cryogels remained unchanged after being stored at 40 °C for 3 days.

Pancreatic pseudocyst-portal vein fistula: a case treated with EUS-guided cyst-drainage and a review of the literature.

Pancreatic pseudocyst and portal vein thrombosis are common conditions resulting from acute and chronic pancreatitis. However, pancreatic pseudocyst-portal vein fistula (PPVF) is a rare and life-threatening complication. In PPVF patients, drainage or operative therapy is necessary under certain conditions, including communication between the pseudocyst and pancreatic duct, pancreatic duct stricture, pancreatic duct stone, and infection that is difficult to control with antibiotics. We describe the case of a 78-year-old woman who presented with an infected pancreatic pseudocyst invading the portal venous system with obstruction due to thromboembolization. Conservative therapy with antibiotics was insufficient. We, therefore, performed endoscopic ultrasound-guided cyst-drainage (EUS-CD). During EUS-CD, PPVF and pseudocyst-pancreatic duct fistula were confirmed by contrast medium injection. Despite the presence of the pseudocyst-pancreatic duct fistula, the pancreatic duct was not visualized in the pancreatic head, suggesting stricture in the main pancreatic duct. We, therefore, performed endoscopic retrograde pancreatography, which revealed pancreatic stone in the main pancreatic duct. Then, we added a 7-Fr pancreatic stent. She was discharged after 89 days of hospitalization. We reviewed the literature on the management of PPVF formation, and EUS-CD is considered to be a good treatment option for PPVF patients without portal vein patency.

Ischemic pancreatitis with infected walled-off necrosis with a colonic fistula after cardiopulmonary bypass successfully treated by endoscopic ultrasound-guided drainage.

A 72-year-old man who had been on continuous ambulatory peritoneal dialysis treatment for 10 years underwent cardiopulmonary bypass for aortic valve replacement due to aortic valve stenosis. After surgery, he experienced pancreatitis, and rupture of a splenic artery aneurysm. He went into cardiopulmonary arrest but was successfully treated by transcatheter arterial embolization (TAE) with cardiopulmonary resuscitation. At three weeks after TAE, CT showed heterogeneous enhancement and the accumulation of pancreatic fluid in the pancreatic tail. At 4 months after TAE, he had sepsis and CT showed greater fluid collection with emphysema in comparison to 3 months previously. We diagnosed infected walled-off necrosis (WON). Conservative therapy with antibiotics was not sufficiently effective; thus, we performed endoscopic ultrasound-guided drainage (EUS-D). Contrast imaging revealed WON with colonic fistula. The WON remarkably decreased in size on CT after EUS-D. We experienced a rare case of ischemic acute pancreatitis (AP) caused by cardiopulmonary bypass complicated with infected WON with a colonic fistula. Ischemic AP more frequently shows a severe course with a fatal outcome in comparison to AP of other causes. However, in our case, ischemic AP with infected WON was successfully treated by EUS-D despite the presence of a WON with a colonic fistula.

Surface Modification of Poly(ether ether ketone) through Friedel-Crafts Reaction for High Adhesion Strength.

Poly(ether ether ketone) (PEEK) possesses attractive mechanical and thermal properties but demonstrates poor adhesion. To overcome this disadvantage, in this study, the surface modification of PEEK or PEEK-based carbon-fiber-reinforced thermoplastics (CFRTP) was performed through the Friedel-Crafts reaction and successive epoxidation. Under optimized reaction conditions, surface modification was achieved without surface deterioration, and epoxy groups were introduced. The progress of the Friedel-Crafts reaction and epoxidation was demonstrated by X-ray photoelectron spectroscopy measurements after fluorine labeling through thiol-en reaction and amine addition, respectively. The adhesive strength between CFRTP and epoxy adhesives was increased to 23.5 MPa, and cohesive fracture of epoxy adhesives, rather than interfacial peeling, occurred. In addition, compared with conventional plasma treatment, the durability of the modified surface and thickness of the modified surface layer increased. Therefore, we succeeded in modifying the surface properties through the epoxidation of the PEEK surface.

Risk Factors Associated with Cisplatin-Induced Nephrotoxicity in Patients with Advanced Lung Cancer.

Cisplatin (CDDP) combination chemotherapy is widely administered to patients with advanced lung cancer. The dose depends on multiple factors, including whether the tumor is non-small-cell lung cancer (NSCLC) or small-cell lung cancer (SCLC). Although efficacy is limited by cisplatin-induced nephrotoxicity (CIN), little is known about the risk factors for this complication. The aim of this study was to identify the risk factors for CIN in patients with advanced lung cancer, both NSCLC and SCLC. We retrospectively reviewed clinical data for 148 patients who underwent initial chemotherapy including CDDP ≥50 mg/m2 per patient per day for the first course at Kyushu Medical Center between October 2010 and September 2013. All data were collected from the electronic medical record system. Nephrotoxicity was defined as an increase in serum creatinine concentration of at least grade 2 during the first course of CDDP chemotherapy, as described by the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. CIN was observed in nine patients. Univariate analysis revealed that cardiac disease and lower baseline serum albumin (Alb) values conferred a higher risk of nephrotoxicity (p<0.05). The cut-off value of Alb was 3.8 g/dL, calculated by receiver operating characteristics (ROC) curves. Multivariable logistic regression analysis revealed that cardiac disease (odds ratio=11.7; p=0.002) and hypoalbuminemia (odds ratio=6.99 p=0.025 significantly correlated with nephrotoxicity. In conclusion, cardiac disease and low baseline Alb values are possible risk factors for CIN.

Highly water repellent but highly adhesive surface with segregation of poly(ethylene oxide) side chains.

Polymer surfaces were modified using methacrylate terpolymers containing both perfluoroalkyl (Rf) groups and poly(ethylene oxide) (PEO) as side chains in the same molecule. The structure and properties of the modified surfaces were evaluated using X-ray photoelectron spectroscopy and by measuring the dynamic contact angles and 90° peel strength. It was found that not only Rf groups but also PEO side chains were segregated on the surface being against the order of the surface free energy. The terpolymer modified surface is hydrophobic in air because Rf groups are predominant, but it becomes hydrophilic in water because the surface is covered with PEO side chains. This response to the environment is rapid and reversible. The modified surface showed high water repellency because of the surface Rf groups and high adhesive strength because of the side chains.