High-Definition Chromoendoscopy Superior to High-Definition White-Light Endoscopy in Surveillance of Inflammatory Bowel Diseases in a Randomized Trial.

BACKGROUND & AIMS: There is debate over the optimal method for colonoscopic surveillance of patients with inflammatory bowel diseases. Guidelines recommend chromoendoscopy, but the value of chromoendoscopy in high-definition colonoscopy has not been proven. Furthermore, the value of random biopsies is controversial. METHODS: We performed a prospective study of 305 patients with ulcerative colitis or Crohn's colitis referred for surveillance colonoscopy at a university hospital in Sweden, from March 2011 through April 2016. Patients randomly assigned to a group that received high-definition chromoendoscopy with indigo carmine (HD-CE; n = 152), collection of 32 random biopsies, and targeted biopsies or polypectomies or to a group that received high-definition white light endoscopy (HD-WLE; n = 153), collection of 32 random biopsies, and targeted biopsies or polypectomies. The primary endpoint was number of patients with dysplastic lesions. RESULTS: Dysplastic lesions were detected in 17 patients with HD-CE and 7 patients with HD-WLE (P = .032). Dysplasias in random biopsies (n = 9760) were detected in 9 patients: 6 (3.9%) in the HD-CE group and 3 (2.0%) in the HD-WLE group (P = .72). Of the 9 patients with dysplasia, 3 patients (33%) had primary sclerosing cholangitis-only 18% of patients (54/305) included in the study had primary sclerosing cholangitis. The number of dysplastic lesions per 10 min of withdrawal time was 0.066 with HD-CE and 0.027 with HD-WLE (P = .056). CONCLUSIONS: In a randomized trial, we found HD-CE with collection of random biopsies to be superior to HD-WLE with random biopsies for detection of dysplasia per colonoscopy. These results support the use of chromoendoscopy for surveillance of patients with inflammatory bowel diseases. ClinicalTrials.gov no: NCT01505842.

Suppression of Aiolos and Ikaros expression by lenalidomide reduces human ILC3-ILC1/NK cell transdifferentiation.

The Ikaros family of transcription factors (TFs) are important regulators of lymphocyte function. However, their roles in human innate lymphoid cell (ILC) function remain unclear. Here, we found that Ikaros (IKZF1) is expressed by all ILC subsets, including NK cells, in blood, tonsil, and gut, while Helios (IKZF2) is preferentially expressed by ILC3 in tonsil and gut. Aiolos (IKZF3) followed the expression pattern of T-bet and Eomes, being predominantly expressed by ILC1 and NK cells. Differentiation of IFN-γ-producing ILC1 and NK cells from ILC3 by IL-1ß plus IL-12-stimulation was associated with upregulation of T-bet and Aiolos. Selective degradation of Aiolos and Ikaros by lenalidomide suppressed ILC1 and NK cell differentiation and expression of ILC1 and NK cell-related transcripts (LEF1, PRF1, GRZB, CD244, NCR3, and IRF8). In line with reduced ILC1/NK cell differentiation, we observed an increase in the expression of the ILC3-related TF Helios, as well as ILC3 transcripts (TNFSF13B, IL22, NRP1, and RORC) and in the frequency of IL-22 producing ILC3 in cultures with IL-1ß and IL-23. These data suggest that suppression of Aiolos and Ikaros expression inhibits ILC1 and NK cell differentiation while ILC3 function is maintained. Hence, our results open up for new possibilities in targeting Ikaros family TFs for modulation of type 1/3 immunity in inflammation and cancer.

Evaluation of narrow-band imaging signs in eosinophilic and lymphocytic esophagitis.

Background and study aims No specific endoscopic signs for diagnosing eosinophilic esophagitis (EoE) have been described and very few studies have reported endoscopic signs for lymphocytic esophagitis (LyE). This study aimed to assess the utility of narrow-band imaging magnifying endoscopy (NBI-ME) in predicting EoE/LyE diagnosis before histopathological assessment. Patients and methods Adult patients with dysphagia and/or food impaction who underwent esophagogastroduodenoscopy followed by NBI-ME and biopsies were included. Three previously reported NBI-ME signs were studied: beige mucosa, dot-shaped intra-epithelial papillary capillary loop (IPCL), and absent cyan vessels. These signs were compared with the histological diagnosis, and studied in patients with and without EoE or LyE. A predictive model containing the NBI-ME signs was analyzed, based on area under the curve (AUC). Results A total of 137 patients were enrolled. Based on histology 26 were diagnosed with EoE, 26 with LyE, and 85 were control patients with neither diagnosis. Significantly more EoE/LyE patients than control patients showed the NBI signs (P  < 0.001 for all three signs). Absent cyan vessels had the highest accuracy for differentiation (sensitivity 88 %, specificity 92 %). A combination of age, dot IPCLs, and absent cyan vessels was highly predictive of EoE/LyE, with an AUC of 0.952. Conclusions Three NBI-ME signs were found in the majority of patients with EoE/LyE and unlikely to be observed in controls. A combination of two NBI-ME signs and younger age had a higher degree of accuracy. This supports the claim that NBI-ME could be a reliable diagnostic modality for EoE/LyE predictors.

Benign and precursor lesions in the esophagus.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of salivary stimulation and esophageal secretion of protective factors in prevention of adenocarcinoma sequelae in gastroesophageal reflux disease; the pediatric conditions associated with esophageal cancer; the relationship of achalasia and pseudoachalasia with esophageal cancer; the potential for malignant transformation in eosinophilic esophagitis and overlap syndromes; the role of lymphocytic esophagitis as an overlapping phenotype; the role of Barrett's esophagus as a premalignant condition; the indications and type of treatment of premalignant conditions of the esophagus; and the decision for use of endoscopical procedures in premalignant conditions of the esophagus.

Endoscopic management of laparoscopic cholecystectomy-associated bile duct injuries.

BACKGROUND/PURPOSE: The efficacy of the endoscopic management of laparoscopic cholecystectomy (LC)-associated bile duct injuries is unclear because few studies on the issue report methods matched to injury type or long-term follow-up data. METHODS: Records from our institution's 11-year experience with the endoscopic management of LC-associated bile duct injuries were reviewed. Leakage was managed with a 5- to 7F endoscopic nasobiliary drainage (ENBD) tube for 1 week without endoscopic sphincterotomy (EST). Stricture was managed with the placement of a single 7F plastic stent for 1-2 months without EST. RESULTS: Fifteen cases were experienced. Of the 11 cases (77.8%) of leakage, 7 improved clinically and on imaging after ENBD, 2 did not resolve until after the placement of a single plastic 7F stent for several more days, and 2 others with leakage and high risk for accidental ENBD removal improved after the placement of a single 7F stent. All 4 cases of stricture resolved completely after the placement of a single 7F stent. There were no severe complications of the endoscopic procedure. At long-term follow-up, no patient had recurrence of symptoms or complications on imaging. CONCLUSIONS: ENBD for leakage and biliary stenting for strictures are safe and effective treatments for these LC-associated injuries.

[Sarcomatoid carcinoma of the liver: a case report and review of the literature].

A 66-year-old woman presented to our outpatient clinic with abdominal discomfort in April, 2008. Ultrasound revealed a hypo-echoic 10cm mass in the right hepatic lobe but no indication of chronic liver disease, with similar results in her history, on physical exam, and imaging. Serum testing did not identify any systemic disease. The mass was suspected to be intrahepatic cholangiocarcinoma and right hepatic lobectomy was performed. Histologic examination of the specimen revealed numerous spindle cells, and immunostaining confirmed a definitive diagnosis of sarcomatoid carcinoma of the liver. On subsequent review of the case, an abdominal CT performed 2.5 years earlier for unrelated symptoms had shown a 1cm faint low density area in the same location as the mass. The doubling time of this tumor was about 95 days.

Clinical features and natural history of serous cystic neoplasm of the pancreas.

AIMS: To clarify the clinical features and the natural history of serous cystic neoplasm (SCN) of the pancreas. METHODS: We retrospectively analyzed data from 30 patients affected by SCN. SCNs were classified as (1) microcystic type, (2) micro- and macrocystic type, and (3) macrocystic type according to the modified WHO classification. Eighteen patients who underwent serial radiographic imaging were identified, and tumor growth rate in these patients was evaluated. RESULTS: The median age was 62 years, and the female:male ratio was 2:1. Twenty-five patients (83%) were asymptomatic and 5 (17%) were symptomatic. The median tumor size was 2.6 cm. Fifteen cases (50%) had the microcystic type, 7 (23%) the micro- and macrocystic type, and 8 (27%) the macrocystic type. Age, gender, symptoms, location or tumor size did not differ significantly among the three subtypes. Eighteen patients were followed up for a median of 58 months. Morphological changes were observed in 3 patients (17%) and enlargement of tumor size in 9 patients (50%) during the follow-up. The growth rate was 0.29 cm per year and doubling time was 3.5 years; these rates did not differ among morphological subtypes or size of tumors. CONCLUSIONS: In asymptomatic patients with a clear imaging diagnosis of SCN, nonoperative management with a careful follow-up should be recommended. Surgery should be suggested in only symptomatic patients, those with giant tumors (>10 cm), rapid growing or when the presence of a potentially malignant tumor cannot be excluded. and IAP.

Endoscopic ultrasonography-guided pancreaticogastrostomy for a case of occlusion of gastro-pancreatic anastomosis after pancreaticoduodenectomy.

BACKGROUND: EUS-guided pancreaticogastrostomy is described as an alternative to surgery for ductal decompression when endoscopic transpapillary access is impossible. We report a case where EUS-guided pancreaticogastrostomy of the pancreatic duct was effective for dilatation of the pancreatic duct caused from occlusion of gastro-pancreatic anastomosis constructed after resection of pancreaticoduodenectomy. PATIENTS AND METHODS: The patient was a 79-year-old woman who had undergone operation for IPMN in the pancreatic head in 1998. Nine years after the operation, she visited us for back pain, and conspicuous dilatation of the main pancreatic duct was found. By observing curved liner array EUS scope, we successfully punctured the main pancreatic duct and placed a plastic stent. RESULTS: After the treatment, the subjective symptom was alleviated and reduction of the dilatation of pancreatic duct was observed in image findings. CONCLUSION: Endoscopic ultrasonography guided pancreaticogastrostomy appears to be an effective treatment for a case of occlusion of gastro-pancreatic anastomosis after pancreaticoduodenectomy.

[A case of primary retroperitoneal mucinous cystadenocarcinoma].

We encountered a case of primary retroperitoneal mucinous cystadenocarcinoma with ovarian-type stroma, an extremely rare condition. The patient was a 56-year-old woman with complaints of diarrhea, nausea, and abdominal fullness. Abdominal ultrasound revealed a nodular multi-cystic mass in the left lower quadrant of the abdomen. Subsequent contrast-enhanced CT and MRI determined it to be of retroperitoneal origin, consistent with a mucinous cystadenocarcinoma. Numerous small nodules were confirmed during the operation around the tumor suggesting local dissemination of the cancer and a left partial colectomy that included these nodules was performed. On histological examination, mucinous fluid was found trapped inside the cavity and poorly differentiated adenocarcinoma was observed in the solid portions. The ovarian-type stroma was confirmed in the layer beneath the epithelial lining and eventually a final diagnosis of mucinous cystadenocarcinoma was reached.

[Clinical features of acute acalculous cholecystits-nosocomial manner and community-acquired manner].

To clarify the clinical features of acute acalculous cholecystitis (AAC), we reviewed 113 cases of AAC experienced from January, 2000 to December, 2007 in regard to patient background, etiology, imaging diagnosis, treatment, and outcomes. Functional bile stasis caused AAC in 34 of 113 cases (30.1%), and 28 of those developed in a nosocomial manner (82.4%). On the contrary, mechanical bile stasis caused 37 cases (32.7%), and all but one case developed in a community-acquired manner. mechanical bile stasis included 9 cases of biliary tract neoplasm (5, cystic duct cancer; 3, gallbladder cancer; 1, papillary adenoma). Since considerable cases of AAC were caused by biliary tract neoplasm, we have to pay attention to their existences.