The clinical accuracy of endoscopic ultrasonography and white light imaging in gastric endoscopic submucosal dissection.

PURPOSE: Gastric mucosal neoplastic lesions should have characteristic endoscopic features for successful endoscopic submucosal dissection. MATERIALS AND METHODS: Out of the 1,010 endoscopic submucosal dissection, we enrolled 62 patients that had the procedure cancelled. Retrospectively, whether the reasons for cancelling the endoscopic submucosal dissection were consistent with the indications for an endoscopic submucosal dissection were assessed by analyzing the clinical outcomes of the patients that had the surgery. RESULTS: The cases were divided into two groups; the under-diagnosed group (30 cases; unable to perform an endoscopic submucosal dissection) and the over-diagnosed group (32 cases; unnecessary to perform an endoscopic submucosal dissection), according to the second endoscopic findings, compared with the index conventional white light image. There were six cases in the under-diagnosed group with advanced gastric cancer on the second conventional white light image endoscopy, 17 cases with submucosal invasion on endoscopic ultrasonography findings, 5 cases with a size greater than 3 cm and ulcer, 1 case with diffuse infiltrative endoscopic features, and 1 case with lymph node involvement on computed tomography. A total of 25 patients underwent a gastrectomy to remove a gastric adenocarcinoma. The overall accuracy of the decision to cancel the endoscopic submucosal dissection was 40% (10/25) in the subgroup that had the surgery. CONCLUSIONS: The accuracy of the decision to cancel the endoscopic submucosal dissection, after conventional white light image and endoscopic ultrasonography, was low in this study. Other diagnostic options are needed to arrive at an accurate decision on whether to perform a gastric endoscopic submucosal dissection.

The cap-assisted technique enhances colonoscopy training: prospective randomized study of six trainees.

BACKGROUND: Colonoscopy and polypectomy procedures have effectively reduced the incidence of colorectal cancer. Currently, competence in colonoscopy is an essential part of the education program for gastrointestinal (GI) trainees. However, considerable training is required for the optimal performance of a colonoscopy. METHODS: This study involved six colonoscopy trainees, three of whom used the cap whereas the others did not. Each trainee managed 100 cases of screening colonoscopy from beginning to end. The cecal intubation success rate, cecal intubation time, polyp detection rate, adenoma detection rate, advanced adenoma detection rate, and adenocarcinoma detection rate were checked. The rate of successful cecal intubation and the cecal intubation time were reviewed every 10 cases. RESULTS: The cecal intubation rate was 80.7 % (242/300) in the cap group and 63.3 % (190/300) in the non-cap group. The average cecal intubation time was 13.7 min in the cap group and 18.7 min in the non-cap group. The statistical analysis of these results suggested that the cap group had a significantly higher success rate (p < 0.001) and a shorter cecal intubation time (p < 0.001) than the non-cap group. However, the two groups did not differ significantly in the detection rate for polyps (45.3 vs 43 %; p = 0.565), adenomas (26.3 vs 25 %; p = 0.709), advanced adenomas (2.6 vs 0.6 %; p = 0.056), or adenocarcinomas (5.3 vs 3 %; p = 0.153). CONCLUSION: Cap-assisted colonoscopies might help to increase the rate of cecal intubation success and shorten the cecal intubation time for GI trainees.

Factors predictive of risk for complications in patients with oesophageal foreign bodies.

BACKGROUND: Reports on predictive risk factors associated with complications of ingested oesophageal foreign bodies are rare. AIMS: The aim of this study was to determine the predictive risk factors associated with the complications of oesophageal foreign bodies. METHODS: Three hundred sixteen cases with foreign bodies in the oesophagus were retrospectively investigated. The predictive risk factors for complications after foreign body ingestion were analysed by multivariate logistic regression, and included age, size and type of foreign body ingested, duration of impaction, and the level of foreign body impaction. RESULTS: The types of oesophageal foreign bodies included fish bones (37.0%), food (19.0%), and metals (18.4%). The complications associated with foreign bodies were ulcers (21.2%), lacerations (14.9%), erosions (12.0%), and perforation (1.9%). Multivariate analysis showed that the duration of impaction (p<0.001), and the type (p<0.001) and size of the foreign bodies (p<0.001) were significant independent risk factors associated with the development of complications in patients with oesophageal foreign bodies. CONCLUSION: In patients with oesophageal foreign bodies, the risk of complications was increased with a longer duration of impaction, bone type, and larger size.

A case of McCune-Albright syndrome with associated multiple endocrinopathies.

McCune-Albright syndrome (MAS) is a rare disorder that develops from an activating mutation in the Gs gene. It is characterized by an association with Polyostotic fibrous dysplasia, and precocious puberty, Caf-au-lait pigmentation, and other endocrinopathies that result from the hyperactivity of a variety of endocrine glands. Recently we encountered a patient with MAS with fibrous dysplasia, skin pigmentation, acromegaly, hyperprolactinemia and a thyroid nodule. A 23-year-old male presented for an evaluation of a change in his facial structures. Fibrous dysplasia was diagnosed by a bone biopsy and radiographic studies. The GH level increased paradoxically after an oral glucose load. The plasma prolactin, IGF-1 and alkaline phosphatase were high. Thyroid ultrasonography revealed multiple nodules. The brain MRI demonstrated a mass in the left pituitary gland. Genetic analysis identified a change from Arg (CGT) at codon 201 to Cys (TGT).

[A case of biliary cast syndrome after cadaveric liver transplantation].

We experienced one fatal case of biliary cast syndrome after cadaveric liver transplantation involving both intrahepatic ducts. A 58-year-old man underwent cadaveric liver transplantation because of hepatitis B virus related liver cirrhosis and concomitant hepatocellular carcinoma. Five weeks after the liver transplantation, postoperative course was complicated by development of acute cholangitis. Subsequent endoscopic retrograde cholangiography revealed diffuse intrahepatic bile duct strictures without filling defects. Percutaneous liver biopsy, which was done to exclude rejection, revealed biliary cast. Successful endoscopic removal was precluded due to its diffuse involvement. Because of the deterioration of patient's condition by refractory biliary obstruction and cholangitis, retransplantation from cadaveric donor was performed. Debridement of the biliary tree after graft removal yielded a near-complete cast of the intrahepatic ductal system. Biliary cast syndrome should be suspected when jaundice or cholangitis is associated with dilated ducts on abdominal imaging studies in cadaveric liver transplantation recipients. Initial therapeutic options include removal of biliary cast after endoscopic or percutaneous cholangiography. Although endoscopic retrieval of biliary cast by endoscopic retrograde cholangiopancreatography could be employed as a first-line management, other modalities such as endoscopic nasobiliary drainage, percutaneous transhepatic drainage, or retransplantation should be considered when complete removal is not feasible and the condition of the recipient deteriorates.