Underwater endoscopic papillectomy for a small neuroendocrine tumor of the ampulla of Vater.

Neuroendocrine tumors (NETs) of the ampulla of Vater are rare. Therefore, there is a lack of comprehensive information regarding their pathogenesis. We herein present the case of a patient with a 5-mm ampullary NET who demonstrated the presence of lymphatic invasion after undergoing endoscopic papillectomy. A 44-year-old woman was referred to our hospital for treatment of a grade 1 NET in the ampulla of Vater. Endoscopic ultrasonography revealed a hypoechoic mass within the submucosal layer without obvious infiltration into the common bile duct or the main pancreatic duct. We performed underwater endoscopic papillectomy (UEP) to remove the tumor with a negative margin. Pathological evaluation of the resected specimen showed a grade 1 NET with a negative margin. However, pancreaticoduodenectomy was subsequently performed because of the risk of lymph node metastasis, which was expected due to the significant number of NET cells infiltrating the endothelium of the lymphatic vessels. No lymph node metastasis or recurrence was observed during the 26-month follow-up period. UEP is a useful method to achieve complete resection for diagnostic and therapeutic purposes. UEP may be a novel option for endoscopic treatment of ampullary NET.

Malignant Peritoneal Mesothelioma with Latent Tuberculosis Infection.

Malignant peritoneal mesothelioma (MPM) is a rare malignant tumor with peritoneal thickening. Tuberculous peritonitis also shows peritoneal thickening, so differentiating between the two is important but difficult if latent tuberculosis infection (LTBI) is present. We herein report a patient with MPM and LTBI. A 79-year-old man was diagnosed with peritoneal thickening on computed tomography. Interferon gamma release assay (IGRA) results were positive, suggesting tuberculous peritonitis. He underwent a laparoscopic omental biopsy and was diagnosed with MPM, which can occur together with LTBI. If peritoneal thickening is observed, an IGRA should be performed early, and the possibility of LTBI should be considered.

[Endoscopic closure of an esophago-pleural fistula resulting from a perforated esophageal ulcer due to systemic sclerosis:filling and shielding using polyglycolic acid sheets and fibrin glue].

A woman in her 70s with systemic sclerosis experienced dyspnea, and consequently, she was diagnosed with an esophago-pleural fistula, which was caused by a perforated esophageal ulcer. We administered conservative treatments including continuous pleural drainage and total parenteral nutrition. The fistula was closed but recurred, at which point we attempted to close the fistula by filling and shielding using polyglycolic acid (PGA) sheets and fibrin glue (FG). We were able to safely and smoothly fill and shield the fistula using the PGA sheets with a guidewire. We show that endoscopic closure of an esophago-pleural fistula using this technique is an effective, low-invasive treatment for gastrointestinal perforation and refractory fistulas.

Filling of Polyglycolic Acid Sheets for Closure of Gastrointestinal Fistulas With an Easily Deliverable Technique Using a Guidewire.

BACKGROUND: This retrospective study aimed to investigate the suitable indications, methodology and long-term effect of the closure of gastrointestinal (GI) fistulas using polyglycolic acid (PGA) sheets and fibrin glue (FG) and to evaluate the usefulness of a delivery technique using a guidewire. METHODS: It involved 10 applications in six patients (median age 73 (range 53 - 78) years old, three men) with GI fistulas. A guidewire was introduced endoscopically or percutaneously into the fistula beyond the opposite orifice of the fistula with radiologic control. A tapered catheter was inserted over the guidewire, and the fistula was cleaned with an adequate quantity of saline. Subsequently, a small piece of PGA sheet was skewered onto the guidewire at the center and then pushed using the tapered catheter over the guidewire and delivered into the fistula. In cases of endoscopic procedure, the mucosa around the fistula was ablated, and the orifice of the fistula along with the surrounding mucosa was shielded with a piece of PGA sheet fixed with hemoclips and FG. RESULTS: Technical success of fistula closure was achieved in all applications, and no complications were observed after the procedure. The long-term occlusion of the fistula was ultimately achieved in four of six patients at 202 - 654 days (median duration, 244 days) after the last procedure with one or two applications. CONCLUSIONS: The closure of GI fistulas using PGA sheets and FG demonstrated long-term efficacy for upper GI fistula of a certain length, and the filling technique using a guidewire ensured a safe smooth procedure.

IgG4-related Autoimmune Hepatitis with a Suspected Drug-induced Etiology.

A 69-year-old man was referred to our department with acute hepatitis. He had been newly treated with benidipine hydrochloride for two months. His blood test results were as follows: aspartate aminotransferase, 1,614 IU/L; alanine aminotransferase, 1,091 IU/L and anti-smooth muscle antibody, ×80. Needle liver biopsy specimen showed interface hepatitis with mainly lymphocytic infiltration and bridging fibrosis in the periportal area. Immunohistochemistry revealed lymphocytic infiltration positive for IgG4. We diagnosed him with IgG4-related AIH with an etiology that was suspected of being drug-induced. Oral prednisolone was started and then tapered after achieving biochemical remission. Hepatitis recurred after the cessation of steroids; however, remission was achieved with ursodeoxycholic acid.

A rare case of Goodpasture syndrome concomitant with bleeding jejunal Dieulafoy's lesion.

An 81-year-old man was diagnosed with Goodpasture syndrome (GS) because he met the criteria of positive anti-GBM antibodies, rapid progressive glomerulonephritis and pulmonary hemorrhage. After starting plasmapheresis and steroid pulse therapy, he experienced tarry stool and contrast-enhanced CT revealed an aneurysmal finding in the jejunum. Paroral enteroscopy showed a jejunal Dieulafoy's lesion (DL) with gush-out hemorrhage. Hemostasis was successfully achieved by hemoclipping, and he then experienced no re-bleeding events. GS can present as a jejunal DL, and contrast-enhanced CT is useful for investigating the etiology and site of small intestinal bleeding, which can lead to smooth, effective endoscopic hemostasis.

Endoscopic Gastrojejunostomy for Superior Mesenteric Artery Syndrome Using Magnetic Compression Anastomosis.

An 89-year-old woman who was bedridden suffered repeated vomiting due to superior mesenteric artery syndrome (SMAS). We performed gastrojejunostomy via the magnetic compression anastomosis (MCA) technique because her situation was not improved by conservative therapy and because the operative risk was high. We prepared two neodymium magnets: a flat plate-shaped magnet (15 × 3 mm) and a ring-shaped magnet of the same size. The ring-shaped magnet which passed through a guidewire was pushed to the duodenum by an endoscope over the guidewire. The duodenal stricture was balloon-dilated in front of the magnet, and the magnet was pushed all together beyond the stricture and placed at the duodenojejunal junction. Subsequently, the flat plate-shaped magnet was delivered endoscopically to the stomach using a biopsy forceps. The magnets were attracted towards each other transmurally after one more flat plate-shaped magnet was added to the gastric-side magnet. Completion of gastrojejunostomy was confirmed while retrieving the magnets 10 days after starting compression. She has been asymptomatic for 1 month since anastomosis. Endoscopic gastrojejunostomy using MCA was an effective, low-invasive treatment for SMAS.

Experience of Endoscopic Jejunojejunostomy for Anastomotic Obstruction After Subtotal Gastrectomy Using Magnetic Compression Anastomosis.

Magnetic compression anastomosis (MCA) was developed as a low-invasive treatment for gastro-enteric or entero-enteric obstruction. A 72-year-old man underwent subtotal gastrectomy with Billroth II reconstruction for early gastric cancer. After the operation, he suffered from repeated aspiration pneumonia due to anastomotic obstruction caused by jejunal kinking at the efferent loop of anastomosis. We therefore performed jejunojejunostomy via the MCA technique, as his situation was not improved despite conservative therapy and he had a high reoperative risk. We prepared two flat plate-shaped neodymium magnets (15 × 3 mm) each with a small hole, and a nylon thread was passed through each hole. Each magnet was then delivered endoscopically to the anal side of the jejunal kinking, subsequently to the anastomosis, using biopsy forceps. The two magnets immediately became attracted towards each other transmurally. Oozing hemorrhage with clot at the mated magnets was observed 10 days after starting the compression. After retrieving the magnets, we confirmed the completion of jejunojejunostomy and then successfully achieved hemostasis of the anastomotic hemorrhage using argon plasma coagulation. The widely patent anastomosis was confirmed endoscopically 1 month after canalization; and he has been asymptomatic and able to eat a normal diet ever since. Endoscopic MCA is an effective, low-invasive treatment for anastomotic obstruction after subtotal gastrectomy. A standardized, safer procedure should be established for general use in the clinical setting.

Prophylactic Biliary Stenting Before Cholecystectomy in Patients With Gallstones and Common Bile Duct Stones.

BACKGROUND: The usefulness of prophylactic biliary stenting for patients with common bile duct stones (CBDS) and gallstones (GS) to prevent recurrent biliary events after endoscopic sphincterotomy (EST) and CBDS extraction before elective cholecystectomy remains controversial. The aim of this study was to evaluate the risk of recurrent CBDS around the perioperative period and clarify its risk factors. METHODS: The clinical data of all patients who received prophylactic biliary stenting after EST for CBDS and later underwent cholecystectomy for GS followed by stent extraction in our institution were retrospectively reviewed. The numbers of residual CBDS at the end first and second endoscopic retrograde cholangiography (ERC) studies were compared. Univariate and multivariate analyses were performed using a logistic regression model to determine risk factors for recurrent CBDS in the perioperative period. RESULTS: Forty-two consecutive patients received prophylactic biliary stenting and subsequent cholecystectomy for GS. Three of these patients were excluded from this study because the number of residual stones was not confirmed. The median maximum CBDS diameter at second ERC was 0 mm (range, 0 - 10 mm); six patients had multiple CBDS (≥ 5). The number of CBDS at second ERC was increased in comparison to that at the first ERC in 15 patients (38.4%), and was unchanged or decreased in 24 patients. The median minimum cystic duct diameter was 4 mm (range, 1 - 8 mm). The median interval between first ERC and operation was 26 days (range, 2 - 131 days). The median interval between operation and second ERC was 41 days (range, 26 - 96 days). Laparoscopic cholecystectomy (LC) was performed in 38 patients, one of whom was converted from LC to open cholecystectomy. Postoperative complications (transient bacteremia) occurred in one patient. The cystic duct diameter was an independent risk factor for an increased number of CBDS at second ERC in the multivariate analysis (odds ratio 0.611 (95% confidence interval (0.398 - 0.939)), P = 0.03). CONCLUSION: Recurrent CBDS around the perioperative period of cholecystectomy is not a rare complication after EST and the removal of CBDS with concomitant GS. Prophylactic biliary stenting is considered useful for preventing CBDS-associated complications, especially for patients in whom the cystic duct diameter is larger (≥ 5 mm).

Risk of colorectal cancer for fecal immunochemistry test-positive, average-risk patients after a colonoscopy.

BACKGROUND AND AIM: Because the risk of colorectal cancer has not been well examined in fecal immunochemistry test (FIT)-positive patients who previously underwent colonoscopy, this study aimed to investigate this topic. METHODS: This was a single-center, observational study of prospectively collected data in Japan. FIT-positive, average-risk patients who underwent colonoscopy were divided into groups as follows: those who never underwent colonoscopy in the past (no colonoscopy group), those with a history of colonoscopy between 6 months and 5 years (0.5- to 5-year colonoscopy group), and those with a history of colonoscopy more than 5 years ago (> 5-year colonoscopy group). We investigated the prevalence of advanced neoplasia and invasive cancer among these groups using multiple logistic regression analysis. RESULTS: Detection rates of advanced neoplasia in the no colonoscopy group, 0.5- to 5-year colonoscopy group, and > 5-year colonoscopy group were 14.8% (240/1626), 3.9% (13/330), and 6.9% (17/248), respectively. Detection rates of invasive cancer in each aforementioned group were 5.7% (92/1,626), 0.3% (1/330), and 1.2% (3/248), respectively. Odds ratios of advanced neoplasia in the 0.5- to 5-year colonoscopy group and > 5-year colonoscopy were 0.23 (95% confidence interval [CI]: 0.13-0.42) and 0.40 (95% CI: 0.24-0.68), respectively, in multivariate analysis. The odds ratios of invasive cancer in each aforementioned group were 0.05 (95% CI: 0.01-0.37) and 0.19 (95% CI: 0.06-0.61), respectively. CONCLUSION: Re-screening with the FIT should not be recommended for at least 5 years for average-risk patients after colonoscopy without high-risk neoplasms, because the risks of colorectal cancer are low in such patients.