Effectiveness of Cytapheresis for Ulcerative Colitis in Special Situations: Delayed Onset of Optimum Efficacy in Elderly Patients.

BACKGROUND: Cytapheresis is a non-pharmacologic treatment option in which depleting elevated/activated leucocytes is known to exacerbate and perpetuate ulcerative colitis (UC) by releasing inflammatory cytokines. Therefore, it is a relevant treatment for elderly patients who wish to avoid pharmacologicals. METHODS: The efficacy of Cytapheresis for remission induction in 72 patients who received Cytapheresis for active UC at our hospital was retrospectively evaluated. Patients included 11 elderly cases, patients on steroids, biologics, calcineurin inhibitor, and 13 with extra-intestinal complications. Lichtiger's UC clinical activity index ≤4 meant remission was assessed at the end of therapy and then 1 month later. The efficacy on extra-intestinal manifestations meant improvement of the main morbidity. RESULTS: At the end of Cytapheresis therapy, the remission rate in the elderly was 36.4%, and 54.2% in the non-elderly patients. One-month post Cytapheresis, the remission rate in the elderly had increased to 72.7% (p = 0.042), but to 58.3% in the non-elderly, suggesting a delayed response phenomenon in the elderly. The efficacy of Cytapheresis in 4 cases with loss of response to biologics was 75%, and 84.6% in the 13 patients with extra-intestinal complications, indicating a dramatic efficacy on dermatitis and arthralgia. CONCLUSIONS: Unlike pharmacologicals, the efficacy of Cytapheresis appears to be time dependent. Accordingly, in the elderly, we observed a delayed response, indicating that elderly patients may respond beyond the end of Cytapheresis therapy. Therefore, patients who do not show efficacy at the end of Cytapheresis therapy should be followed up for delayed response. Further, Cytapheresis is favored by patients for its good safety profile.

Budesonide Foam for Ulcerative Colitis Patients Experiencing Inadequate Response to Biological Therapy.

BACKGROUND In recent years, a plethora of therapeutic agents for ulcerative colitis (UC), especially novel biologics (Bio), have become available. Although it is now possible to use biological drugs, there should be no need for frequently changing medications. To avoid first-pass metabolism in the liver, thus reducing systemic bioavailability, budesonide foam has been applied as a topical steroid. We therefore evaluated whether budesonide foam has therapeutic value in UC patients who responded inadequately to Bio or to tacrolimus. MATERIAL AND METHODS We enrolled 10 patients who were experiencing an inadequate response to Bio (n=7) or to tacrolimus (n=3) at Juntendo University. We used Lichtiger's index to assess UC activity and clinical response. RESULTS Of the study patients, 4 were receiving adalimumab, 3 golimumab, and 3 tacrolimus. The average Lichtiger's index before budesonide administration was 7.1 (range 13-3), which improved to 3.4 (range 7-0) after budesonide therapy (p=0.01). Notably, 4 of the 6 cases with a Lichtiger's index >4 before budesonide administration achieved improvement of ≥3 points or remission. CONCLUSIONS Although the number of patients was small, budesonide foam had significant efficacy when added to the treatment of patients having an inadequate response to Bio or to tacrolimus. These results suggest that in cases responding poorly to Bio, adding budesonide foam as combination therapy can achieve a clinical remission.

Efficacy and Acceptability of 1 Liter of Polyethylene Glycol with Ascorbic Acid vs. 2 Liters of Polyethylene Glycol Plus Mosapride and Sennoside for Colonoscopy Preparation.

BACKGROUND [color=black]Bowel preparation is an important factor for an optimal outcome of colonoscopy. Recently, polyethylene glycol (PEG) solution has been in common use for bowel cleansing for colonoscopy, but some patients are intolerant of PEG because of taste or volume. A low-volume PEG administered with ascorbic acid solution (PEG-Asc) was designed to improve tolerability, but the administration of this method is more complex than that with PEG alone. This study aimed to compare bowel cleansing efficacy, safety, and tolerability of 1 L PEG-Asc with a 2 L PEG preparation with use of sennosides and mosapride.[/color] MATERIAL AND METHODS [color=black]This was a prospective, single-center, non-inferiority trial that included 112 patients (PEG-Asc group, 68; PEG group, 44). The primary endpoint was the efficacy of colon cleansing assessed by endoscopists using a validated 4-point scale according to the Aronchick scale and was verified by a blinded investigator. Acceptability, tolerability, and adenoma detection rate (ADR) of these 2 regimens were secondary endpoints.[/color][color=black] [/color] RESULTS [color=black]We found no statistically significant differences between the groups in colon-cleansing efficacy or in the adenoma detection rate (ADR). Moreover, overall, patients significantly favored PEG-Asc over PEG, reflecting better acceptance of PEG-Asc. Additionally, more patients favored PEG-Asc over PEG for a hypothetical future colonoscopy. [/color] CONCLUSIONS [color=black]The alternate 1 L PEG-Asc regimen and standard 2 L PEG regimen were clinically equivalent with respect to cleansing efficacy, safety, and ADR, and more patients favored PEG-Asc than PEG. This alternate regimen may improve patient compliance and acceptance of surveillance colonoscopy.[/color].

Efficacy of cytapheresis for remission induction and dermatological manifestations of ulcerative colitis.

BACKGROUND: In ulcerative colitis (UC) patients, cytapheresis depletes elevated and activated leucocytes, which are known to release inflammatory cytokines including tumor necrosis factor (TNF)-α. Further, there are UC patients who develop erythema nodosum (EN) or pyoderma gangrenosum (PG) as extra-intestinal manifestations of UC. METHODS: Between 2008 and 2015, 181 consecutive patients with active UC received cytapheresis with either a granulocyte and monocyte apheresis (GMA) column or with a leucocyte removal filter (LCAP) as remission induction therapy. Each patient received weekly or intensive (2-3 sessions/week) cytapheresis up to 10 sessions. In 13 patients, UC was complicated by EN or PG. Lichtiger's clinical activity index (CAI) ≤4 meant remission, while ≥3 decrease in CAI meant response to therapy. Prednisolone sparing and the changes in the extra-intestinal manifestations were factored for assessing treatment efficacy. RESULTS: The overall remission and response rates were 52.5% and 71.8%, respectively, CAI fell from 9.4 ± 3.3 to 4.9 ± 3.5 (P < 0.001). The efficacy rates in subgroups on concomitant corticosteroid, anti-TNF or tacrolimus, and those without concomitant medications were not significantly different (P > 0.05). However, in 84 patients on prednisolone, the average daily prednisolone dose was reduced from 18.15 to 12.43 mg/day (P < 0.001) with 21.7% being corticosteroid free. All patients with EN or PG showed favorable response to cytapheresis, notably 2 EN patients achieving remission after just 2 cytapheresis sessions without concomitant medication. CONCLUSIONS: In this retrospective efficacy evaluation, cytapheresis was effective as remission induction therapy with steroid sparing effect and desirable safety profile. Further, patients with EN or PG responded favorably to cytapheresis.

Continuation of antithrombotic therapy may be associated with a high incidence of colonic post-polypectomy bleeding.

BACKGROUND AND AIM: Post-polypectomy bleeding (PPB) is the most common complication of endoscopic procedures. To reduce the risk of thromboembolic incidents, Japanese guidelines for gastroenterological endoscopy were revised to indicate that antithrombotic agents were not to be discontinued for endoscopic treatment. However, carrying out endoscopic procedures under antithrombotic medication potentially increases the incidence of hemorrhagic complications. The present study investigated the impact of the revised guidelines on the frequency of complications after colonoscopic procedures. METHODS: The surveillance period comprised the year before the initiation of the new guidelines (2012), which served as a control period, and 2 years after initiation of the new guidelines (2013 and 2014). During the control period, 3955 cases were examined colonoscopically and 1601 lesions were treated endoscopically. During the 2-year period under the new guidelines, 8749 colonoscopies and 3768 endoscopic treatments were carried out. Changes in treatment methods and rates of complications were compared. RESULTS: PPB rate was not significantly different before and after the revision (0.87% vs 1.01%). With the new guidelines, PPB rates in antithrombotic non-users and users were 0.60% and 3.13%, respectively (OR 5.11, P = 0.000). Multivariable analysis showed that the risks for PPB were as follows: heparin bridging therapy (OR 6.34, P = 0.0002); low-dose aspirin (LDA) continuation (OR 5.30, P = 0.0079); and lesion size (OR 1.06, P < 0.0001). CONCLUSION: The present study showed that the overall PPB rate under the new guidelines was not significantly higher when compared with the previous data obtained before the new guidelines were introduced.

Closure with clips to accelerate healing of mucosal defects caused by colorectal endoscopic submucosal dissection.

BACKGROUND: Most mucosal defects that occur with endoscopic submucosal dissection (ESD) can be closed completely using endoscopic clips. However, benefits of such closure in wound healing are unknown. A randomized controlled study evaluated the efficacy of closure with clips compared with no closure. METHOD: Twenty-eight patients who had undergone ESD were randomly divided into two groups: closure (n = 14) and non-closure groups (n = 14). In the closure group, the mucosal defect resulting from ESD was closed using endoscopic clips. Four weeks after ESD, defects in both groups were observed by colonoscopy. Efficacy was based on change in the area of the defect, percentage of complete healing in each group, and complications. RESULT: Data were analyzed for 26 of the 28 patients (13, closure group; 13, non-closure group). All tumors were resected en bloc by ESD without bleeding or perforation. In the closure group, the area of the defect just after ESD was 677 ± 306 mm(2) (mean ± SD) as determined by the size of the removed lesion and had decreased to 2.17 ± 4.51 mm(2) at 4 weeks after ESD (reduction, 99.7 %), but in the non-closure group that area was 790 ± 221 mm(2) and had decreased to 27.42 ± 25.72 mm(2) at 4 weeks post-ESD (reduction, 96.2 %). The reduction rate was significantly higher in the closure than in the non-closure group (99.7 vs. 96.2 %, p = 0.010). Complete healing was 69.2 % in the closure group vs. 7.7 % in the non-closure group (p = 0.005). Multivariate analysis showed that closure of the mucosal defect (OR 24.029, 95 % CI 2.09-276.15, p = 0.011) was an independent factor associated with complete healing at 4 weeks after ESD. Delayed perforation or post-ESD bleeding was not observed in any participant. CONCLUSION: Use of endoscopic clips for closure of defects after ESD is safe and efficacious in accelerating wound healing. TRIAL REGISTRATION: UMIN-CTR UMIN000009112.

Usefulness of flexible spectral imaging color enhancement for the detection and diagnosis of small intestinal lesions found by capsule endoscopy.

OBJECTIVE: Capsule endoscopy (CE) is an established technique for the detection and diagnosis of obscure gastrointestinal bleeding (OGIB). Flexible spectral imaging color enhancement (FICE) is a software feature of RAPID 6.5. This study assessed the value of FICE for accurate identification of red lesions during CE. METHODS: We randomly selected 10 patients who underwent CE for OGIB at Juntendo University. The CE images were read by five endoscopists. Small bowel videos, which were recorded by regular CE devices (PillCam SB2, Given Imaging), were evaluated on RAPID 6.5. We standardized the reading condition to a dual view, at a speed of 20 frames/s in manual mode. This interpreted FICE-CE images obtained at settings 1-3. Both conventional and FICE images were read at random. We defined a conventional image as standard and investigated the potential of FICE in detecting small intestinal lesions by the Steel-Dwass test. RESULTS: We considered that conventional images represented baseline (100). On this basis, detection rates for FICE images were as follows: FICE1 = 266.4 ± 33.1 (p < 0.0001); FICE2 = 255.4 ± 25.6 (p < 0.0001); and FICE3 = 117.0 ± 12.3 (p = 0.9447). Detection rates using FICE1 and FICE2 images were significantly higher than conventional CE images. FICE1 and FICE2 were more useful in detecting erosions than conventional CE (p < 0.0001) and FICE3 (p < 0.0001). CONCLUSIONS: FICE-CE has a high level of visibility by transparentizing bile or enhancing the color difference associated with reddish mucosa. We found that FICE-CE images were useful in the diagnosing of small intestinal lesions.

Frequent occurrence of fever in patients who have undergone endoscopic submucosal dissection for colorectal tumor, but bacteremia is not a significant cause.

BACKGROUND: We examined the incidence of and factors associated with fever, as well as the frequency of bacteremia, in patients who had undergone endoscopic submucosal dissection (ESD) for colorectal tumor. METHOD: A total of 199 patients (120 male and 79 female) were included. The patients were classified into two groups based on the body temperature on the day after ESD treatment: group A, body temperature <37 °C; and group B, body temperature ≥37 °C. The following factors were analyzed to determine their potential association with post-ESD fever: gender, age, tumor size, form, location, and presence or absence of intraoperative perforation. In addition, blood samples from 50 patients were obtained for blood culture and 16S rRNA gene analysis by polymerase chain reaction. RESULTS: Group A included 106 patients (70 male and 36 female), with a median age of 63 years. Group B included 93 patients (50 male and 43 female), with a median age of 70 years. The incidence of post-ESD fever in the entire cohort was 46.7%. Univariate analysis based on comparison between groups A and B showed that the following factors were significantly associated with post-ESD fever: age [mean ± standard deviation (SD)], 64.5 ± 9.2 versus 68.5 ± 10.8 years, P = 0.006; and tumor size (mean ± SD) 30.6 ± 10.8 versus 39.1 ± 16.6 mm, P < 0.001. Logistic regression analysis for post-ESD fever also found that age {odds ratio 1.04 (95% CI [1.01-1.07], P = 0.009)} and lesion size {odds ratio 1.05 (95% CI [1.03-1.08], P = 0.0002)} were closely associated with post-ESD fever. Of the 50 patients who had blood samples cultured and 16S rRNA gene analyzed, bacteria in blood culture and the 16S rRNA gene were not detectable in any of the samples from the 50 patients. CONCLUSIONS: This study indicated that older patients and patients with large tumors were more likely to develop post-ESD fever, but there was a low probability that bacteremia was the cause of fever.

Prospective clinical trial of traction device-assisted endoscopic submucosal dissection of large superficial colorectal tumors using the S-O clip.

BACKGROUND: Endoscopic submucosal dissection (ESD) allows en bloc resection of superficial colorectal tumors regardless of size. However, ESD is technically difficult, hazardous, and time consuming. New devices may help overcome these drawbacks. We focused on traction methods and designed a new traction device, the "S-O clip." Its main advantage is that it allows direct visualization of the cutting line during submucosal dissection. Moreover, it can be used at any location without withdrawing the endoscope. The purpose of this study was to evaluate the efficacy and safety of traction device-assisted ESD for large colorectal tumors using the S-O clip. METHODS: Between August 2010 and December 2011, ESD was performed in 70 patients with a superficial colorectal tumor ≥20 mm in diameter in our department. Patients were randomized into two groups: 27 cases in the S-O clip-assisted ESD group and 23 cases in the conventional ESD group. Included in the analysis were patient's gender and age, tumor form, size, and location, rate of en bloc resection, procedure time, presence or absence of intraoperative perforation or delayed bleeding, and pathological findings. Subgroup analysis stratified by these factors and multivariate analyses were conducted. RESULTS: In the S-O clip-assisted ESD group, all 27 tumors were resected en bloc without any complications. Although a micro perforation occurred in one patient in the conventional ESD group, further surgical treatment was not required. None of the other 22 cases in the conventional ESD group experienced complications. The mean procedure time for the S-O clip-assisted ESD group was significantly shorter than for the conventional ESD group (37.4 ± 32.6 vs. 67.1 ± 44.1 min, p = 0.03). No significant between-group differences were found for the other factors. CONCLUSION: Our results demonstrated that S-O clip-assisted ESD is safe and fast for en bloc resection of large superficial colorectal tumors.

Development and clinical usability of a new traction device "medical ring" for endoscopic submucosal dissection of early gastric cancer.

BACKGROUND: Although various traction devices exist for endoscopic submucosal dissection (ESD), the effects of the material used in the devices on the human body has not been considered. Moreover, there has been no report on a device that facilitates dissection both on the oral and anal side of the lesion. We made a traction device that has no deleterious effects on the body and is noninvasive, easy to use, and enables a bilateral approach in ESD. We report the process of its creation and a prospective evaluation of its usage in actual ESD procedures. METHODS: This study is prospective case control study. Thirty-seven patients for whom the device would be used were consecutively and prospectively enrolled (device used group). Control subjects in whom the device would not be used and who had lesions matched for size and location with those of the device used group were randomly selected (device not used group). Both groups were classified into three subgroups according to treatment difficulty: group A: easy; group B: intermediate; and group C: difficult. The dissection time per cm(2) in each group was examined. RESULTS: Dissection times in the device not used group/device used group were as follows: group A, 5.8/2.1 min/cm(2) (p < 0.01); group B, 6.1/3.8 min/cm(2) (p < 0.05); and group C, 7.9/3.6 min/cm(2) (p < 0.01), respectively. CONCLUSIONS: The newly developed medical ring was shown to be feasible and safe and allowed excellent visualization through suitable tension and facilitated rapid gastric ESD.

Multiple carcinoid tumors of the small intestine preoperatively diagnosed by double-balloon endoscopy.

BACKGROUND: Multiple carcinoid tumors of the small intestine are rare and are very difficult to detect preoperatively. CASE REPORT: A 75-year-old woman in whom the bleeding focus could not be found by upper and lower endoscopy and abdominal CT was admitted for evaluation of anemia. We examined the patient with total double-balloon endoscopy (DBE) and located multiple submucosal tumors. The multiple carcinoid tumors were resected successfully under laparoscopy. CONCLUSIONS: We report a case of a successful laparoscopic operation for multiple carcinoid tumors in the small intestine without intraoperative endoscopy. Total digestive tract observation using DBE is very useful for laparoscopic operation for multiple tumors in the small intestine.

Colonic mucosal lesions associated with low-dose aspirin: a case control study.

OBJECTIVE: Low-dose aspirin (LDA) is widely used because it reduces the risk of vascular events in patients with atherosclerosis. Recently, there has been a substantial increase in prescriptions for LDA. We analyzed the risk of colonic mucosal lesions associated with the long-term use of LDA. MATERIAL AND METHODS: Among Japanese patients who underwent a colonoscopy between January 2004 and December 2006, 199 colitis cases and 5764 non-colitis controls were identified after excluding 749 patients based on study criteria. The history of LDA use was compared between the cases and controls and the multivariate (age-, sex- and underlying diseases-) adjusted odds ratio (OR) was estimated using a multiple logistic regression model. RESULTS: The adjusted OR for colonic mucosal lesions associated with LDA use versus non-use was 1.45 [95% confidence interval (CI), 0.87-2.42; p = 0.152]. In terms of gender differences, the OR for LDA-induced colitis in females was significantly increased at 2.55 (95% CI, 1.31-4.94; p = 0.006) but was not significantly increased in males at 0.70 (95% CI, 0.34-1.45; p = 0.334). CONCLUSIONS: In females, LDA increased the risk of colonic mucosal lesions, suggesting that LDA may contribute to the pathogenesis of colonic ulceration or colitis. Therefore, it is essential that prescribing physicians be aware of the risk of LDA-induced colonic lesions.

Metastatic renal cell carcinoma diagnosed by capsule endoscopy and double balloon endoscopy.

BACKGROUND: Renal cell carcinoma commonly metastasizes to lung, liver, and bone. Small intestinal metastases are exceedingly rare. CASE REPORT: A 75-year-old man presented at our hospital with tarry stools. He had undergone a right nephrectomy for renal cell carcinoma (RCC) 6 years previously; in addition, he had received antiplatelet treatment for ischemic heart disease. Esophagogastroduodenoscopy, total colonoscopy, and computed tomography did not identify any cause for the gastrointestinal bleeding. He underwent capsule endoscopy (CE), which revealed an ulcerated submucosal tumor in the jejunum. We performed a double-balloon endoscopy (DBE), and histological findings identified a clear cell carcinoma. We diagnosed metastasis from the RCC. We performed a jejunectomy to resect the tumor and thus eliminate the source of the bleeding. CONCLUSIONS: CE and DBE are useful diagnostic tools. We recommend investigating the possibility of small intestinal metastases in cases of intestinal bleeding or anemia in patients with a history of malignant tumor.

Clinicopathological characteristics of colorectal cancer less than 10 mm in diameter and invading submucosa and below.

BACKGROUND AND AIMS: Identifying the invasive depth of cancers less than 10 mm in diameter remains a challenge. This study examines the clinicopathological characteristics of colorectal cancers less than 10 mm in diameter and invading submucosal layer (SM)3 and below, which require surgery and must never be treated by endoscopic mucosal resection. METHODS: We studied 54 cases of colorectal cancer less than 10 mm in diameter and invading the submucosa and deeper tissues, by dividing them into two groups: those invading SM1 and SM2 versus those invading SM3 and below. We investigated the clinicopathological characteristics of cancers invading SM3 and below by comparing them with cancers invading SM1 and SM2. Similarly, 38 cases, whose endoscopic findings could be analyzed, were selected and examined. RESULTS: In cases invading SM3 and below, the rates of moderately to poorly differentiated adenocarcinoma, lymphatic and venous permeation and lymph node metastasis were significantly higher than those invading SM1 and SM2. Among cases invading SM3 and below, the presence of endoscopic findings-including white spots of the protruded type, and fullness, white spots, hardness and protruded lesions in the depressed area of the depressed type-was significantly higher than among those invading SM1 and SM2. CONCLUSION: Colorectal cancers less than 10 mm in diameter and invading SM3 and below have high malignant potential. Cancers of this invasive depth can be identified by looking for characteristics such as white spots, fullness, hardness and protruded lesions in the depressed area. Careful endoscopic observation for these signs aids in determining the appropriate treatment.

Colonic mucosal lesions associated with long-term or short-term administration of nonsteroidal anti-inflammatory drugs.

AIM: The effects of short- or long-term administration of nonsteroidal anti-inflammatory drugs (NSAIDs) on the colon have not been well characterized. We assessed the risk of developing colonic mucosal lesions according to the duration of exposure to NSAIDs: short-term and/or long-term use. METHOD: A case-controlled study was performed by reviewing medical records for endoscopic findings, underlying disease, pre-endoscopic symptoms, category of NSAIDs used and duration of use. The patients underwent colonoscopy between January and October 2004, and 75 colitis cases and 1801 non-colitis controls were identified. The prevalence of NSAID use was compared between the cases and controls. The age- and sex- adjusted odds ratios (OR) were estimated using multiple logistic regression models. RESULTS: NSAIDs had been used in colitis cases and non-colitis controls for over six months in 20.0% and 12.7%, and for one week in 4.0% and 2.1%. Overall 76.0% and 85.2% had not received NSAIDs. The adjusted OR (95% confidence interval) for colonic mucosal lesions with short- and long term NSAID administration combined vs. non-use was 2.04 (1.16-3.61). When determined separately for short- and long-term NSAID users, the adjusted ORs were 1.48 (0.42-5.25) and 2.21 (1.19-4.11), compared to non-users. These values signify a trend toward an increased frequency of colonic mucosal lesions with longer use of NSAIDs (P=0.011 for trend). CONCLUSION: Long-term use of NSAIDs increased the risk of colonic mucosal lesions, suggesting that NSAIDs may contribute to the pathogenesis of colonic ulcer or colitis.

Response to chemotherapy in a case of gastric adenocarcinoma producing granulocyte colony-stimulating factor.

BACKGROUND: Little is known about the patient characteristics and tumor characteristics associated with a high level of granulocyte colony-stimulating factor (G-CSF) and leukocytosis. Moreover, the prognosis of G-CSF-producing gastric cancer has been extremely poor. CASE REPORT: A 72-year-old man presented with fatigue and body weight loss. Laboratory testing showed pronounced leukocytosis (white blood cell count, 34900×106/L). Bone marrow aspiration biopsy excluded leukemia and metastatic leukemoid reaction. G-CSF-producing cancer was suspected as the cause of the abnormally elevated serum G-CSF level (293 pg/ml). Gastrointestinal endoscopy showed type 3 gastric cancer, and the biopsy specimens were histologically proven to include moderately to well differentiated adenocarcinoma with positive expression of G-CSF. Abdominal computed tomography showed a lymph node lesion and multiple hepatic metastatic lesions. This patient was diagnosed as having stage IV gastric cancer that produced G-CSF. We treated the patient with 3 chemotherapy regimens, and he survived for almost 2 years after diagnosis. CONCLUSIONS: The possibility of a G-CSF-producing tumor should be investigated in patients who present with severe leukocytosis in the absence of infection. This unusual gastric cancer should be treated as soon as possible after diagnosis.

Endoscopic submucosal dissection of large colorectal tumors by using a novel spring-action S-O clip for traction (with video).

BACKGROUND: Endoscopic submucosal dissection (ESD) allows en bloc resection of large GI neoplasms, regardless of their size; however, technical difficulties associated with ESD in the colorectum make it less widely applied in the treatment of tumors in this region. To address this difficulty, we designed a rubber strip-based traction device, called the S-O clip (Sakamoto-Osada clip) and reported previously that ESD with this device was effective for complete resection of large, superficial colorectal neoplasms. In this report, we describe a novel spring-action version of the S-O clip (spring S-O clip) that improves the facility of clip use during ESD of colorectal tumors. OBJECTIVE: To evaluate the efficacy and safety of the spring S-O clip for ESD of colorectal neoplasms. DESIGN: Case series. SETTING: Juntendo University Hospital. MAIN OUTCOME MEASUREMENTS: The efficacy and safety of the spring S-O clip traction device during ESD of colorectal tumors. RESULTS: In 3 cases, a large, superficial neoplasm in the right side of the colon was removed safely and successfully en bloc without complication. Procedure times for the 3 cases were 44, 27, and 49 minutes, with resected specimens measuring 40, 24, and 35 mm, respectively. LIMITATION: Uncontrolled study. CONCLUSION: This limited case series demonstrates that spring S-O clip-assisted ESD is safe and effective for en bloc resection of large superficial neoplasms in the right side of the colon.

Gastrointestinal tuberculosis as a cause of massive bleeding.

BACKGROUND: Although minor bleeding is fairly common among cases of gastrointestinal tuberculosis, massive hemorrhage necessitating blood transfusion is rare. CASE REPORT: A 72-year-old woman presented to the hospital with hematochezia. Colonoscopy revealed multiple ulcers, including round ulcers, throughout the large intestine. Upper gastrointestinal endoscopy revealed multiple duodenal ulcers. Hemostasis was performed on the bleeding point, but other untreated ulcers exhibited recurrent bleeding. Fecal culture results established the diagnosis of gastrointestinal tuberculosis. The patient was put on a standard antituberculosis regimen and remains in remission. CONCLUSIONS: Gastrointestinal tuberculosis should be considered as one of the causes for massive and intractable gastrointestinal bleeding.

Double-balloon endoscopy for treatment of long-term abdominal discomfort due to small bowel penetration by an eel bone.

BACKGROUND: Penetration of the GI tract by a fish bone was treated by laparotomy. DBE is a useful procedure for removal of a foreign body from the small bowel. CASE REPORT: A 33-year-old male presented with bothersome postprandial fullness. He was diagnosed previously with functional dyspepsia, and had been treated with medication for 8 months with no success. During antegrade DBE, which was performed to rule out of small intestinal abnormalities, an eel bone found stuck in the jejunum was grasped with forceps and pulled out. Following removal of the bone, the patient's postprandial fullness ameliorated dramatically. CONCLUSIONS: This is the first report of DBE-based diagnosis and treatment of a small bowel penetration by a fish bone.