It has been established that removal of adenomas reduces the prevalence and mortality of colorectal cancers.1Winawer S.J. Zauber A.G. Ho M.N. et al.Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.N Engl J Med. 1993; 329: 1977-1981Crossref PubMed Scopus (3675) Google Scholar,2Zauber A.G. Winawer S.J. O'Brien M.J. et al.Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.N Engl J Med. 2012; 366: 687-696Crossref PubMed Scopus (1750) Google Scholar Because the miss rate of polyps in colonoscopy remains high, an appropriate approach for all polyps, even for lesions detected upon endoscope insertion, plays an important role in achieving high-quality colonoscopy. During colonoscopy, although left-sided polyps detected upon endoscope insertion are often missed after withdrawal of the endoscope, they are commonly not removed instantly during insertion of the endoscope; rather, they are removed during the withdrawal phase (WP) after the cecum has been reached. Teramoto et al3Teramoto A. Iwatate M. Sano Y. et al.Clinical importance of cold polypectomy during insertion phase in left side colon and rectum: a pilot study.J Gastroenterol Hepatol. 2018; 33: 132Google Scholar reported that instant polypectomy upon endoscope insertion is associated with a shorter procedure time, but this strategy requires advanced insertion and polypectomy techniques. Here, we propose a novel marking technique termed “suction marking method” as an alternative to performing polypectomy during the insertion phase (IP) of colonoscopy. Suction marks can be easily created by artificially applying suction pressure onto the mucous membrane, and these red marks assist redetection of polyps upon withdrawal of the colonoscope. We designed this prospective single-center study to investigate whether the application of suction marks near polyps detected during the IP improves their redetection rate upon withdrawal of the endoscope. All patients aged ≥20 years referred for total colonoscopy at Sano Hospital between March and May 2019 were screened for eligibility for the study. Written informed consent was obtained from each patient before the study. The exclusion criteria were as follows: colonoscopy indication due to bleeding, history of colectomy (excluding appendectomy), inflammatory bowel disease, polyposis of the alimentary tract, use of anticoagulant agents, pregnancy, and failure to reach the cecum or severe discomfort in a previous colonoscopy. The suction marking method was applied to patients, and the details of the examination were fully documented when at least 1 target polyp was detected during the IP. Target lesions in the left side of the colon were defined as follows: (1) adenomas or sessile serrated adenomas/polyps <10 mm and (2) hyperplastic polyps 6 to 10 mm in size. Patients with ≥6 polyps, poor bowel preparation, disinhibition/agitation due to sedation, and difficulty with endoscope insertion were excluded from the analysis. The study was approved by the institutional review board of Sano Hospital, Kobe, Japan (No. 201902-02) and was registered in a clinical trial registry (UMIN000036030). Eight senior endoscopists with at least 5 years of experience who had performed over 300 colonoscopies per year participated in this study. Premedications included scopolamine butylbromide (10-20 mg), midazolam (2.5-5 mg), and meperidine (25-50 mg, additionally used when required). Colonic insufflation was performed with CO2 gas in all cases. We used the Olympus 260 and 290 series colonoscopes with EVIS Lucera Spectrum or EVIS Lucera Elite video processors (Olympus Corporation, Tokyo, Japan). Distal attachments or transparent caps were not used during this trial. Yox Dispo Ope (Koike Medical, Tokyo, Japan) was used to apply the suction marks, and its pressure setting was 60 kPa. Upon endoscope insertion, 1 suction mark was created per lesion by aspiration of colonic mucosa for at least 10 seconds once a target lesion was detected (Figure 1, Figure 2, Figure 3, Figure 4). Each suction mark was made beside the lesion on either the oral or the distal side. The endoscopists chose the location where suction marking was technically easier to apply. This process was repeated when the suction mark was unclear. After a clear suction mark was confirmed, endoscope insertion was resumed, and all polyps were removed upon withdrawal of the endoscope by cold snare polypectomy. To measure the rate of successful redetection of polyps detected during the IP, we used 2 terms suggested by Teramoto et al:3Teramoto A. Iwatate M. Sano Y. et al.Clinical importance of cold polypectomy during insertion phase in left side colon and rectum: a pilot study.J Gastroenterol Hepatol. 2018; 33: 132Google Scholar (1) hiding polyp, a polyp detected during endoscope insertion, lost in the WP but eventually found after reinsertion of the colonoscope, and (2) missed polyp, a polyp detected during endoscope insertion but not found after a minimum of 2 minutes of reinspection.3Teramoto A. Iwatate M. Sano Y. et al.Clinical importance of cold polypectomy during insertion phase in left side colon and rectum: a pilot study.J Gastroenterol Hepatol. 2018; 33: 132Google ScholarFigure 2Applying suction pressure from 5 o’clock position for more than 10 seconds.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3A red suction mark is clearly visible. Endoscope insertion was resumed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4The mark remains prominent upon endoscope withdrawal and assists redetection of diminutive lesions.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The data capture sheet we used for this study included the following parameters: name of endoscopist, detection of target lesions (yes or no), quality of bowel preparation (excellent, good, or poor), use of analgesics and/or sedation, endoscope model used, number of target lesions detected during the IP, number of hiding and missed polyps, number of resected polyps during the WP, cecal intubation time, total procedure time, treatment time, time required to find each hiding polyp, time spent searching for missed polyps, endoscopic diagnosis, size, morphologic type, and location of polyps. The primary endpoint of this study was the proportion of hiding and missed polyps. The secondary endpoint included the duration of suction applied per lesion. A total of 166 patients were recruited for the trial from March to May 2019, and 39 patients (23.5%) had at least 1 detectable target lesion during the IP. Thirty-nine target lesions from 33 patients were eligible for full assessment (Fig. 5). The mean age of the study population was 63.6 ± 9.9 years, and 51.5% were men. Ninety-seven percent of patients received sedation, and the most common indication was surveillance colonoscopy after polypectomy (Table 1). Target lesions were mostly adenomas (34 [87.2%]) in the sigmoid colon (23 [59.0%]); their morphologic feature was type 0-IIa (34 [87.2%]), and their mean size was 4.3 ± 1.9 mm (Table 2). All target polyps were successfully redetected on endoscope withdrawal (Table 3). However, 1 hiding polyp (2.6%, 6 mm) in the sigmoid colon was reported. A mean suction duration of 30.2 ± 24.2 seconds was required to create a visible mark on the colonic mucosa. The mean withdrawal time was 7.5 ± 2.9 minutes. Adverse events were not reported during this trial.Table 1Baseline characteristics of patientsTotal number of patients (n)33 Male:female17:16 Age (mean ± SD)63.6 ± 9.9Sedation Sedatives only30 Sedatives + analgesics2 No sedatives or analgesics1Bowel preparation Excellent14 Good19Indications Surveillance after polypectomy13 FIT positive9 Symptomatic6 Other5FIT, Fecal immunochemical testing; SD, standard deviation. Open table in a new tab Table 2Characteristics of polypsSuction marked polyps (n)39Location Rectum/sigmoid/descending10/23/6Morphology Size (mm)4.3 ± 1.9 0-Is/0-IIa5/34Endoscopic diagnosis Adenoma34 Hyperplastic polyp5Time Cecal intubation time (min)6.7 ± 3.6 Withdrawal time (min)7.5 ± 2.9Data are presented as means ± standard deviation. Open table in a new tab Table 3Main outcomes in suction-marked polyps (n = 39)Outcomen(%) Successful redetection upon single withdrawal38(97.4) Hiding polyp1Winawer S.J. Zauber A.G. Ho M.N. et al.Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.N Engl J Med. 1993; 329: 1977-1981Crossref PubMed Scopus (3675) Google Scholar(2.6) Missed polyp0(0)Duration of suction applied per lesion (sec)30.2 ± 24.2∗Mean ± standard deviation.∗ Mean ± standard deviation. Open table in a new tab FIT, Fecal immunochemical testing; SD, standard deviation. Data are presented as means ± standard deviation. Our trial demonstrated the effectiveness of the suction marking method for successful redetection of polyps found during the IP. As presented in Video 1 (available online at www.VideoGIE.org), the suction marks were sufficiently prominent to assist redetection of polyps, and all marks were readily visible upon withdrawal. Notably, the proportion of hiding and missed polyps dropped significantly from 38% to 2.6% and 10% to 0%, respectively, in comparison with our previous randomized trial.3Teramoto A. Iwatate M. Sano Y. et al.Clinical importance of cold polypectomy during insertion phase in left side colon and rectum: a pilot study.J Gastroenterol Hepatol. 2018; 33: 132Google Scholar Recent data have shown that the miss rate of small and diminutive adenomas remains high, at 23.3%.4van Rijn J.C. Reitsma J.B. Stoker et al.Polyp miss rate determined by tandem colonoscopy: a systematic review.Am J Gastroenterol. 2006; 101: 343-350Crossref PubMed Scopus (934) Google Scholar Our strategy is advantageous because it can reduce the rate of missed lesions without requiring specific devices or skills. Another advantage of suction marking is that it does not cause excessive gas insufflation because air is automatically aspirated during the marking procedure; therefore, theoretically it does not lead to difficult endoscope insertion. The only disadvantage of our strategy is the 30-second interval needed to create a suction mark, which may be frustrating in comparison with the conventional strategy. To maintain the time efficiency of routine colonoscopy, our trial focused on left-sided and small/diminutive polyps and excluded multiple polyps. The main limitation of our study is that it was conducted in a single center with a small number of patients, and there was no control group. In conclusion, the suction marking method is a novel technique to prevent missing polyps detected upon endoscope insertion. Although this technique requires a short interval during endoscope insertion, it is a simple, reliable, cost-free, and widely available method for achieving better quality of colonoscopy. All authors disclosed no financial relationships relevant to this publication. The authors thank Wataru Sano, Mikio Fujita, Santa Hattori, and Mineo Iwatate for providing technical support, and Stephen Landua for English narration. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI1OTQ4ZWIwNWIwMGNhMmIwMjBkZmFhOWJlMjBiNDNkYiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjM2ODA3NDIzfQ.bZsF2UYXxDJ8SPwJwiyzTqHROgJFH66YG9ctErGWGPnwt__5b_x9VWUE6qrrkmZZd_Ai_Kz4FF7yiZkHY3ld0b0mcnFaw8kb384OQ79ufwKOwrzC7IxpKu9XVLB_tsLoUoOL_CNZZ3sW2Sdz5-dzFiZQ2s1iLd1WbF-df_tVOjp3Fn0EsODF3VK9XUK07ZHkvVNHnPM9kXMUTA5J8Nx18rZrQL_kSSdjrElZZ0Po2rSZEQVAHyByX2z7Il7o02APbt8va5W5hSDiAW5Z2Tpn5MZeZivbTrpSxYSq9jEMxDPfEL3OmYKll65gS7pKHiBHyr-r6FpLWeBhf_ezOkQIBA Download .mp4 (94.39 MB) Help with .mp4 files Video 1Clinical advantages of suction marking method during insertion phase of colonoscopy in left side colon and rectum.
A 74-year-old man developed hepatic injury after intravesical Bacillus Calmette-Guérin (BCG) therapy for bladder carcinoma. Although hepatitis-associated disseminated BCG was suspected, granulomatous formations were undetectable. The hepatic injury was considered to have resulted from an allergic reaction to BCG therapy because a histopathological assessment revealed enlarged portal areas with eosinophils and neutrophils. The hepatic injury was resolved by prednisolone. This case suggested that hepatic injury associated with BCG therapy might be due to an allergic mechanism unrelated to disseminated BCG disease. A liver biopsy is needed to confirm the histopathological findings of hepatic injury after BCG therapy in order to differentiate allergic hepatic injury from infectious hepatic injury.
A 54-year-old male patient underwent upper gastrointestinal endoscopy, which revealed a 25-mm brown region in the angular section of the greater curvature of the stomach. The region was histologically determined to be gastric mucosa with an accumulation of histiocytes containing eosinophilic substances in the cytoplasm and chronic inflammatory cell infiltration. Histiocytes were immunohistologically positive for CD68, IgG, and κ. Based on these findings, the patient was diagnosed with gastric crystal-storing histiocytosis comprised of histiocytes phagocytosing IgG-κ-type immunoglobulin. This is a rare disease of which there have been no previous reports that included long-term follow-up. Here, we report the case with a literature review.
Five years have passed since the Japan Narrow Band Imaging Expert Team (JNET) classification was proposed in 2014.However, the diagnostic performance of this classification has not yet been established.We conducted a retrospective study and a systematic search of Medical Literature Analysis and Retrieval System On-Line.There were three retrospective single center studies about the diagnostic performance of this classification.In order to clarify this issue, we reviewed our study and three previous studies.This review revealed the diagnostic performance in regards to three important differentiations.(1) Neoplasia from non-neoplasia; (2) malignant neoplasia from benign neoplasia; and (3) deep submucosal invasive cancer (D-SMC) from other neoplasia.The sensitivity in differentiating neoplasia from non-neoplasia was 98.1%-99.8%.The specificity in differentiating malignant neoplasia from benign neoplasia was 84.7%-98.2%and the specificity in the differentiation D-SMC from other neoplasia was 99.8%-100.0%.This classification would enable endoscopists to identify almost all neoplasia, to appropriately determine whether to perform en bloc resection or not, and to avoid unnecessary surgery.This article is the first review about the diagnostic performance of the JNET classification.Previous reports about the diagnostic performance have all been retrospective single center studies.A large-scale prospective multicenter evaluation study is awaited for the validation.
A 67-year-old male was diagnosed with advanced esophageal cancer. A computed tomography scan showed multiple intra-abdominal lymphadenopathies. Because the tumor was thought to be unresectable, we initiated chemotherapy. Twelve months later, the patient was admitted to our hospital because of hematemesis. Gastroduodenoscopy revealed oozing bleeding from the esophageal tumor. Hemostasis was not achieved with conservative treatment, and frequent blood transfusions were required. Endoscopic hemostasis was difficult to achieve because of the malignant esophageal stenosis. To treat the malignant esophageal stricture and esophageal tumor bleeding, we attempted to insert an esophageal covered self-expandable metallic stent. After the procedure, hemostasis was achieved by mechanical tamponade. Here we report a rare case of esophageal tumor bleeding that was managed with mechanical tamponade using an esophageal covered self-expandable metallic stent.
A 75-year-old woman with epigastric pain was admitted to our emergency department. She was diagnosed with an acute exacerbation of chronic pancreatitis based on the results of blood tests and abdominal computed tomography (CT). The abdominal CT and magnetic resonance cholangiopancreatography revealed pancreas divisum. Abdominal CT also showed a stone in the minor papilla, with impaction of the stone being the most likely cause of the acute episode. Therefore, endoscopic sphincterotomy of the minor papilla and endoscopic naso-pancreatic duct drainage were performed to remove the stone and decrease the internal pressure of the pancreatic duct. These procedures improved the patient's clinical status. The naso-pancreatic drainage tube was removed, and her pancreatitis has not recurred. Herein, we report a rare case of an impacted minor papilla stone in a patient with pancreas divisum that caused an acute exacerbation of chronic pancreatitis.
A 58‑year‑old woman was admitted to Suzuka General Hospital with fever. She was diagnosed with infectious endocarditis based on the presence of anterior mitral leaflet vegetation on the echocardiography analysis and isolation of Pseudomonas guariconensis by blood culture. During treatment, the hepatic enzymes levels, including aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH) and alkaline phosphatase (ALP) were increased without any abdominal symptoms. Prolonged prothrombin time (PT) and prothrombin time international normalized ratio were observed, and acute hepatic failure was diagnosed. However, the hepatic injury resolved spontaneously with restoration of the PT value after the hepatic enzymes (AST, ALT, LDH and ALP) peaked. Diffusion‑weighted imaging of hepatic magnetic resonance imaging showed diffuse high intensity of the entire liver except for part of the left lobe. The hepatic injury was diagnosed as ischemic hepatitis caused by embolization from the vegetation associated with infectious endocarditis. The recovery from hepatic ischemia was thought to be due to hepatic blood supply from extrahepatic collateral blood. After antibiotic treatment, the patient underwent resection of the vegetation on the anterior mitral valve leaflet. Hepatic artery occlusion is rare, but it may cause severe hepatic complications. During follow‑up of infectious endocarditis, clinicians should be aware of the potential for whole organ ischemic damage caused by vessel occlusion, as well as hepatic ischemic damage.
A married couple who developed hepatitis was referred to our hospital. The husband was diagnosed with acute hepatitis C virus (HCV) infection based on HCV RNA positivity and seroconversion to HCV antibody. The wife was also diagnosed with HCV-related hepatitis; however, she could not be confirmed to have acute hepatitis due to the lack of information on her HCV negativity just before this event. The HCV strains recovered from the couple were genotype 2b and shared 100% identities within the 5'-untranslated region-core region sequence (655 nucleotides/nt) and non-structural (NS)5B region sequence (502 nt). The amplified hypervariable region 1 (HVR-1) sequence indicated that all 10 clones from the wife shared 100% identity and were identical to 3 of 10 heterogeneous clones (separable into 4 groups) from the husband. The husband had a history of intravenous drug use. These results suggested that one of four quasispecies 2b HCV strains was transmitted from the husband to the wife, with the husband being the infectious source for acute HCV infection in the wife, most likely via sexual intercourse. A sequence analysis of the HCV genomes and the further comparison of the HVR-1 amino acid sequence variability may be useful for defining the infectious source of HCV, especially in couples or cluster cases.
