Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, 807-8555, Japan. amurata@med.uoeh-u.ac.jp
Abstract: Purpose: Little information is available on the influence of diabetes mellitus on the short-term clinical outcomes of patients with bleeding peptic ulcers. The aim of this study is to investigate whether diabetes mellitus influences the short-term clinical outcomes of patients with bleeding peptic ulcers using a Japanese national administrative database. Materials and Methods: A total of 4863 patients treated by endoscopic hemostasis on admission for bleeding peptic ulcers were referred to 586 participating hospitals in Japan. We collected their data to compare the risk-adjusted length of stay (LOS) and in-hospital mortality of patients with and without diabetes mellitus within 30 days. Patients were divided into two groups: patients with diabetes mellitus (n=434) and patients without diabetes mellitus (n=4429). Results: Mean LOS in patients with diabetes mellitus was significantly longer than those without diabetes mellitus (15.8 days vs. 12.5 days, p<0.001). Also, higher in-hospital mortality within 30 days was observed in patients with diabetes mellitus compared with those without diabetes mellitus (2.7% vs. 1.1%, p=0.004). Multiple linear regression analysis revealed that diabetes mellitus was significantly associated with an increase in risk-adjusted LOS. The standardized coefficient was 0.036 days (p=0.01). Furthermore, the analysis revealed that diabetes mellitus significantly increased the risk of in-hospital mortality within 30 days (odds ratio=2.285, 95% CI=1.161-4.497, p=0.017). Conclusion: This study demonstrated that presence of diabetes mellitus significantly influences the short-term clinical outcomes of patients with bleeding peptic ulcers.
Abstract: BACKGROUND: Little information is available on the analysis of medical costs of acute pancreatitis hospitalizations.
AIM: This study aimed to determine the factors affecting medical costs of patients with acute pancreatitis during hospitalization using a Japanese administrative database.
METHODS: A total of 7193 patients with acute pancreatitis were referred to 776 hospitals. We defined "patients with high medical costs" as patients whose medical costs exceeded the 90th percentile in medical costs during hospitalization and identified the independent factors for patients with high medical costs with and without controlling for length of stay.
RESULTS: Multiple logistic regression analysis demonstrated that necrosectomy was the most significant factor for medical costs of acute pancreatitis during hospitalization. The odds ratio of necrosectomy was 33.64 (95% confidence interval, 14.14-80.03; p<0.001). Use of an intensive care unit was the most significant factor for medical costs after controlling for LOS. The OR of an ICU was 6.44 (95% CI, 4.72-8.81; p<0.001).
CONCLUSION: This study demonstrated that necrosectomy and use of an ICU significantly affected the medical costs of acute pancreatitis hospitalization. These results highlight the need for health care implementations to reduce medical costs whilst maintaining the quality of patient care, and targeting patients with severe acute pancreatitis.
Abstract: At present, there is a shortage of detailed data on head and neck cancer treatment in acute care hospitals in Japan. We conducted an analysis of the care process for laryngeal cancer inpatients in Japan using a national administrative database based on the case-mix system known as the Diagnosis Procedure Combination to evaluate the recent clinical situation of a relatively high incidence of head and neck cancers. We obtained discharge data relating to 2790 cases (one case = one hospitalization) involving 2319 laryngeal cancer patients from 346 acute care hospitals that participated in the Japanese national case-mix project between July and December of 2008. The details of their treatment procedures were analyzed according to the Japanese procedure codes managed by the Ministry of Health, Labour, and Welfare of Japan. There were 2156 male and 163 female patients. The median age was 69 years (range: 22-96 years). The most frequent surgical procedure was endoscopic resection which was performed for 781 cases. Chemotherapy was given in 31.6% of cases in the < 60 age group, 28.2% in the 60-79, and 14.1% in the ≥ 80. The most frequently used chemotherapy regimen was a single drug, S-1 (compound of tegafur, gimeracil and oteracil potassium), which was more frequently used in the ≥ 70 age group than in the younger age group. The Diagnosis Procedure Combination database, which collects a large volume of data from all over the country, is useful for analysis of the care process for head and neck cancers in Japan.
Abstract: BACKGROUND/PURPOSE: We aimed to evaluate compliance with the clinical practice guidelines for acute cholangitis (Tokyo Guidelines) using the Japanese administrative database associated with the Diagnosis Procedure Combination (DPC) system.
METHODS: We collected database data from 60,842 acute cholangitis patients, examining 10 recommendations in the Tokyo Guidelines. We counted how many recommendations had been complied with for every patient. The patient compliance score was defined as the rate of compliance with these recommendations (score 0 = 0% to score 10 = 100%). An aggregated patient compliance score was measured according to the severity of acute cholangitis. Severity was categorized as grade I (mild cholangitis; n = 49,630), grade II (moderate cholangitis; n = 10,444), and grade III (severe cholangitis; n = 768).
RESULTS: The mean patient compliance score was significantly higher for patients with grade III than for those with grades II and I (7.6 ± 2.1 vs. 6.5 ± 3.0 vs. 2.9 ± 0.9, p < 0.001, respectively). Multiple linear regression analysis revealed that the severity of acute cholangitis was the parameter most significantly associated with the patient compliance score. The standardized coefficient of grade III was higher than that of grade II (0.657 vs. 0.248, p < 0.001).
CONCLUSIONS: Compliance with the Tokyo Guidelines became higher in accordance with the severity of acute cholangitis.
Abstract: The clinical outcomes of treatments for several medical conditions are better in teaching hospitals than in non-teaching hospitals. However, there is only limited information for comparisons of the clinical outcomes of bleeding peptic ulcers between teaching and non-teaching hospitals. A total of 4,863 patients treated by endoscopic hemostasis on admission for bleeding peptic ulcers were evaluated in 586 hospitals of the Diagnosis Procedure Combination (DPC) system. We collected their data from the database associated with the DPC system to compare the risk-adjusted length of stay (LOS) and in-hospital mortality within 30 days with respect to the hospital characteristics. The hospitals were categorized into two groups: teaching hospitals that were certified by the Japanese Society of Gastroenterology (3,332 patients in 360 hospitals) and non-teaching hospitals (1,531 patients in 226 hospitals). There was no significant difference with regard to the mean LOS and the crude in-hospital mortality within 30 days between groups (p = 0.181 and 0.174, respectively). Multiple linear regression analyses revealed that the hospital characteristics were not associated with the risk-adjusted LOS. The standardized coefficient for non-teaching hospitals was 0.019 (p = 0.172). Multiple logistic regression analyses further showed no significant difference in the in-hospital mortality within 30 days (non-teaching hospitals, odds ratio = 1.35, 95% confidence interval = 0.786 - 2.319, p = 0.277). In conclusion, both teaching and non-teaching hospitals have equivalent qualities in management of bleeding peptic ulcers. These findings suggest that the standardization of medical treatments for bleeding peptic ulcers has become disseminated in Japan.
Abstract: BACKGROUND: Although a downward trend in stroke mortality over the last decades has been observed in many countries, stroke remains an important contributor to the total burden of disease. In the present study, we provided additional measures, namely years of life lost (YLLs) and average years of life lost (AYLLs) to reflect the burden of this condition in Japan.
METHODS: We obtained stroke mortality data for Japan from the World Health Organization mortality database for the period 1980-2005 to analyze trends of age-standardized rates (ASRs) per 100 000 of stroke mortality. YLLs and AYLLs were also estimated according to Japanese life tables.
RESULTS: Decreases in ASRs by 68% in men and by 74% in women were observed at the end of this study period. In men, there were total of 1 684 482 YLLs in 1980; 776 350 in 1995 and 745 636 in 2005, corresponding to an overall AYLLs for all stroke deaths of 20.6; 11.2 and 11.7 years earlier than expected, respectively. In women, the respective numbers were 1 567 817 YLLs in 1980; 810 135 in 1995 and 726 650 in 2005, corresponding to an overall AYLLs for all stroke deaths of 19.4; 10.5 and 10.5 years.
CONCLUSIONS: The findings showed shorter AYLLs due to stroke in Japan, suggesting that stroke patients died from this condition at older age at the end of the study period. This change in premature mortality was consistent with decreased trend in the stroke mortality.
Abstract: BACKGROUND: Little information is available on the relationship between hospital volume and compliance with clinical practice guidelines (CPGs).
OBJECTIVES: To investigate the relationship between hospital volume and compliance with CPGs using a Japanese administrative database.
DESIGN AND SUBJECTS: This was an observational study that included 60,842 patients with acute cholangitis from 829 hospitals in Japan.
MEASURES: Hospital volume was categorized into the following 3 groups based on the number of cases of acute cholangitis during the study period: low-volume hospitals (LVHs; n = 20,869), medium-volume hospitals (MVHs; n = 18,387), and high-volume hospitals (HVHs; n = 21,586). We further collected patient data with regard to CPGs for acute cholangitis, and counted the number of recommendations that had been complied with for each patient. CPGs compliance score was defined as the rate of compliance with these recommendations for each patient (range, 0-10). Aggregated CPGs compliance score was measured according to hospital volume.
RESULTS: Mean CPGs compliance score in HVHs was significantly higher than that in MVHs and LVHs (6.8 ± 1.6 vs. 5.6 ± 1.5 vs. 3.9 ± 1.4, respectively; P < 0.001). Multiple linear regression analysis revealed that hospital volume was most significantly associated with CPGs compliance score. The standardized coefficient for CPGs compliance score in HVHs was 0.689, whereas that of MVHs was 0.366 (P < 0.001).
CONCLUSIONS: This study demonstrated that hospital volume was significantly associated with compliance with CPGs and that the Japanese administrative database was a viable tool for the monitoring of compliance with CPGs.
Abstract: PURPOSE: To examine the circumstances of medical treatment for acute pancreatitis before publication of the new Japanese (JPN) guidelines using the Japanese administrative database associated with the Diagnosis Procedure Combination system.
METHODS: We collected data from 7,193 patients with acute pancreatitis in 2008 and examined the recommended medical treatment in the new JPN guidelines [from recommendations B (considered to be recommended treatments) to D (considered to be unacceptable treatments)] according to severity of acute pancreatitis. Patients were divided into two groups: mild cases (n = 6,520) and severe cases (n = 673).
RESULTS: Enteral nutrition for severe cases without ileus (recommendation B) was uncommon (13.5%). In contrast, prophylactic antibiotics were administered in a large number (80.4%) of mild cases without acute cholangitis (recommendation D). Furthermore, administration of H(2) receptor antagonists, except for cases of upper gastrointestinal bleeding (recommendation D), were performed in many patients with both mild and severe cases (66.8 vs. 78.6%).
CONCLUSIONS: This study demonstrated a discrepancy between actual medical treatment performed and the new JPN guidelines with regard to some of the medical treatments. Future studies are required after publication of the new JPN guidelines to determine how they affect medical treatments.
Abstract: OBJECTIVE: This study aimed to investigate the relationship between hospital volume and clinical outcome in patients with acute pancreatitis, using a Japanese national administrative database.
METHODS: A total of 7007 patients with acute pancreatitis were referred to776 hospitals in Japan. Patient data were corrected according to the severity of acute pancreatitis to allow the comparison of risk-adjusted in-hospital mortality and length of stay in relation to hospital volume. Hospital volume was categorized based on the number of cases during the study period into low-volume (<10 cases), medium-volume (10-16 cases), and high-volume hospitals (HVHs, >16 cases).
RESULTS: Increased hospital volume was significantly associated with decreased relative risk of in-hospital mortality in both patients with mild and those with severe acute pancreatitis. The odds ratios for HVHs were 0.424 (95% confidence interval [CI], 0.228-0.787; P = 0.007) and 0.338 (95% CI, 0.138-0.826; P = 0.017), respectively. Hospital volume was also significantly associated with shorter length of stay in patients with mild acute pancreatitis. The unstandardized coefficient for HVHs was -0.978 days (95% CI, -1.909 to -0.048; P = 0.039).
CONCLUSIONS: This study demonstrated that hospital volume influences the clinical outcome in both patients with mild and those with severe acute pancreatitis.
Abstract: Objective The goal of this study was to determine the prevalence of type 2 diabetes among acute inpatients and evaluate its impact on the length of hospital stay in Japan. Research Design and Methods The discharge records of 2,120,170 acute inpatients who were 30 years old or older and discharged between July and December of 2008 were obtained from the Japanese administrative case-mix system, Diagnosis Procedure Combination (DPC), and allocated for analysis. Type 2 diabetes was defined by E11 of the ICD-10 coding system on patient records. Other types of diabetes, including type 1 diabetes and diabetes in pregnancy (defined by ICD-10 codes E10 E12-14 and O24, respectively) were excluded from the analyses. Results Type 2 diabetes was observed among 11.4% of the records, 9.9% of which were cases of diabetes as a comorbidity. Total length of hospital stay was 33,468,152 days, with diabetes patients occupying 13.9% of the total bed days. Patients with type 2 diabetes as a comorbidity had prolonged lengths of hospital stay compared to patients free from diabetes, and stratification by sex, age, surgical treatment, and disease category did not alter these results. The median length of hospital stay was 9 days among patients without diabetes and 13 days among patients with diabetes. Conclusion Japanese acute health care is experiencing an epidemic of type 2 diabetes, with 1 out of 10 acute inpatients suffering from the disease. Complication of type 2 diabetes is associated with prolonged length of hospital stay.
Abstract: Purpose: To investigate whether a high salted food intake increases the risk of gastrointestinal tract cancer mortality. Methods: We conducted a prospective study of 6830 Japanese inhabitants to evaluate the association between salted food consumption and the risk of gastrointestinal tract cancer mortality. Data were obtained from a prospective cohort study in Japan. Salted food consumption, determined from a baseline questionnaire, was classified into the two categories of 'low intake' and 'high intake'. The Cox proportional hazards model was used to estimate hazard ratios (HRs) and 95% confidence intervals (CI). Findings: Total of 174 gastrointestinal tract cancer deaths (47 esophagus cancer, 87 stomach cancer, 23 colon cancer and 17 rectal cancer) were observed during 94996 person-years of follow-up, with a mean follow-up period of 8.9 years. After adjustment for age, body mass index, physical activity, smoking, alcohol, history of diabetes mellitus and dietary items, including vegetables, fruit, tea, red meat and processed meat, the HR for stomach cancer in males with high salt intake was 2.05 (95% CI:1.25 - 3.38) whereas that of rectal cancer was 3.58 (95% CI: 1.08 - 11.89). In contrast, no association was seen in females. Further, no association was seen between higher salted food consumption and esophagus and colon cancer in either sex. Conclusions: A significant association was seen between higher salted food consumption and stomach and rectal cancer mortality in men, but not in women. No association was seen between higher consumption and esophagus and colon cancer mortality in either men or women.
Abstract: BACKGROUND: We aimed to determine the relationship between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis, using the Japanese administrative database associated with the diagnosis procedure combination (DPC) system. METHODS: A total of 8698 patients with endoscopic biliary drainage were referred to 654 hospitals. We corrected patients' data from the database to compare risk-adjusted length of stay (LOS) and drainage-related complications in relation to the hospital volume. Hospital volume was categorized into three groups based on number of cases during the study period: low-volume hospitals (LVHs; <16 cases), medium-volume hospitals (MVHs; 16-32 cases), and high-volume hospitals (HVHs; >32 cases). RESULTS: Significant variation in mean LOS was observed between hospital volume categories (26.8 ± 22.6 days in LVHs vs. 23.3 ± 21.5 days in MVHs vs. 19.7 ± 17.2 days in HVHs, P < 0.001). There was a significant difference with regard to complications of endoscopic biliary drainage (5.6% in LVHs vs. 4.3% in MVHs vs. 3.2% in HVHs, P < 0.001). Multiple linear regression analysis revealed that hospital volume was most significantly associated with a decrease in risk-adjusted LOS. The standardized coefficient of MVHs was -0.155, whereas that of HVHs was -0.802. Multiple logistic regression analysis showed that hospital volume decreased the relative risk of drainage-related complications. The odds ratio (OR) of MVHs was 0.764 [95% confidence interval (CI), 0.604-0.965], whereas the OR of HVHs was 0.561 (95% CI, 0.434-0.725). CONCLUSIONS: There was a significant association between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis
Abstract: We report the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis in patients 80 years of age and older. Recently, therapeutic ERCP has been shown to be an alternative to open　surgery for the treatment of choledocholithiasis, and is of particular value in elderly　patients, especially those with concomitant diseases that increase the risks associated　with surgery. However, little information is available on the efficacy and safety of　therapeutic ERCP for choledocholithiasis in the elderly patients. To evaluate the efficacy and safety of therapeutic ERCP in managing choledocholithiasis in patients 80 years of age and older, we analyzed the short-term outcomes and complications of therapeutic ERCP for choledocholithiasis and compare them retrospectively with the results from younger patients. A total of 558 consecutive therapeutic ERCP for choledocholithiasis were performed on 283 patients (148 men and 135 women) from December 2004 to February 2007 at
our endoscopy unit. These patients were divided into two groups according to age: 80 years of age and older (group A, n = 100) and younger than 80 years of age (group B, n= 183). The details of all patients were analyzed retrospectively from an endoscopy database and review of medical records. All therapeutic ERCP were performed by experienced endoscopists of our hospital. For common bile duct stones, standard removal techniques were performed by dormia basket and extraction balloon, adding mechanical lithotripsy in difficult cases. Data was collected on, chronic concomitant diseases, cannulation success rate, complete removal of common bile duct stones, procedure-related complications, and early mortality after complications. Post ERCP complications and their severity were defined according to published criteria. The patients in group A had more frequent pulmonary diseases (p = 0.007). Specifically, there were significantly higher incidences of cardiovascular diseases (p < 0.001) and of neurologic diseases (p < 0.001) in group A than in group B. In 98 of 100 patients (98.0%) of group A and 181 of 183 patients (98.9%) of group B, cannulation into common bile duct was successful (p > 0.05). Two patients in either group in whom cannulation failed were switched to surgical treatment. Total complete removal of common bile duct stones was achieved in 96 of 98 patients (98.0%) of group A and in 179 of 181 patients (98.9%) of group B (p > 0.05). Two patients in group A and two in group B had to repeat the plastic stent exchange once every several months because of the difficulty of removing their common bile duct stones and their concomitant medical conditions. Early complications occurred in 12 of 100 patients (12.0%) in group A and 25 of 183 patients (13.7%) in group B (p > 0.05). There were no serious periprocedural complications, and no patients in either group experienced subjective deterioration in mental status or required ventilatory support. No respiratory insufficiency, cardiopulmonary complications, or basket impaction occurred in either group. No deaths were reported as a result of these complications. We retrospectively compared the short-term outcomes and complications of therapeutic ERCP for choledocholithiasis between older and younger patients. The cannulation success rate and total complete removal of common bile duct stones were similar in the two groups in our study. The complication rate of 12.0% in older patients
and 13.7% in younger patients was slightly higher than those of previous studies, ranging from 6.3 to 11.0%. However, there were no serious periprocedural and cardiopulmonary complications after therapeutic ERCP and no deaths were reported in our study. In general, patients of advanced age are often unable to tolerate endoscopic procedures because they are critically ill or uncooperative. However, the results of our retrospective study show that therapeutic ERCP for choledocholithiasis represents a successful interventional endoscopic procedure in older patients as well as in younger patients. Although the complication rates were slightly higher than those of previous studies, therapeutic ERCP for choledocholithiasis seems to be acceptable for older patients because of the efficacy. We believe that patients 80 years of age and older who have undergone therapeutic ERCP for choledocholithiasis are expected to survive as long as members of the general population.
Abstract: A 57-year-old man was admitted after suffering left lower quadrant abdominal pain. On admission, the abdomen was smooth without any sign of peritonitis. There were no significant findings on an abdominal X-ray examination. Abdominal CT showed a retroperitoneal cavity secondary to the colon. Conventional colonoscopy failed to reveal any significant lesions because of extensive fluid in the rectum and sigmoid colon. Therefore, we performed CT Colonography (CTC), and a volume-rendered image of CTC revealed a retroperitoneal fistula secondary to the descending colon (Figure). The patient then underwent left hemi-colectomy with side-to-side colo-colostomy. Histologic analysis of the resected specimen revealed a fistula of the colonic wall with chronic inflammatory cells and some neutrophilic infiltration. The postoperative course was without complication. Retroperitoneal fistula of the colon is a rare condition and usually requires surgical treatment. A correct image is important for diagnosis and preoperative assessment of a retroperitoneal fistula of the colon. Recent advances in imaging techniques have enabled more accurate preoperative diagnosis of colonic diseases. CTC, also referred to as virtual colonoscopy, is an innovative technology that entails CT examination of the entire colon and computerized processing of the raw data after colon cleansing and colonic distention.In our case, CTC readily disclosed a retroperitoneal fistula of the descending colon from characteristic features seen on a volume-rendered image. A potential advantage of CTC, as opposed to colonoscopy or barium study, is that clinically significant extracolonic findings may be identifiable. CTC is a useful modality for diagnosis of retroperitoneal fistula of the colon.
Abstract: We report endoscopic polypectomy with a detachable snare in a patient with a hemorrhagic pedunculated duodenal lipoma. A 67-year-old man with a history of spinal canal stenosis was admitted to our hospital because of recurrent tarry stools and anemia. Esophagogastroduodenoscopy revealed a pedunculated submucosal tumor measuring approximately 4 cm, in the second part of the duodenum. The tumor had a slightly yellowish coloration, and longitudinal erosion was noted on the surface of the tumor. There were no significant findings in the esophagus, stomach and bulbs. Barium study revealed a pedunculated submucosal tumor measuring 40 x 12 mm in the second portion of the duodenum. We judged that the submucosal tumor may have been the hemorrhagic source, and removed it by endoscopic snare polypectomy with a detachable snare. No complications occurred during endoscopic procedures. Histopathological examination revealed that the tumor was composed of mature adipose tissue in the submucosa, which was consistent with a diagnosis of lipoma In our experience, endoscopic polypectomy with a detachable snare is useful for the treatment of hemorrhagic pedunculated duodenal lipoma.
Abstract: GOALS: The aim of this prospective study was to compare the acceptance and tolerance for unsedated transnasal esophagogastroduodenoscopy (EGD) between younger and older patients. BACKGROUND: Little information is available on comparisons of younger and older patients with regard to acceptance and tolerance of transnasal EGD. STUDY: A total of 260 patients were referred for unsedated transnasal EGD and divided into 2 groups according to their age: less than 60 years of age (group A, n=160) and 60 years of age and older (group B, n=100). A questionnaire for tolerance was completed by each patient (a validated 0 to 10 scale where "0" represents no discomfort/well tolerated and "10" represents severe discomfort/poorly tolerated). RESULTS: In 94.4% of group A and 95.0% of group B, insertions were successfully completed (P>0.05). Between groups A and B, discomfort during nasal anesthesia (1.7+/-0.2 vs. 1.6+/-0.2) and overall tolerance during procedure (1.7+/-0.2 vs. 1.5+/-0.2) were similar (P>0.05). However, discomfort during insertion was significantly greater in group A than in group B (2.5+/-0.2 vs. 1.9+/-0.2, P=0.02). Of all, 97.4% of group A and 94.7% of group B were willing to undergo unsedated transnasal EGD in the future (P>0.05). CONCLUSIONS: There was no significant difference in acceptability between younger and older patients for unsedated transnasal EGD. Otherwise, younger patients experienced significantly more discomfort during insertion than did older patients.
Abstract: We herein report successful endoscopic hemostasis in a patient with a bleeding from acquired ileal diverticulum. A 65-year-old woman was introduced to our hospital after the sudden onset of painless hematochezia. When emergency colonoscopy was performed, the site of bleeding could not be identified because of extensive blood pooling in the colon and ileocecal region. After admission, repeat colonoscopy with a transparent hood device after bowel preparation disclosed oozing of blood from an ileal diverticulum approximately 15 cm proximal to the ileocecal junction. We performed endoscopic therapy with injection of a hypertonic saline-epinephrine solution and placement of additional hemoclips in the diverticulum. Since the latter treatment, the patient had no recurrent hematochezia, and occult blood tests in stool had been negative. In cases of lower gastrointestinal bleeding, bleeding from an acquired ileal diverticulum should be considered and the terminal ileum carefully observed.
Abstract: Eosinophilic gastroenteritis is a chronic inflammatory disorder of the gastrointestinal tract characterized by the infiltration of eosinophils. It is a rare disease. There are no reports in the history of eosinophilic gastroenteritis being consecutively observed in the whole gastrointestinal tract by esophagogastroduodenoscopy (EGD), double-balloon enteroscopy (DBE), and endoscopic ultrasonography (EUS). A 66-year-old woman was admitted to our hospital because of abdominal pain and diarrhea. Laboratory findings included peripheral eosinophilia and a high serum immunoglobulin E level. We observed the whole gastrointestinal tract by EGD, DBE (antegrade and retrograde approaches), and EUS. DBE showed slightly edematous and reddish mucosa in the jejunum, ileum, and ascending colon, respectively. EUS in all portion of the gastrointestinal tract demonstrated almost normal five-layered structure without ascites. Histologic examination of the biopsy specimens from the stomach, duodenum, jejunum, ileum, colon and rectum revealed eosinophilic infiltration. No evidence of parasites, granulomas, malignancy, vasculitis or embolism was founded in any of the biopsy specimens. The patient was diagnosed with eosinophilic gastroenteritis with predominant mucosal layer form. She was treated with oral corticosteroid, and her symptoms subsided. To the best of our knowledge, this is the first case of eosinophilic gastroenteritis in which the whole gastrointestinal tract was consecutively observed by EGD, DBE, and EUS.
Abstract: Most endosonographers use radial scanning instruments for diagnostic imaging, and use longitudinal scanning instruments primarily for endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). The use of two separate instruments for radial and longitudinal scanning means 2 different echoendoscopes are required, each with its own dedicated US processing unit. Currently available electronic radial echoendoscopes and linear instruments made by the same company require the same other brand US unit. Furthermore, no forward-viewing optics type 360 degrees electronic radial echoendoscope currently exists. We have developed an all-in-one one cart EUS system that saves space and is available for both the forward-viewing type 360 degrees radial electronic echoendoscope and the oblique-viewing type convex echoendoscope. These scopes have a transducer with variable frequency (5.0, 7.5, 10.0, 12.0 MHz) and color and power Doppler flow mapping capabilities. We performed a clinical development test for thirteen patients with sixteen lesions (Radial EUS on 8 lesions and EUS-FNA on 8 lesions) using this new EUS system. These new instruments provided satisfactory US and endoscopic images. The forward-viewing optics of the prototype enhanced intubation and instrument advancement. The radial scanning prototype provided an adequate diagnosis in 8 (100%) out of 8 lesions for EUS. The convex type achieved successful puncture in 8 (100%) out of 8 lesions and collection of adequate specimen for diagnosis of EUS-FNA in 4 (50%) out of 8 lesions. There were no complications in this series. This new system appears to be an attractive alternative for efficient EUS.
Abstract: Endoscopic submucosal dissection (ESD) with a knife is a technically demanding procedure that is associated with a high complication rate. The shortcoming of this method is the difficulty in fixing the knife to the target lesion. This difficulty can lead to unexpected incision, resulting in major complications such as perforation and bleeding. To reduce the risk of complications related to ESD, we developed a new grasping type scissors forceps (GSF), which can grasp and incise the targeted tissue using an electrosurgical current. The ESD procedure using the GSF was carried out in an animal model (resected porcine stomachs in vitro). After marking the lesion and injecting a solution into the submucosa, the lesion was separated from the surrounding normal mucosa following complete incision around the lesion using the GSF. A piece of submucosal tissue was grasped and cut with the GSF using an electrosurgical current to achieve submucosal exfoliation. ESD using the GSF was carried out safely and easily without unintentional incision. ESD using GSF appears to be an easy, safe, and technically efficient method for resecting gastrointestinal neoplasms.
Abstract: AIM: The aim of this study was to compare the acceptance and tolerance of transnasal and peroral esophagogastroduodenoscopy (EGD) using an ultrathin videoendoscope in unsedated patients. METHODS: A total of 124 patients referred for diagnostic endoscopy were assigned randomly to have an unsedated transnasal EGD (n = 64) or peroral EGD (n = 60) with local anesthesia. An ultrathin videoendoscope with a diameter of 5.9 mm was used in this study. A questionnaire for tolerance was completed by the patient (a validated 0-10 scale where '0' represents no discomfort/well tolerated and '10' represents severe discomfort/poorly tolerated). RESULTS: Of the 64 transnasal EGD patients, 60 patients (94%) had a complete examination. Four transnasal EGD examinations failed for anatomical reasons; all four patients were successfully examined when switched to the peroral EGD. All 60 peroral EGD patients had a complete examination. Between the transnasal and peroral groups, there was a statistically significant difference in scores for discomfort during local anesthesia (1.5 +/- 0.2 vs 2.6 +/- 0.3, P = 0.003), discomfort during insertion (2.3 +/- 0.3 vs 4.3 +/- 0.3, P = 0.001), and overall tolerance during procedure (1.6 +/- 0.2 vs 3.8 +/- 0.2, P = 0.001). In all, 95% of transnasal EGD patients and 75% of peroral EGD patients (P = 0.002) were willing to undergo the same procedure in the future. Four patients in the transnasal EGD group experienced mild epistaxis. CONCLUSION: For unsedated endoscopy using an ultrathin videoendoscope, transnasal EGD is well tolerated and considerably reduces patient discomfort compared with peroral EGD.
Abstract: AIM: To prospectively evaluate the indications, methodology, safety, and clinical impact of double-balloon endoscopy. METHODS: A total of 60 patients with suspected or documented small- or large-bowel diseases were investigated by double balloon endoscopy. A total of 103 procedures were performed (42 from the oral route, 60 from the anal route, and 1 from the stoma route). The main outcome measurements were the time of insertion and the entire examination, complications, diagnostic yields, and the ability to successfully perform treatment. RESULTS: Observation of the entire small intestine was possible in 10 (40%) of 25 patients with total enteroscopy. The median insertion time was 122 min (range, 74-199 min). Observation of the entire colon was possible in 13 (93%) of 14 patients after failure of total colonoscopy using a conventional colonoscope. Small-intestine abnormalities were found in 20 (43%) of 46 patients with indications of suspected or documented small bowel diseases, obscure GI tract bleeding, or a history of ileus. Endoscopic procedures including tattooing (n = 33), bite biopsy (n = 17), radiographic examination (n = 7), EUS (n = 5), hemostasis (n = 1), polypectomy (n = 5), balloon dilatation (n = 1), endoscopic mucosal resection (n = 1) and lithotripsy (n = 1) were all successfully performed. No relevant technical problems or severe complications were encountered. CONCLUSION: Double balloon endoscopy is a feasible technique that allows adequate small and large bowel examination and potentially various endoscopic procedures of small-intestinal lesions. It is safe, useful, and also provides a high clinical impact.
Abstract: AIM: To evaluate whether an automatically controlled cut system (endocut mode) could reduce the complication rate of endoscopic sphincterotomy (EST) and serum hyperamylasemia after EST compared to the conventional blended cut mode. METHODS: From January 2001 to October 2003, 134 patients with choledocholithiasis were assigned to either endocut mode group or conventional blended cut mode group at the time of sphincterotomy. The two groups were retrospectively compared for the complications after EST and serum amylase level before and 24 h after the procedure. RESULTS: Of the 134 patients treated, 79 were assigned to conventional blended cut mode group and 55 to endocut mode group. There was no significant difference in age, sex, and serum amylase level before EST between the two groups. Complications were found in 5 patients of the endocut mode group (9%): hyperamylasemia (5 times higher than normal) in 4 and moderate pancreatitis in 1. Complications were found in 13 patients of the conventional blended cut mode group (16%): hyperamylasemia in 12 and moderate pancreatitis in 1. Serum amylase levels were elevated in both groups 24 h after EST (P<0.02). The average serum amylase level 24 h after EST in the conventional blended cut mode group was significantly higher than that in the endocut mode group (P<0.05). CONCLUSION: Endocut mode offers a safety advantage over conventional blended cut mode for pancreatitis after EST by reducing hyperamylasemia.
Abstract: Colonic muco-submucosal elongated polyp is a new clinical entity first reported in 1998. The purpose of this report is to determine the value of endoscopic ultrasound in the diagnosis of this condition. We reviewed the endosonographic and histological findings of seven colonic muco-submucosal elongated polyps that were removed completely by endoscopic resection or surgery. The lesions appeared as pedunculated submucosal tumours, measuring 1-4 cm in maximal diameter. Endosonographically, all lesions consisted of mucosal and submucosal layers, and microcystic components were found in the submucosal layer. There were no echogenic masses or muscularis propria within the polyps. These endosonographic features corresponded to histological findings of this type of polyp which was covered with normal mucosa and composed of submucosal layer alone. The submucosal layer consisted of oedematous, loose, connective tissue and/or fibrous tissue, accompanied by dilated blood vessels and lymphatics. Endoscopic ultrasound enabled differentiation of colonic muco-submucosal elongated polyp from other submucosal lesions.
