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Hepatocellular carcinoma (HCC) with bile duct invasion is considered rare. A case in which a fragment of intraductal tumor dropped into the common bile duct after transarterial chemoembolization (TACE) and caused abdominal pain, and obstructive jaundice secondary to biliary obstruction is presented. This case was successfully managed by emergent endoscopic sphincterotomy. Physicians should recognize one of the complications due to TACE for HCC with intraductal tumor invasion.

OBJECTIVES: The usefulness of non-magnifying endoscopy with narrow-band imaging (NBI; NM-NBI) in the screening of early esophageal squamous cell carcinoma (SCC) and high-grade intraepithelial neoplasia (HGIN) remains unclear. Here, we aimed to compare NM-NBI and chromoendoscopy with iodine staining (CE-Iodine) in terms of the diagnostic performance, and to evaluate the usefulness of NM-NBI in detecting early esophageal SCC. METHODS: We prospectively enrolled 202 consecutive patients (male/female=180/22; median age, 67 years) with high-risk factors for esophageal SCC. All patients received endoscopic examination with NM-NBI and CE-Iodine to screen for early esophageal SCC or HGIN. We conducted the examinations sequentially, and calculated the accuracy, sensitivity, and specificity through a per-lesion-based analysis. A propensity score matching analysis was performed to reduce the effects of selection bias, and we compared the respective outcomes according to NM-NBI and CE-Iodine after matching. RESULTS: The accuracy, sensitivity, and specificity of NM-NBI were 77.0, 88.3, and 75.2%, respectively, and those for unstained areas by CE-Iodine were 68.0, 94.2, and 64.0, respectively. The accuracy and specificity of NM-NBI were superior to those of CE-Iodine (P=0.03 and P=0.01, respectively). However, the sensitivity did not significantly differ between NM-NBI and CE-Iodine (P=0.67). The accuracy and specificity of NM-NBI before matching were superior to those of CE-Iodine after matching (P=0.04 and P=0.03). CONCLUSIONS: NM-NBI was useful and reliable for the diagnosis of esophageal SCC and can be a promising screening strategy for early esophageal SCC.

Background Endoscopic submucosal dissection (ESD) is a widely accepted procedure for superficial esophageal squamous cell neoplasia (ESCN) because of a high complete resection rate. However, there were a few reports about the long-term outcomes of these patients due to short follow-up periods. Aims We aimed to evaluate the 5-year survival after ESD for superficial ESCN. Methods This was a retrospective cohort study performed at a single institution. Between 2006 and 2009, 94 patients with superficial ESCN underwent ESD. Eighty-three patients (93.3%) who had completed an extended period of observation of at least 5 years were enrolled. The main outcomes were the 5-year survival rates. The secondary outcomes were the cumulative incidence rate of metachronous ESCN, and the clinical outcomes. Results The 5-year relative overall survival rate was 99.0%, whereas the cause specific survival rate was 100% during 72.9 months of median follow up period. Subgroup analysis showed that the 5 year survival of patients with EP/LPM and MM/SM1 (submucosal invasion ≤200 μm) were 100% and 89.0%, respectively. The cumulative incidence rate of metachronous ESCN at 5 years was 16.8%. Conclusion ESD for superficial ESCN is a curative treatment with a favorable 5-year survival rate.

Although balloon-occluded retrograde transvenous obliteration (B-RTO) is useful for management of gastric varices, worsening of esophageal varices (EV) is the most important complication of B-RTO. The predictive factors of worsening of EV have not been evaluated in detail. This study was designed to evaluate the role of endoscopic color Doppler ultrasonography (ECDUS) in the detection of possible risk factors for worsening of EV after B-RTO.A total of 39 cirrhotic patients with high-risk gastric varices successfully treated by B-RTO were included in this study. All patients underwent ECDUS before B-RTO to measure hemodynamic parameters of gastric varices and regular endoscopic follow-up after B-RTO to detect worsening of EV. The risk factors were analyzed by Cox's proportional hazards regression.Worsening of EV was found in 24 (61.5%) patients. The presence of esophageal varices before B-RTO and a lower degree of liver dysfunction (Child-Pugh class B) were statistically independent risk factors for worsening of EV after B-RTO (hazard ratio, HR, 5.81, 95% confidence interval, CI, 1.71-19.77 and HR 2.92, 95% CI: 1.21-7, respectively). High resistance index (or =0.24), measured by ECDUS, is also an independent risk factor for worsening of EV after B-RTO (HR 4.06, 95% CI: 1.14-14.38) and increase in resistance index is associated with worsening of EV (P for trend=0.028).The presence of EV, higher Child-Pugh class, and higher resistance index assessed by ECDUS before B-RTO were significant risk factors for worsening of EV after B-RTO.

Background & Aims With capsule endoscopy, the ulcerogenic effect of low-dose enteric-coated aspirin on the small bowel and the therapeutic effect of misoprostol on intestinal injury were evaluated. Methods Eleven patients who developed gastric ulcers while undergoing low-dose enteric-coated aspirin therapy were enrolled. They continued aspirin therapy while taking proton pump inhibitors (PPIs) for 8 weeks to heal the gastric ulcers. Then misoprostol 200 μg 4 times a day was administered instead of PPIs for 8 weeks. When the patients could not tolerate misoprostol as a result of side effects, they received another 8 weeks of PPI therapy. Results Capsule endoscopy performed after 8 weeks of PPI treatment identified red spots and mucosal breaks in 100% (11/11) and 90.9% (10/11) of patients, respectively. In 7 patients who completed the study protocol, misoprostol significantly decreased the median number of red spots and mucosal breaks, with complete disappearance of mucosal breaks in 4 patients. Intestinal lesions tended not to heal in 3 patients who discontinued misoprostol. Conclusions Low-dose enteric-coated aspirin frequently damages the small intestine, and misoprostol is effective in the treatment of aspirin-induced enteropathy.

OBJECTIVE: Gastrointestinal stromal tumors (GISTs) are the most frequently occurring mesenchymal tumors of the GI tract. Double-balloon enteroscopy (DBE) and capsule endoscopy (CE) promise the detection and accurate diagnosis of small bowel diseases in patients with obscure GI bleeding (OGIB). The aim of the present study was to analyze the clinical characteristics of small bowel GISTs and the usefulness of DBE, CE and computed tomography (CT). METHODS: Among 705 cases with OGIB examined between December 2003 and January 2011, 12 (1.7%) cases of small bowel GIST were identified. We analyzed endoscopic appearance, tumor-size and location, detection rate by DBE, CE and CT and clinical course in each of these cases. RESULTS: Of the 12 patients with GIST, eight were men. The mean patient age was 53.6 years. The presenting symptoms in most patients included tarry stools and/or anemia. Six patients required blood transfusions. The detection rates of DBE, CE and CT were 92%, 60% and 67%, respectively. All cases, except for one incomplete study, were identified using DBE; however, one case was not diagnosed as a tumor because of the presence of extramural growth. A pathological diagnosis of GIST was obtained using biopsies during DBE in three (45%) of seven cases. Lower detection rates were found in cases with intramural and extramural growth, larger tumors (≥35 mm) detected by CE and intraluminal growth and smaller tumors (

Video capsule endoscopy (VCE) and double-balloon enteroscopy (DBE) enable the detection of small intestinal lesions. To examine causes of acute overt gastrointestinal (GI) bleeding and the prevalence of mid-GI bleeding, defined as small intestinal bleeding from the ampulla of Vater to the terminal ileum, in a multi-center experience in Japan in the VCE/DBE era. Data were collected retrospectively from consecutive patients with acute overt GI bleeding in ten participating hospitals. All patients were examined by esophagogastroduodenoscopy and/or colonoscopy. When the source of bleeding was not identified after these procedures, patients suspected to have mid-GI bleeding were referred to our hospital and VCE/DBE was performed to determine the source of bleeding. Of the 1044 patients with acute overt GI bleeding, 524 (50.2%) patients were diagnosed with upper GI bleeding, 442 (42.3%) with lower GI bleeding, and 13 (1.2%) with mid-GI bleeding. Gastric ulcer was the most common cause of bleeding (20.4%). Among cases of mid-GI bleeding, ulcers were found in 4 (30.8%) patients, erosions in 3 (23.1%), angiodysplasia in 3 (23.1%), submucosal tumor in 2 (15.4%), and hemangioma in one (7.7%). Seven lesions were located in the jejunum, 5 in the ileum, and one in both the jejunum and ileum. Analysis of age-related cause showed that the prevalence of mid-GI bleeding among younger patients under 40 years of age was higher (5%) than in other age groups (1–2%). mid-GI bleeding is rare among Japanese patients with acute overt GI bleeding.

In recent years, various endoscopic treatments have become available to treat gastroesophageal reflux disease (GERD) in Western countries. The Stretta procedure, which uses radiofrequency energy, is one type of safe and effective endoluminal treatment for GERD. However, the feasibility, safety, and efficacy of the Stretta procedure in Japanese patients with GERD, who differ from Western peoples in their physiological characteristics, are not known. In 2006, we imported a Stretta system from the United States and investigated important clinical aspects of the system in Japanese patients with GERD. This study was an open-label trial that enrolled patients with GERD who desired to undergo the Stretta procedure. Heartburn scores, medication use, overall satisfaction with the procedure, and adverse events were evaluated. Nine patients received the Stretta treatment between February and September 2006. Esophagogastroduodenoscopy just after treatment revealed a remarkable reduction in the expansion of the gastric cardia and small erosions in all patients. At 3 or 6 months after treatment, heartburn scores were significantly improved compared with pretreatment scores (5.0 ± 1.7 pretreatment vs. 0.7 ± 1.4 posttreatment, P = 0.007). In six of nine patients (66.7%), treatment significantly (P = 0.009) decreased medication use. There were no major adverse events. All patients were satisfied with this treatment. The Stretta procedure safely reduced GERD symptoms and decreased medication use in Japanese patients with GERD. This treatment may thus be very useful for such patients, and it is hoped that a nationwide trial will be undertaken in Japan to obtain more extensive data.

802 Final Result of a Prospective Non-Randomized Study for Accuracy of Detection and Diagnosis of Esophageal Squamous Cell Carcinoma by Tandem Non-Magnifying Endoscopy With Narrow-Band Imaging and Iodine Staining Yasuaki Nagami*, Hirohisa Machida, Kazunari Tominaga, Masami Nakatani, Natsuhiko Kameda, Satoshi Sugimori, Hirotoshi Okazaki, Tetsuya Tanigawa, Naoshi Kubo, Masatsugu Shiba, Kenji Watanabe, Toshio Watanabe, Yasuhiro Fujiwara, Masaichi Ohira, Tetsuo Arakawa Gastroenterology, Osaka City University Graduate School of Medicine, Osaka City, Japan; Gastroenterology, Ohno Memorial Hospital, Osaka City, Japan; Gastroenterology, Minamiosaka Hospital, Osaka City, Japan; Surgical Oncology, Osaka City University Graduate School of Medicine, Osaka City, Japan Background/Aim: Chromoendoscopy with iodine staining facilitates the detection of esophageal cancer but causes severe chest discomfort. Narrow-band imaging (NBI) also facilitates the detection of esophageal cancer without causing discomfort. However, only few studies have reported the use of non-magnifying endoscopy with NBI for routine screening examination. This prospective nonrandomized study aimed to investigate the efficacy of non-magnifying endoscopy with NBI in detecting esophageal squamous cell carcinoma (SCC) compared to that of chromoendoscopy using iodine. Methods: Between May 2008 and January 2011, 202 patients (M/F 180/22; mean age, 67 years) who had not undergone chemotherapy or radiotherapy were included in this study. Among these patients, 120 had a history of head and neck carcinoma, 78 had previously undergone endoscopic resection (ER) for esophageal cancer, and 4 had a history of head and neck carcinoma and had undergone ER. Endoscopic examination was performed by the same endoscopist using the following modalities: the presence of a well-demarcated brownish area (BA) in NBI or an unstained area with or without pink coloration (PC) after iodine staining. The final diagnoses for all the lesions were determined by pathological evaluations. The sensitivity and specificity of esophageal-cancer diagnosed by NBI was the main outcome and was compared to that by iodine staining as the secondary outcome. Results: Histological examination of 113 lesions for suspected SCC or high-grade intraepithelial neoplasia (HGIN) revealed 31 (27.7%) lesions as SCC or HGIN. NBI detected 49 BAs, including 28 lesions diagnosed as SCC or HGIN on histological examination, thus indicating that the sensitivity and specificity for NBI were 90.3% and 74.4%, respectively. Iodine staining revealed 111 unstained areas, including the 31 lesions; the sensitivity and specificity were 100% and 2.4%, respectively. Further, we observed 38 unstained areas with PC, including 30 lesions; the sensitivity and specificity were 96.8% and 90.2%, respectively. Although the specificity of NBI was superior to that of iodine staining (P 0.01) and inferior to that of PC (P 0.01), there was no significant difference in the sensitivity of NBI and iodine staining (P 0.08). Conclusion: These findings suggest that initial use of non-magnifying endoscopy with NBI for detection of BA lesions and subsequent iodine staining for these lesions would be a promising screening strategy for patients with high risks for esophageal cancers.

Usefulness of Narrow-Band Imaging in Delineating Early Gastric Cancer Sayoko Nakayama, Hirohisa Machida, Kazunari Tominaga, Masatsugu Shiba, Yasuaki Nagami, Satoshi Sugimori, Masami Nakatani, Natsuhiko Kameda, Hirotoshi Okazaki, Hirokazu Yamagami, Tetsuya Tanigawa, Kenji Watanabe, Toshio Watanabe, Yasuhiro Fujiwara, Tetsuo Arakawa Osaka City University Graduate School of Medicine, Osaka, Japan; Department of Gastroenterology, Osaka City General Hospital, Osaka, Japan [Background & Aims]: Endoscopic submucosal dissection (ESD) has been widely accepted as an endoscopic therapy for early gastric cancer (EGC), to obtain a precise pathological diagnosis and promising curability for EGC. Appropriately margining resection at will is one of distinctive features of ESD, therefore, the precise estimation for the lateral extent of the lesion has an important role in successful ESD. The aim of this study is to investigate the usefulness in delineating the lateral extent of EGC using narrow-band imaging (NBI) endoscopy with magnification. [Methods]: February 2004 to October 2010, a total of 503 patients who underwent ESD for EGC achieving en bloc resection were enrolled in this study from. Patients were assigned to two groups, according to whether or not they underwent NBI endoscopy with magnification before ESD; Group A: 37 lesions evaluated with chromoendoscopy, as a historical control and group B: 465 lesions evaluated with NBI endoscopy. As outcome measures, complete resection rate (defined as en bloc resection and cancer free margin), location, size, macroscopic type, histology and presence of ulcer scar (UL) were compared between groups. In estimating the lateral extent, the margin was determined according to surface structure of mucosa in chromoendoscopy with indigo-carmine dye spraying and the presence of irregular microvascular pattern and demarcation line which were specific for EGC in NBI endoscopy. [Results]: Complete resection rate in group B was superior to that in group A (98.3% (8/ 465) vs. 91.9% (34/37), p 0.01). The incidence of incomplete resection was as followed; 1) Location; upper/ middle/ low: 1.5% (2/132)/ 3.5% (5/144)/ 0.5% (1/ 189), 2) Size; less than 20mm/ over 20mm: 1.3% (4/305)/ 2.5% (4/160), 3) Macroscopic type; elevated/ flat/ depressed: 0% (0/244)/ 6.7% (1/15)/ 3.4% (7/ 206), 4) Histology; differentiated/ undifferentiated: 1.3% (6/446)/ 5.3% (2/38), 5) Presence of an ulcer scar; 6.2%(5/81)/ 0.8% (3/384). As a result of univariate analysis in group B, complete resection rate was significantly inferior in the point of macroscopic type (p 0.01), presence of UL (p 0.01) and histology (p 0.027), in comparison with cancer positive and negative in margin. And it was not significant in location and size. In multivariate analysis, it was significant in the point of histology (p 0.025) and presence of UL (p 0.025). [Conclusions]: NBI endoscopy with magnification might be usefulness in an appropriate delineating the lateral extent of EGC. Features of histology or ulcer scar may affect the accurate endoscopic marginal estimation for EGC even though using NBI endoscopy.

AIM: To examine the portal hemodynamics of gastric fundal varices (GV) without gastro-renal shunt (GRS), and to retrospectively investigate the effects of various kinds of treatment on eradication. METHODS: Ninety-four liver cirrhosis patients at high-risk of GV were treated in our hospital and enrolled in this study. We retrospectively examined their characteristics, liver function, and portal hemodynamics of GV. We performed balloon-occluded retrograde transvenous obliteration (BRTO) at first. If it was not technically possible to perform BRTO, endoscopic injection sclerotherapy using α-cyanoacrylate glue (CA) or percutaneous transhepatic obliteration (PTO) was performed. RESULTS: Among the 94 patients, a GRS was present in 79 (84.0%), and absent in the remaining 15 (16.0%). The subphrenic vein was connected to the inferior vena cava as the drainage vein in 13 (86.7%) out of the 15 cases without GRS. We performed BRTO in 6 patients, CA in 4 patients and PTO in 5 patients. The eradication rate was 100% for each procedure, but the rate of early recurrence within 6 mo was 16.7% for BRTO, 50.0% for CA and 40.0% for PTO, respectively. CONCLUSION: We should examine the hemodynamics before treatment of GV irrespective of the existence of GRS. If this hemodynamic examination reveals that the drainage vein connects directly to the inferior vena cava in GV without GRS, BRTO may be an effective treatment for GV with GRS.

Wireless Capsule Endoscopy and Double-Balloon Enteroscopy in Japanese Patients with Obscure Gastrointestinal Bleeding Masatsugu Shiba, Kazuhide Higuchi, Natsuhiko Kameda, Kaori Kadouchi, Hirohisa Machida, Kazuki Yamamori, Hirotoshi Okazaki, Masaki Hamaguchi, Tomoko Wada, Yoshio Jinnno, Eiji Sasaki, Kenji Watanabe, Kazunari Tominaga, Toshio Watanabe, Yasuhiro Fujiwara, Shirou Nakamura, Nobuhide Oshitani, Tetsuo Aeakawa Background: Capsule endoscopy has demonstrated its clinical utility in the evaluation of small bowel pathology in several Western studies and increasingly being used in the investigation of obscure gastrointestinal bleeding. Double-balloon enteroscopy is emerging as another interesting alternative or complementary method. We aimed to evaluate the clinical utility of capsule endoscopy and compare the usefulness of double-balloon enteroscopy with capsule endoscopy. Patiens and Methods: From March 2004 through October 2004, we examined by CE 26 patients with complained of obscure GI bleeding and between June 2004 and October 2004, we used double-balloon enteroscopy on 14 patients and retrospectively evaluated the usefulness of double-balloon enteroscopy compared with capsule endoscopy. All patients had undergone non-diagnostic EGD, colonoscopy, and barium contrast radiography of the small bowel. Results: M2A capsule endoscopy disclosed abnormal small bowel findings in 23 (88%) out of 26 patients. Sixteen of them had significant pathological findings explaining their clinical disorders. Diagnostic yield was therefore 58% (15 of 26 patients). Definite bleeding sites diagnosed by capsule endoscopy in 15 patients included angiodysplasia (4), small-bowel erosion (8), small-bowel ulcer (1) small-bowel tumors (2). Double-balloon enteroscopy detected the definite sources of bleeding in 11 (79%) of the 14 patients. Patients with definite bleeding sources included small-bowel erosion (4), small-bowel ulcer (4) small-bowel tumors (2), angiodysplasias (1), small-bowel polyp (1), small-bowel hemorrhagic polyp (1) and not detectable (1). Double-balloon enteroscopy localized an additional bleeding source in comparison with capsule endoscopy in 4 patients. On the other hand, capsule endoscopy localized an additional bleeding source in comparison with double-balloon enteroscopy in 2 patients. Capsule endoscopy was well tolerated by all patients. One patient had a complication of capsule retention due to stricture of ileum. Conclusions: Many of the bleeding sources recognized by both imaging methods were small-bowel erosions or small-bowel ulcers in this study; although angiodysplasia was most popular bleeding source of obscure gastrointestinal bleeding in several Western studies. Double-balloon enteroscopy resulted in more positive findings than capsule endoscopy, although there is no significant difference in both imaging methods.