Interobserver Agreement for the Detection of Barrett’s Esophagus with Optical Frequency Domain Imaging

Background

Optical frequency domain imaging (OFDI) is a second-generation form of optical coherence tomography (OCT) providing comprehensive cross-sectional views of the distal esophagus at a resolution of ~7 μm.

Aim

Using validated OCT criteria for squamous mucosa, gastric cardia mucosa, and Barrett’s esophagus (BE), the objective of this study was to determine the inter- and intra-observer agreements by a large number of OFDI readers for differentiating these tissues.

Methods

OFDI images were obtained from nine subjects undergoing screening and surveillance for BE. Sixty-four OFDI image regions of interest were randomly selected for review. A training set of 19 images was compiled distinguishing squamous mucosa from gastric cardia and BE using previously validated OCT criteria. The ten readers then interpreted images in a test set of 45 different images of squamous mucosa (n = 15), gastric cardia (n = 15), or BE (n = 15). Interobserver agreement differentiating the three tissue types and BE versus non-BE mucosa was determined using multi-rater Fleiss’s κ value. The images were later randomized again and four readers repeated the test 3 weeks later to assess intraobserver reliability.

Results

All ten readers showed excellent agreement for the differentiation of BE versus non-BE mucosa (κ = 0.811 p < 0.0001) and for differentiating BE versus gastric cardia versus squamous mucosa (κ = 0.866, p < 0.0001). For the four readers who repeated the test, the median intraobserver agreement (BE vs. non-BE) was high (κ = 0.975, IQR: 0.94, 1.0).

Conclusions

Trained readers have a high interobserver agreement for differentiating BE, squamous, and gastric cardia mucosa using OFDI.     

An endoscopic training model to improve accuracy of colonic polyp size measurement

Purpose

Most studies of colonic polyps rely on visual estimation when regarding polyp size; however, the reliability of a visual estimate is questionable. Our study aims to develop a training model to improve the accuracy of size estimation of colonic polyps in vivo.

Methods

Colon polyps were recorded on 160 video clips during colonoscopy. The size of each polyp was estimated by visual inspection and subsequently measured with a flexible linear measuring probe. The study included a pretest, an intervention, and a posttest. The pretest included 160 video clips, which comprised the visual-estimation portion of the study. The intervention was an educational model consisting of 30 video clips which included a visual-estimation section and a linear-measuring-probe section, designed to help the endoscopists to compare their visual estimate of size with the measured size of the polyps. The posttest included the 160 video clips used in the pretest, presented in random order. Intraobserver agreement and diagnostic accuracy were compared before and after the training session.

Results

Eight beginners and four experienced colonoscopists were enrolled. The overall kappa (κ) values of intraobserver agreement for pretest and posttest were 0.74 and 0.85 for beginner group as well as 0.83 and 0.88 for experienced group, respectively. The overall diagnostic accuracy improved from 0.52 to 0.78 for beginner group and 0.71 to 0.87 for experienced group (P?<?0.05) after education with the training model.

Conclusions

This training model could help endoscopists improve the accuracy of measurement of polyps on colonoscopy in a short period. The durability of learning effect needs further investigation.     

Inter-Observer Agreement in the Endoscopic Classification of Colorectal Laterally Spreading Tumors: A Multicenter Study Between Experts and Trainees

Background and Aim

The risk of cancer varies with the subtype of colorectal “laterally spreading tumors” (LSTs). However, visual interpretations vary among endoscopists. The aim of this study was to evaluate inter-observer agreement and accuracy in the endoscopic classification of LST subtypes among experts and trainees.

Methods

In total, 40 LST images were collected and reviewed independently by 14 gastroenterology experts and 10 trainees. All investigators recorded their findings as one of the following four categories: homogeneous, nodular mixed, flat-elevated, and pseudo-depressed. Agreement was assessed in terms of the kappa (κ) statistic and AC1 estimate. Accuracy is reported as percentage agreement with the gold standard, based on the gross morphology of the resected specimens.

Results

Of the possible 91 pair-wise κ estimates among experts, 41 (45.1 %) were >0.75, indicating excellent agreement, while only 2 (4.44 %) of the 45 pair-wise κ estimates among trainees were >0.75. Agreements for individual LST subtypes in the trainee group were significantly lower than those in the expert group. The κ and AC1 estimates showed similar values in individual subtypes of LSTs. The overall accuracy of LST was also significantly higher for the experts than the trainees (85.9 vs. 72.5 %, P < 0.001). Notably, the flat-elevated subtype showed the lowest agreement and accuracy and was frequently misclassified as the pseudo-depressed subtype by both groups.

Conclusions

Inter-observer agreement and accuracy for LST subtype classification differ significantly between experts and trainees. Implementation of an adequate training system for beginners is necessary to better identify colorectal LSTs.     

Endoclip-Assisted Resection of Large Pedunculated Colorectal Polyps: Technical Aspects and Outcome

Background

The most common complication of polypectomy is hemorrhage, and various techniques have been used to prevent this complication.

Aim

This study evaluates the outcomes of endoclip-assisted polypectomy in patients with large pedunculated colorectal polyps, in comparison with a historical control group of patients treated with endoloop-assisted polypectomy.

Methods

Between January and December 2007, 32 patients with 32 large pedunculated polyps (≥15 mm) were treated with endoclip-assisted polypectomy (group A). Between January and December 2006, 35 patients with 35 large pedunculated polyps were treated; 33 with endoloop-assisted polypectomy (control, group B) and two cases with endoclips and needle knife, which were included in group A for the analysis.

Results

The mean (± standard deviation [SD]) size of polyp head was 26.8 ± 8.1 mm (range 15–50) in group A and 22.3 ± 4.1 mm (range 15–30) in group B (P = 0.004). In group A, six polyps had a mean (±SD) head size of 40.8 ± 5.8 mm (range 35–50) and were resected with clips and needle knife. In group A, bleeding occurred in two cases (5.9%), which were associated with the presence of cancer at histology (P = 0.006) and were managed by applying new clips. No bleeding occurred in patients of group B and no perforation and post-polypectomy syndrome occurred in either group. There were three (8.8%) cancerized adenomas in group A and one (3%) in group B. Clip application was possible in all patients, while in two cases, loop placement was impossible.

Conclusions

In our experience, endoclip-assisted resection is a safe alternative to endoloop for the resection of large pedunculated colorectal polyps when endoloop placement is difficult or impossible.     

Use of narrow band imaging in assessing duodenal villous atrophy

Background and Objective

Narrow band imaging endoscopy with magnification (NBI-ME) has already been established in Barrett’s esophagus, stomach, and colonic mucosa, but limited work has been done in the mucosal evaluation of duodenum. A study was done to determine the correlation between NBI and histology in grading villous architecture in varied etiology.

Method

A prospective observational study comprising 105 subjects with suspected malabsorption. The presence of a diagnosed celiac disease, severe life threatening comorbidity, or pregnancy was considered as exclusion criteria. Standard endoscopy (SE), NBI-ME, multiple duodenal biopsies with histopathological examination were done in all.

Results

Fifty-one patients had celiac disease while 54 patients comprised mainly functional dyspepsia, iron deficiency anemia, tropical malabsorption syndrome, and irritable bowel syndrome. Four NBI-ME image subtypes of villous morphology have been proposed (NBI type I/II/III/IV). NBI-ME had 95 % sensitivity, 90.2 % specificity, 91.2 % positive predictive value, and 94.2 % negative predictive value for diagnosing altered villous morphology. Intraobserver kappa agreement coefficient (κ) for NBI-ME was 0.83 while interobserver agreement was 0.89 (95 % CI 0.8–0.97).

Conclusion

NBI-ME has good performance characteristics and very good kappa intra/interobserver agreement coefficient for varied subtypes of villous morphology. NBI-ME is most useful for obtaining a targeted biopsy which can be missed by conventional white light endoscopy.     

The ability of a novel blue laser imaging system for the diagnosis of invasion depth of colorectal neoplasms

Background

Fujifilm has developed a novel endoscope system with two kinds of lasers that enables us to allow narrow-band light observation with blue laser imaging (BLI). The aim of this study was to evaluate BLI magnification in comparison with narrow-band imaging (NBI) magnification for the diagnosis of colorectal neoplasms.

Methods

This was a multicenter open study. A total of 104 colorectal neoplasms were examined with BLI and NBI magnifications in Kyoto Prefectural University of Medicine and Fukuoka University Chikushi Hospital. Vascular and surface patterns of tumors under BLI magnification were compared with those under NBI magnification, using a published NBI classification. The main outcome was the correlation between the NBI classification diagnosed by BLI or NBI magnification and the histopathological analyses.

Results

Sixty-two cases of adenoma, 34 cases of intramucosal cancer and shallowly invaded submucosal cancer, and eight cases of deeply invaded submucosal cancer were diagnosed. The diagnostic accuracy of BLI magnification in the NBI classification was 74.0 % (77/104), similar to that of NBI magnification (77.8 %). The consistency rate between BLI and NBI magnification in the NBI classification was 74.0 %. Concerning image evaluation, the interobserver variability of two expert endoscopists (N.Y. and T.H.) in BLI magnification was κ = 0.863. On the other hand, the intraobserver variability of the two endoscopists was κ = 0.893 (N.Y.) and 0.851 (T.H.).

Conclusions

BLI magnification by laser source could predict histopathological diagnosis and invasion depth of colorectal neoplasms. The diagnostic effectiveness of this method was similar to that of NBI magnification.     

Intrastomal 3D ultrasound; an inter- and intra-observer evaluation

Background

The aim of this study was to determine intra- and interobserver reliability in 3D intrastomal ultrasound imaging of parastomal hernia and protrusion.

Method

A total of 40 patients were investigated. Two or three physicians evaluated the images twice, 1 month apart.

Results

Inter-observer agreement was 72 % with a kappa value 0.59. For the last 10 patients there was an agreement of 80 % with a kappa value of 0.70. Intraobserver agreement was 80 % for one observer and 95 % for the other. The learning curve levelled out at around 30 patients.

Conclusion

Considering the learning curve of 30 patients, 3D intrastomal ultrasound is a reliable investigation method. 3D intrastomal ultrasonography has the potential to be the investigation of choice to differentiate between a bulge, a hernia, or a protrusion.     

Contrast-Enhanced Harmonic Endoscopic Ultrasonography in the Differential Diagnosis of Gallbladder Wall Thickening

Background and Aims

Differentiation of gallbladder (GB) carcinoma from benign GB wall thickening is challenging. The recent introduction of second-generation ultrasonic contrast agents has made contrast harmonic imaging with EUS possible. The aim of our study was to evaluate the utility of contrast-enhanced harmonic EUS (CH-EUS) for the differential diagnosis of GB wall thickening.

Methods

Thirty-six consecutive patients with GB wall thickening imaged by CH-EUS and then underwent surgery were enrolled in this study. After the lesions were observed with conventional harmonic EUS (H-EUS), CH-EUS was performed with intravenous injection of 0.015 ml/kg of Sonazoid. Three reviewers with various levels of experience of EUS (Reviewer A: experienced endosonographer, B: EUS trainee, C: experienced gastroenterologist with expertise in transabdominal ultrasound but no EUS experience) were blinded to findings of recorded video of H-EUS and CH-EUS. The diagnostic accuracy of H-EUS and CH-EUS for malignant GB wall thickening was compared.

Results

Final diagnoses based on surgical histology were GB carcinoma in 16, cholecystitis in 11, adenomyomatosis in 6 and cholesterolosis in 3. Overall sensitivity, specificity and accuracy for diagnosing malignant GB wall thickening of H-EUS and CH-EUS were 83.3 versus 89.6, 65 versus 98 % (p < 0.001) and 73.1 versus 94.4 % (p < 0.001). The inter-observer agreement for H-EUS was moderate (κ = 0.51), whereas that for CH-EUS was substantial (κ = 0.77). The inhomogeneous enhanced pattern on CH-EUS was a strong predictive factor of malignant GB wall thickening.

Conclusion

CH-EUS has the potential to improve the preoperative diagnostic accuracy and inter-observer agreement in the differential diagnosis of GB wall thickening.     

Portal hypertensive polyps: distinct entity

Introduction

Gastric mucosal changes in portal hypertension (PH) are well known, but gastroduodenal polyps in PH are rarely described.

Aim

This study aims to estimate prevalence of upper gastrointestinal (GI) polyps in patients with PH of any etiology and to evaluate the role of angiogenesis in portal hypertensive polyps.

Material and Methods

This is a retrospective analysis of all patients undergoing upper GI endoscopy to compare the etiology of the polyps in the portal hypertensive group vs. those without PH. The diagnosis of polyps was done using standard histological criteria. Another part of the study consisted of prospective analysis of vascular proliferative marker CD 34 and morphometry in 47 patients.

Results

A total of 3,811 upper GI endoscopies were done of which 121 patients (3.2 %) had polyps in upper GI tract. In patients with PH (=631), polyps were noted in 16, portal hypertensive polyps in 9, hyperplastic in 6, and fundic gland polyp in 1. In the patients without PH (n?=?3,180), polyps of various etiologies were noted in 105 patients. The prevalence of polyps of all causes was similar in both groups (2.5 % vs. 3.3 %, p?=?0.3957). Prevalence of hyperplastic polyps was similar in PH (0.95 %) and non-PH group (1.3 %). On immunohistochemistry, PH polyps and PH gastric mucosa had significantly higher vessel diameter of >50 μm, increased vascular density as compared to non-portal hypertensive polyps (PHP) and normal gastric mucosa.

Conclusion

PHP are definite identifiable lesion in patients of cirrhosis with PH. PHP are probably related to increased angiogenesis in gastric mucosa.     

Does Magnifying Narrow-Band Imaging or Magnifying Chromoendoscopy Help Experienced Endoscopists Assess Invasion Depth of Large Sessile and Flat Polyps?

Background

Distinguishing deep submucosa (SM) from superficial SM cancer in large sessile and flat colorectal polyps (>2 cm) is crucial in making the most appropriate therapeutic decision. We evaluated the additional role of magnifying narrow-band imaging (NBI) and magnifying chromoendoscopy (MCE) in assessing the depth of invasion in large sessile and flat polyps in comparison to morphological evaluation performed by experienced endoscopists.

Methods

From May 2011 to December 2011, a total of 85 large sessile and flat polyps were analyzed. Endoscopic features of the polyps were independently evaluated by experienced endoscopists. Subsequently, the polyps were observed using magnifying NBI and MCE.

Results

A total of 58 intramucosal lesions and 27 SM cancers (five superficial and 22 deep) were identified. The diagnostic accuracy of the experienced endoscopists, NBI, and MCE were 92.9, 90.6, and 89.4 %, respectively, for deep SM cancer. In combination with NBI or MCE, the diagnostic accuracy of the experienced endoscopists did not change significantly for deep SM cancer, with an accuracy of 95.3 % for both NBI and MCE.

Conclusions

Conventional colonoscopy can differentiate superficial from deep SM cancers with an accuracy of as high as 92.9 % in large sessile and flat polyps. Further diagnostic strategies are required in order to precisely assess the depth of invasion, especially in large colorectal polyps.     

A Triple Approach for Diagnostic Assessment of Endoscopic Ultrasound-Guided Fine Needle Aspiration in Pancreatic Solid Masses and Lymph Nodes

Background and Aims

Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) has been becoming the standard tool for acquiring pancreatic lesion tissue. However, a single cytologic or histologic evaluation is not satisfactory for diagnosis. In this study, we evaluated the diagnostic yield of EUS–FNA for pancreatic solid masses and intra-abdominal lymph nodes using a triple approach.

Methods

This study included patients undergoing evaluation for a solid pancreatic mass (n = 59) or intra-abdominal lymph nodes (n = 16) using EUS–FNA with a 22- or 25-gauge (G) needle, respectively. The specimens from each pass were analyzed by on-site cytology using Diff-Quick stain, cytology using Papanicolaou stain, and histology with immunohistochemical (IHC) staining.

Results

A total of 75 patients (49 males; mean age; 63.7 years) were included. The median number of needle pass for diagnosis of malignancy was 2.0, and there was no technical failure. The diagnostic accuracies with on-site cytology, cytology using Papanicolaou staining, and histology were 70.7, 80.0, and 80.0 %, respectively. The diagnostic accuracy using a triple approach was significantly greater than cytology using Papanicolaou staining alone (94.7 vs. 80.0 %; p = 0.007). In patients with malignant lesions, cytology identified 12 of 71 (16.9 %) malignant lesions that were not diagnosed by histology using IHC, and histology identified six (8.5 %) malignant lesions that were not diagnosed by cytology.

Conclusion

On-site cytopathologic evaluation combined with cytologic and histologic analysis with IHC stain for one-pass specimen is considered to be able to increase the overall accuracy of EUS–FNA in pancreatic solid masses and lymph nodes.     

Endoscopic Estimation of Tumor Size in Early Gastric Cancer

Background

Although the accurate estimation of tumor size is essential for proper patient selection for endoscopic resection in early gastric cancer (EGC), no study has been conducted to date on tumor size estimation. We aimed to evaluate the accuracy of endoscopic visual estimation of tumor size of EGC.

Methods

In 508 EGC patients that underwent endoscopic resection, endoscopic visual estimations were performed retrospectively by independent two endoscopists using still images. Data were compared with pathologic measurements as gold standard. Inter-observer agreement was determined using the Bland–Altman method and intra-class correlation coefficients (ICC). Measurement discrepancies were presented as differences between measurements.

Results

The ICC between the two endoscopists was 0.915 (95 % CI 0.900–0.928). Mean endoscopic estimates for both endoscopists were significantly lower than mean pathologic measurements (1.50 and 1.67 vs. 1.80 cm, P < 0.001). Absolute differences between average endoscopic estimates and pathologic measurements were found to be acceptable in most cases: an absolute difference of <0.4 cm was found for 80 % (404/508) of cases. Bland–Altman plot showed that 94 % of cases lay within the 95 % limits of agreement. Measurement discrepancy was proportional to tumor size and increased for an undifferentiated histology.

Conclusions

Endoscopic visual estimations were found to show reliable agreement with pathologic measurement in EGC patients undergoing endoscopic resection, together with good inter-observer agreement. Further prospective study is needed to confirm the validity of this method.     

Multicenter study of endoscopic mucosal resection using 0.13 % hyaluronic acid solution of colorectal polyps less than 20 mm in size

Purpose

Endoscopic mucosal resection (EMR) of colorectal polyps should be curative and safe. This study aimed to determine the efficacy and safety of colorectal EMR using 0.13 % hyaluronic acid (HA) solution.

Methods

This was a single-armed multicenter prospective open trial conducted at 11 Japanese institutions. Lesion characteristics and various measures of clinical outcome, including en bloc resection, histopathologically complete resection, and postoperative bleeding were analyzed for 624 consecutive patients who underwent EMR of colorectal polyps at ≤20 mm in size from August 2010 to September 2011.

Results

En bloc and complete resection were achieved in 93.3 and 78.3 % of 624 lesions. The median EMR procedure time was 2.1?±?1.5 min. The rates of postoperative bleeding and perforation were 1.1 and 0 %. The rate of en bloc resection was higher for polyps at 5–10 mm than for polyps at 11–20 mm (95.1 vs. 85.1 %; P?<?0.001) and was higher for protruding polyps than for superficial polyps (94.5 vs. 87.1 %; P?<?0.05). The rate of en bloc resection was also higher for polyps in the left-side colon than for those in the right-side colon or rectum (96.7 vs. 91.6 vs. 90.8 %; P?<?0.05). Multivariate analysis showed that polyp at 11–20 mm in size and location not on the left-side colon was significantly independent risk factors for failure of en bloc resection.

Conclusion

EMR using 0.13 % HA of colorectal polyps less than 20 mm in size had high rates of en bloc and complete resection and few complications.     

Retrospective study of neuroblastoma in Chinese neonates from 1994 to 2011: an evaluation of diagnosis, treatments, and prognosis

Purpose

The purpose of the study is to review the clinical features, treatments, and outcomes of neonatal neuroblastoma (NB).

Methods

A retrospective analysis was performed on 42 patients with NB between January 1994 and December 2011.

Results

MYCN amplification was detected in nine tumor samples. The ratio of unfavorable histology to favorable histology was 1:2 in NB patients. The 5-year overall survival (OS) of NB patients was 85.7 %. The 5-year OS in patients in the operation group was 83.3 %, chemotherapy group was 83.3 %, and the “wait-and-see” group was 100 % (P = 0.04). Overall, the prognosis was favorable, except in patients with elevated MYCN amplification or vanillylmandelic acid.

Conclusions

NB patients were more sensitive and vulnerable to chemotherapy and operation. The “wait-and-see” strategy should be highlighted in the treatment of NB.     

Efficacy and safety of sequential therapy versus standard triple therapy in Helicobacter pylori eradication in Kashmir India: a randomized comparative trial

Background

Increasing resistance against Helicobacter pylori has resulted in reduced eradication rates.

Objective

This study aims to determine whether eradication rates for H. pylori infection with sequential therapy is better than standard triple therapy.

Patients

Patients with endoscopy documented peptic ulcer and H. pylori infection confirmed by histology and rapid urease test.

Intervention

Patients were randomized into two groups; 134 received standard triple therapy (pantoprazole 40 mg, clarithromycin 500 mg and amoxicillin 1 g each administered twice daily) for 10 days and 138 received sequential regimen (pantoprazole 40 mg plus amoxicillin 1 g twice daily for 5 days followed by 40 mg pantoprazole, 500 mg clarithromycin, and 500 mg tinidazole each administered twice daily for 5 days). Eradication was confirmed by histology and rapid urease test. Compliance and adverse effects were determined by the recovery of empty medicine strips and questioning.

Results

The eradication rates with sequential therapy were significantly greater than with standard therapy on both intention-to-treat analysis (76.0 % vs. 61.9 %, p?=?0.005; difference, 14.1 % [95 % CI, 6.5–19 %] and per protocol analysis (84.6 % vs. 67.4 %, p?=?0.002; difference, 17.2 % [95 % CI, 8.5–23.5 %]). The incidence of side effects did not differ between the two therapy groups. One patient in standard therapy discontinued treatment due to side effects.

Limitation

Cultures were not performed. Loss to follow up was 5.2 % in standard therapy and 6.5 % in sequential therapy.

Conclusion

Sequential therapy was significantly more effective than standard therapy for eradicating H. pylori infection in peptic ulcer disease in Asian patients. Side effects were similar.     

Association between colonic diverticulosis and prevalence of colorectal polyps

Introduction

Diverticulosis and colorectal polyps increase in frequency as the population ages. Proposed common mechanisms for both include lack of dietary fiber, increased saturated fats, and slow colonic transit time. The association of diverticulosis and colorectal polyps has been previously reported with conflicting results. Despite sharing common epidemiologic predisposing factors, the association between diverticulosis and colon polyps remains unclear and needs better clarification.

Aim

The primary aim of our study is to evaluate if there is any association between diverticular disease and colorectal polyps.

Materials and methods

This is a retrospective cohort study. All consecutive patients who underwent colonoscopy between January 2009 and December 2011 were included, except those with history of inflammatory bowel disease, polyposis syndrome, and poor bowel preparation. Univariate and multivariate logistic regression analysis was conducted to analyze the association between colon polyps and diverticulosis. Hyperplastic polyps were excluded from the statistical analysis, and only pre-cancerous adenomas were included.

Results

A total of 2,223 patients met the inclusion criteria. The prevalence of colorectal polyps in patients with diverticulosis was significantly higher than those without diverticulosis (odds ratio (OR) 1.54; 95 % confidence interval (CI) 1.27–1.80, p?=?0.001). This association was found significant for all locations of polyps and all histological subtypes. There was also a statistically significant association between age, presence of diverticulosis, and colorectal polyps (OR 1.03; 95 % CI 1.02–1.04). The incidence of colorectal polyps increases as age advances in patients with diverticulosis, with the highest association in patients >70 years of age (OR 3.55; 95 % CI 2.50–5.04). There was no significant association between indication for colonoscopy and presence of colorectal polyps in patients with diverticulosis (OR 0.98; 95 % CI 0.95–1.01). The incidence of diverticulitis was low (<1 %), and there was no association between diverticulitis and colon polyps.

Conclusion

There is a significant association between diverticulosis and synchronous pre-cancerous colorectal polyps (adenomas). Patients with diverticulosis have a higher risk of colorectal polyps as compared to those without. This observation needs further validation by a large prospective cohort study.     

Transanal endoscopic microsurgery for giant polyps of the rectum

Background

The potential for malignancy in rectal polyps increases with the size of the polyp, and unexpected malignancy is reported in up to 39 % of large rectal adenomas. Transanal endoscopic microsurgery (TEM) offers the possibility of an en bloc full-thickness excision for lesions in the rectum. We present our results with TEM in the removal of giant polyps equal or greater than 4 cm in diameter.

Methods

In the period between 1998 and 2012, TEM was performed in 39 patients with rectal polyps measuring at least 4 cm in diameter. Transrectal ultrasound and/or magnetic resonance imaging of the rectum was used when cancer was suspected.

Results

The polyp was removed with en bloc full-thickness excision in 77 % (n = 30). The preoperative diagnosis was benign rectal adenoma in 89.7 % (n = 35). The median size of the polyps was 30 cm² (range 16–100 cm²). Postoperative complications included bleeding in 4 patients (10.3 %). Histological examination showed unexpected cancer in 4 patients (10.3 %). TEM was curative in 2 of these patients, and the other 2 underwent further surgery. Recurrences occurred in 10 patients (25.6 %) and consisted of 5 adenomas and 5 adenocarcinomas. In 5 patients, these recurrences were treated with endoscopic removal or re-TEM. The remaining 5 underwent total mesorectal excision and/or chemotherapy.

Conclusions

Full-thickness TEM provides a safe and efficient treatment for excision of giant polyps. In case of unexpected cancer, TEM can be curative. Local recurrence can be often treated with a second TEM procedure.     

Evaluation of two-dimensional intraoperative neuromonitoring for predicting urinary and anorectal function after rectal cancer surgery

Purpose

The aim of this study was to compare the results of two-dimensional intraoperative neuromonitoring (IONM) with the postoperative urinary and anorectal function of rectal cancer patients.

Methods

A consecutive series of 35 patients undergoing low anterior resection were investigated prospectively. IONM was performed with electric stimulations of the pelvic splanchnic nerves under simultaneous manometry of the bladder and electromyography (EMG) of the internal anal sphincter (IAS). Urinary and anorectal function were evaluated preoperatively and at follow-up by standardized questionnaires, digital rectal examination scoring system, and long-term catheterization rate.

Results

The rate of postoperative newly developed bladder dysfunction was 17 %. IONM with bladder manometry had a sensitivity of 100 %, specificity of 96 %, positive predictive value of 83 %, negative predictive value of 100 %, and overall accuracy of 97 %, respectively. The proportion of patients with severely impaired anorectal function at follow-up was 8 %. The sensitivity, specificity, and positive and negative predictive values for IONM with EMG of the IAS were, respectively, 100, 96, 67, and 100 % with an accuracy of 96 %. The degree of agreement for IONM with EMG of the IAS was good for anorectal function (к?=?0.780) and poor for urinary function (к?=?0.119). IONM with bladder manometry yielded a very good degree of agreement for urinary function (к?=?0.891) and a fair agreement for anorectal function (к?=?0.336).

Conclusions

The two-dimensional IONM method is suitable for verification of bladder and IAS innervation. Accurate prediction of urinary and anorectal function necessitates both bladder manometry and EMG of the IAS.     

Diagnostic and prognostic value of immunohistochemical expression of S100P and IMP3 in transpapillary biliary forceps biopsy samples of extrahepatic bile duct carcinoma

Background

Because the biopsy specimen of extrahepatic bile duct carcinoma (EHBDC) is small and shows reactive changes, the histological distinction between malignant and benign tissue can be difficult. Recent studies reported that S100P and insulin-like growth factor II mRNA-binding protein 3 (IMP3) were not only diagnostic molecules but also prognostic biomarkers in several organs. The objective of this study is to clarify the diagnostic and prognostic value of immunohistochemical expression of S100P and IMP3 in transpapillary biliary forceps biopsy (TBFB) samples.

Methods

The TBFB samples were collected from 80 patients (EHBDC, 68 patients; benign, 12 patients), retrospectively.

Results

When using cytoplasmic-positive staining for IMP3 as a marker of malignancy, the sensitivity and specificity reached 79.4 and 91.7 %, respectively. The sensitivity, specificity and accuracy achieved 89.7, 91.7 and 90.0 %, respectively, when using positive staining for IMP3 and/or positive histology as a maker of malignancy. While univariate (P = 0.033) and multivariate (P = 0.039) analysis revealed that S100P-positive EHBDC patients showed significantly shorter survival.

Conclusions

The results of this study suggest that immunohistochemical staining for IMP3 is useful in the diagnosis of EHBDC and that of S100P is useful as a prognostic marker for EHBDC.     

Evaluating the Diagnoses of Gastric Antral Lesions Using Magnifying Endoscopy with Narrow-Band Imaging in a Chinese Population

Aim

To evaluate the accuracy of diagnosing gastric antral lesions in routine clinical practice using magnifying endoscopy with narrow-band imaging (M-NBI) as a real-time diagnosing technique.

Methods

Consecutive patients undergoing upper endoscopy were selected for the study. In each patient, the mucosa of the gastric antrum was observed by M-NBI, and the gastric microstructure was categorized into five types (A–E). Based on these patterns, histological types were predicted in a real-time manner. The accuracy of these predictions was evaluated based on histological findings. Inter-observer agreement was also assessed.

Results

A total of 207 sites in 90 patients were examined by M-NBI. Compared with type A gastric microstructure, types B and C gastric microstructure showed a significantly higher degree of inflammation (P < 0.001). The sensitivity, specificity and accuracy of types B + C microstructure as a predictor of gastric inflammation were 85.4, 81.7 and 83.1 %, respectively. Similarly, the sensitivity, specificity and accuracy of type D microstructure as a predictor of gastric intestinal metaplasia were 71.8, 95.2 and 90.8 %, respectively, and those of type E microstructure as a predictor of early gastric cancer were 80.0, 98.9 and 97.6 %, respectively. The sensitivity and specificity of type B alone, type C alone and types B + C combined for the detection of Helicobacter pylori infection were 52.2 and 87.0 %, 22.8 and 92.2 %, 75.0 and 79.1 %, respectively. The kappa value for the inter-observer agreement was 0.715 (95 % confidence interval 0.655–0.895).

Conclusions

In conclusion, M-NBI can significantly improve the accuracy of the prediction of histopathology of gastric antral lesions in vivo, implying the possibility of using M-NBI as an effective diagnosis technique.