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Background and Aim: In Japan, patient acceptance of bowel preparation methods before colonoscopy remains unknown. This study was conducted to evaluate the patient acceptance of sodium phosphate (NaP) tablets and polyethylene glycol solution (PEG) with sodium picosulfate. Methods: One hundred patients were randomized into one of the following two groups: the NaP tablet first-use group or the PEG with sodium picosulfate first-use group in a crossover design trial. Patient acceptance and incidence of adverse events were evaluated using a questionnaire. Colon-cleansing effectiveness was also evaluated. Results: Patients' overall impressions of the preparations were significantly different between the NaP tablet (77.9%, 67/86) and PEG with sodium picosulfate (60.5%, 52/86; P = 0.001). Nausea incidence as an adverse event was significantly different between the two regimens (P = 0.03). Colon-cleansing effectiveness was not significantly different between the two regimens. Conclusions: The results of this crossover study showed that patient acceptance was similar to those previously reported in a parallel-group comparison. In Japanese patients, preference for and acceptance of NaP tablets was significantly higher than that for PEG with sodium picosulfate solution.

Background and study aims Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) has improved the success rate of en-bloc resection. We report here on a new technique using an external grasping forceps. Patients and methods A total of 25 patients with suitable EGCs over 10 mm in diameter located in the gastric body were enrolled. After submucosal injection followed by circumcision of the lesion with a needle-knife, an external grasping forceps was introduced with the help of a second grasping forceps and anchored at the distal margin of the lesion. With gentle oral traction applied with this forceps, the lesion was dissected endoscopically in retroversion from the aboral side. Results The mean lesion size was 15.0 mm (range 10 - 25 mm). Using the technique described, all lesions could be resected en bloc with free margins. The mean procedure time was 45 min (range 30 - 80 minutes). No significant bleeding requiring blood transfusion or perforation occurred. Conclusions This technical modification may simplify and shorten the gastric ESD procedure, except for lesions in distal locations, without compromising the efficacy.

We report the case of a 71-year-old woman with acute hepatitis C infection and persistent viremia since 2 years. Her clinical course was characterized by general fatigue and prolonged jaundice with unusually high serum bilirubin levels. Liver histology showed lymphocyte infiltration, marked fibrosis, and severe cholestasis in the periportal zone, findings mimicking fibrosing cholestatic hepatitis (FCH). Fibrosing cholestatic hepatitis is a life-threatening form of recurrent hepatitis C infection that typically occurs in immunosuppressed patients. Here we report the rare case of an immunocompetent patient who developed this condition.

In Japan, patient acceptance of bowel preparation methods before colonoscopy remains unknown. This study was conducted to evaluate the patient acceptance of sodium phosphate (NaP) tablets and polyethylene glycol solution (PEG) with sodium picosulfate.One hundred patients were randomized into one of the following two groups: the NaP tablet first-use group or the PEG with sodium picosulfate first-use group in a crossover design trial. Patient acceptance and incidence of adverse events were evaluated using a questionnaire. Colon-cleansing effectiveness was also evaluated.Patients' overall impressions of the preparations were significantly different between the NaP tablet (77.9%, 67/86) and PEG with sodium picosulfate (60.5%, 52/86; P = 0.001). Nausea incidence as an adverse event was significantly different between the two regimens (P = 0.03). Colon-cleansing effectiveness was not significantly different between the two regimens.The results of this crossover study showed that patient acceptance was similar to those previously reported in a parallel-group comparison. In Japanese patients, preference for and acceptance of NaP tablets was significantly higher than that for PEG with sodium picosulfate solution.

Ceramide has been suggested to play a role in apoptosis during gastric ulcerogenesis. The present study is designed to investigate whether accumulated ceramide could serve as the effector molecules of ulcer formation in a rat model of acetic acid-induced gastric ulcer.The effect of fumonisin B1, an inhibitor of ceramide synthase, and of d,l,-threo-1-phenyl-2-hexadecanoylamino-3-morpholino-1-propanol (PPMP) and N-butyldeoxynojirimycin (NB-DNJ), both inhibitors of glucosylceramide synthase, on the accumulation of ceramide and formation of gastric ulcer were examined in the rat model of acetic acid-induced gastric ulcer.Fumonisin B1 attenuated acetic acid-induced gastric ulcer formation, associated with a decrease in the number of apoptotic cells. Our results showed that it is neither the C18- nor the C24-ceramide itself, but the respective metabolites that were ulcerogenic, because PPMP and NB-DNJ attenuated gastric mucosal apoptosis and the consequent mucosal damage in spite of their reducing the degradation of ceramide.The ceramide pathway, in particular, the metabolites of ceramide, significantly contributes to acetic acid-induced gastric damage, possibly via enhancing apoptosis. On the other hand, PPMP and NB-DNJ treatment attenuated gastric mucosal apoptosis and ulcer formation despite increasing the ceramide accumulation, suggesting that it was not the ceramides themselves, but their metabolites that contributed to the ulcer formation in the acetic acid-induced gastric ulcer model.

Ceramides have emerged as key participants in the signaling pathway of cytokines and apoptosis. We previously revealed that phorbol 12-myristate 13-acetate (PMA) induced experimental ulcers in rat gastric mucosa. In this study, we investigated the role of ceramide in ulcer formation and its relation to the activation of transcription factors and apoptosis. PMA was subserosally injected to rat glandular stomach. Fumonisin B1 (FB1), an inhibitor of ceramide synthase, was administered together with the PMA. The time course of ceramide content was quantified using thin layer chromatography and the number of apoptotic cells was determined by immunohistochemistry. The activation of transcription factor nuclear factor-kappaB (NF-kappaB) or activator protein-1 (AP-1) was evaluated using an electrophoretic mobility shift assay. The administration of FB1 attenuated PMA-induced gastric ulcer formation in a dose-dependent manner. Before the ulcers became obvious, the ceramide content (C18 and C24 ceramide) increased significantly in the gastric wall. The activation of NF-kappaB and AP-1 and an increase in the number of apoptotic cells were also observed. Both of these were significantly inhibited by the coadministration of FB1. However, NF-kappaB inhibitors attenuated gastric ulcer formation without affecting the ceramide content or the number of apoptotic cells. Ceramide formation in the stomach significantly contributes to PMA-induced tissue damage, possibly via the activation of transcription factors and an increase in apoptosis in the gastric mucosa. However, after the increase in ceramide levels, the NF-kappaB and apoptosis pathways may be separately involved in ulcer formation.

Novel Procedure of Endoscopic Submucosal Dissection Using Double Graspers for Early Stage Gastric Cancer Hiroyuki Imaeda, Yasushi Iwao, Haruhiko Ogata, Hitoshi Ichikawa, Hidekazu Suzuki, Nagamu Inoue, Mikiji Mori, Naoki Hosoe, Tatsuhiro Masaoka, Manabu Nakashita, Koichi Aiura, Hiroshi Nagata, Koichiro Kumai, Toshifumi Hibi Background and Aim: Endoscopic submucosal dissection (ESD) for early stage gastric cancer (EGC) has improved the success rate for en bloc resection. It has been also reported that several techniques of traction of lesions are useful for ESD; however, these are complicated and invasive. The aim of this study is to assess the usefulness of ESD using double graspers for EGC. Subjects and Methods: Subjects were 23 lesions of EGC, which were histopathologically differentiated adenocarcinomas within the mucosa and without ulcers. Mean size of the lesions was 16.3 mm, range from 10-35 mm. Sixteen of 23 lesions were at the gastric body, 5 at the antrum and 2 at the angulus. A short hood was attached to the distal tip of an endoscope. After marking around lesions, 10% glycerin with indigocarmine and epinephrine was injected into the submucosa. After circumferential cutting around the lesions using a needle knife at a Endo-Cut mode, the endoscope was pulled out once. Next, a grasper (inside grasper) inserted through an accessory channel of the endoscope grasped the tip of the other grasper (outside grasper), which was outside the endoscope. Both graspers and endoscope were inserted into the stomach, and the anal side of the lesions was grasped by the outside grasper controlled by the endoscope and the inside grasper. Thereafter, the inside grasper was released and pulled out. Finally, with traction of the lesions towards the oral side by the outside grasper, the submucosal layer of lesions was dissected using the needle knife at a forced coagulation mode. Hemostasis for bleeding was carried out using the needle knife at a spray coagulation mode or clips. Results: (1) All lesions were able to be grasped with the outside grasper. (2) Traction of the lesion towards the oral side by the outside grasper was able to make the submucosal layer wider and more visible. Therefore, dissection could be more easily carried out under direct vision, with both safety and certainty. (3) Both the endoscope and the outside grasper was able to be moved easily and independently. (4) All lesions were able to be resected en block. (5) No bleeding requiring blood transfusion or a perforation occurred. Conclusion: ESD using double graspers is very useful for easily dissecting EGC with safety and certainty not only at the body but also the angulus and the antrum. M1339 New Diagnostic and Therapeutic Strategy: Combination of Capsule Endoscopy (CE) and Double-Balloon Endoscopy (DBE) Michiko Iwamoto, HIronori Yamamoto, Hiroto Kita, Keijiro Sunada, Yoshikazu Hayashi, Hiroyuki Sato, Kentaro Sugano, Katuro Shirakawa, Tetuya Nakamura, Akira Terano Background: Capsule endoscopy (CE) and double-balloon endoscopy (DBE) both offer visualization of the entire small intestine (SI). CE is considered an effective diagnostic procedure, while DBE is potentially a therapeutic as well as a diagnostic technique but DBE requires both oral and anal approaches to view entire SI. Aim: To determine if the combination of CE and DBE is a useful as a diagnostic and therapeutic strategy for SI diseases. Methods: Thirteen patients with melena and anemia who had no specific findings by previous esophagogastroduodenoscopy (EGD) and colonoscopy were examined by both CE and DBE. CE was performed prior to DBE in order to both compare the findings of both tests, and to determine if CE data about the location of lesions CE was helpful in to the endoscopist performing DBE. Results: Visualization of the entire small bowel was adequate in all subjects. CE and DBE both identified the same source of bleeding in 9 of 13 (69%) subjects, 1 bleeding polyp, 2 arteriovenous malformations (AVM), 2 submucosal tumors (SMT), 1 bleeding small intestinal ulcer, 1 segmental edematous lesion, 1 gastric ulcer, 1 gastric antral vascular ectasia (GAVE); in one additional patient no lesions were seen by either exam. In 3 cases, SMTwas suggested by CE but not found by DBE. Endoscopic treatment was performed in 6 patients (1 polypectomy, argon plasma coagulation in 3 patients, 2 for AVMs and 1 for GAVE, and clipping for 1 bleeding gastric ulcer.) Surgical resection was performed for 2 SMT. In 1 patient with bleeding small intestinal ulcer, capsule retention occurred near the ring like stricture DBE with Balloon dilatation of the stricture to 15 mm allowed the capsule to pass naturally within 2 days. DBE was helpful for this case. Conclusion: In this small series the combination of CE and DBE appeared to be complementary. The identification and localization of lesions by CE was useful to the endoscopist performing DBE and DBE with stricture dilatation allowed a retained capsule to pass.

Procedure of Endoscopic Hemostasis Using a Distal Attachment and Short Clips Against Upper Gastrointestinal Bleeding Naoki Hosoe, Hiroyuki Imaeda, Haruhiko Ogata, Hidekazu Suzuki, Tatsuhiro Masaoka, Manabu Nakashita, Tomoko Tsuda, Hiroyuki Kimura, Koichi Aiura, Yasushi Iwao, Hiroshi Nagata, Koichiro Kumai, Toshifumi Hibi, Hiromasa Ishii BACKGROUND and AIM: Endoscopic hemostasis using hemoclips is useful against upper gastrointestinal bleeding, however it is difficult to perform hemoclipping against tangent view-lesions. A hood which is attached to a distal tip of an endoscope makes hemoclipping more easier, however it is sometimes difficult to observe lesions because clot is put into the hood. The aim of this study is to assess endoscopic hemostasis using a distal attachment and short clips against upper gastrointestinal bleeding. SUBJECTS and METHODS: Subjects were 103 patients with 117 lesions of upper gastrointestinal bleeding. A distal attachment, which was a short hood (4 mm in length) was attached to the distal tip of an endoscope from start of endoscopic examination. If lesions of upper gastrointesitinal bleeding were detected, hemoclipping using short clips was performed against them. This procedure had been performed against 50 lesions, including 20 of gastric ulcer, 14 of duodenal ulcer, 12 of lesion resected endoscopically against early gastric cancer and gastric adenoma, 3 of Mallory-Weiss syndrome and 1 of stomal ulcer. Endoscopic hemostasis by this procedure was analyzed. RESULTS: It was easy to insert the endoscope with the distal attachment into the upper GI in all patients.Appropriate endoscopic view using the distal attachmentwas achieved without disturbance of clot in all lesions. For tangent view-lesions, this attachment made endoscopic observation and treatment more easier. In addition, the entire short clip was able to be stored into this attachment, and certainly clamped a protruded visible vessel even if the bottom of the lesion was hard. Forty-seven of 50 lesions (94.0%) had temporal hemostasis and forty-six lesions (90.0%) had permanent hemostasis. One patient with multiple gastric ulcers, advanced hepatocellular carcinoma and bleeding tendency associated with DIC had temporal hemostasis, however he died of rebleeding from the ulcers. Two patients with duodenal ulcer and one patient with gastric ulcer underwent interventional radiology because visible vessels were more than 3mm. One patient with duodenal Dieulafoy’’s lesion close to papilla of Vater underwent endoscopic hemoclipping using a lateral-viewing endoscope. CONCLUSION: Endoscopic hemostasis with a distal attachment and short clips is useful against upper gastrointestinal bleeding. *M1777 Sensitivity and Inter-Observer Variability for Capsule Endoscopy Image Analysis in a Cohort of Novice Readers Gary Chen, Simon Chan, Clifford Quan, Mary Kalpakian, Tam Tran, Pedram Enayati, Mary Lee Henderson, Gareth Dulai, Ian Arnott, Fumiaki Kitahara, Jeff Gornbein, Rome Jutabha Capsule endoscopy image analysis is a time consuming and tedious process. The process for selecting, training, and validating an individual’s (reader) ability to accurately detect abnormalities has not been well studied. Aim: To determine the sensitivity, specificity, and concordance rate of novice readers (4th year medical students withminimal endoscopic background) for detecting pre-specified capsule endoscopic findings. Hypotheses: 1) Medical students can reliably detect small bowel lesions deemed as definitive lesions for obscure bleeding with a high degree of sensitivity but low specificity, and 2) the concordance rates between the readers and gold standard will be high. Methods: Ten encoded test cases with definitive sites for bleeding were administered to the readers (n=9) in a pre-set order (bleeding: AVM-3, Meckel’s-1, ulcers/aphthous lesions-3, foreign body with ulceration-2). The gold standard findings were pre-defined by 2 expert capsule endoscopists (over 75 capsule cases each). Twelve gold standard targets were identified among the 10 test cases. The readers were given a 30 minute overview of the Rapid Reader (GIVEN Imaging) software and instructions for thumbnailing anatomic landmarks and any potential abnormality. A proprietary software program was developed to compile and analyze thumbnailed finding with respect to sensitivity and specificity as compared to a gold standard and overall concordance rates. Results: The average sensitivity among the 9 medical students was 67% with gradual improvement in sensitivity and specificity over time. All findings were detected by at least 2 to 9 of the students. An average of 19 false positive incidental finding’s per case were made by each student. The concordance (Kappa statistic) between readers was 22% for these 12 gold standard findings (intra-class correlation=0.22). Conclusions: A panel of medical students with minimal endoscopic experience can reliably detect high risk bleeding lesions on capsule endoscopy with moderate sensitivity, and can pre-screen recordings to thumbnail potential abnormalities. Due to low specificity, expert capsule endoscopists must review these thumbnails to determine the clinical relevance of each finding. Additional studies are ongoing to assess other reader cohorts (nurses, GI fellows, non-medical) abilities to detect various bleeding as well as nonbleeding abnormalities on capsule endoscopy.

Novel Procedure of Grasper-associated Endoscopic Mucosal Resection Against Early Gastric Cancer Hiroyuki Imaeda, Yasushi Iwao, Haruhiko Ogata, Hidekazu Suzuki, Naoki Hosoe, Tatsuhiro Masaoka, Manabu Nakashita, Tomoko Tsuda, Koichi Aiura, Hiroshi Nagata, Koichiro Kumai, Toshifumi Hibi, Hiromasa Ishii BACKGROUND and AIM: Endoscopic mucosal resection (EMR) by submucosal dissection against early gastric cancer has improved the rate of en blocresection, however more skillful technique should be necessary in comparisonwith strip biopsy technique, and it has been claimed that there are more complications. Recently many kinds of devices of instruments in EMR have been reported, however it is still difficult to dissect the submucosa of lesions especially located in gastric body. The aim of this study is to assess the usefulness of grasper-associated endoscopicmucosal resection which we have designed against early gastric cancer. SUBJECTS and METHODS: Subjects were 11 lesions of early gastric cancer which has been thought to be remained within the mucosa of gastric body. The average size of those lesions was 16.5mm (range 10-25mm). A short hood (4-mm in length) was attached to the distal tip of an endoscope, and a flexible overtube was inserted with the endoscope. After marking around lesions, 10% glycerin with indigocarmine and epinephrine was injected into the submucosa. After the circumferential mucosa around the lesion was cut by a needle knife, then the endoscope was pulled out once. Next, a grasper (inside grasper) was inserted through a working channel, and a distal portion of another grasper outside the endoscope (outside grasper) was grasped by inside grasper, thereafter the endoscope was inserted again with the outside grasper. After the lesion was grasped by the outside grasper under control of the inside grasper and the endoscope, the inside grasper was pulled out. Finally, while pulling up the lesion from anal towards oral side by the outside grasper, the submucosal dissection was performed from the anal side lesion. RESULTS: (1) Traction of those lesions towards the oral side by the outside grasper achieved more open and wide range of the vision of the submucosa. (2) All 11 lesions were able to be resected en block by this procedure. (3) Operating time was approximately 60minutes and shorter than conventional procedure. (4) During procedure, small amount of hemorrhage was the only complication, and there happened no perforation. Furthermore, combined this procedure with squirting water, detection of bleeding spot and instant hemostasis was able to be performed. CONCLUSION: This novel procedure of grasper-associated EMR could make submucosal dissection certainly, more easier and safer against early gastric cancer located in gastric body. **186 Testing of a New Device for Endoscopic Mucosal Resection for the Esophagus and Colon Paul Swain, Per-Ola Park, Maria Bergson, Annette Fritscher-Ravens, Keiichi Ikeda Background: Endoscopic mucosal resection of Barrett segments or other dysplastic abnormalites in the esophagus or colon is difficult to control precisely with injection and snare closure. A cylindrical end-cap on the tip of an endoscope limits the area of tissue that can be resected and takes circular disks of tissue from tubular structures. Large volume resections in esophagus and colon risk perforation. Aim: To test a device designed to resect large volumes of esophageal or colonic tissue in strips controlling the depth of resected tissue. Materials and methods: The resection device was formed using a flexible over-tube with an operating tip. The proximal end of the over-tube featured an airtight seal allowing passage of conventional endoscopes of 6-11mm, thumb control allowed the linear resection wire to be moved to cut a rectangular section of tissue at the tip, diathermy connector, adjustable needle injector and port for saline injection. At the distal end tissue could be sucked into a rectangular cavity of 13 3 cm.Depth of tissue cutwas controlled by a soft plastic sling under the cavity. The needle could be advanced into tissue in the centre of the proximal edge of the cavity. Saline could be injected with precision at any predetermined point in the proximal margin of the area to be resected. The overtube had a soft open conical endpiece, which could be occluded by pushing it against tissue and applying suction. The endoscope could be pushed through the cone to examine the stomach or colon. Results: The device was used in postmortem esophagus and colon, and the esophagus of the anesthetized pig. Intubation over an endoscope or catheter was atraumatic. The device was used with 11 mm (2.8 mm channel) and 5.9 mm (2.2 mm channel) endoscopes. Suction was effective in filling the rectangular resection cavity. The raised semitransparent bleb after injection filled half the cavity. The separation of the mucosa from the muscle could be clearly viewed as the linear diathermy wire cut through the tissue in the rectangular cavity. The resected specimens were a neat rectangle of mucosa and submucosal exposing the deep muscle. The tissue was retained in the tube for removal. Optimal diathermy settings were 40-60 W pure cut. No bleeding was observed. Perforation did not occur. Conclusion: A new device for resection of Barrett segments or other mucosal or submucosal abnormalities was described. It was easy to use, removedmucosal and submucosal strips of predetermined depth and appeared safe in bench and live animal testing.