Evaluating the usefulness of considering the size and morphological type of type B2 vessel area based on Japan Esophageal Society classification in estimating tumor invasion depth in superficial esophageal squamous cell carcinomas: study protocol for a prospective observational study (Japan BEES study).

BACKGROUND: Accurate evaluation of tumor invasion depth is essential to determine the appropriate treatment strategy for patients with superficial esophageal cancer. The pretreatment tumor depth diagnosis currently relies on the magnifying endoscopic classification established by the Japan Esophageal Society (JES). However, the diagnostic accuracy of tumors involving the muscularis mucosa (MM) or those invading the upper third of the submucosal layer (SM1), which correspond to Type B2 vessels in the JES classification, remains insufficient. Previous retrospective studies have reported improved accuracy by considering additional findings, such as the size and macroscopic type of the Type B2 vessel area, in evaluating tumor invasion depth. Therefore, this study aimed to investigate whether incorporating the size and/or macroscopic type of the Type B2 vessel area improves the diagnostic accuracy of preoperative tumor invasion depth prediction based on the JES classification. METHODS: This multicenter prospective observational study will include patients diagnosed with MM/SM1 esophageal squamous cell carcinoma based on the Type B2 vessels of the JES classification. The tumor invasion depth will be evaluated using both the standard JES classification (standard-depth evaluation) and the JES classification with additional findings (hypothetical-depth evaluation) for the same set of patients. Data from both endoscopic depth evaluations will be electronically collected and stored in a cloud-based database before endoscopic resection or esophagectomy. This study's primary endpoint is accuracy, defined as the proportion of cases in which the preoperative depth diagnosis matched the histological depth diagnosis after resection. Outcomes of standard- and hypothetical-depth evaluation will be compared. DISCUSSION: Collecting reliable prospective data on the JES classification, explicitly concerning the B2 vessel category, has the potential to provide valuable insights. Incorporating additional findings into the in-depth evaluation process may guide clinical decision-making and promote evidence-based medicine practices in managing superficial esophageal cancer. TRIAL REGISTRATION: This trial was registered in the Clinical Trials Registry of the University Hospital Medical Information Network (UMIN-CTR) under the identifier UMIN000051145, registered on 23/5/2023.

Muscular metastasis of superficial esophageal squamous cell carcinoma: a rare case of recurrence after endoscopic submucosal dissection with additional chemoradiotherapy.

Esophageal cancer after endoscopic treatment may recur depending on the risk. We present a case of a rare T1b esophageal cancer after endoscopic treatment plus chemoradiotherapy (CRT) that recurred with metastasis of the dorsal muscles. A 70-year-old man was referred for treatment of early-stage esophageal carcinoma. Endoscopic submucosal dissection (ESD) was performed and histopathology showed a poorly differentiated squamous cell carcinoma with invasion to the submucosal layer (sm2) with INFc-type invasion and positive venous invasion. After subsequent CRT, the patient was monitored every 6 months, using computed tomography (CT) and endoscopy. Fifteen months after the treatment, contrast CT revealed a spherical mass with 9 cm ring enhancement within the right erector spinae, that had squamous cell carcinoma confirmed by CT-guided biopsy. Radiation and systemic chemotherapy were initiated for the metastasis of the esophageal carcinoma. However, he died of respiratory failure due to rapid pleural effusion 26 months after ESD. Pathological autopsy showed diffuse squamous cell carcinoma invasion of the cystic wall, forming a lumbar mass, and absence of cancer cell remnants or recurrences in the esophagus. This case report emphasizes the need for systemic observation of superficial esophageal cancer after treatment with a high risk of recurrence.

Impact of COVID-19 on the endoscopy department since the early phase of the pandemic in 2020: A questionnaire study among patients with canceled examinations at a single Japanese institution.

INTRODUCTION: In early 2020, the Japanese government declared a nationwide state of emergency for the COVID-19 pandemic. We investigated the impact of the emergency declaration on endoscopy adherence and conducted a follow-up study of patients with canceled examinations at a tertiary endoscopy facility in Japan in 2020. METHODS: We compared the number of endoscopies performed, and cancelations at the endoscopy unit between 2019 and 2020 and used the Bayesian structural time series (BSTS) model to estimate the decrease in the number of endoscopies in 2020. We administered a questionnaire to those who had not undergone a scheduled endoscopy. RESULTS: Of 14 146 and 13 338 scheduled examinations, 1233 (8.7%) and 1403 (10.5%) were canceled in 2019 and 2020, respectively. During both years, age < 50 years, age > 80 years, upper endoscopy, and experience of endoscopy in the past 5 years were significantly associated with cancelations. In 2020, cancelations in the 14th-26th week of the year, including the period of state of emergency, increased significantly, and more women canceled. Of the 409 questionnaire-respondents, 174 (42.5%) indicated that COVID-19 had influenced their cancelation, and 315 (77.0%) had not undergone similar endoscopic examinations since then. The BSTS model predicted a decrease of 957 (95% CI -1213 to -708, P = .003) examinations. CONCLUSION: In 2020, despite low numbers of COVID-19 cases in the study site, the number of endoscopies decreased, and cancelation increased. Further research is needed on the future impact of a decrease in the number of endoscopies during a COVID-19 pandemic.

Assigning a different endoscopist for each annual follow-up may contribute to improved gastric cancer detection rates.

Background and study aims Esophagogastroduodenoscopy (EGD) is an effective and important diagnostic tool to detect gastric cancer (GC). Although previous studies show that examiner, patient, and instrumental factors influence the detection of GC, we analyzed whether assigning a different examiner to surveillance EGD would improve the detection of GC compared to assigning the same examiner as in the previous endoscopy. Patients and methods We retrospectively reviewed patients who underwent two or more consecutive surveillance EGDs at a single center between 2017 and 2019. We identified factors associated with GC detection using multivariable regression analysis and propensity-score matching. Results Among 7794 patients, 99 GC lesions in 93 patients were detected by surveillance EGD (detection rate; 1.2 %), with a mean surveillance interval of 11.2 months. Among the detected 99 lesions, 87 (87.9 %) were curatively treated with endoscopy. There were no differences in the clinicopathologic characteristics of GC detected by the same or different endoscopists. GC detection in the group examined by different endoscopists was more statistically significant than in the group examined by the same endoscopist, even after propensity-score matching (1.6 % and 0.7 %; P  < 0.05). Endoscopic experience and other factors were not statistically significant between the two groups. Conclusions In surveillance EGD, having a different endoscopist for each exam may improve GC detection rates, regardless of the endoscopist's experience.

Influence of anticoagulants on the risk of delayed bleeding after gastric endoscopic submucosal dissection: a multicenter retrospective study.

BACKGROUND AND AIMS: Delayed bleeding after gastric endoscopic submucosal dissection (ESD) in patients receiving anticoagulants remains an unpreventable adverse event. Although direct-acting oral anticoagulants (DOACs) have superior efficacy in preventing thromboembolism, their effects on the occurrence of delayed bleeding remain unclear. This study aimed to elucidate the clinical effect of DOACs on delayed bleeding after gastric ESD. PATIENTS AND METHODS: We retrospectively examined 728 patients who received anticoagulants and were treated for gastric neoplasms with ESD in 25 institutions across Japan. Overall, 261 patients received DOACs, including dabigatran (92), rivaroxaban (103), apixaban (45) and edoxaban (21), whereas 467 patients were treated with warfarin. RESULTS: Delayed bleeding occurred in 14% of patients taking DOACs, which was not considerably different in patients receiving warfarin (18%). Delayed bleeding rate was significantly lower in patients receiving dabigatran than in those receiving warfarin and lower than that observed for other DOACs. Multivariate analysis showed that age ≥ 65, receiving multiple antithrombotic agents, resection of multiple lesions and lesion size ≥ 30 mm were independent risk factors, and that discontinuation of anticoagulants was associated with a decreased risk of bleeding. In multivariate analysis among patients taking DOACs, dabigatran therapy was associated with a significantly lower risk of delayed bleeding. CONCLUSIONS: The effects of DOACs on delayed bleeding varied between agents, but dabigatran therapy was associated with the lowest risk of delayed bleeding. Switching oral anticoagulants to dabigatran during the perioperative period could be a reasonable option to reduce the risk of delayed bleeding after gastric ESD.

The risks and characteristics of the delayed bleeding after endoscopic submucosal dissection for early gastric carcinoma in cases with anticoagulants.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for early gastric carcinoma. Vitamin K antagonists and direct oral anticoagulants (DOAC) were reported to increase the risk of delayed bleeding after ESD. However, the evaluation of ESD cases taking anticoagulants is scarce. We analyzed the risk and characteristics of delayed bleeding after gastric ESD in patients on anticoagulants. METHODS: We performed a retrospective observational study at a single center. Consecutive patients who underwent ESD for early gastric carcinoma and took anticoagulants, including warfarin, rivaroxaban, dabigatran, apixaban, and edoxaban, between January 2012 and December 2018, were analyzed. We also calculated delayed bleeding rates for those without anticoagulants. RESULTS: Of 1855 eligible patients who underwent gastric ESDs, 143 took anticoagulants. Delayed bleeding occurred in 30 (21.0%) cases taking anticoagulants, with 15 (19.5%) cases in the DOAC group [rivaroxaban, seven cases (21.2%); dabigatran, four cases (20.0%); apixaban, four cases (23.5%); and edoxaban, zero cases (0%)] and 15 cases (22.7%) in the warfarin group. Furthermore, 43/344 (12.5%) patients taking antiplatelets and 76/1368 (5.6%) patients without antithrombic drugs experienced delayed bleeding. Multivariable logistic analysis revealed post-heart valve replacement (OR, 6.56; 95% CI, 1.75-24.7; p < .05) as a risk for delayed bleeding in warfarin-taking patients, while no statistically significant factor was found in DOAC-taking patients. CONCLUSIONS: Anticoagulants were associated with a high incidence of severe delayed bleeding. Careful attention should be paid to patients on anticoagulants after gastric ESD, especially those on warfarin after heart valve replacement.

A case of gastric adenocarcinoma considered to originate from a sporadic fundic gland polyp in a Helicobacter pylori-uninfected stomach.

We encountered a rare case of gastric adenocarcinoma considered to arise from a sporadic fundic gland polyp (FGP). A woman in her 70 s, who had been prescribed a proton pump inhibitor for 5 years, was referred to our institution for further investigation and treatment of a gastric lesion. White light endoscopy showed numerous isochromatic FGPs in the greater curvature of the gastric body and a 15-mm reddish polypoid lesion with uneven surface characteristics. Magnifying endoscopy with narrow band imaging revealed an irregular granular microsurface structure with irregular microvessels, which is suggestive of cancer. The absence of atrophic changes in the entire gastric mucosa was confirmed endoscopically and histologically, and multiple Helicobacter pylori (HP) tests were negative. An en bloc resection was performed by polypectomy. The specimen showed adenocarcinoma that was thought to arise from an FGP. The lesion consisted of cystically dilated fundic glands in the basal part and neoplastic cells with nuclear atypia and high nuclear-cytoplasmic ratio in the foveolar part; on the basis of these findings, noninvasive adenocarcinoma was diagnosed. Although both adenocarcinoma in an HP-uninfected stomach and epithelial high-grade dysplasia in a sporadic FGP are extremely rare, this possibility should be considered when performing esophagogastroduodenoscopy.

The sub-classification of type B2 vessels according to the magnifying endoscopic classification of the Japan Esophageal Society.

OBJECTIVES: Guidelines for magnified endoscopic diagnosis of esophageal squamous cell carcinoma (SCC) have been proposed by the Japan Esophageal Society. Type B1, B2, and B3 reflect increasing tumor invasion depths (within mucosal epithelium or into lamina propria mucosa [T1a-EP/LPM], into muscularis mucosa or superficial invasion into submucosa [T1a-MM/T1b-SM1], and into submucosa [T1b-SM2], respectively). The diagnostic accuracy of type B1 and B3 is high, but accuracy of type B2 is low. We aimed to improve the diagnostic accuracy of type B2. METHODS: We retrospectively reviewed 248 SCC lesions treated with endoscopic submucosal dissection between January 2012 and July 2018 and identified the B2 lesions. The maximum diameter of the area presenting B2 was measured and evaluated in relation to tumor invasion, for which receiver-operating characteristic (ROC) curves were generated. The optimal area size for distinguishing T1a-EP/LPM from T1a-MM or deeper invasion was determined. RESULTS: There were 78 lesions with B2, of which 26 (33%) were T1a-MM or T1b-SM1 SCCs. ROC curve analysis indicated that the optimal cut-off for the target area showing B2 was 4 mm. The invasion depth (EP/LPM: MM/SM1: SM2) of B2 observed in an area with a diameter <4 mm (B2-Narrow) and those with diameter ≥4 mm (B2-Broad) was 46:11:1 and 1:15:4, respectively. To predict T1a-MM or deeper invasion, B2-Broad had a sensitivity, specificity, positive predictive value, and negative predictive value of 61%, 98%, 95%, and 79%, respectively. CONCLUSION: The diagnostic accuracy of type B2 was improved by evaluating the area of type B2.

Efficacy of polyglycolic acid sheets and fibrin glue for prevention of bleeding after gastric endoscopic submucosal dissection in patients under continued antithrombotic agents.

BACKGROUND: A novel method for the prevention of bleeding after gastric endoscopic submucosal dissection (ESD) is necessary, as the numbers of patients taking antithrombotic agents have increased. This study aimed to assess the efficacy and safety of the covering method using polyglycolic acid (PGA) sheets and fibrin glue for ESD-induced ulcer in preventing post-ESD bleeding in patients under continued antithrombotic agents. METHODS: One hundred five consecutive gastric tumors among 84 patients who were treated by ESD under continued antithrombotic agents between April 2014 and September 2015 were enrolled in this study. The patients were classified into two groups, the covering group (52 lesions among 38 patients; those with ESD in whom PGA sheets and fibrin glue were used as the covering method) and the control group (53 lesions among 46 patients; ESD only), and their post-ESD bleeding rates were compared. RESULTS: No significant differences were seen in the number and type of antithrombotic agents, lesion location, median procedure time, and median resected specimen size between the groups. ESD was completed in all cases, with no cases of uncontrollable bleeding during the procedure. Post-ESD bleeding occurred in 5.8% (3/52) and 20.8% (11/53) in the covering and control groups, respectively. The post-ESD bleeding rate significantly differed between the groups (P = 0.04; odds ratio, 0.23; 95% confidential interval, 0.06-0.89). No adverse events were associated with the use of PGA sheets and fibrin glue. CONCLUSIONS: The covering method using PGA sheets and fibrin glue has the potential to reduce post-ESD bleeding in patients receiving continued antithrombotic agents.

Use of a novel shorter minimum caliber needle for creating endoscopic tattoos for preoperative localization: a comparative ex vivo study.

BACKGROUND AND STUDY AIMS: In colorectal cancer surgery, inadvertent deep injections during endoscopic tattooing can cause India ink leakage into the peritoneum, leading to complications or to poor visualization of the surgical plane. This ex vivo animal study compared the use of novel shorter, minimum caliber needles versus conventional injection needles for endoscopic tattooing. ANIMALS AND METHODS: Four endoscopists used the novel needles and conventional needles to make ten endoscopic tattoos (five tattoos/needle type/endoscopist) in harvested porcine rectum using a saline test-injection method. India ink leakage and the success of the tattoo (i. e. visible, < 40 mm, plus no India ink leakage) were compared. RESULTS: India ink leakage was observed for 30 % (6/20) of the conventional needle tattoos but for none of the novel needle tattoos ( P  = 0.02). Tattoos created using the novel needles were more successful than those made with the conventional needles: 18/20 (90 %) vs. 11/20 (55 %); P  = 0.01. CONCLUSIONS: The use of novel shorter minimum caliber needles may be safe and effective for endoscopic tattooing for preoperative localization prior to colorectal cancer surgery.

Learning curve and clinical outcome of gastric endoscopic submucosal dissection performed by trainee operators.

BACKGROUND: Although endoscopic submucosal dissection (ESD) represents a significant progress in therapeutic endoscopy, little is known about how trainees attain its technical proficiency. The aims of this study were to evaluate the learning curve and clinical outcomes of gastric ESD performed by trainee endoscopists. METHODS: Between April 2009 and March 2014, 334 gastric ESD procedures were performed by seven trainees (42-50 consecutive cases per trainee). The learning curve for gastric ESD was evaluated using the cumulative sum (CUSUM) method. Long-term outcomes were also analyzed. RESULTS: The calculated CUSUM learning curve comprised three phases: Phase I (the initial 15 cases), Phase II (the middle 15 cases), and Phase III (the final 20 cases). The resection speed was 5.7 ± 3.2 min/cm2 in Phase I, 4.7 ± 2.7 min/cm2 in Phase II, and 4.3 ± 2.2 min/cm2 in Phase III. The resection speed was significantly faster in Phase II than in Phase I (p = 0.019). The rate of self-completion reached more than 95% in Phases II and III. The overall complete resection rate was 95%, showing no significant differences between the three phases. Local recurrence was diagnosed in none of the patients during a median follow-up of 38 months. CONCLUSIONS: For the trainees, 30 cases were required to attain a higher technical level of competence in gastric ESD. After the learning curve phase, trainee operators could be expected to complete the procedure successfully with favorable long-term outcomes.

Should antithrombotic therapy be stopped in patients undergoing gastric endoscopic submucosal dissection?

BACKGROUND: The management of antithrombotic therapy in the patients undergoing gastric endoscopic submucosal dissection (ESD) is of concern. This study aimed to assess delayed bleeding rate after gastric ESD in the patients receiving antithrombotic therapy. METHODS: This study was a retrospective observational study held in a single institute. The patients undergoing gastric ESD from January 2009 to October 2014 were reviewed. Delayed bleeding rate in the patients receiving antithrombotic therapy was compared with that in matched controls. We also compared delayed bleeding rate in the patients continuing antithrombotic therapy with that in the patients with heparin bridging or cessation of antithrombotic therapy. Among 2388 lesions resected by gastric ESD, 367 lesions were resected in the patients with antithrombotic therapy, and 722 lesions were selected as controls. The lesions in the patients receiving antithrombotic therapy were divided into three subgroups: 54 lesions without preoperative cessation (continuation group), 37 lesions with heparin bridging (heparin group), and 276 lesions with cessation of antithrombotic therapy (cessation group). RESULTS: The incidence of delayed bleeding was significantly higher in the patients receiving antithrombotic therapy (9.5 % [35/367] vs. 4.2 % [30/722]; p < 0.01). Delayed bleeding rate in continuation group, heparin group, and cessation group was 9.2 % (5/54), 10.8 % (4/37), and 9.4 % (26/276), respectively, and no significant difference was observed. Thrombosis occurred only in cessation group (1.6 %). CONCLUSIONS: Delayed bleeding rate associated with gastric ESD is significantly higher in the patients receiving antithrombotic therapy. No significant difference in delayed bleeding rate was observed among patients with and without cessation of antithrombotic therapy. To prevent thrombosis, gastric ESD without cessation may be feasible.

Can positron emission tomography detect colorectal adenomas and cancers?

BACKGROUND AND AIM: Fluorine-18 2-fluoro-2-deoxy-d-glucose positron emission tomography (PET) is effective and less invasive than other modalities used to diagnose tumors, including colorectal cancer (CRC). However, the detectability of adenomas and CRCs, especially in the early stages, is unclear. METHODS: We evaluated the records of 2323 consecutive eligible patients who underwent both a total colonoscopy (TCS) and PET between October 2002 and September 2012 at a tertiary cancer center. The PET findings were verified by TCS performed independently within 1 year. Target lesions were defined as CRCs and adenomas that were 6 mm or larger in size. RESULTS: Total colonoscopy detected 532 target lesions ≥ 6 mm in size: 56 T2-T4 CRCs, 39 T1 CRCs, 223 advanced adenomas, and 214 low-grade adenomas. Of the 532 lesions, 216 (40.6%) were PET positive. Of the 369 cases with positive uptakes, PET detected target lesions in the matched segments for 58.5% (216/369). Sensitivity of PET to T2-T4 CRCs, T1 CRCs, advanced adenomas, and low-grade adenomas was 92.9%, 79.5%, 50.7%, and 9.3%, respectively. PET could detect 76.5% (13/17) of T1 CRCs whose size is 10 to 19 mm and 85.0% (17/20) of T1 CRCs equal or larger than 20 mm. The multivariate analysis excluding T2-T4 CRCs showed malignant histology, larger size, protruded lesions, villous histology, and lesions in distal colon were significant factors. CONCLUSIONS: Sensitivity of PET for detecting T2-T4 and even T1 cancers are promising. However, sensitivity of PET to adenomas, even advanced adenomas, is limited.

Preliminary Experience Using Full-Spectrum Endoscopy for Colorectal Cancer Screening: Matched Case Controlled Study.

Background/Aim. High-quality colonoscopy is needed to reduce the morbidity and mortality of colorectal cancer. Full-spectrum endoscopy (FUSE) has recently shown potential in improving adenoma detection during colonoscopy. This study aimed to evaluate the feasibility and utility of FUSE colonoscopy. Methods. From April 2015 to February 2016, 130 patients underwent FUSE colonoscopy for screening at a tertiary cancer center. Cecal intubation rate (CIR), procedure time, polyp/adenoma detection rate (PDR/ADR), and mean number of adenomas per colonoscopy (APC) were compared in matched-control patients (n = 260) who underwent standard colonoscopy (SC). Accordingly, endoscopists subjectively evaluated the utility of FUSE colonoscopy. Results. The CIR of FUSE colonoscopy was 94.6%. Cecal intubation time (8.8 min versus 5.1 min, P < 0.001) and total procedure time (21.6 min versus 17.3 min, P < 0.001) in the FUSE group were significantly longer than those in the SC group. PDR (68.3 versus 71.2%, P = 0.567), ADR (63.4% versus 58.5%, P = 0.355), and APC (1.4 versus 1.4, P = 0.917) were not significantly different between the two groups. The wide view of FUSE colonoscopy was superior to that of SC based on the questionnaires. Conclusions. FUSE colonoscopy did not demonstrate superiority to SC in a clinical setting.

A novel wide viewing endoscope for upper gastrointestinal screening: a pilot study.

The feasibility of full-spectrum endoscopy (FUSE) esophagogastroduodenoscopy (EGD), providing a 245-degree field of view with double imagers on the front and left side of the endoscope was evaluated. Twenty-one healthy individuals (15 male, median age, 35 years) underwent upper gastrointestinal screening using FUSE-EGD. The primary end point was the rate of successful visualization of Vater's papilla. Secondary end points were visualization of the squamo-columnar junction (SCJ) and the anal side of the pyloric ring, and the endoscopists' subjective evaluation of usability based on maneuverability and imaging of FUSE-EGD. The mean procedure time was 6.5 min, with a median of 91 images captured. The rate of successful visualization of Vater's papilla was 90 % (19/21). The whole circumference of the SCJ was observed with two video monitors in all cases. The anterior anal side of the pyloric ring was observed in 29 % (6/21) of cases. However, the general impression of the usability of FUSE-EGD was that it was rather inferior to that of a standard front viewing endoscope. Although the usability requires further modification, FUSE-EGD provided excellent results for imaging Vater's papilla and the SCJ.

Efficacy of endoscopic submucosal dissection with dental floss clip traction for gastric epithelial neoplasia: a pilot study (with video).

BACKGROUND: Providing appropriate tension to the lesion and securing a stable view of the submucosal layer is important for accomplishing successful endoscopic submucosal dissection (ESD) in gastric cancer. Dental floss clip traction (DFC), a new traction method, is proposed to reduce the difficulty of ESD. The objective of this pilot study was to investigate the efficacy of DFC for gastric ESD. METHODS: From August to November 2014, a total of 95 patients with 104 gastric epithelial neoplasms underwent DFC-ESD (DFC group). Historical controls treated by conventional ESD (control group) were individually matched to cases at a 1:1 ratio by lesion location, ulcer findings, resected specimen size, and the proficiency of the operator (trainee/expert). The outcomes of the procedure in the two groups were then compared. RESULTS: The mean ± SD procedure time was 43 ± 24 min in the DFC group and 52 ± 30 min in the control group (P < 0.01). Fewer lesions in the DFC group needed >80 min compared with the control group (3-vs-16 cases, P = 0.01). There were no significant differences in adverse events between the groups. Perforation and delayed bleeding occurred in one and four lesions, respectively, in the DFC group, and three and nine in the control group. En bloc resection was achieved in all cases. No significant differences were found regarding curability of ESD between the groups. CONCLUSIONS: DFC effectively reduced ESD procedure time without increasing adverse events. DFC is helpful for rapid, safe ESD.

Proper muscle layer damage affects ulcer healing after gastric endoscopic submucosal dissection.

BACKGROUND AND AIM: Endoscopic submucosal dissection (ESD) is the established therapy for superficial gastrointestinal neoplasms. However, management of the artificial ulcers associated with ESD has become important and the relationship between ulcer healing factors and treatment is still unclear. We aimed to evaluate ESD-related artificial ulcer reduction ratio at 4 weeks to assess factors associating with ulcer healing after ESD that may lead to optimal treatment. METHODS: Between January 2009 and December 2013, a total of 375 lesions fulfilled the expanded criteria for ESD. We defined ulcer reduction rate <90% as (A) poor-healing group; and rate ≥90% as (B) well-healing group. After exclusion, 328 lesions were divided into two groups and analyzed. These two groups were compared based on clinicopathological/endoscopic features, concomitant drugs, and treatment. RESULTS: Ulcer reduction rate was significantly correlated with factors related to the ESD procedure (i.e. procedure time, submucosal fibrosis, and injury of the proper muscle layer, in univariate analysis. Multivariate logistic regression analysis showed that submucosal fibrosis (F2) (P = 0.03; OR, 16.46; 95% CI, 1.31-206.73) and injury of the proper muscle layer (P = 0.01; OR, 4.27; 95% CI, 2.04-8.92) were statistically significant predictors of delayed healing. CONCLUSION: This single-center retrospective study indicated that ESD-induced artificial ulcer healing was affected by submucosal fibrosis and injury of the proper muscle layer, which induced damage to the muscle layer. Therefore, the preferable pharmacotherapy can be determined on completion of the ESD procedure.

Autoimmune pancreatitis with colonic stenosis: an unusual complication and atypical pancreatographic finding.

BACKGROUND: Type 1 autoimmune pancreatitis (AIP) often accompanies various systematic disorders such as sclerosing cholangitis, sialoadenitis, retroperitoneal fibrosis, interstitial pneumonitis and nephritis. Although rarely reported in acute pancreatitis, colonic stenosis is an uncommon complication in cases with AIP. CASE PRESENTATION: A 69-year-old Japanese man complained of abdominal pain and continuous diarrhea, resistant to intake of antimuscarinic and probiotic agents. A colonoscopy demonstrated a stenosis at the splenic flexure. Computed tomography revealed a focal enlargement of the pancreatic tail with a capsule-like rim, contacting with the descending colon. Endoscopic retrograde pancreatography (ERP) was unable to visualize the main pancreatic duct (MPD) at the pancreatic tail, despite a full contrast injection. A high serum IgG4 level (1060 mg/dL) and exclusion of pancreatic cancer by endoscopic ultrasound guided-fine needle aspiration suggested AIP, but did not fulfill the diagnostic criteria, and steroid therapy was initiated. One month after starting steroid intake, pancreatic swelling was minimized and the MPD was visualized by ERP, fulfilling the international consensus diagnostic criteria (ICDC) of AIP. Colonic stenosis was relieved and the patient's symptoms disappeared. CONCLUSION: The present case is the first report of AIP developing colonic stenosis by the inflammatory infiltration. In this case, steroid therapy was effective for the diagnosis and treatment of pancreatic mass involving the descending colon.