Safety of Cold Snare Polypectomy during Continuous Use of Antithrombotic Drugs for Delayed Post-Polypectomy Bleeding: A Pilot Study.

BACKGROUND: Cold snare polypectomy is a high-risk endoscopic procedure with a low delayed post-polypectomy bleeding rate. However, it is unclear whether delayed post-polypectomy bleeding rates increase during continuous antithrombotic treatment. This study aimed to determine the safety of cold snare polypectomy during continuous antithrombotic treatment. METHODS: This single-center, retrospective cohort study enrolled patients who underwent cold snare polypectomy during antithrombotic treatment between January 2015 and December 2021. Patients were divided into continuation and withdrawal groups based on whether they continued with antithrombotic drugs or not. Propensity score matching was performed using age, sex, Charlson comorbidity index, hospitalization, scheduled treatment, type of antithrombotic drugs used, multiple medications used, indication for antithrombotic drugs, and gastrointestinal endoscopist qualifications. The delayed polypectomy bleeding rates were compared between the groups. Delayed polypectomy bleeding was defined as the presence of blood in stools and requiring endoscopic treatment or a decrease in hemoglobin level by 2 g/dL or more. RESULTS: The continuation and withdrawal groups included 134 and 294 patients, respectively. Delayed polypectomy bleeding was observed in 2 patients (1.5%) and 1 patient (0.3%) in the continuation and withdrawal groups, respectively (p = 0.23), before propensity score matching, with no significant difference. After propensity score matching, delayed polypectomy bleeding was observed in 1 patient (0.9%) in the continuation group but not in the withdrawal group, with no significant difference. CONCLUSION: Cold snare polypectomy during continuous antithrombotic treatment did not significantly increase delayed post-polypectomy bleeding rates. Therefore, this procedure may be safe during continuous antithrombotic treatment.

Metachronous Multiple Gastric Cancer Discovered as Endoscopic Curability C2 during Regular Follow-Up after Gastric Endoscopic Submucosal Dissection.

INTRODUCTION: The objective of this study was to clarify characteristics of metachronous endoscopic curability C2 (eCura C2) cancer during post-endoscopic submucosal dissection (ESD) follow-up. METHODS: Of 4,355 gastric lesions treated by ESD at our hospital during 2005-2021, 657 were metachronous. After excluding lesions found ≥2 years since the prior examination or in the gastric remnant, the remaining 515 were analyzed. Study 1: We compared 35 eCura C2 cancers and 480 eCura A-C1 cancers. Study 2: Endoscopic findings of the 35 lesions were examined to determine why they had been missed. RESULTS: Mean tumor size was larger (34.0 mm vs. 12.1 mm, p < 0.01) and the proportions of mixed-type and poorly differentiated cancers were higher (highly:mixed:poorly, 34.3:57.1:8.6 vs. 94.2:5.0:0.8, p < 0.01) in the eCura C2 group. Study 2: At the prior examination, 4 lesions were noticed but considered benign, 2 lacked sufficient imaging, 19 were detectable on imaging but missed, and 10 were not detectable on imaging. Over half the lesions that were detectable but missed at the prior examination were in the lesser curvature, many being type IIa-IIb lesions with color similar to the background mucosa. All lesions not detectable on imaging at the prior examination were mixed-type or poorly differentiated type. DISCUSSION: Metachronous cancer detected as eCura C2 cancers was significantly larger, and a significantly higher proportion was mixed-type or poorly differentiated cancers, compared with eCura A-C1 cancers. Possible reasons why these lesions were missed include rapid progression of mixed-type and poorly differentiated cancers, and poor recognition that lesions showing only slight color changes may be present at the lesser curvature.

Immunohistochemical analysis of tumor budding as predictor of lymph node metastasis from superficial esophageal squamous cell carcinoma.

BACKGROUND: Tumor budding is known predictors of lymph node metastasis from esophageal squamous cell carcinoma. However, it is not easy to detect such small cell clusters on hematoxylin-eosin (HE) staining. Therefore, we evaluated tumor budding using immunohistochemistry (IHC) for epithelial cell markers. METHOD: We analyzed tumor budding in 50 cases of superficial esophageal squamous cell carcinoma. We evaluated the impact of clinicopathological factors and tumor budding to predict lymph node metastasis. A total of 565 tumor sections were assessed using HE staining and IHC for cytokeratin 5/6. RESULTS: Based on receiver operating characteristic curves, the cut-off values for high-grade tumor budding evaluated using HE staining or IHC were 2 and 11, respectively. High-grade tumor budding evaluated using HE staining (P = 0.007) and IHC (P ≤ 0.001) were significantly correlated with lymph node metastasis. For tumors with pT1a-MM to pT1b-SM1, high-grade tumor budding evaluated using IHC was correlated with lymph node metastasis (P = 0.050). CONCLUSIONS: Tumor budding was significantly associated with lymph node metastasis. The optimal cut-off values of tumor budding on HE staining and tumor budding on IHC were 2 and 11, respectively. Even though both tumor budding on HE staining and tumor budding on IHC were significantly associated with lymph node metastasis, tumor budding on IHC tend to be more associated with lymph node metastasis.

Validity of Endoscopic Submucosal Dissection for Gastric Cancer Diagnosed as Differentiated Adenocarcinoma Before Treatment Regardless of Lesion Size.

BACKGROUND/AIMS: We investigated the validity and safety of endoscopic submucosal dissection for gastric tumors by examining shortand long-term outcomes by tumor diameter. MATERIALS AND METHODS: Endoscopic submucosal dissection for gastric tumor was performed on 4259 lesions at our hospital between January 2005 and June 2021. [Study 1] Patients were divided into 5 tumor diameter groups: 3751 lesions, ≤30 mm; 366 lesions, 31-50 mm; 106 lesions, 51-75 mm; 24 lesions, 76-100 mm; and 12 lesions, ≥101 mm. Short-term gastric endoscopic submucosal dissection outcomes were investigated. [Study 2] Long-term outcomes (delayed gastric emptying and prognosis) were investigated in 508 cases with tumor diameter ≥31 mm. RESULTS: [Study 1] Perforation rate (%) was 1.2, 3.6, 3.8, 12.5, and 25.0 for lesions with tumor diameter ≤30 mm, in the range 31-50 mm, 51-75 mm, and 76-100 mm, and ≥101 mm, respectively. Postoperative bleeding rate (%) was 4.8, 9.0, 6.6, 20.8, and 33.3, respectively, R0 resection rate (%) was 96.8, 90.2, 89.6, 70.8, and 66.6, respectively, and curative resection rate (%) was 92.0, 61.2, 63.2, 45.8, and 8.3, respectively. [Study 2] There were 7 cases of delayed gastric emptying after wide resection, with 3 patients requiring balloon dilatation, 1 of whom subsequently underwent distal gastrectomy. Among 205 cases of noncurative resection, 110 underwent additional surgery, residual cancer was present in 11 cases, and lymph node metastasis was observed in 7 cases (1 patient died of disease). To date, 1 of the 95 patients being followed up has died of disease (mean follow-up: 2042 days). CONCLUSION: Even with a tumor diameter ≥31 mm, curative resection was achieved in about 60% of cases in which intramucosal lesions were considered possible preoperatively, but the rate was low at 8.3% for tumor diameter ≥101 mm. Long-term outcomes appear favorable, with only 0.4% of the patients dying of disease but delayed gastric emptying observed in 1.7% of cases.

Feasibility of Rescue Colonoscopy Using a Short-type Enteroscope (SIF-H290S) without Overtube after Incomplete Colonoscopy: A Single-center Retrospective Pilot Study.

Objectives: Recently, a newly designed short-type single-balloon enteroscope (SBE), SIF-H290S, has been developed with a smaller outer diameter and a longer working length than conventional colonoscopes. It has passive bending and high-force transmission, making insertion easier. However, it is difficult to perform rescue colonoscopy with an SBE after incomplete colonoscopy in the same session. Therefore, this study evaluated the feasibility of consecutive rescue colonoscopy using SIF-H290S without overtube after incomplete colonoscopy. Methods: This was a single-center retrospective study. We included 19 rescue colonoscopies (19 patients) with SIF-H290S without overtube performed by 11 endoscopists in the SIF group and 38 rescue colonoscopies (38 patients) using a small-caliber colonoscope (PCF-PQ260L) were randomly selected for the control group from procedures performed by the same 11 endoscopists. We compared the cecal intubation rate and other outcomes, such as insertion time, between the two groups. Results: The median age of the patients was 72 and 69 years, with 8 and 26 males in the SIF and control groups, respectively. The median body mass index was 21.6 and 22.7 kg/m2 in the SIF and control groups, respectively. There were no significant differences in the patient backgrounds between the groups, except for the reason for incomplete colonoscopy (p = 0.048). The cecal intubation rate was 78.9% (15/19 procedures) and 92.1% (35/38 procedures) in the SIF and control groups, respectively. Conclusions: This study revealed the real-world experience and feasibility of rescue colonoscopy using SIF-H290S, which could be a potential rescue device option after incomplete colonoscopy.

Evaluation of contrast-enhanced ultrasonography for hepatocellular carcinoma prior to and following stereotactic body radiation therapy using the CyberKnife® system: A preliminary report.

The CyberKnife® is expected to be a novel local treatment for hepatocellular carcinoma (HCC), however, a long-term follow-up using dynamic computed tomography and magnetic resonance imaging is required to determine the effect of treatment in a number of the affected patients. Therefore, there is a requirement to evaluate procedures for early determination of the effect of CyberKnife treatment. The present study aimed to evaluate the changes in the hemodynamics of the tumors and the hepatic parenchyma surrounding the tumor prior to and following CyberKnife treatment for HCC. A total of 4 HCC patients were enrolled in this study. These patients underwent CyberKnife treatment and were evaluated by image analysis prior to and following treatment using contrast-enhanced ultrasonography (CEUS) with Sonazoid. CEUS was performed prior to treatment, at 2 and 4 weeks post-treatment, and every 4 weeks thereafter for as long as possible. The dynamics of the enhancement of the tumor and the hepatic parenchyma surrounding the tumor in the vascular phase, and the presence or absence of a hypoechoic area in the hepatic parenchyma surrounding the tumor in the post-vascular phase were assessed. Results showed that: i) In the patient with earlier changes, hemodynamic changes were evident in the tumor at 4 weeks and in the hepatic parenchyma surrounding the tumor at 2 weeks post-treatment, respectively; ii) the tumor showed hypoenhancement in all patients; and iii) with regard to findings in the hepatic parenchyma surrounding the tumor, strong hyperenhancement appeared in the vascular phase initially, followed by a hypoechoic area in the post-vascular phase. Evaluation of the hemodynamics of tumors and hepatic parenchyma surrounding the tumor using CEUS with Sonazoid may be therapeutically applicable, as it is less invasive than dynamic computed tomography (CT) and provides an early evaluation of the effectiveness of CyberKnife treatment.