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BACKGROUND/AIMS: Residual common bile duct (CBD) stones occasionally become symptomatic after stone removal with endoscopic retrograde cholangiopancreatography (ERCP) upon removal of the endoscopic biliary stent (EBS). An accurate evaluation of residual stones before stent removal is necessary. This study evaluated a new two-step check method using endoscopic ultrasound (EUS) for the detection of residual stones after ERCP stone removal. METHODS: Fifty-six patients who underwent CBD stone removal and EBS placement were prospectively enrolled. Residual stones were evaluated by the check method. EBS was removed at the time of the check method or at a later time of residual stone removal. The primary outcome was to evaluate the efficacy of this check method. RESULTS: Residual CBD stone/sludge was detected in 20 of 56 patients (35.7%; stones: 28.6%, sludge: 7.1%) by the check method and removed by the ERCP procedure at a later time. After stent and final stone removal, patients were followed for an average of 211 days; cholangitis recurred in only 1.8% of patients. There were no adverse events associated with the check method. Temporary EBS prevented the recurrence of cholangitis by residual stone and caused no adverse events in the pancreatobiliary tract until the two-step check method (median, 113 days; range, 17-232 days). CONCLUSION: The new check method may be ideal and feasible for EBS removal because recurrences are very rare when a clear CBD has been verified, and an additional ERCP procedure is also possibly avoided.
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Colangitis , Coledocolitiasis , Cálculos Biliares , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Colangitis/etiología , Conducto Colédoco/diagnóstico por imagen , Conducto Colédoco/cirugía , Cálculos Biliares/complicaciones , Cálculos Biliares/diagnóstico por imagen , Cálculos Biliares/cirugía , Humanos , Estudios Retrospectivos , Aguas del Alcantarillado , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: Postpolypectomy bleeding (PPB) is the most common adverse event after colorectal polypectomy. Use of anticoagulants is an important risk factor for PPB. This study aimed to evaluate PPB in patients receiving treatment with warfarin and direct oral anticoagulants (DOACs). METHODS: Between August 2017 and July 2019, 5449 patients with 12,601 polyps who underwent endoscopic snare resection of colorectal polyps were enrolled. Endoscopic snare resection was performed in patients receiving continuous warfarin (C-warfarin) and in patients who experienced 1 day cessation of (O-) of DOACs in accordance with the Japanese Gastroenterological Endoscopy Society guidelines. RESULTS: The PPB rate in the group receiving anticoagulants was statistically higher than that in the group without anticoagulants (8.5% [33/387] vs 1.2% [63/5,062], respectively; P < .001). By multivariate logistic regression analysis, male gender (odds ratio [OR], 2.17; P = .007), warfarin (OR, 4.64; P < .001), DOACs (OR, 6.59; P < .001), and multipolyp removal (OR, 1.77; P = .007) were significant risk factors for PPB. PPB was observed in 9 and 21 patients in the C-warfarin and O-DOACs groups, respectively: C-warfarin (8.0% [9/113]), O-dabigatran (6.1% [2/33]), O-rivaroxaban (14.8% [9/61]), O-apixaban (9.8% [9/92]), and O-edoxaban (1.8% [1/56]). The PPB rate with the O-edoxaban group was significantly lower than that with the O-rivaroxaban group (P < .05). CONCLUSIONS: Use of anticoagulant therapy was an independent risk factor for PPB. The rates of PPB in patients receiving C-warfarin and O-DOACs were also higher than those in patients not receiving anticoagulants. Edoxaban may be safe through short-term withdrawal in patients undergoing endoscopic snare resection of colorectal polyps.
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Fibrilación Atrial , Pólipos del Colon , Administración Oral , Anticoagulantes/efectos adversos , Fibrilación Atrial/complicaciones , Fibrilación Atrial/tratamiento farmacológico , Pólipos del Colon/cirugía , Dabigatrán/efectos adversos , Hemorragia , Humanos , Masculino , Piridonas , Rivaroxabán/efectos adversos , Warfarina/efectos adversosRESUMEN
BACKGROUND AND AIM: Colonic diverticulosis (CD) has been reported to be associated with presence of colon neoplasms (CNs) in Western patients, since most of the associated risk factors are common between them. However, such correlation has not been fully investigated in Asian patients. In this study, the association of CNs with CD was evaluated in a multicenter investigation. METHODS: We enrolled 5633 patients who underwent both colonoscopy and esophagogastroduodenoscopy due to annual follow-up, screening for positive occult blood testing and abdominal symptoms between January 2016 and December 2017 at three institutions. The relationship between the presence of CNs and CD was investigated, and predictors for presence of CNs were determined by multivariate logistic analysis. RESULTS: The enrolled patients consisted of 1799 (31.9%) with CD (average age 70.0 years, male 64.0%) and 3834 without CD (66.0 years, male 52.9%), with the prevalence of CNs in those groups 46.6% and 44.2%, respectively (P = 0.090). Predictors for early colon cancer were shown to be age (OR 1.02, 95% CI 1.01-1.04, P = 0.010), laxatives use (OR 1.76, 95% CI 1.17-2.64, P = 0.007), gastric neoplasms (OR 2.16, 95% CI 1.23-3.81, P = 0.008), and CD (OR 1.64, 95% CI 1.16-2.31, P = 0.005). Early colon cancer in the distal colon was most frequently detected in patients with right-sided CD (RR 2.50, P = 0.001). CONCLUSION: In Japanese patients, early colon cancer was more frequently found in those with as compared to those without CD. The presence of CD may be an important indicator for an index colonoscopy examination to detect colon cancer. (Clinical-trial-registry: UMIN000038985).
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Neoplasias del Colon , Diverticulosis del Colon , Anciano , Neoplasias del Colon/diagnóstico , Neoplasias del Colon/epidemiología , Colonoscopía , Diverticulosis del Colon/complicaciones , Diverticulosis del Colon/diagnóstico , Diverticulosis del Colon/epidemiología , Humanos , Japón/epidemiología , Masculino , Factores de RiesgoRESUMEN
BACKGROUND AND AIMS: The withdrawal of antithrombotic therapy from patients at high risk of thromboembolism is controversial. Previously, treatment with anticoagulants, such as warfarin and dabigatran, was recommended for heparin bridge therapy (HBT) during endoscopic submucosal dissection (ESD). However, HBT is associated with a high risk of bleeding during and after ESD. This study aimed to investigate the clinical outcomes of colorectal ESD in patients treated with warfarin and direct oral anticoagulants (DOAC). METHODS: This study included 412 patients with superficial colorectal neoplasms that were resected by ESD between June 2010 and June 2018. The patients were classified into two groups: without antithrombotics (n = 286) and with anticoagulants (n = 51). The anticoagulants group was further divided into two groups: warfarin (n = 26) and DOAC (n = 25). RESULTS: Among all patients, delayed bleeding occurred in 35 (8.5% [35/412]) patients. The bleeding rate in the anticoagulants group (11.8% [6/51]) was higher than that in the group without antithrombotics (6.6% [19/286]), but the difference was not statistically significant (P = 0.240). The bleeding rate in the DOAC group (16.0% [4/25]) was higher than that in the warfarin group (7.7% [2/26]), but the difference was not statistically significant (P = 0.419). All delayed bleeding was successfully managed with endoscopic hemostasis. Thromboembolic events were not observed in any patients. CONCLUSIONS: The bleeding rate with anticoagulants was relatively high. However, all bleeding events with anticoagulants were minor and clinically controllable. Colorectal ESD with DOAC and warfarin may be feasible and acceptable.
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Anticoagulantes , Resección Endoscópica de la Mucosa , Hemorragia Posoperatoria/epidemiología , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Colon/cirugía , Neoplasias Colorrectales/cirugía , Inhibidores del Factor Xa/administración & dosificación , Inhibidores del Factor Xa/efectos adversos , Inhibidores del Factor Xa/uso terapéutico , Humanos , Recto/cirugía , Factores de Riesgo , Tromboembolia/tratamiento farmacológico , Tromboembolia/prevención & controlRESUMEN
OBJECTIVES: Patients with acute cholecystitis receiving antithrombotic therapy (ATT) have an increased risk of bleeding complications during surgery and percutaneous drainage. Endoscopic transpapillary gallbladder drainage (ETGBD) is recommended for such cases; however, evidence is limited. To investigate this issue further, we performed a retrospective multicenter study. METHODS: One hundred thirty patients with acute cholecystitis who underwent ETGBD were enrolled. They were divided into an ATT group (continuation of ATT on the day of the procedure and/or heparin substitution) and a Non-ATT group (discontinuation or no use of ATT). The primary outcome was bleeding complication rate, and the secondary outcomes were technical success rate, clinical success rate and total complication rate. RESULTS: Eighty-three patients were enrolled in the ATT group, and 47 were enrolled in the Non-ATT group. In the ATT group, 42.2% continued multi-agent ATT. No bleeding complications occurred in either group. There were no significant differences between the ATT and Non-ATT groups in the technical success rate (84.3% vs 89.4%, P = 0.426 respectively) or the clinical success rate (97.1% vs 100%, P = 0.259, respectively). The overall early complication rate was 3.1% (4/130): mild pancreatitis (n = 3) and cholangitis (n = 1). Stent dysfunction was found in 10.9% of patients (at 196 days on average), and the 12-month stent patency rate was 69.0%. CONCLUSIONS: No significant difference was found in the bleeding complication rate between ETGBD with and without ATT. ETGBD may be an ideal drainage method for patients with acute cholecystitis receiving ATT.
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Colecistitis Aguda , Fibrinolíticos , Colecistitis Aguda/cirugía , Drenaje , Fibrinolíticos/efectos adversos , Vesícula Biliar , Humanos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: Colorectal endoscopic submucosal dissection (ESD) is a time-consuming procedure because of the technical difficulty. The newly developed saline-pocket ESD (SP-ESD) provides a clearer view and better traction of the submucosal layer compared with the standard ESD with gas insufflation (S-ESD). This study aimed to prospectively compare the efficacy and safety between S-ESD and SP-ESD in patients with superficial colorectal neoplasms (SCNs). METHODS: From April 2017 to November 2018, 95 patients with SCNs ≥20 mm in diameter were prospectively and randomly enrolled. Four patients were excluded because of an incomplete ESD procedure. Patients were finally allocated to 2 groups, S-ESD with 45 patients and SP-ESD with 46 patients. The primary outcome was dissection speed. Secondary outcomes were ESD procedure time, en bloc and complete resection rates, perforation rate, and adverse effects. RESULTS: Median dissection speed was significantly faster in the SP-ESD than the S-ESD group (20.1 mm2/min [range, 17.3-28.1] vs 16.3 mm2/min [range, 11.4-19.8]; P < .001). Median procedure time was significantly shorter in the SP-ESD than the S-ESD group (29.5 minutes [range, 22.3-44] vs 41 minutes [range, 31-55]; P < .001). The en bloc and complete resection rates were 100% in both groups. No perforations occurred among patients. The volume of saline solution used in the SP-ESD group was significantly greater than that in the S-ESD group (200 mL [range, 120-250] vs 150 mL [range, 100-200]; P = .016). CONCLUSIONS: SP-ESD improved dissection speed and procedure time compared with S-ESD. SP-ESD may be an alternative method for resection of SCNs. (Clinical trial registration number: UMIN 000026317.).
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Neoplasias Colorrectales/cirugía , Disección/métodos , Resección Endoscópica de la Mucosa/métodos , Solución Salina/administración & dosificación , Anciano , Anciano de 80 o más Años , Neoplasias Colorrectales/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
BACKGROUND AND AIMS: During endoscopic submucosal dissection (ESD), a clear view is essential for precise dissection of the appropriate submucosal layer. Some advantages have been reported for underwater techniques of endoscopic resection in comparison with the gas insufflation method. We have developed a new ESD method with the creation of a local water pocket (WP) that provides a clear view in the dissection field. Therefore, we aimed to investigate the feasibility and safety of WP-ESD for superficial gastric neoplasms. METHODS: We prospectively recruited 50 patients with gastric neoplasms (early gastric cancer or gastric adenomas) between April 2017 and December 2017. Among them, 48 patients were treated with the WP-ESD technique. The patients undergoing WP-ESD were compared with 48 patients treated with standard ESD (S-ESD) who were selected by propensity score matching. The primary outcome was the ESD procedure time. RESULTS: Total procedure time was significantly shorter in the WP-ESD group than in the S-ESD group (median [interquartile range], 27.5 [19-45] minutes vs 41 [29.8-69] minutes; P < .001). Similarly, the dissection speed was significantly greater in the WP-ESD group than in the S-ESD group (median [interquartile range], 22.5 [16.8-35.3] mm2/min vs 17.3 [12.7-22.1] mm2/min; P < .001). The rates of complete en bloc resection in the WP-ESD group and the S-ESD group were 97.9% and 95.8%, respectively (P > .99). There were no perforations in either group. CONCLUSION: WP-ESD was associated with a shorter procedure time than S-ESD. WP-ESD may provide an alternative method for resection of superficial gastric neoplasms. (Clinical trial registration number: UMIN 000030266.).
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Resección Endoscópica de la Mucosa/métodos , Tempo Operativo , Neoplasias Gástricas/cirugía , Anciano , Anciano de 80 o más Años , Disección , Resección Endoscópica de la Mucosa/efectos adversos , Femenino , Humanos , Masculino , Puntaje de Propensión , Estudios Prospectivos , AguaRESUMEN
Backgrounds and Objectives: Although pancreatic cancer (PC) has an extremely poor prognosis, the 5-year survival rate of patients with pancreatic high-grade precancerous lesion without invasive carcinoma (PHP) is favorable. PHP diagnosis and identification of patients requiring intervention are needed. We aimed to validate a modified PC detection scoring system regarding its detection ability for PHP and PC in the general population. Subjects and Methods: We modified an existing PC detection scoring system that incorporates low-grade risk (LGR) factors (family history, presence of diabetes mellitus [DM] or worsening DM, heavy drinking, smoking, stomach symptoms, weight loss, and pancreatic enzyme) and high-grade risk (HGR) factors (new-onset DM, familial PC, jaundice, tumor biomarkers, chronic pancreatitis, intraductal papillary mucinous neoplasm, cysts, hereditary PC syndrome, and hereditary pancreatitis). Each factor was scored as one point; LGR score ≥3 points and/or HGR score ≥1 point (positive scores) were indicative of PC. The newly modified scoring system incorporated main pancreatic duct dilation as an HGR factor. The PHP diagnosis rate using this scoring system combined with EUS was prospectively analyzed. Results: Among 544 patients with positive scores, 10 had PHP. The diagnosis rates were 1.8% for PHP and 4.2% for invasive PC. Although the number of LGR and HGR factors tended to increase with PC progression, none of the individual factors were significantly different between patients with PHP and those without lesions. Conclusion: The newly modified scoring system evaluating multiple factors associated with PC could potentially identify patients with higher risk of PHP or PC.
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Colon Transverso/irrigación sanguínea , Colonoscopía/métodos , Mucosa Intestinal/cirugía , Enfermedades Vasculares/cirugía , Venas/cirugía , Colon Transverso/patología , Colon Transverso/cirugía , Neoplasias del Colon/diagnóstico , Diagnóstico Diferencial , Disección/métodos , Humanos , Mucosa Intestinal/irrigación sanguínea , Mucosa Intestinal/patología , Masculino , Persona de Mediana Edad , Enfermedades Vasculares/diagnóstico , Venas/patologíaRESUMEN
The bleeding complication risk of surgery or percutaneous transhepatic gallbladder drainage (PTGBD) may increase in patients with acute cholecystitis receiving antithrombotic therapy (ATT). Endoscopic gallbladder drainage (EGBD) may be recommended for such patients. English articles published between 1991 and 2018 in peer-reviewed journals that discuss cholecystectomy, PTGBD, and EGBD in patients with ATT or coagulopathy were reviewed to assess the safety of the procedures, especially in terms of the bleeding complication. There were 8 studies on cholecystectomy, 3 on PTGBD, and 1 on endoscopic transpapillary gallbladder drainage (ETGBD) in patients receiving ATT. With respect to EGBD, 28 studies on ETGBD (including 1 study already mentioned above) and 26 studies on endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) were also analyzed. The overall bleeding complication rate in patients with ATT who underwent cholecystectomy was significantly higher than that in patients without ATT (6.5% [23/354] vs. 1.2% [26/2,224], p<0.001). However, the bleeding risk of cholecystectomy and PTGBD in patients receiving ATT was controversial. The overall technical success, clinical success, and bleeding complication rates of ETGBD vs. EUS-GBD were 84% vs. 96% (p<0.001), 92% vs. 97% (p<0.001), and 0.65% vs. 2.1% (p=0.005), respectively. One patient treated with ETGBD experienced bleeding complication among 191 patients with bleeding tendency. ETGBD may be an ideal drainage procedure for patients receiving ATT from the viewpoint of bleeding, although EUS-GBD is also efficacious.
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BACKGROUND/AIMS: Endoscopic transpapillary gallbladder drainage (ETGBD) is useful for the treatment of acute cholecystitis; however, the technique is difficult to perform. When intraductal ultrasonography (IDUS) is combined with ETGBD, the orifice of the cystic duct in the common bile duct may be more easily detected in the cannulation procedure. The aim of this study was to evaluate the efficacy of ETGBD with IDUS compared with that of ETGBD alone. METHODS: A total of 100 consecutive patients with acute cholecystitis requiring ETGBD were retrospectively recruited. The first 50 consecutive patients were treated using ETGBD without IDUS, and the next 50 patients were treated using ETGBD with IDUS. Through propensity score matching analysis, we compared the clinical outcomes between the groups. The primary outcome was the technical success rate. RESULTS: The technical success rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (92.0% vs. 76.0%, p=0.044). There was no significant difference in procedure length between the two groups (74.0 min vs. 66.7 min, p=0.310). The complication rate of ETGBD with IDUS was significantly higher than that of ETGBD without IDUS (6.0% vs. 0%, p<0.001); however, only one case showed an IDUS technique-related complication (pancreatitis). CONCLUSION: The assistance of IDUS may be useful in ETGBD.
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BACKGROUND: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) as a treatment for patients with acute cholecystitis has been shown to obtain high technical and clinical success rates and a low recurrence rate. However, the safety of EUS-GBD for patients receiving antithrombotic therapy (ATT) has not been proven. The aim was to evaluate the safety and efficacy of EUS-GBD in patients receiving ATT. METHODS: Twelve patients with acute cholecystitis associated with gallstones who were receiving antithrombotic therapy and underwent EUS-GBD were enrolled in this retrospective study. Patients with grade II or III cholecystitis who had failed endoscopic transpapillary GBD (ETGBD) or developed recurrence after multiple ETGBD procedures underwent urgent drainage by EUS-GBD. The primary outcome was the rate of bleeding complications after the procedure and the secondary outcomes were the technical and clinical success rates, complications, and recurrence. RESULTS: Eleven (91.6%) patients underwent EUS-GBD with continuation of ATT (at least 1 agent). Five of 12 patients (41.7%) were receiving more than 1 agent for ATT. The rate of bleeding complications was 0% and the technical success rate was 100%, even though some patients had high-grade (severe) cholecystitis and/or several underlying diseases. Early complications were found in 2 (16.7%) patients. The clinical success rate was 91.7% (11/12). There were no recurrences of cholecystitis during the follow-up period (mean 261 [range 5-650] days). CONCLUSIONS: EUS-GBD yielded high technical and clinical success rates and a low recurrence rate. No patients receiving ATT developed bleeding complications. EUS-GBD might be a good option for patients on ATT.
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BACKGROUND: Endoscopic submucosal dissection (ESD) for gastric neoplasms during continuous low-dose aspirin (LDA) administration is generally acceptable according to recent guidelines. This retrospective study aimed to investigate the effect of continuous LDA on the postoperative bleeding after gastric ESD in patients receiving dual antiplatelet therapy (DAPT). AIM: To investigate the feasibility of gastric ESD with continuous LDA in patients with DAPT. METHODS: A total of 597 patients with gastric neoplasms treated with ESD between January 2010 and June 2017 were enrolled. The patients were categorized according to type of antiplatelet therapy (APT). RESULTS: The postoperative bleeding rate was 6.9% (41/597) in all patients. Patients were divided into the following two groups: no APT (n = 443) and APT (n = 154). APT included single-LDA (n = 95) and DAPT (LDA plus clopidogrel, n = 59) subgroups. In the single-LDA and DAPT subgroups, 56 and 39 patients were received continuous LDA, respectively. The bleeding rate with continuous single-LDA (10.7%) was similar to that with discontinuous single-LDA (10.3%) (P > 0.99). Although the bleeding rate with continuous LDA in patients receiving DAPT (23.1%) was higher than that with discontinuous LDA in patients receiving DAPT (5.0%), no significant difference was observed (P = 0.141). CONCLUSION: The bleeding rate with continuous LDA in patients receiving DAPT was not statistically different from that with discontinuous LDA in patients receiving DAPT. Therefore, continuous LDA administration may be acceptable for ESD in patients receiving DAPT, although patients should be carefully monitored for possible bleeding.
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Resección Endoscópica de la Mucosa/efectos adversos , Hemorragia Gastrointestinal/epidemiología , Inhibidores de Agregación Plaquetaria/efectos adversos , Hemorragia Posoperatoria/epidemiología , Neoplasias Gástricas/cirugía , Trombosis/prevención & control , Anciano , Anciano de 80 o más Años , Aspirina/administración & dosificación , Aspirina/efectos adversos , Clopidogrel/administración & dosificación , Clopidogrel/efectos adversos , Resección Endoscópica de la Mucosa/métodos , Estudios de Factibilidad , Femenino , Mucosa Gástrica/irrigación sanguínea , Mucosa Gástrica/patología , Mucosa Gástrica/cirugía , Hemorragia Gastrointestinal/etiología , Gastroscopía/efectos adversos , Gastroscopía/métodos , Humanos , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/administración & dosificación , Inhibidores de Agregación Plaquetaria/normas , Hemorragia Posoperatoria/etiología , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Factores de Riesgo , Neoplasias Gástricas/patología , Resultado del TratamientoRESUMEN
BACKGROUND: Given that risk factors for Barrett's carcinogenesis are predictive, appropriate management and surveillance of Barrett's esophagus (BE) may be provided. The presence of colorectal neoplasms (CRNs) is a possible predictor of the development of BE and the progression to esophageal adenocarcinoma (EAC). We evaluated the relationship between BE or EAC and colonic diseases, including neoplasms and diverticulosis. METHODS: Patients (N = 5606) who underwent both colonoscopy and esophagogastroduodenoscopy between January 2016 and December 2017 at three institutions were enrolled. The relationships between the presence of colonic diseases and BE or EAC and other clinical or endoscopic predictors of the presence of BE were investigated retrospectively. RESULTS: The prevalence of BE ≥ 1 cm and ≥ 3 cm in length was 13.0% and 0.52%, respectively. BE was closely related with the presence of colorectal adenoma (48.4% vs. 37.2% in non-BE; P < 0.001), adenocarcinoma (16.6% vs. 8.4%, P < 0.001) and colonic diverticulosis (CD) (34.1% vs. 29.3%, P < 0.001). In patients with long-segment BE, CRNs (79.3%, P < 0.001) and CD (48.2%, P = 0.038) were more common. EAC patients also had a statistically significantly higher incidence of CRNs than non-BE patients (87.5% vs. 45.6%, P = 0.027). Diverticulosis at the distal colon correlated significantly with EAC and BE (50.0%, P = 0.010 and 15.4%, P = 0.024, vs. 12.0% in non-BE). Multivariate analysis showed that CRNs (t = 8.55, P < 0.001), reflux esophagitis (t = 5.26, P < 0.001) and hiatal hernia (t = 11.68, P < 0.001) were predictors of BE. CONCLUSIONS: The presence of CRNs was strongly associated with BE and EAC. Therefore, colonoscopy may be useful for establishing a strategy for the surveillance of BE.
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Adenocarcinoma/diagnóstico , Esófago de Barrett/patología , Enfermedades del Colon/diagnóstico , Neoplasias Colorrectales/diagnóstico , Neoplasias Esofágicas/diagnóstico , Adenocarcinoma/patología , Anciano , Anciano de 80 o más Años , Enfermedades del Colon/epidemiología , Enfermedades del Colon/patología , Colonoscopía/métodos , Neoplasias Colorrectales/epidemiología , Neoplasias Colorrectales/patología , Progresión de la Enfermedad , Endoscopía del Sistema Digestivo/métodos , Neoplasias Esofágicas/patología , Esofagitis Péptica/epidemiología , Femenino , Hernia Hiatal/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Background and study aims Patients who receive warfarin usually require heparin bridge therapy (HBT) to prevent thromboembolic events during endoscopic submucosal dissection (ESD); however, clinical evidence demonstrating the safety and efficacy of HBT during gastric ESD is limited. Conversely, warfarin can be continuously used as a substitute for HBT to endoscopic procedures which have a low risk of bleeding. This study aimed to clarify the safety and efficacy of continuous low-dose warfarin (LDW) for gastric ESD. Patients and methods This was a prospective observational study at a single institution. A total of 22 patients who received warfarin between December 2014 and January 2016 were enrolled. The patients were treated with gastric ESD with a low dose of warfarin (â≤â4âmg) at approximately 1.6â-â2.6 of the international normalized ratio (INR) levels. Furthermore, we analyzed a total of 23 patients with HBT who underwent gastric ESD between January 2011 and November 2014. Results The average of warfarin dose and the INR level on the day of gastric ESD in the continuous LDW group were 2.3âmg/day (range 0.5â-â4.0) and 1.87 (range 1.41â-â2.75), respectively. Two of the 22 patients (9.1â%) in the continuous LDW group and 5 of the 23 patients (21.7â%) in the HBT group had postoperative bleeding after gastric ESD. Although the postoperative bleeding rate in the continuous LDW group was lower than that in the HBT group, no significant difference was observed between the 2 groups (Pâ=â0.414). Conclusions Gastric ESD with continuous LDW as a substitute for HBT was feasible and may be acceptable.
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AIM: To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for small rectal submucosal tumors (SMTs). METHODS: Between August 2008 and March 2016, 39 patients were treated with endoscopic submucosal resection with a ligation device (ESMR-L) (n = 21) or ESD (n = 18) for small rectal SMTs in this study. Twenty-five lesions were confirmed by histological evaluation of endoscopic biopsy prior to the procedure, and 14 lesions were not evaluated by endoscopic biopsy. The results for the ESMR-L group and the ESD group were retrospectively compared, including baseline characteristics and therapeutic outcomes. RESULTS: The rate of en bloc resection was 100% in both groups. Although the rate of complete endoscopic resection was higher in the ESD group than in the ESMR-L group (100% vs 95.2%), there were no significant differences between the two groups (P = 0.462). In one patient in the ESMR-L group with a previously biopsied tumor, histological complete resection with a vertical margin involvement of carcinoid tumor could not be achieved, whereas there was no incomplete resection in the ESD group. The mean length of the procedure was significantly greater in the ESD group than in the ESMR-L group (14.7 ± 6.4 min vs 5.4 ± 1.7 min, P < 0.05). The mean period of the hospitalization was also significantly longer in the ESD group than in the ESMR-L group (3.7 ± 0.9 d vs 2.8 ± 1.5 d, P < 0.05). Postoperative bleeding was occurred in one patient in the ESMR-L group. CONCLUSION: Both ESMR-L and ESD were effective for treatment of small rectal SMTs. ESMR-L was simpler to perform than ESD and took less time.
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BACKGROUND AND STUDY AIMS: Endoscopic submucosal dissection (ESD) is useful for en bloc resection of superficial colorectal neoplasms to ensure accurate histologic diagnoses. However, colorectal ESD is associated with a high frequency of adverse events (AEs). We aimed to investigate the effectiveness of prophylactic clip closure (PCC) of mucosal defects for AEs after colorectal ESD. PATIENTS AND METHODS: This study included 197 patients with 211 lesions who underwent colorectal ESD between June 2010 and August 2016.âPatients who had delayed perforation, delayed bleeding, abdominal pain, or fever were defined as AEs after colorectal ESD. Complete PCC was defined as completely sutured mucosal defect using endoclips following colorectal ESD, whereas incomplete PCC was defined as the mucosal defects that did not enable PCC or were partially sutured. Clinical records were retrospectively reviewed and clinical outcomes evaluated. RESULTS: AEs occurred in 29 lesions (13.7 %), including 12 with delayed bleeding, 12 with fever, 2 with abdominal pain, 2 with fever and abdominal pain, and 1 with delayed bleeding and fever. Delayed perforation was not observed in any patient. The frequency of AEs was significantly lower in the group with complete PCC than in the group with incomplete PCC (7.3â% [9/123] vs. 22.7â% [20/88]; P â<â0.001). Multivariate analysis revealed that AEs after colorectal ESD were significantly associated with tumor size and submucosal fibrosis. Subgroup analysis among the resected specimen size ofâ<â40âmm revealed that there was no significant difference in AEs between the 2 groups (5.6â% [6/107] vs. 17.8â% [8/45]; P â=â0.069). However, the frequency of fever with complete PCC was significantly lower than that with incomplete PCC (2.8â% [3/107] vs. 13.3â% [6/45]; P â=â0.020). CONCLUSIONS: Tumor size and submucosal fibrosis were independent risk factors for AEs after colorectal ESD. PCC may be effective in minimizing AEs after colorectal ESD, especially the frequency of fever.