Histopathologic vertical margin positivity in cold snare polypectomy and mucosal resection for sessile serrated lesions.

BACKGROUND AND AIMS: Data regarding the status of the vertical margin of sessile serrated lesions (SSLs) resected using cold snare polypectomy (CSP) are lacking, and whether a histopathologically positive vertical margin is related to recurrence remains unclear. Therefore, this preliminary study aimed to clarify the rates of positive or unassessable vertical and horizontal margins and the rate of muscularis mucosae resection in SSLs treated using CSP compared with those treated with EMR. METHODS: Histologic outcomes of patients treated with CSP or EMR for SSLs were evaluated in this single-center observational study. The primary outcome was the incidence of histopathologically positive vertical margins in CSP and EMR. Furthermore, the comparisons were adjusted for confounding factors using propensity score matching. RESULTS: Overall, 82 patients with SSLs were included in the CSP and EMR groups after matching. The incidence of positive histologic vertical margins in the CSP and EMR groups were 67.1% and 2.4%, respectively (P < .001). Regarding the evaluation of the presence of muscularis mucosae, 29.3% and 98.8% of patients in the CSP and EMR groups, respectively, had a complete muscularis mucosae resection (P < .001). CONCLUSIONS: A rigorous histopathologic evaluation revealed that for SSLs, CSP more frequently leads to positive vertical margins than EMR. (Clinical trial registration number: UMIN 000051569.).

Clinical benefit of the multibending endoscope for gastric endoscopic submucosal dissection: a randomized controlled trial.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a technically difficult and time-consuming procedure. We aimed to investigate the efficacy and safety of ESD using a multibending endoscope to treat superficial gastrointestinal neoplasms. METHODS: Patients with a single early gastric cancer who met the absolute or expanded indications for ESD according to the Japanese gastric cancer treatment guidelines were enrolled and randomly assigned to undergo ESD using a conventional endoscope (C-ESD) or a multibending endoscope (M-ESD). Randomization was stratified by ESD operator experience and tumor location. The primary outcome was ESD procedure time, calculated as the time from the start of submucosal injection to complete removal of the tumor. RESULTS: 60 patients were analyzed (30 C-ESD, 30 M-ESD). The mean (standard deviation [SD]) ESD procedure times for M-ESD and C-ESD were 34.6 (SD 17.2) and 47.2 (SD 26.7) minutes, respectively (P = 0.03). Muscle layer damage occurred significantly less frequently with M-ESD (0.2 [SD 0.7] vs. 0.7 [SD 1.0]; P = 0.04). There were no significant differences between the two techniques in procedure time or damage to muscle layers for tumors located in the lower third of the stomach. CONCLUSIONS: ESD procedure time was significantly shorter with the multibending endoscope and fewer muscles were damaged. We recommend multibending endoscopy for ESD in the upper and middle thirds of the stomach to reduce procedure time and incidence of complications.

[A case of rectum metastasis of breast cancer].

A 53-year-old woman visited the hospital of this study complaining of constipation. Colonoscopy revealed a circumferential tumor with severe stenosis, and a computed tomography scan showed neoplastic lesions in the rectum and right breast area. Histology was poorly differentiated adenocarcinoma, requiring differentiation between type 4 and metastatic rectal cancer. Additional immunohistochemical tests were performed and a rectal metastasis of breast cancer diagnosis was made. Hormonal therapy was effective and the tumor volume was significantly reduced. Rectal metastasis of breast cancer is said to be rare. However, in the case of patients diagnosed with breast cancer or with a history of breast cancer, considering the possibility of gastrointestinal metastasis using histopathological examination is important.

[A Case of Endoscopic Submucosal Dissection for Recurrent Gastric Cancer after Chemotherapy with Arterial Infusion].

The patient was a 90-year-old male. For early gastric cancer on the posterior wall of the upper gastric body, which is not indicated for endoscope treatment, chemotherapy with arterial infusion was carried out at other facilities at the request of the patient and his family. Thereafter, he suffered a relapse during follow-up, for which our hospital carried out endoscopic submucosal dissection(ESD). The outcome was a resection without cure. Taking into consideration his age and the fact that the scoring system for early gastric cancer with excised lesions without cure by ESD indicated a medium risk, we carried out no additional treatment but did conduct a follow-up. There has been no recurrence for 15 months following surgery. ESD does not provide evidence with regard to recurrence after other treatments. This patient had a scar following arterial infusion chemotherapy and a local injection solution was not infused into the submucosa right under the lesion. Although the treatment of exfoliation was difficult due to fibrosis of the submucosa, en-bloc resection was possible without any complications.

A gastric invasive tubular adenocarcinomatous lesion arising from foveolar-type neoplasia: molecular histogenesis.

Here, we report a rare case of a depressed lesion exhibiting both tubular differentiated adenocarcinomatous (TDA) and intraepithelial foveolar neoplasia (IFN) components (with the histological appearance of foveolar hyperplasia due to low-grade atypia). Histologically, the TDA surrounded the IFN, suggesting that the TDA may have originated from the IFN. Therefore, we examined molecular alterations in the TDA and IFN components separately. MUC5AC and MUC6 expression was observed immunohistochemically in both components. p53 expression was wild type in both components, suggesting no mutation of TP53. We investigated allelic imbalances at multiple loci (1p, 3p, 4p, 5q, 8q, 9p, 13q, TP53, 18q, and 22q), mutations (KRAS, BRAF, and GNAS), and DNA methylation and microsatellite status in both components using PCR-based analyses. Although multiple allelic imbalances were common to both components, allelic imbalances at 3p and TP53 were found only in the TDA component. No mutations were found, and DNA methylation status was low epigenotype for both components. Ultimately, this tumor was considered microsatellite stable. Considering the origin of TDA, which is frequently encountered in routine practice, IFN may develop into TDA.

Superficial esophageal squamous cell carcinoma with melanocytosis that was endoscopically difficult to differentiate from malignant melanoma.

Esophageal squamous cell carcinoma (SCC) with dark spots caused by melanocytosis is very rare. A reddish and flat lesion, 4 cm in length and covering over two-thirds of the circumference, was found in the midthoracic esophagus of a 66-year-old male. Multiple brown and black spots are observed in the lesion. Superficial SCC with melanocytosis or malignant melanoma was also suspected. Endoscopic submucosal dissection was performed without biopsies of the spots. Histologically, a few melanocytes were observed in the black spots, and the lesion was diagnosed as SCC (T1a-lamina propria mucosae) with melanocytosis. We report a case of esophageal SCC with dark black spots that were difficult to differentiate endoscopically from malignant melanoma.

Neuroendocrine tumor of the ampulla of Vater treated with endoscopic papillectomy: A case report.

We report the case of a 62-year-old female with a 6.3-mm low-grade neuroendocrine tumor of the ampulla of Vater, who underwent an endoscopic papillectomy. An endoscopic papillectomy was performed without complications. In the 26 months of follow-up, no local recurrence or metastasis occurred. Endoscopic treatment of ampullary neuroendocrine tumors is controversial. However, endoscopic papillectomy may be considered a treatment option if neuroendocrine tumors are small (<10 mm), have a low grade (G1), or do not have muscle layer or bile duct invasion.

Delayed Perforation after Endoscopic Detachable Snare Ligation for Colonic Diverticular Hemorrhage.

A 74-year-old man was admitted to our hospital with severe hematochezia. Abdominal enhanced computed tomography (CT) demonstrated extravasation of contrast material from the descending colon. Colonoscopy revealed recent bleeding in the descending colon diverticulum. Bleeding was stopped using detachable snare ligation. Eight days later, the patient developed abdominalgia, and CT revealed free air caused by delayed perforation. The patient underwent emergency surgery. Perforation at the ligation site was detected using intraoperative colonoscopy. This report is the first to describe a case of delayed perforation after endoscopic detachable snare ligation for colonic diverticular hemorrhage.

Delayed Perforation of Colorectal Endoscopic Submucosal Dissection Treated by Endoscopic Ultrasound-Guided Drainage.

We report a case of a 70-year-old male with delayed perforation in the cecum treated by endoscopic ultrasonography-guided drainage for a pelvic abscess. The lesion was a 50-mm laterally spreading tumor, and endoscopic submucosal dissection (ESD) was performed. No perforation was detected during the operation, and en bloc resection was achieved. He had fever and abdominal pain on postoperative day (POD) 2. Computed tomography (CT) revealed the intra-abdominal free air, leading to a diagnosis of delayed perforation after ESD. Vital signs were stable, the perforation was considered minor, and endoscopic closure was attempted. The colonoscopy under fluoroscopy showed no perforation in the ulcer and no leakage of the contrast medium. He was managed conservatively with antibiotics and nothing per os. Symptoms improved; however, a follow-up CT on POD 13 revealed a 65-mm pelvic abscess, and endoscopic ultrasound (EUS)-guided drainage was successfully performed. The follow-up CT on POD 23 showed the reduction of abscess, and the drainage tubes were removed. Emergent surgical treatment is crucial in delayed perforation because it has a poor prognosis, and reports of conservative therapy for colonic ESD with delayed perforation are few. The present case was managed with antibiotics and EUS-guided drainage. Thus, EUS-guided drainage can be a treatment option for delayed perforation after colorectal ESD, if the abscess is localized.

Treatment strategy after noncurative endoscopic resection for early gastric cancers in patients aged ≥ 85 years: a multicenter retrospective study in a highly aged area of Japan.

BACKGROUND: The guidelines recommend additional gastrectomy after noncurative endoscopic resection for early gastric cancers (EGCs). However, no additional treatment might be acceptable in some patients aged ≥ 85 years. We aimed to identify this patient group using the data in a highly aged area. METHODS: We enrolled patients aged ≥ 85 years after noncurative endoscopic resection for EGCs at 30 institutions of the Tohoku district in Japan between 2002 and 2017. Treatment selection and prognosis after noncurative endoscopic resection were investigated. Fourteen candidates were evaluated using the Cox model to identify risk factors for poor overall survival (OS) in patients with no additional treatment. RESULTS: Of 1065 patients aged ≥ 85 years, 143 underwent noncurative endoscopic resection. Despite the guidelines' recommendation, 88.8% of them underwent no additional treatment. The 5-year OS rates in those with additional gastrectomy and those with no additional treatment were 63.1 and 65.2%, respectively. Multivariate analysis showed independent risk factors for poor OS in patients with no additional treatment were the high-risk category in the eCura system (hazard ratio [HR], 2.91), Charlson comorbidity index (CCI) ≥ 3 (HR, 2.78), and male (HR, 2.04). In patients with no additional treatment, nongastric cancer-specific survival was low (69.0% in 5 years), whereas disease-specific survival rates were very high in the low- and intermediate-risk categories of the eCura system (100.0 and 97.1%, respectively, in 5 years). CONCLUSIONS: No additional treatment may be acceptable in the low- and intermediate-risk categories of the eCura system in patients aged ≥ 85 years with noncurative endoscopic resection for EGCs.

Prediction model of 3-year survival after endoscopic submucosal dissection for early gastric cancer in elderly patients aged ≥ 85 years: EGC-2 model.

PURPOSE: Little is known about the prognostic factors for survival after endoscopic submucosal dissection (ESD) in elderly patients with early gastric cancer (EGC). The aim of this study is to determine prognostic factors and a prediction model of 3-year survival after ESD for EGC in patients aged ≥ 85 years. METHODS: We retrospectively evaluated the clinical outcomes of 740 patients with EGC aged ≥ 85 years, who were treated by ESD at 30 institutions in Japan. Overall survival (OS) and disease-specific survival (DSS) were calculated with the Kaplan-Meier method. Prediction models for 3-year OS after ESD were estimated using the Cox proportional hazards model based on Uno's C-statistics. RESULTS: During the follow-up period, 309 patients died of any cause and 10 patients died of gastric cancer. OS and DSS after 3 years were 82.7% and 99.2%, respectively. No significant differences in OS were found among curability categories. The Cox proportional hazards model revealed the geriatric nutritional risk index (GNRI) and the Charlson comorbidity index (CCI) to be predictors of 3-year survival. We established a final model (EGC-2 model) expressed by GNRI - (2.2×CCI) with a cutoff value of 96. The overall survival rate was significantly lower in the model value < 96 group than in the model value ≥ 96 group (P < 0.001). CONCLUSIONS: The prediction model using GNRI and CCI will be useful to support decision-making for the treatment of EGC in elderly patients aged ≥ 85 years.

[Antimicrobial susceptibilityof clinical isolates of aerobic gram-negative bacteria in 2008].

We determined MICs of antibacterial agents against 1145 clinical strains of aerobic Gram-negative bacteria (22 species) isolated at 16 Japanese facilities in 2008. MICs were determined using mostly broth microdilution method and antibacterial activity was assessed. Strains producing extended-spectrum beta-lactamases (ESBL) accounted for 3.8% of Escherichia coli, 2.6% of Klebsiella pneumoniae, 6.8% of Klebsiella oxytoca, 5.5% of Proteus mirabilis and 1.8% of Proteus vulgaris. ESBL produced strains were 6.8% at K. oxytoca that increased compared with 3.2% and 5.5% at P. mirabilis that decreased compared with 18.8% in 2006. Among Haemophilus influenzae, 61.7% that decreased compared with 67.7% in 2006, equaled 58.7% in 2004, were strains when classified by penicillin-binding protein 3 mutation. Against Pseudomonas aeruginosa, the activity of most antibacterial agents was similar to that in 2006. Although two antibacterial agents that tobramycin showed an MIC90 of 1 microg/mL and doripenem showed an MIC90 of 4 microg/mL against P. aeruginosa have potent activity. Of all P. aeruginosa strains, 4.3% were resistant to six agents of nine antipseudomonal agents, that decreased compared to 12.2% in 2004 and 5.7% in 2006. Against other glucose-non-fermentative Gram-negative rods, the activity of most antibacterial agents was similar to that in 2006.

[Antimicrobial susceptibility of clinical isolates of aerobic gram-positive cocci and anaerobic bacteria in 2008].

The activity of antibacterial agents against aerobic Gram-positive cocci (25 genus or species, 1029 strains) and anaerobic bacteria (21 genus or species, 187 strains) isolated from clinical specimens in 2008 at 16 clinical facilities in Japan were studied using either broth microdilution or agar dilution method. The ratio of methicillin-resistant strains among Staphylococcus aureus and Staphylococcus epidermidis was 59.6% and 81.2%, suggesting that resistant strains were isolated at high frequency. Vancomycin (VCM), linezolid (LZD) and quinupristin/dalfopristin (QPR/DPR) had good antibacterial activity against methicillin-resistant S. aureus and methicillin-resistant S. epidermidis, with MIC90s of < or = 2 microg/mL. The ratio of penicillin (PC) intermediate and resistant strains classified by mutations of PC-binding proteins among Streptococcus pneumoniae was 92.0% that was highest among our previous reports. Cefpirome, carbapenems, VCM, teicoplanin (TEIC), LZD and QPR/DPR had MIC90s of < or = 1 microg/mL against PC-intermediate and resistant S. pneumoniae strains. Against all strains of Enterococcus faecalis and Enterococcus faecium, the MICs of VCM and TEIC were under 2 microg/mL, and no resistant strain was detected, suggesting that these agents had excellent activities against these species. 15.9% of E. faecalis strains and 1.2% of E. faecium strains showed intermediate to LZD. 17.1% of E. faecium strains showed intermediate or resistant to QPR/DPR. Against all strains of Clostridium difficile, the MIC of VCM was under 1 microg/mL, suggesting that VCM had excellent activity. Carbapenems showed good activity against Clostridiales, Bacteroides spp., and Prevotella spp., but one strain of Bacteroides fragilis showed resistant to carbapenems. And so, the susceptibility of this species should be well-focused in the future at detecting continuously.

Endoscopic Detachable Snare Ligation Therapy for Colonic Diverticular Hemorrhage Improves Procedure Time Compared to Endoscopic Band Ligation.

BACKGROUND: The clipping method is widely used in endoscopic hemostasis for colonic diverticular hemorrhage. Recently, rebleeding was shown to be less common in ligation therapy than in clipping. Ligation methods include endoscopic band ligation (EBL) and endoscopic detachable snare ligation (EDSL). No studies have compared procedure times for EBL and EDSL. The present study aimed to compare EDSL and EBL in terms of procedure time. METHODS: In this single-center retrospective observational cohort study, we evaluated the data of 39 patients who underwent EBL or EDSL for colonic diverticular hemorrhage. The primary and secondary outcomes measured were the total procedure time and early rebleeding rate, respectively. RESULTS: Among the 39 patients included in the study, 18 underwent EBL, and 21 underwent EDSL for hemostasis. The median total pro- cedure times for the EBL and EDSL groups were 50 (range, 30-80) minutes and 35 (range, 18-55) minutes, respectively, demonstrating that the total colonoscopy time was significantly shorter in the EDSL group (P < .001). The early rebleeding rate was 11.1% (2/18) in the EBL group and 4.8% (1/21) in the EDSL group (P = .246). CONCLUSION: Important improvements in procedure time were achieved in the EDSL group. Based on our results, we believe that EDSL may reduce patient and endoscopist burden.

Clinical Benefit of Polypectomy With Cutting Current for Colorectal Polyps: A Randomized Controlled Trial.

BACKGROUND/AIM: This study aimed to examine the effectiveness of polypectomy with cutting current (PCC) for colorectal polyps, compared with cold snare polypectomy (CSP). PATIENTS AND METHODS: The study design was a singlecenter randomized controlled trial. We included patients with one or more non-pedunculated colorectal polyps of 6 mm or more and less than 10 mm. The primary endpoint was the proportion of complete resection of the muscularis mucosae. RESULTS: Twenty-seven patients (37 polyps) were assigned to the CSP group, and 22 (29 polyps) were assigned to the PCC group. The number of polyps that could achieve complete muscularis mucosae resection was 7 (20.0%) in the CSP group and 24 (92.3%) in the PCC group, and the rate of complete muscularis mucosae resection was statistically significantly higher in the PCC group. CONCLUSION: PCC is a safer procedure because it can remove the muscularis mucosae more reliably.

[Nationwide surveillance of parenteral antibiotics containing meropenem activities against clinically isolated strains in 2009].

The antibacterial activity of meropenem (MEPM) and other parenteral antibiotics against clinical isolates of 2655 strains including 810 strains of Gram-positive bacteria, 1635 strains of Gram-negative bacteria, and 210 strains of anaerobic bacteria obtained from 30 medical institutions during 2009 was examined. The results were as follows; (1) MEPM was more active than the other carbapenem antibiotics tested against Gram-negative bacteria, especially against enterobacteriaceae and Haemophilus influenzae. MEPM was also active against most of the species tested in Gram-positive and anaerobic bacteria, except for multidrug resistant strains including methicillin-resistant Staphylococcus aureus (MRSA). (2) MEPM maintained potent and stable antibacterial activity against Pseudomonas aeruginosa. The proportion of MEPM-resistant strains to ciprofloxacin-resistant strains or imipenem-resistant strains were 53.1% and 58.0% respectively. (3) The proportion of extended-spectrum beta-lactamase (ESBL) strains was 3.1% (26 strains) in enterobacteriaceae. And the proportion of metallo-beta-lactamase strains was 2.0% (6 strains) in P. aeruginosa. (4) Of all species tested, there were no species except for Bacteroides fragilis group, which MIC90 of MEPM was more than 4-fold higher than those in our previous study. Therefore, there is almost no significant decrease in susceptibility of clinical isolates to meropenem. In conclusion, the results from this surveillance study suggest that MEPM retains its potent and broad antibacterial activity and therefore is a clinically useful carbapenem for serious infections treatment at present, 14 years passed after available for commercial use in Japan.