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1.
J Gastroenterol Hepatol ; 39(7): 1358-1366, 2024 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-38556810

RESUMO

BACKGROUND AND AIM: Perforation is one of the most important complications of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Several studies have examined risk factors for intraoperative and delayed perforations, but most were retrospective analyses with small numbers of patients. METHODS: This study represents a secondary analysis of a Japanese multicenter prospective cohort study. We investigated the factors associated with each type of perforation using 9015 patients with 9975 EGCs undergoing ESD between July 2010 and June 2012. RESULTS: Intraoperative perforation occurred in 198 patients (2.2%) with 203 lesions (2.0%), necessitating emergency surgery for four lesions (0.04% [2.0%, 4/203]). Delayed perforation occurred in another 37 patients (0.4%) with 42 lesions (0.4%), requiring emergency surgery for 12 lesions (0.12% [28.6%, 12/42]). Factors showing significant independent correlations with intraoperative perforation were upper or middle third of the stomach; remnant stomach or gastric tube; procedure time ≥100 min; tumor size >35 mm; body mass index (BMI) < 18.5 kg/m2; and ≥72 years. Factors showing significant independent correlations with delayed perforation were procedure time ≥60 min; BMI < 18.5 kg/m2; ≥75 years; ulceration; and tumor size >20 mm. Intraoperative perforation occurred most frequently at the greater curvature in the upper third of the stomach (7.9%), whereas delayed perforation occurred most frequently at the greater curvature in the middle third (1.2%). CONCLUSION: This multicenter prospective cohort study clarified the risk and risk factors of intraoperative and delayed perforation related to ESD for EGCs, providing information to help endoscopists reduce perforation.


Assuntos
Ressecção Endoscópica de Mucosa , Complicações Intraoperatórias , Neoplasias Gástricas , Humanos , Fatores de Risco , Neoplasias Gástricas/cirurgia , Idoso , Masculino , Ressecção Endoscópica de Mucosa/efeitos adversos , Ressecção Endoscópica de Mucosa/métodos , Feminino , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/epidemiologia , Pessoa de Meia-Idade , Fatores de Tempo , Estudos Prospectivos , Idoso de 80 Anos ou mais , Duração da Cirurgia , Estudos de Coortes , Índice de Massa Corporal , Gastroscopia/efeitos adversos , Mucosa Gástrica/cirurgia , Mucosa Gástrica/lesões , Mucosa Gástrica/patologia
2.
Dig Endosc ; 2024 Aug 08.
Artigo em Inglês | MEDLINE | ID: mdl-39117368

RESUMO

OBJECTIVES: This study investigated the incidence of lymph node metastasis and long-term outcomes in patients with T1 colorectal cancer where endoscopic submucosal dissection (ESD) resulted in noncurative treatment. It is focused on those with deep submucosal invasion, a factor considered a weak predictor of lymph node metastasis in the absence of other risk factors. METHODS: This nationwide, multicenter, prospective study conducted a post-hoc analysis of 141 patients with T1 colorectal cancer ≥20 mm where ESD of the lesion resulted in noncurative outcomes, characterized by poor differentiation, deep submucosal invasion (≥1000 µm), lymphovascular invasion, high-grade tumor budding, or positive vertical margins. Clinicopathologic features and patient prognoses focusing on lesion sites and additional surgery requirements were evaluated. Lymph node metastasis incidence in the low-risk T1 group, identified by deep submucosal invasion as the sole high-risk histological feature, was assessed. RESULTS: Lymph node metastasis occurred in 14% of patients undergoing additional surgery post-noncurative endoscopic submucosal dissection for T1 colorectal cancer. In the low-risk T1 group, in the absence of other risk factors, the frequency was 9.7%. The lymph node metastasis rates in patients with T1 colon and rectal cancers did not differ significantly (14% vs. 16%). Distant recurrence was observed in one patient (2.3%) in the ESD only group and in one (1.0%) in the additional surgery group, both of whom had had rectal cancer removed. CONCLUSION: The risk of lymph node metastasis or distant occurrence was not negligible, even in the low-risk T1 group. The findings suggest the need for considering additional surgery, particularly for rectal lesions (Clinical Trial Registration: UMIN000010136).

3.
Gastroenterology ; 163(5): 1423-1434.e2, 2022 11.
Artigo em Inglês | MEDLINE | ID: mdl-35810779

RESUMO

BACKGROUND & AIMS: To determine the long-term outcomes after colorectal endoscopic submucosal dissection (ESD), we conducted a large, multicenter, prospective cohort trial with a 5-year observation period. METHODS: Between February 2013 and January 2015, we consecutively enrolled 1740 patients with 1814 colorectal epithelial neoplasms ≥20 mm who underwent ESD. Patients with noncurative resection (non-CR) lesions underwent additional radical surgery, as needed. After the initial treatment, intensive 5-year follow-up with planned multiple colonoscopies was conducted to identify metastatic and/or local recurrences. Primary outcomes were overall survival, disease-specific survival, and intestinal preservation rates. The rates of local recurrence and metachronous invasive cancer were evaluated as the secondary outcomes. RESULTS: The 5-year overall survival, disease-specific survival, and intestinal preservation rates were 93.6%, 99.6%, and 88.6%, respectively. Patients with CR lesions had no metastatic occurrence, and patients with non-CR lesions had 4 metastatic occurrences. Kaplan-Meier curves revealed that overall survival and disease-specific survival rates were significantly higher in patients with CR lesions than in those with non-CR lesions (P > .001 and P = .009, respectively). Local recurrence occurred in only 8 lesions (0.5%), which were successfully resected by subsequent endoscopic treatment. Multiple logistic regression analyses revealed that piecemeal resection (hazard ratio, 8.19; 95% CI, 1.47-45.7; P = .02) and margin-positive resection (hazard ratio, 8.06; 95% CI, 1.76-37.0; P = .007) were significant independent predictors of local recurrence after colorectal ESD. Fifteen metachronous invasive cancers (1.0%) were identified during surveillance colonoscopy, most of which required surgical resection. CONCLUSIONS: A favorable long-term prognosis indicates that ESD can be the standard treatment for large colorectal epithelial neoplasms. CLINICAL TRIAL REGISTRATION NUMBER: UMIN000010136.


Assuntos
Neoplasias Colorretais , Ressecção Endoscópica de Mucosa , Neoplasias Epiteliais e Glandulares , Humanos , Ressecção Endoscópica de Mucosa/efeitos adversos , Japão/epidemiologia , Estudos Prospectivos , Recidiva Local de Neoplasia/epidemiologia , Colonoscopia , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/patologia , Resultado do Tratamento , Estudos Retrospectivos , Mucosa Intestinal/diagnóstico por imagem , Mucosa Intestinal/cirurgia , Mucosa Intestinal/patologia
4.
Dig Endosc ; 2023 Dec 26.
Artigo em Inglês | MEDLINE | ID: mdl-38148178

RESUMO

OBJECTIVES: We previously demonstrated that a favorable long-term prognosis indicated that endoscopic submucosal dissection (ESD) could be the standard treatment for large colorectal epithelial neoplasms, but the usefulness of ESD for local residual or recurrent tumors with submucosal fibrosis has not been fully demonstrated. The aim of the present study was to assess the usefulness of ESD for local residual or recurrent colorectal tumors. METHODS: We conducted a nationwide multicenter prospective study to evaluate the outcomes of ESD for colorectal tumors. In this post hoc analysis, a total of 54 local residual or recurrent colorectal tumors in 54 patients were included, and we analyzed the short-term and long-term outcomes of ESD for these lesions. RESULTS: The median size of the lesions was 16.0 (interquartile range [IQR] 11-25) mm. ESD was completed in 53 cases (98.1%) with a median procedure time of 65.0 min, but it was discontinued in one case because of submucosal cancer invasion. En bloc resection was achieved in 52 cases (96.3%), whereas R0 resection was achieved in 45 cases (83.3%). Intraoperative perforation was observed in four cases (7.4%) and delayed perforation in one (1.9%), but all cases could be managed conservatively. Delayed bleeding was not observed. There were no significant differences in short-term outcomes between the rectal and colonic lesions. There was no recurrence of the tumor during the median follow-up period of 60 (IQR 50-64) months. CONCLUSION: An analysis of our multicenter prospective study suggests that ESD is an effective salvage management for local residual or recurrent colorectal lesions.

5.
Surg Endosc ; 36(1): 515-525, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-33569725

RESUMO

BACKGROUND AND AIMS: Colorectal neoplastic lesions (≥ 20 mm) are commonly treated via piecemeal endoscopic mucosal resection (p-EMR) but have a high rate of local recurrence. We aimed to clarify the optimal surveillance interval after p-EMR for these neoplasias. METHODS: In this multicenter (15 participating institutions) prospective, randomized trial, 180 patients recruited over a 4-year period and were classified based on tumor location, tumor diameter, histological diagnosis, institution, and number of resected specimens. The patients underwent curative p-EMR followed by scheduled surveillance colonoscopy at 3, 6, 12, and 24 months after p-EMR (group A; n = 90) or at 6, 12, and 24 months after p-EMR (group B; n = 90). The primary endpoint was cumulative local recurrence at 6 months after p-EMR. Secondary endpoints included local recurrence and the cumulative surgical resection rate of recurrent tumors during the 24-month follow-up period. RESULTS: The median tumor diameter was 25 mm (IQR 20-30). Six months after p-EMR, 12 and 6 local recurrences were noted in groups A and B, which corresponded to 13 and 8 recurrences, respectively, during the 24-month surveillance period. The primary and secondary endpoints of recurrence were not significantly different between the groups on either intention-to-treat or per-protocol analysis; no surgery case was observed in group B when a strict surveillance protocol of 6-, 12-, and 24-month follow-up post-EMR was followed. CONCLUSIONS: For patients who underwent p-EMR for neoplastic lesions, additional postprocedural 3-month surveillance did not show superior results in detecting recurrence compared with a 6-month surveillance interval. CLINICAL TRIAL REGISTRATION: UMIN000015740.


Assuntos
Neoplasias Colorretais , Ressecção Endoscópica de Mucosa , Colonoscopia/métodos , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Ressecção Endoscópica de Mucosa/métodos , Humanos , Mucosa Intestinal/patologia , Mucosa Intestinal/cirurgia , Recidiva Local de Neoplasia/patologia , Estudos Prospectivos , Resultado do Tratamento
6.
Dig Endosc ; 34(5): 1042-1051, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34963034

RESUMO

OBJECTIVES: Endoscopic mucosal resection (EMR) is the gold standard for the treatment of noninvasive large colorectal lesions, despite challenges associated with nonlifting lesions and a high rate of local recurrence. Endoscopic submucosal dissection (ESD) offers the possibility of overcoming these EMR limitations. However, a higher risk of complications and longer procedure time prevented its dissemination. As ESD now provides more stable results because of standardized techniques compared with those used earlier, this study aimed to quantify the rates of en bloc and curative resections, as well as ESD complications, in the present situation. METHODS: A multicenter, large-scale, prospective cohort trial of ESD was conducted at 20 institutions in Japan. Consecutive patients scheduled for ESD were enrolled from February 2013 to January 2015. RESULTS: ESD was performed for 1883 patients (1965 lesions). The mean procedure time was 80.6 min; en bloc and curative resections were achieved in 1759 (97.0%) and 1640 (90.4%) lesions, respectively, in epithelial lesions ≥20 mm. Intra- and postprocedural perforations occurred in 51 (2.6%) and 12 (0.6%) lesions, respectively, and emergency surgery for adverse events was performed in nine patients (0.5%). CONCLUSIONS: This trial conducted after the standardization of the ESD technique throughout Japan revealed a higher curability, shorter procedure time, and lower risk of complications than those reported previously. Considering that the target lesions of ESD are more advanced than those of EMR, ESD can be a first-line treatment for large colorectal lesions with acceptable risk and procedure time. (Clinical Trial Registration: UMIN000010136).


Assuntos
Neoplasias Colorretais , Ressecção Endoscópica de Mucosa , Colonoscopia/métodos , Neoplasias Colorretais/patologia , Ressecção Endoscópica de Mucosa/efeitos adversos , Ressecção Endoscópica de Mucosa/métodos , Humanos , Mucosa Intestinal/patologia , Mucosa Intestinal/cirurgia , Recidiva Local de Neoplasia/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento
7.
Oncologist ; 19(4): 358-66, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24668328

RESUMO

BACKGROUND: In advanced gastric cancer (AGC), no globally accepted prognostic scoring system has been developed. Therefore, we explored baseline prognostic factors in Japanese AGC patients using the data from a randomized controlled trial, Japan Clinical Oncology Group (JCOG) 9912, which investigated the efficacy of systemic chemotherapy as a first-line treatment. PATIENTS AND METHODS: Prognostic factors and prognostic indices for overall survival were screened and evaluated in patients enrolled in JCOG9912 using the Cox proportional hazard model. The Royal Marsden Hospital prognostic model was also applied to the JCOG9912 trial. RESULTS: A total of 650 (92.3%) of the 704 patients randomized in the JCOG9912 trial, for whom complete data were available for multivariate analyses, was included in the present study (5-fluorouracil arm, n = 215; irinotecan plus cisplatin arm, n = 216; S-1 arm, n = 219). The median survival time (MST) for all patients was 11.8 months. To construct a prognostic index, we selected four risk factors by multivariate analysis: performance status ≥ 1, number of metastatic sites ≥ 2, no prior gastrectomy, and elevated alkaline phosphatase. MSTs were 17.0 months for patients categorized into the low-risk group, who had zero or one risk factor (n = 225); 10.4 months for patients in the moderate-risk group, who had two or three risk factors (n = 368); and 5.0 months for patients in the high-risk group, who had all four risk factors (n = 57). CONCLUSION: In the present study, we propose a new prognostic index for patients with AGC. This can be used for more appropriate patient stratification in future clinical trials.


Assuntos
Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/mortalidade , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Camptotecina/análogos & derivados , Camptotecina/uso terapêutico , Cisplatino/uso terapêutico , Feminino , Fluoruracila/uso terapêutico , Humanos , Irinotecano , Japão , Masculino , Metástase Neoplásica/patologia , Prognóstico , Fatores de Risco , Neoplasias Gástricas/tratamento farmacológico , Neoplasias Gástricas/patologia
8.
Lancet ; 372(9636): 392-7, 2008 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-18675689

RESUMO

BACKGROUND: The relation between Helicobacter pylori infection and gastric cancer has been proven in epidemiological studies and animal experiments. Our aim was to investigate the prophylactic effect of H pylori eradication on the development of metachronous gastric carcinoma after endoscopic resection for early gastric cancer. METHODS: In this multi-centre, open-label, randomised controlled trial, 544 patients with early gastric cancer, either newly diagnosed and planning to have endoscopic treatment or in post-resection follow-up after endoscopic treatment, were randomly assigned to receive an H pylori eradication regimen (n=272) or control (n=272). Randomisation was done by a computer-generated randomisation list and was stratified by whether the patient was newly diagnosed or post-resection. Patients in the eradication group received lansoprazole 30 mg twice daily, amoxicillin 750 mg twice daily, and clarithromycin 200 mg twice daily for a week; those in the control group received standard care, but no treatment for H pylori. Patients were examined endoscopically at 6, 12, 24, and 36 months after allocation. The primary endpoint was diagnosis of new carcinoma at another site in the stomach. Analyses were by intention to treat. This trial is registered with the UMIN Clinical Trials Registry, number UMIN000001169. FINDINGS: At 3-year follow-up, metachronous gastric carcinoma had developed in nine patients in the eradication group and 24 in the control group. In the full intention-to-treat population, including all patients irrespective of length of follow-up (272 patients in each group), the odds ratio for metachronous gastric carcinoma was 0.353 (95% CI 0.161-0.775; p=0.009); in the modified intention-to-treat population, including patients with at least one post-randomisation assessment of tumour status and adjusting for loss to follow-up (255 patients in the eradication group, 250 in the control group), the hazard ratio for metachronous gastric carcinoma was 0.339 (95% CI 0.157-0.729; p=0.003). In the eradication group, 19 (7%) patients had diarrhoea and 32 (12%) had soft stools. INTERPRETATION: Prophylactic eradication of H pylori after endoscopic resection of early gastric cancer should be used to prevent the development of metachronous gastric carcinoma. FUNDING: Hiroshima Cancer Seminar Foundation.


Assuntos
2-Piridinilmetilsulfinilbenzimidazóis/uso terapêutico , Anti-Infecciosos/uso terapêutico , Claritromicina/uso terapêutico , Infecções por Helicobacter/tratamento farmacológico , Helicobacter pylori/patogenicidade , Recidiva Local de Neoplasia/patologia , Neoplasias Gástricas/prevenção & controle , Idoso , Endoscopia Gastrointestinal , Determinação de Ponto Final , Feminino , Infecções por Helicobacter/complicações , Helicobacter pylori/efeitos dos fármacos , Humanos , Japão , Lansoprazol , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/prevenção & controle , Neoplasias Gástricas/etiologia , Neoplasias Gástricas/cirurgia
9.
Intern Med ; 56(23): 3205-3209, 2017 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-29021435

RESUMO

Herein, we report on an 82-year-old woman who presented with anorexia. The patient had hyponatremia with preserved urinary osmotic pressure. T1-weighted magnetic resonance imaging (MRI) showed a lack of high signal intensity (SI) in the posterior pituitary lobe. Based on the patient's high levels of N-terminal prohormone of brain natriuretic peptide (NT-proBNP), heart failure was suspected. The heart failure may have caused arginine vasopressin (AVP) secretion. The depletion of AVP secretory granules may therefore cause the posterior pituitary gland to disappear on T1-weighted MRI.


Assuntos
Insuficiência Cardíaca/etiologia , Hiponatremia/complicações , Hiponatremia/fisiopatologia , Natriuréticos/sangue , Neuro-Hipófise/diagnóstico por imagem , Neuro-Hipófise/fisiopatologia , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca/fisiopatologia , Humanos , Imageamento por Ressonância Magnética , Resultado do Tratamento
10.
Intern Med ; 56(22): 3073-3076, 2017 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-28943546

RESUMO

We herein report a case of hemichorea-hemiballism in an 85-year-old man diagnosed with diabetes at 76 years of age. After a one-year interruption in treatment, he was treated with a low-calorie diet, linagliptin, and nateglinide. Over 51 days, his HbA1c level decreased from 15.8% to 7.7%. After a prompt improvement in his hyperglycemia, he began experiencing involuntary movements in the right upper and lower extremities. T1-weighted magnetic resonance imaging showed a high signal intensity in the left lens nucleus. The patient was diagnosed with diabetic hemichorea-hemiballism and received haloperidol (1 mg/day) as treatment.


Assuntos
Complicações do Diabetes/fisiopatologia , Discinesias/fisiopatologia , Hiperglicemia/fisiopatologia , Coreia/fisiopatologia , Cicloexanos/uso terapêutico , Hemoglobinas Glicadas , Humanos , Hiperglicemia/tratamento farmacológico , Hipoglicemiantes/uso terapêutico , Linagliptina/uso terapêutico , Extremidade Inferior/patologia , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Nateglinida , Fenilalanina/análogos & derivados , Fenilalanina/uso terapêutico
11.
Nihon Shokakibyo Gakkai Zasshi ; 99(2): 145-51, 2002 Feb.
Artigo em Japonês | MEDLINE | ID: mdl-11877950

RESUMO

Six patients with dissection of the superior mesenteric artery (SMA) who were treated at our hospital between 1993 and 1999 were studied. Hypertension was considered significant as a risk factor. The clinical features were characterized by severe abdominal pain which radiated posteriorly, back pain, weak bowel sounds and exacerbation by eating. An ultrasonographic examination and a computed tomographic scan of the abdomen were useful for diagnosis. Four cases showed full recovery under conservative management with anticoagulant or antiplatelet drugs. Two cases without recovery should be considered intervention if they have progressive courses. This disease should be kept in mind on differential diagnosis of abdominal pain, because it may be overlooked without a correct diagnosis.


Assuntos
Dissecção Aórtica/diagnóstico , Artéria Mesentérica Superior , Adulto , Idoso , Dissecção Aórtica/fisiopatologia , Dissecção Aórtica/terapia , Anticoagulantes/uso terapêutico , Diagnóstico Diferencial , Feminino , Humanos , Hipertensão , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/uso terapêutico , Fatores de Risco , Tomografia Computadorizada por Raios X , Ultrassonografia
13.
World J Gastroenterol ; 15(34): 4290-7, 2009 Sep 14.
Artigo em Inglês | MEDLINE | ID: mdl-19750572

RESUMO

AIM: To investigate the effects of Helicobacter pylori (H pylori) eradication therapy for treatment of peptic ulcer on the incidence of gastric cancer. METHODS: A multicenter prospective cohort study was conducted between November 2000 and December 2007 in Yamagata Prefecture, Japan. The study included patients with H pylori-positive peptic ulcer who decided themselves whether to receive H pylori eradication (eradication group) or conventional antacid therapy (non-eradication group). Incidence of gastric cancer in the two groups was determined based on the results of annual endoscopy and questionnaire surveys, as well as Yamagata Prefectural Cancer Registry data, and was compared between the two groups and by results of H pylori therapy. RESULTS: A total of 4133 patients aged between 13 and 91 years (mean 52.9 years) were registered, and 56 cases of gastric cancer were identified over a mean follow-up of 5.6 years. The sex- and age-adjusted incidence ratio of gastric cancer in the eradication group, as compared with the non-eradication group, was 0.58 (95% CI: 0.28-1.19) and ratios by follow-up period (< 1 year, 1-3 years, > 3 years) were 1.16 (0.27-5.00), 0.50 (0.17-1.49), and 0.34 (0.09-1.28), respectively. Longer follow-up tended to be associated with better prevention of gastric cancer, although not to a significant extent. No significant difference in incidence of gastric cancer was observed between patients with successful eradication therapy (32/2451 patients, 1.31%) and those with treatment failure (11/639 patients, 1.72%). Among patients with duodenal ulcer, which is known to be more prevalent in younger individuals, the incidence of gastric cancer was significantly less in those with successful eradication therapy (2/845 patients, 0.24%) than in those with treatment failure (3/216 patients, 1.39%). CONCLUSION: H pylori eradication therapy for peptic ulcer patients with a mean age of 52.9 years at registration did not significantly decrease the incidence of gastric cancer.


Assuntos
Antibacterianos/uso terapêutico , Antiulcerosos/uso terapêutico , Helicobacter pylori , Úlcera Péptica/tratamento farmacológico , Neoplasias Gástricas/prevenção & controle , 2-Piridinilmetilsulfinilbenzimidazóis/uso terapêutico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Amoxicilina/uso terapêutico , Claritromicina/uso terapêutico , Feminino , Helicobacter pylori/isolamento & purificação , Humanos , Lansoprazol , Masculino , Pessoa de Meia-Idade , Omeprazol/uso terapêutico , Úlcera Péptica/complicações , Úlcera Péptica/microbiologia , Neoplasias Gástricas/epidemiologia , Neoplasias Gástricas/etiologia , Adulto Jovem
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