Oral breathing facilitates endoscopic operability compared to nasal breathing in peroral endoscopy: a randomized controlled trial.

INTRODUCTION: Unsedated peroral endoscopy, including ultrathin endoscopy (UE) and conventional endoscopy (CE), is feasible in clinical practice but requires improved endoscopic operability and patient tolerance. Currently, the impact of breathing method on these factors remains unclear. We conducted the first randomized controlled trial comparing oral breathing (OB) and nasal breathing (NB) during both UE and CE to assess their influence. METHODS: 252 eligible patients undergoing CE or UE were randomly assigned to OB or NB groups. Endoscopists and patients rated endoscopic operability and patient tolerance using a 100-mm visual analog scale (VAS). Visibility from the oral cavity to the middle pharynx was recorded. RESULTS: OB led to a higher rate of improved visibility from the oral cavity to the middle pharynx compared to NB, ranging from 79.3% to 81.0%. Multivariate correlation analyses showed significantly lower VAS scores for endoscopic operability with OB compared to NB in both UE and CE groups (p < 0.05). No significant differences were found in the overall evaluation of patient tolerance between OB and NB groups in UE and CE, while the smaller diameter of UE exhibited better patient tolerance compared to CE. Discriminant analysis comparing endoscope types and breathing methods revealed that UE with OB outperformed other combinations in the overall evaluation of endoscopic operability and patient tolerance (p < 0.05). CONCLUSIONS: OB facilitates endoscopic operability compared to NB in peroral endoscopy. UE with OB is recommended as the preferred choice for unsedated peroral endoscopy in daily practice.

Risk Factors for Post-Colorectal Endoscopic Submucosal Dissection Bleeding and Efficacy of Carbazochrome Sodium Sulfonate: A Multicenter Retrospective Cohort Study.

INTRODUCTION: Carbazochrome sodium sulfonate (CSS) is a hemostatic agent that reduces capillary permeability and enhances capillary resistance. However, its specific effects on colorectal endoscopic submucosal dissection (ESD) outcomes remain uncertain. This study aimed to assess the risk factors for post-ESD bleeding and the effect of CSS on colorectal ESD outcomes. METHODS: First, we retrospectively analyzed the risk factors for post-ESD bleeding using data from 1,315 lesions in 1,223 patients who underwent ESD for superficial colorectal neoplasms at eight institutions. Second, patients were divided into CSS and non-CSS groups using propensity score matching, and their outcomes from colorectal ESD were analyzed. RESULTS: The risk factors for post-colorectal ESD bleeding were identified as age of ≥70 years, tumor located in the rectum, tumor size of ≥40 mm, and post-ESD defect unclosure in both univariate and multivariate analyses. The CSS and non-CSS groups each consisted of 423 lesions after propensity score matching. The post-colorectal ESD bleeding rate was 3.5% (15/423) and 3.3% (14/423) in the CSS and non-CSS groups, respectively, indicating no significant differences. Among patients with the high-risk factors for post-ESD bleeding, the administration of CSS also did not demonstrate a significant reduction in the post-ESD bleeding rate compared to the non-CSS group. CONCLUSION: CSS administration is ineffective in preventing post-colorectal ESD bleeding in both the general population and individuals at a high risk for such bleeding. Our results indicate the necessity to reconsider the application of CSS for preventing post-colorectal ESD bleeding.

Nasal breathing is superior to oral breathing when performing and undergoing transnasal endoscopy: a randomized trial.

BACKGROUND : Transnasal endoscopy presents a technical difficulty when inserting the flexible endoscope. It is unclear whether a particular breathing method is useful for transnasal endoscopy. Therefore, we conducted a prospective randomized controlled trial to compare endoscopic operability and patient tolerance between patients assigned to nasal breathing or oral breathing groups. METHODS : 198 eligible patients were randomly assigned to undergo transnasal endoscopy with nasal breathing or with oral breathing. Endoscopists and patients answered questionnaires on the endoscopic operability and patient tolerance using a 100-mm visual analog scale ranging from 0 (non-existent) to 100 (most difficult/unbearable). The visibility of the upper-middle pharynx was recorded. RESULTS : Patient characteristics did not differ significantly between the groups. Nasal breathing showed a higher rate of good visibility of the upper-middle pharynx than oral breathing (91.9 % vs. 27.6 %; P < 0.001). Nasal breathing showed lower mean [SD] scores than oral breathing in terms of overall technical difficulty (21.0 [11.4] vs. 35.4 [15.0]; P < 0.001). Regarding patient tolerance, nasal breathing showed lower scores than oral breathing for overall discomfort (22.1 [18.8] vs. 30.5 [20.9]; P = 0.004) and other symptoms, including nasal and throat pain, choking, suffocating, gagging, belching, and bloating (all P < 0.05). The pharyngeal bleeding rate was lower in the nasal breathing group than in the oral breathing group (0 % vs. 9.2 %; P = 0.002). CONCLUSIONS : Nasal breathing is superior to oral breathing for those performing and undergoing transnasal endoscopy. Nasal breathing led to good visibility of the upper-middle pharynx, improved endoscopic operability, and better patient tolerance, and was safer owing to decreased pharyngeal bleeding.

Concomitant pharmacologic medications influence the clinical outcomes of granulocyte and monocyte adsorptive apheresis in patients with ulcerative colitis: A multicenter retrospective cohort study.

BACKGROUND: Granulocyte and monocyte adsorptive apheresis (GMA) with Adacolumn has been used as a remission induction therapy for patients with active ulcerative colitis (UC). Herein, we investigated the influence of concomitant medications in the remission induction of GMA in patients with active UC. METHODS: This multicenter retrospective cohort study included patients with UC underwent GMA in five independent institutions in Japan from January 2011 to July 2021. Factors including concomitant medications associated with clinical remission (CR) were analyzed statistically. RESULT: A total of 133 patients were included. Seventy-four patients achieved a CR after GMA. The multivariable analysis revealed that concomitant medication with 5-aminosalicylic acid, Mayo endoscopic subscore (MES), and concomitant medication with immunosuppressors (IMs) remained as predictors of CR after GMA. In the subgroup analysis in patients with MES of 2, concomitant medication with IMs was demonstrated as a significant negative factor of CR after GMA (P = .042, OR 0.354). Seventy-four patients who achieved CR after GMA were followed up for 52 weeks. In the multivariable analysis, the maintenance therapy with IMs was demonstrated as a significant positive factor of sustained CR up to 52 weeks (P = .038, OR 2.214). Furthermore, the rate of sustained CR in patients with biologics and IMs was significantly higher than that in patients with biologics only (P = .002). CONCLUSION: GMA was more effective for patients with active UC that relapsed under treatment without IMs. Furthermore, the addition of IMs should be considered in patients on maintenance therapy with biologics after GMA.

[A case of systemic amyloidosis presenting with gastric emphysema].

The patient was an elderly woman in her 80s. Upper and lower gastrointestinal endoscopies were conducted as a thorough analysis for cardiac amyloidosis, revealing no abnormal findings. A mucosal biopsy, however, resulted in an amyloid AA-type amyloidosis diagnosis. About 2 months later, she visited our department with sudden vomiting and epigastric pain onset. Plain abdominal radiography and computed tomography demonstrated gastric emphysema, and thus, she was admitted to our department. The gastric emphysema was alleviated with conservative treatment. Herein, we report a valuable case in which gastric emphysema manifested as a gastrointestinal tract lesion of amyloidosis.

[Hepatic echinococcosis that required 11 years for a definitive diagnosis: a case report].

A woman in her 80s underwent computed tomography that revealed a 22-mm-sized unilocular mass in segment 4 of her liver. The mass grew to 26mm at the 4-year follow-up and to 36mm at the 11-year follow-up, becoming a multilocular mass that invaded the bile duct. At this point, the patient was diagnosed with hepatic echinococcosis based on a serological examination and oral albendazole treatment was initiated. The patient developed cholangitis and underwent endoscopic biliary stenting 12 years after her initial diagnosis. We consider this case valuable as it allowed us to follow the natural course of hepatic echinococcosis.

[The task of the medical cooperation system for patients with inflammatory bowel disease in the northern and eastern regions of Hokkaido].

In Japan, establishing a medical cooperation system for patients with inflammatory bowel disease (IBD) between IBD flagship and local care hospitals is a crucial task. Thus, this retrospective multicenter cohort study aims to examine the actual state of medical treatment in patients with IBD via a questionnaire survey administered to eight dependent institutes in Hokkaido, Japan. The present results clarified the clinical disparities of IBD treatment and hospital function between IBD flagship hospitals and local care hospitals. Moreover, the understanding level of IBD treatment in medical staff was significantly lower in local care than in IBD flagship hospitals. Furthermore, an abounding experience of IBD treatment affected the understanding level of IBD treatment of both medical doctors and staff. These findings indicate that selecting patients with IBD corresponding to disease activity, educational system for the current IBD treatment, and promotion of team medicine with multimedical staff can resolve clinical discrepancies between IBD flagship and local care hospitals. The IBD treatment inequities in Japan will be eliminated with the development of an appropriate medical cooperation system between IBD flagship and local care hospitals.

[Effect of adding X-ray examination to endoscopy in the assessment of the invasion depth of early gastric cancer].

In the assessment of invasion depth of early gastric cancer (EGC), the effect of adding X-ray examination to endoscopy was retrospectively investigated in 84 EGC lesions diagnosed at our hospital, including 62 differentiated and 22 undifferentiated lesions. Overall diagnostic accuracy was 75% with endoscopy and 82.1% when X-ray examination was performed in addition to endoscopy. This demonstrated an increase in the accuracy of 7.1% by adding X-ray examination. In terms of presence of ulceration, the additional effect of X-ray examination was higher for lesions without ulceration for both differentiated and undifferentiated lesions. In terms of tumor diameter, the additional effect of X-ray examination was higher for differentiated lesions of ≤30mm and for undifferentiated lesions of ≥21mm. In terms of tumor location, the additional effect of X-ray examination was higher for lesions located in the upper gastric corpus. Depending on the lesion, the addition of X-ray examination to endoscopy contributed to an increase in the accuracy of the assessment of the invasion depth of EGC.

[A case of duodenal neuroendocrine carcinoma composed of small- and large-cell types].

A 78-year-old man underwent a detailed examination by upper gastrointestinal endoscopy for the complaint of epigastric pain. The examination revealed a hemicircumferential type 2 tumor in the descending duodenum. A subsequent biopsy led to a diagnosis of neuroendocrine carcinoma. Subtotal stomach-preserving pancreaticoduodenectomy was performed. The lesion was composed of small- and large-cell neuroendocrine carcinomas. The large-cell type component was positive for both caudal homeobox protein 2 and the cluster of differentiation 138, whereas the small-cell type component was negative for both. Our report may provide valuable information regarding the pathogenesis of neuroendocrine carcinoma.

A case of synchronous quintuple gastric cancer with large-cell endocrine carcinoma.

The patient was a 73-year-old man who visited our department with black stools as the chief complaint. Upper digestive tract endoscopy revealed three type 2 lesions in the lesser curvature of the gastric antrum and the gastric angle and the posterior wall of the upper gastric body, which were diagnosed by biopsy as tub2, por, and sig, respectively. Total gastrectomy was performed. The final pathological diagnosis was quintuple gastric cancer with a main lesion of large-cell endocrine carcinoma and four adenocarcinoma sublesions. We report this extremely rare case of gastric endocrine cell carcinoma complicated by adenocarcinoma.

A case of mixed adenoneuroendocrine carcinoma of the stomach.

A 71-year-old man who tested positive in a pepsinogen test also underwent upper gastrointestinal endoscopy. A 0-IIc lesion was identified at the posterior wall of the antrum. Biopsy findings indicated endocrine cell carcinoma. The patient underwent distal gastrectomy, and subsequent histopathological examination of the resected specimens showed a moderately differentiated adenocarcinoma (tub2) in the mucosa with transformation to small cell carcinoma in the submucosal and muscle layers. The final diagnosis was of a mixed adenoneuroendocrine carcinoma. We herein describe a case report of this patient with this rare form of gastric carcinoma.

[A case of large cell neuroendocrine carcinoma of the rectum].

A 77-year-old woman was referred to our hospital because of blood in feces and anal pain. Colonoscopy revealed a villous semicircular tumor in the rectum. A biopsy showed well-differentiated adenocarcinoma. Miles' operation was performed because of the persistence of anal pain and blood in feces. Histological and immunohistochemical analysis showed coexistent tubulovillous adenoma, tubulovillous adenocarcinoma, and large cell neuroendocrine carcinoma (LCNEC), which was positive for CD56, chromogranin A, and synaptophysin. Pathological examination revealed that most of the lesion was occupied by the LCNEC. The tumor was therefore diagnosed as LCNEC of the rectum. The patient underwent adjuvant chemotherapy with cisplatin (CDDP), irinotecan (CPT-11), and mFOLFOX6, but died because of LCNEC progression 10 months after the operation. LCNEC rarely occurs in the gastrointestinal tract; here we report a case of rectal LCNEC.

The clinical efficacy and safety of granulocyte and monocyte adsorptive apheresis in patients with Crohn's disease: A multicenter retrospective pilot study.

INTRODUCTION: A remission induction therapy of granulocyte and monocyte adsorptive apheresis (GMA) was given to patients with Crohn's disease (CD). However, establishing an appropriate treatment strategy for GMA in patients with CD remains unclear. METHODS: This study evaluated the clinical efficacy and subsequent clinical progression after GMA in patients with CD who underwent GMA in seven independent institutions in Japan from 2010 to 2023. RESULTS: Sixteen patients were enrolled. The overall remission and response rates were 25.0% and 68.8%, respectively. All patients responding to GMA received biologics that were continuously used and 36.4% of patients remained on the same biologics 52 weeks after GMA. Notably, all patients who continued the same biologics had previously experienced a loss of response to biologics. CONCLUSION: GMA may exhibit effectiveness even in cases with refractory CD. Moreover, it represents a potential novel therapeutic option for refractory CD with loss of response to biologics.

A therapeutic barium enema is a practical option to control bleeding from the appendix.

BACKGROUND: Acute lower gastrointestinal hemorrhage originating from the appendix is rare and often intractable, because it is almost impossible to approach the bleeding point by endoscopy. We herein describe the first case of bleeding from the appendix, which was successively controlled by a therapeutic barium enema administered into the appendix. CASE PRESENTATION: A 71-year-old male visited our hospital because of melena. He has been receiving an anti-coagulation drug, ticlopidine hydrochloride, for 10 years. By an emergency colonoscopy, a hemorrhage was detected in the appendix, and the lesion responsible for the bleeding was regarded to exist in the appendix. Two hundred milliliters of 50 W/V% barium was sprayed into the orifice of the appendix using a spraying tube. The bleeding could thus be immediately stopped, and a radiological examination revealed the accumulation of barium at the cecum and the orifice of the appendix. The barium accumulation disappeared by the next day, and no obvious anal bleeding was observed. Two weeks after stopping the bleeding from the appendix, an appendectomy was performed to prevent any further refractory hemorrhaging. The patient has had no complaints of any abdominal symptoms or anal bleeding for 10 months. CONCLUSIONS: A therapeutic barium enema is a useful procedure to control bleeding from the appendix and to avoid emergency surgery, such as partial cecectomy and hemicolectomy.

Successful Treatment of Advanced Gastric Cancer with Brain Metastases through an Abscopal Effect by Radiation and Immune Checkpoint Inhibitor Therapy.

The abscopal effect refers to the phenomenon in which local radiotherapy is associated with the regression of metastatic cancer that is distantly located from the irradiated site. Here, we present a case of a patient with advanced gastric cancer and brain metastases who was successfully treated with brain radiotherapy and anti-programmed death-1 (PD-1) therapy-induced abscopal effect. Although anti-PD-1 therapy alone could not prevent disease progression, the metastatic lesions in the brain and also in the abdominal lymph node showed a drastic response after brain radiotherapy and anti-PD-1 therapy. To our knowledge, this is the first reported case of successful treatment of advanced gastric cancer with multiple brain and abdominal lymph node metastases, possibly through anti-PD-1 therapy combined with brain radiotherapy-induced abscopal effect. We suggest that the combination of brain radiotherapy and anti-PD-1 therapy may be considered as a therapeutic option for advanced gastric cancer, especially when there is brain metastasis.

Multiple Cancers of the Biliary Tract and Pancreatic Duct after Cholecystectomy for Gallbladder Cancer in a Patient with Pancreaticobiliary Maljunction.

We herein report the rare case of a 76-year-old woman who underwent cholecystectomy with bile duct resection for advanced gallbladder cancer associated with pancreaticobiliary maljunction (PBM) and subsequently developed multiple cancers of the pancreaticobiliary system (the distal bile duct, intrahepatic duct and pancreatic duct) after the operation. We performed conventional endoscopic retrograde cholangiopancreatography (ERCP) using a side-viewing scope to evaluate the masses in the distal bile duct and the pancreatic duct. We also performed ERCP using double-balloon enteroscopy (DBE) to observe the mass in the intrahepatic duct. It was possible to directly observe the lesion using DBE and to perform a biopsy under visual control. All lesions were correctly diagnosed by the combination of ERCP using different endoscopes. The present case suggests that it is necessary to pay close attention (with regard to carcinogenesis) to the whole pancreaticobiliary system in patients with PBM. In addition, the combination of ERCP using DBE and a side-viewing scope may be useful for making a precise diagnosis in patients with altered biliary anatomy who have multiple cancers of the pancreaticobiliary system.

An invasive extragastrointestinal stromal tumor curably resected following imatinib treatment.

Extragastrointestinal stromal tumors (EGISTs) are rare tumors located outside the gastrointestinal tract. While curable resection is accepted as a noninvasive EGIST treatment, the therapeutic strategy for invasive EGISTs has not yet been established. The present report is the first to show a case of invasive EGIST completely resected after downsizing the tumor with imatinib treatment. A 69-year-old female had multiple masses adjacent to the stomach and ileocecum. The primary lesion measured 18 cm in size and had invaded the stomach, pancreas and liver. The histological findings of fine-needle aspiration samples revealed a proliferation of dysplastic spindle cells that exhibited immunoreactivity for anti-c-kit antibodies. The masses were therefore diagnosed as multiple GISTs with invasion to other organs, with origin difficult to determine at the time. Nineteen months after the imatinib treatment, the tumors were downsized and distinct from the stomach, pancreas and liver. Accordingly, the tumors were regarded to be EGISTs derived from the mesentery. Because they slightly regressed 26 months after treatment, surgery was applied to remove the EGISTs. The intraoperative findings showed no invasive signs, and the tumors were completely removed. The histological findings revealed the presence of dysplastic and c-kit-positive spindle cells in the tumor with an MIB-I index of more than 5%, resulting in a final diagnosis of high-risk EGIST derived from the mesentery. No recurrence was detected for 16 months after resection. In conclusion, preoperative treatment with imatinib followed by curable resection is a feasible option to cure invasive EGISTs.