Risk factors of unintentional piecemeal resection in endoscopic mucosal resection for colorectal polyps ≥ 10 mm.

This study aimed to investigate the lesion and endoscopist factors associated with unintentional endoscopic piecemeal mucosal resection (uniEPMR) of colorectal lesions ≥ 10 mm. uniEPMR was defined from the medical record as anything other than a preoperatively planned EPMR. Factors leading to uniEPMR were identified by retrospective univariate and multivariate analyses of lesions ≥ 10 mm (adenoma including sessile serrated lesion and carcinoma) that were treated with endoscopic mucosal resection (EMR) at three hospitals. Additionally, a questionnaire survey was conducted to determine the number of cases treated by each endoscopist. A learning curve (LC) was created for each lesion size based on the number of experienced cases and the percentage of uniEPMR. Of 2557 lesions, 327 lesions underwent uniEPMR. The recurrence rate of uniEPMR was 2.8%. Multivariate analysis showed that lesion diameter ≥ 30 mm (odds ratio 11.83, 95% confidence interval 6.80-20.60, p < 0.0001) was the most associated risk factor leading to uniEPMR. In the LC analysis, the proportion of uniEPMR decreased for lesion sizes of 10-19 mm until 160 cases. The proportion of uniEPMR decreased with the number of experienced cases in the 20-29 mm range, while there was no correlation between the number of experienced cases and the proportion of uniEPMR ≥ 30 mm. These results suggest that 160 cases seem to be the minimum number of cases needed to be proficient in en bloc EMR. Additionally, while lesion sizes of 10-29 mm are considered suitable for EMR, lesion sizes ≥ 30 mm are not applicable for en bloc EMR from the perspective of both lesion and endoscopist factors.

Treatment strategy changes for inflammatory bowel diseases in biologic era: results from a multicenter cohort in Japan, Far East 1000.

Many molecular targeted agents, including biologics, have emerged for inflammatory bowel diseases (IBD), but their high prices have prevented their widespread use. This study aimed to reveal the changes in patient characteristics and the therapeutic strategies of IBD before and after the implementation of biologics in Japan, where the unique health insurance system allows patients with IBD and physicians to select drugs with minimum patient expenses. The analysis was performed using a prospective cohort, including IBD expert and nonexpert hospitals in Japan. In this study, patients were classified into two groups according to the year of diagnosis based on infliximab implementation as the prebiologic and biologic era groups. The characteristics of therapeutic strategies in both groups were evaluated using association analysis. This study analyzed 542 ulcerative colitis (UC) and 186 Crohn's disease (CD). The biologic era included 53.3% of patients with UC and 76.2% with CD, respectively. The age of UC (33.9 years vs. 38.8 years, P < 0.001) or CD diagnosis (24.3 years vs. 31.9 years, P < 0.001) was significantly higher in the biologic era group. The association analysis of patients with multiple drug usage histories revealed that patients in the prebiologic era group selected anti-tumor necrosis factor (TNF)-α agents, whereas those in the biologic era group preferred biologic agents with different mechanisms other than anti-TNF-α. In conclusion, this study demonstrated that both patient characteristics and treatment preferences in IBD have changed before and after biologic implementation.

[Current state of hepatocellular carcinoma surveillance for chronic liver disease in 91 cases of primary hepatocellular carcinoma].

We retrospectively evaluated the effect of follow-up for chronic liver disease in 91 patients with primary hepatocellular carcinoma. Of these patients, 38 (41.8%) were followed-up for chronic liver disease, while 53 patients (58.2%) were not followed-up. Regarding the baseline status of the liver, the proportion of patients with non-viral hepatitis was significantly higher among patients who were not followed-up (p<0.001). Furthermore, the cumulative survival rate was significantly lower among patients who were not followed-up (p=0.013). Among the 53 patients who were not followed-up, 20 (37.7%) patients did not undergo abdominal imaging for hepatic evaluation despite recorded hepatic issues, and 31 patients (58.5%) were treated by a primary care doctor. Our study suggests that the identification of patients with non-viral hepatitis and confirmation that they are followed-up are vital for improving the prognosis of patients with chronic liver disease.

Safety and Efficacy of Early Tube Removal Following Percutaneous Transhepatic Gallbladder Drainage: an Observational Study.

BACKGROUND: There are currently no guidelines concerning the advisability and timing of tube removal following percutaneous transhepatic gallbladder drainage (PTGBD). The present study aimed to assess the feasibility and risks of early removal of the PTGBD tube under the scenario of subsiding inflammation, patent cystic and common bile ducts, and absence of intraperitoneal leakage. METHODS: Patient background and outcomes were assessed retrospectively in 701 cases of acute cholecystitis treated with PTGBD. The median times until tube removal and tube dislodgement and the cumulative rates of tube dislodgement were calculated. RESULTS: Tube removal was performed in 275 patients after a median time of 16 days (range: 6 to 213 d); biliary peritonitis was observed in 2 patients following tube removal. Tubes were removed in 8 and 35 patients within 7 and 10 days, respectively. Tube dislodgement was observed in 82 patients after a median time of 12 days (range: 1 to 125 d). CONCLUSION: The present study suggests that drainage tube removal is safe and effective when performed after a short drainage period of 7 to 10 days if the criteria for the removal of the drainage tube were met.

The potential of transabdominal 3D color doppler ultrasonography for diagnosis of gastric varices.

GOALS/BACKGROUND: To examine the potential of transabdominal 3-dimensional (3D) color Doppler ultrasonography (3D-US) as a noninvasive tool to characterize gastric varices. STUDY: This was a prospective study in which endoscopy was performed on 107 patients with chronic liver disease. Among these patients, 70 (42 males, 28 females) had gastric varices (46 fundal varices, 24 cardia varices; 30 small, 28 medium, and 12 large), and the 37 patients (25 males, 12 females) without gastric varices served as controls. The 3D-US data and endoscopic findings were compared with respect to grade, location, and similarity of varices. RESULTS: The sensitivity and specificity of the 3D-US technique to detect gastric varices were 88.6% (62/70) and 100% (37/37), respectively. Although all fundal varices appeared adjacent to the posterior gastric wall, cardia varices were detected separately from the wall with a mean distance of 21.2 mm. The vascular volumes (mL) were 0.84±0.71 in small varices, 5.52±3.81 in medium varices, and 10.9±6.3 in large varices, with significant differences between different grades. The best cutoff value to detect medium-grade/large-grade gastric varices was 2.0 mL, with 83.3% sensitivity and 95.8% specificity. Seventy-nine percent (55/70) of patients showed partial resemblance or better between the 3D images and the endoscopic findings with good interreviewer agreement. CONCLUSIONS: 3D-US can quantitatively characterize gastric varices noninvasively in terms of grade, location, and appearance. This approach has the potential to improve objectivity and reduce invasiveness in the management of gastric varices.

Characterization of hepatic lesions (≤ 30 mm) with liver-specific contrast agents: a comparison between ultrasound and magnetic resonance imaging.

PURPOSE: Imaging-based differentiation of hepatic lesions (≤ 30 mm) between well-differentiated hepatocellular carcinomas (w-HCC) and regenerative nodules (RN) presents difficulties. The aim was to compare the diagnostic abilities to differentiate w-HCC from RN using contrast-enhanced ultrasound and magnetic resonance imaging (MRI) both with liver-specific contrast agents. MATERIALS AND METHODS: This prospective study included 67 pathologically proven hepatic lesions (17.5 ± 5.4mm, 54 w-HCCs, 13 RNs) in 56 patients with chronic hepatitis/cirrhosis (male 40, female 16; 29-79y). Hepatic-arterial/liver-specific phase enhancements were assessed quantitatively by ultrasound with perflubutane microbubble agent and MRI with gadolinium-ethoxybenzyl-diethylenetriamine with respect to the histological findings. RESULTS: Sensitivity, specificity and accuracy of hepatic-arterial phase hyper-enhancement for w-HCC were 59.3%, 100% and 67.2% by ultrasound and 46.3%, 100% and 56.7% by MRI without significant difference. Meanwhile, those of liver-specific-phase hypo-enhancement for w-HCC were 44.4%, 100% and 55.2% by ultrasound and 87.0% (p<0.0001), 46.2% (p=0.0052) and 79.1% (p=0.0032) by MRI. Diagnostic accuracies for w-HCC by area under the receiver operating characteristic curves were higher in the hepatic-arterial phase in ultrasound (0.8316) than MRI (0.6659, p=0.0101) and similar in the liver-specific phase in ultrasound (0.7225) and MRI (0.7347, p=0.8814). CONCLUSIONS: Hypervascularity is a significant feature which distinguishes w-HCC from RN, and ultrasound exerts a beneficial impact better than MRI for such characterization. However, both imaging have comparable abilities in the characterization of non-hypervascular lesions, compensating mutually for the poor sensitivity of ultrasound and the poor specificity of MRI in the liver-specific phase.

Linear enhancement after radio-frequency ablation for hepatocellular carcinoma: is it a sign of recurrence?

This prospective study was performed in 179 hepatocellular carcinoma (HCC) lesions treated by radio-frequency ablation (RFA) to explore the clinical outcome of "linear enhancement" on contrast-enhanced sonogram. Thirty-three lesions (18.4%) showed linear enhancement, a linear-shaped positive enhancement in the RFA-treated area. Seventeen of them were followed up with no treatment (remaining 16; dropout in eight, additional RFA in six and ineffective treatment in two) and three lesions (3/17, 17.6%) showed local tumor progression corresponding to linear enhancement at 7, 14, 19 months after RFA. Although there was no significant difference in local recurrence rate between the lesions with (3/17) and without linear enhancement (10/35), local tumor progression inside the ablation zone occurred only in the lesions with linear enhancement. In conclusion, linear enhancement inside the RFA-treated area should be followed up within 7 months because it has a risk of local tumor progression. Histology of linear enhancement and its influence on distant recurrence remain to be solved.