Computed diffusion-weighted magnetic resonance imaging with high b-values in the diagnosis of gallbladder lesions.

PURPOSE: The diagnosis of gallbladder lesions remains challenging. The efficacy of computed diffusion-weighted imaging (DWI) with high b-values and apparent diffusion coefficient (ADC) for the diagnosis of gallbladder cancer remains unknown. We aimed to investigate the usefulness of computed DWI with high b-values and the combination of computed DWI and ADC in differentiating malignant and benign gallbladder lesions. METHODS: Sixty patients (comprising 30 malignant and 30 benign lesions) who underwent magnetic resonance imaging for gallbladder lesions were included in this retrospective study. Qualitative evaluations were performed using conventional DWI with b1000, computed DWI with b1500, b1000 DWI/ADC, and computed b1500 DWI/ADC, and their diagnostic performances were compared. RESULTS: The sensitivity, specificity, and accuracy of computed b1500 DWI/ADC were 90% (27/30), 80% (24/30), and 85% (51/60), respectively. The accuracy of computed b1500 DWI/ADC was higher than that of conventional b1000 DWI (52%, 31/60, p < 0.001), computed b1500 DWI (72%, 43/60, p = 0.008), and b1000 DWI/ADC (78%, 47/60, p = 0.125). The specificity of computed b1500 DWI/ADC was also higher than that of conventional b1000 DWI (7%, 2/30, p < 0.001), computed b1500 DWI (47%, 14/30, p = 0.002), and b1000 DWI/ADC (67%, 20/30, p = 0.125). No significant difference was observed in the sensitivity between the groups. CONCLUSION: This study shows that computed DWI with high b-values combined with ADC can improve diagnostic performance when differentiating malignant and benign gallbladder lesions. Computed diffusion-weighted magnetic resonance imaging with high b-values in the diagnosis of gallbladder lesions. *Computed DWI with b1500 combined with ADC can improve diagnostic performance when differentiating gallbladder lesions compared with conventional methods (b1000 DWI).

Prognostic Impact of Sarcopenia in Patients With Biliary Tract Cancer Undergoing Chemotherapy.

AIM: Sarcopenia affects the treatment of various cancer types but its impact on chemotherapy efficacy and prognosis in biliary tract cancer remains unclear. Thus, we evaluated whether sarcopenia independently affects the outcome of chemotherapy for biliary tract cancer. PATIENTS AND METHODS: Data of 50 patients who underwent chemotherapy for biliary tract cancer at two affiliated centres were retrospectively analysed. The association of clinical factors, including sarcopenia, with overall survival and time to treatment failure was analysed. RESULTS: Sarcopenia was an independent factor negatively influencing overall survival and time to treatment failure in univariate and multivariate analyses (median overall survival, sarcopenic vs. non-sarcopenic patients: 10.6 vs. 16.6 months; hazard ratio=2.19, p=0.018; time to treatment failure: 5.3 vs. 13.1 months, hazard ratio=2.50, p=0.019). CONCLUSION: Sarcopenia may affect the efficacy of chemotherapy and prognosis in biliary tract cancer. Thus, improving sarcopenia may improve the prognosis of patients with biliary tract cancer undergoing chemotherapy.

Efficacy of sedation with dexmedetomidine plus propofol during esophageal endoscopic submucosal dissection.

BACKGROUND AND AIM: During endoscopic submucosal dissection for superficial esophageal cancer, patient body movement can sometimes occur, which may cause discontinuation of the procedure. Propofol and dexmedetomidine have recently been found to be useful sedatives for endoscopic submucosal dissection. This study investigated whether sedation using propofol plus dexmedetomidine can suppress the patient's body movements during esophageal endoscopic submucosal dissection and compared this combination with sedation using propofol alone. METHODS: This was a prospective double-blind randomized controlled trial. Patients with superficial esophageal cancers who underwent esophageal endoscopic submucosal dissection at Yokohama City University Hospital were prospectively enrolled and were randomly assigned to the propofol and the propofol plus dexmedetomidine groups. The primary endpoint was the incidence of restlessness. The secondary endpoints were the satisfaction score, maintenance dose of propofol, and number of rescue propofol injections. RESULTS: Sixty-six patients (propofol group: n = 33; combination group: n = 33) were included. The combination group had a significantly lower incidence of restlessness than the propofol group (3.0% vs 27.3%, P = 0.02). In the combination group, the satisfaction scores of the endoscopists were significantly higher, the maintenance dose of propofol was significantly lower, and the number of rescue propofol injections was lower than those in the propofol group (3.0% vs 18.2%, P < 0.001). Although the incidence of bradycardia was significantly higher in the combination group (30.3% vs 3.0%, P < 0.01), no serious adverse effects occurred. CONCLUSION: The propofol plus dexmedetomidine combination provided excellent sedation that effectively suppressed the patient's body movements during esophageal endoscopic submucosal dissection.

Clinical impact of evaluation of frailty in endoscopic submucosal dissection for early gastric cancer in elderly patients.

AIMS: Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is performed safely and effectively in elderly patients; however, whether ESD for EGC in elderly patients with frailty is safe and improves prognosis remains unclear. METHODS: In total, 142 patients aged ≥80 years who underwent ESD for EGC between September 2008 and September 2014 were included. We compared outcomes between patients with frailty and those without frailty. Frailty was assessed using the Clinical Frailty Scale (CFS) based on a patient's status before admission. Study endpoints were short- and long-term clinical outcomes after ESD. RESULTS: Patients were allocated into two groups: no frailty (CFS 1-3, n = 101) versus frailty (CFS 4-7, n = 41). Short-term clinical outcomes, specifically, adverse events and curability, did not differ between the two groups. For the long-term clinical outcomes, patients with frailty had significantly worse outcomes after ESD than those without frailty (the 3-year overall survival rates were 73.2% vs. 93.1%; P < 0.001 with log-rank test). The Cox proportional hazards model showed that frailty was only an independent risk factor for poor prognosis. CONCLUSIONS: ESD for EGC is safe for elderly patients with or without frailty. However, elderly patients with frailty have a significantly poorer prognosis than those without frailty after ESD. Our results indicate that the frailty evaluation may be helpful to determine whether ESD for EGC should be performed. Geriatr Gerontol Int 2020; 20: 461-466.

Investigation of the Local Recurrence Rate after Colorectal Endoscopic Mucosal Resection: Is Incomplete Polyp Resection Really a Clinically Important Problem? Analysis of the Rationale for the "Resect and Discard" Strategy.

Background/Aims: The "Resect and Discard" strategy is a potentially useful strategy. At present, only the lesion size and accuracy of diagnosis are cited as considerations for clinical adoption of this strategy. On the other hand, histopathology of the resected specimens after Endoscopic Mucosal Resection (EMR) reveals often an unclear or positive-margin status, implying Incomplete Polyp Resection (IPR). If IPR indeed increased the risk of local recurrence, histopathological evaluation of the margin would be indispensable and clinical adoption of this strategy is difficult. The aim of this study is to verify the association between IPR and the risk of local recurrence. Methods: The 1872 polyps and 603 EMR cases in 597 patients who had EMR between May 2013 and May 2014 were enrolled. The local recurrence rate until 3 years after the EMR in cases with the target lesions of the "Resect and Discard" strategy was determined in the negative-margin and IPR groups. Results: The final analysis was performed using the data of 1092 polyps, and 222 were categorized into the IPR group. There were no cases of recurrence in either of the groups. Conclusion: This is the world's first report conducted to examine the correlation of IPR and the local recurrence rate for clinical practice of "Resect and Discard" strategy. There is the possibility that pathological evaluation of the margins after EMR in patients with small polyps can be skipped.

Can sedation using a combination of propofol and dexmedetomidine enhance the satisfaction of the endoscopist in endoscopic submucosal dissection?

BACKGROUND AND STUDY AIMS: The aim of this pilot randomized controlled trial was to evaluate and compare the satisfaction of the endoscopist along with the effectiveness and safety of sedation between sedation protocol using a combination of propofol (PF) and dexmedetomidine (DEX) (Combination group) and sedation protocol using PF alone (PF group) during gastric endoscopic submucosal dissection (ESD). PATIENTS AND METHODS: Fifty-eight patients with gastric neoplasias scheduled for gastric ESD were enrolled and randomly assigned to the two groups. The satisfaction scores of the endoscopists and the parameters for the effectiveness and safety of sedation were evaluated by comparisons between the two groups. RESULTS: The satisfaction scores of the endoscopists, which were measured using a visual analogue scale, were significantly higher in the Combination group than in the PF group (88 vs. 69, P  = 0.003). The maintenance dose of PF was lower in the Combination group than in the PF group (2 mg/kg/h vs. 5 mg/kg/h, P  < 0.001), and the number of rescue PF injections was fewer in the Combination group than in the PF group (2 times vs. 6 times, P  < 0.001). The incidence of bradycardia (defined as a pulse rate ≤ 45 bpm) in the Combination group was higher than that in the PF group (37.9 % vs. 10.3 %, P  = 0.029). CONCLUSIONS: This study suggests that gastroenterologist-directed sedation using a combination of PF and DEX during gastric ESD can enhance the satisfaction levels of endoscopists by providing stable sedation with an acceptable safety profile.

Continued Use of a Single Antiplatelet Agent Does Not Increase the Risk of Delayed Bleeding After Colorectal Endoscopic Submucosal Dissection.

BACKGROUND: With the aging of the population and rising incidence of thromboembolic events, the usage of antiplatelet agents is also increasing. There are few reports yet on the management of antiplatelet agents for patients undergoing colorectal endoscopic submucosal dissection (ESD). AIMS: The aim of this study is to evaluate whether continued administration of antiplatelet agents is associated with an increased rate of delayed bleeding after colorectal ESD. METHODS: A total of 1022 colorectal neoplasms in 927 patients were dissected at Yokohama City University Hospital and its three affiliate hospitals between July 2012 and June 2017. We included the data of 919 lesions in the final analysis. The lesions were divided into three groups: the no-antiplatelet group (783 neoplasms), the withdrawal group (110 neoplasms), and the continuation group (26 neoplasms). RESULTS: Among the 919 lesions, bleeding events occurred in a total of 31 (3.37%). The rate of bleeding after ESD was 3.3% (26/783), 4.5% (5/110), and 0% (0/26), respectively. There were no significant differences in the rate of bleeding after ESD among the three groups (the withdrawal group vs. the no-antiplatelet group, the continuation group vs. the no-antiplatelet group, and the withdrawal group vs. the continuation group). CONCLUSIONS: Continued administration of antiplatelet agents is not associated with any increase in the risk of delayed bleeding after colorectal ESD. Prospective, randomized studies are necessary to determine whether treatment with antiplatelet agents must be interrupted prior to colorectal ESD in patients who are at a high risk of thromboembolic events.

The α-glucosidase inhibitor voglibose stimulates delayed gastric emptying in healthy subjects: a crossover study with a 13C breath test.

The gastrointestinal effects of α-glucosidase inhibitors have not been sufficiently investigated. The aim of this study was to determine whether a single dose of pre-prandial voglibose might affect the rate of gastric emptying, determined using the 13C breath test. Ten healthy male volunteers participated in this randomized, two-way crossover study. The subjects fasted overnight and received 0.2 mg voglibose or a placebo 2 h before a test meal. They were then served a liquid test meal consisting of 200 kcal per 200 ml that contained 100 mg 13C-acetate. Breath samples were collected under both conditions until 150 min after the meal. A comparison of the control and voglibose conditions revealed that for gastric emptying rates (with values expressed as median: range), T1/2 [(87.9: 78.0-104.9 min) vs (88.4: 74.3-106.3 min), p = 1], Tlag [(47.1: 39.6-60.1 min) vs (45.4: 31.2-63.3 min), p = 0.432], ß [(1.89: 1.68-2.18) vs (1.90: 1.35-2.15), p = 0.846] and κ [(0.81: 0.71-0.98) vs (0.81: 0.50-0.94), p = 0.922] did not significantly differ between conditions. A significant difference between the control and voglibose conditions was found for the GEC [(4.28: 4.09-4.44) vs (4.06: 3.69-4.50), p = 0.0138]. In conclusion, this study demonstrated that the ingestion of oral voglibose led to delayed gastric emptying of a liquid meal.

Can magnifying endoscopy with narrow-band imaging discriminate between carcinomas and low grade adenomas in gastric superficial elevated lesions?

Background and study aims: The aim of this study was to investigate the capability of magnifying endoscopy with narrow-band imaging (ME-NBI) to discriminate between early carcinomas (EC) and low grade adenomas (LGA) in gastric superficial elevated epithelial neoplasias. Patients and methods: We investigated 100 consecutive cases of gastric superficial elevated epithelial neoplasias that were removed using endoscopic submucosal dissection. The pathological diagnostic criteria were based on the revised Vienna classification; category 4 (mucosal high grade neoplasia) and category 5 (submucosal invasion by carcinoma) lesions were diagnosed as EC, whereas category 3 (mucosal low grade neoplasia) lesions were diagnosed as LGA. The associations between the postoperative pathological diagnoses and the ME-NBI findings were analyzed, and included the shape, specification, and area of irregularity in the microvascular architecture (MV) and the microsurface structure (MS). Results: Seventy-nine EC and 21 LGA cases diagnosed postoperatively were evaluated retrospectively. The lesion size (median; range (mm)) was significantly larger in the EC group (14; 2 - 95) compared to the LGA group (5; 2 - 16) (P < 0.001). Wavy forms in the MV shapes (P = 0.031), extension in the MV specifications (P = 0.035), and area with MV irregularity (P = 0.001) were found to be statistically significant predictive findings for EC. Villous forms in the MS shapes (P = 0.026), enlargement in the MS specifications (P = 0.044), and area with MS irregularity (P = 0.021) were also found to be statistically significant predictive findings for EC. The rates of preoperative sensitivity, specificity, and diagnostic accuracy of ME-NBI for discriminating EC were 86.1 %, 38.9 %, and 75 %, respectively. Conclusions: The present study suggests that ME-NBI is useful for the differential diagnosis of EC and LGA in gastric superficial elevated epithelial neoplasias. STUDY REGISTRATION: UMIN000012925.

Evaluation of endoscopic findings for discriminating between early carcinomas and low-grade adenomas in superficial elevated gastric lesions.

BACKGROUND/AIMS: This study aimed to determine the useful endoscopic findings in a differential diagnosis between early carcinomas (EC) and low-grade adenomas (LGA) in superficial elevated gastric epithelial neoplasia during conventional endoscopy with white-light imaging (C-WLI). MATERIALS AND METHODS: We investigated 270 consecutive cases of superficial elevated gastric epithelial neoplasias, which were removed by endoscopic submucosal dissection. The pathological diagnostic criteria were based on the revised Vienna classification: category 4 (mucosal high-grade neoplasia) or 5 (submucosal invasion by carcinoma) lesions were diagnosed as EC, while category 3 (mucosal low-grade neoplasia) lesions were diagnosed as LGA. The association between the postoperative pathological diagnoses (EC or LGA) and the following endoscopic findings: localized site, lesion size, color (reddish or whitish), shape (smooth, petal, or irregular), and presences of depression, erosion, ulceration, or nodularity on the surface, were evaluated. RESULTS: Of 270 epithelial neoplasias, 222 (58 LGA and 164 EC) were retrospectively evaluated. Multiple logistic regression analysis revealed that the lesion size [odds ratio (OR), 1.216; p<0.001) and reddish color (OR, 5.274; p<0.001) were independent findings for EC. CONCLUSION: The lesion size and reddish color were useful optical findings for discriminating between EC and LGA.

Feasibility of deep sedation with a combination of propofol and dexmedetomidine hydrochloride for esophageal endoscopic submucosal dissection.

BACKGROUND AND AIM: The aim of the present study was to evaluate the efficacy and safety of sedation with a combination of propofol (PF) and dexmedetomidine (DEX) compared with sedation with benzodiazepines in esophageal endoscopic submucosal dissection (ESD). METHODS: We retrospectively reviewed clinical data for 40 consecutive patients who had undergone esophageal ESD at the Yokohama City University Hospital between July 2012 and August 2014. Of these patients, 20 were sedated with benzodiazepines (conventional group) and another 20 patients were sedated with a combination of PF and DEX (combination group). Parameters for efficacy and safety of sedation were evaluated by comparisons between the two groups. RESULTS: Median procedural times in the combination group were shorter than those in the conventional group (61 min vs. 89 min, P = 0.03), and the percentage of patients who showed restlessness in the combination group was significantly lower than that in the conventional group (25% vs. 65%, P = 0.025). Incidences of hypotension and bradycardia in the combination group were higher than those in the conventional group (60% vs. 15%, P = 0.008, and 60% vs. 15%, P = 0.008, respectively). CONCLUSION: This retrospective study suggests that a combination of PF and DEX may provide stable deep sedation with less body movement than benzodiazepines during esophageal ESD.

[A case of HER2-positive gastric cancer successfully treated with trastuzumab plus capecitabine plus cisplatin chemotherapy as third-line treatment].

A 67-year-old woman was diagnosed as having advanced gastric cancer(poorly differentiated adenocarcinoma)with multiple liver metastases. She had received combined S-1 plus cisplatin chemotherapy as first-line treatment and weekly paclitaxel chemotherapy as second-line treatment, however, both had eventually proved ineffective. Because the gastric cancer was HER2-positive, she was treated with trastuzumab plus capecitabine plus cisplatin(XP)chemotherapy as third-line treatment. The primary lesion and liver metastatic lesions were confirmed to show remarkable regression. The ToGA trial revealed increased efficacy of trastuzumab in first-line treatment of cancers showing high expression levels of the HER2- protein. This case suggested the increased efficacy of trastuzumab in third-line treatment. Neutropenia and hand foot syndrome of grade 2 were all reported adverse events. She could receive trastuzumab plus XP chemotherapy safely by dose reduction or dormancy temporarily of capecitabine.