A Retrospective Analysis of Risk Factors for Mortality during Hemodialysis at a General Hospital That Treats Comprehensive Diseases.

Objective We analyzed adverse events retrospectively during a three-year follow-up of patients undergoing hemodialysis at the dialysis center of our general hospital that can treat comprehensive diseases and conducted an exploratory study focusing on the risk factors that determine the prognosis of hemodialysis patients. Methods A total of 132 hemodialysis patients at our dialysis center as of June 2017 were included in the study. Data on event incidence, including death and various clinical indicators, were collected in the electronic medical record for three years until June 2020. Results Between June 2017 and June 2020, 33 of the 132 patients died. The mortality group had a lower body mass index (BMI) and a longer duration of hemodialysis already carried out with more preexisting upper gastrointestinal (GI) bleeding, infections, ischemic heart disease (IHD), and malignancy than the survival group. Furthermore, the mortality group took more warfarin, aspirin, proton pump inhibitors and less H2 blockers than the survival group. Occurrence of upper or lower GI bleeding was similar between the mortality and survival groups. In a univariate analysis for mortality, the odds ratio was significantly higher for a low BMI (<18), long duration of hemodialysis, history of upper GI bleeding, and presence of IHD. Multivariable-adjusted odds ratios for mortality were significantly higher for cases with a history of upper GI bleeding and BMI <18. Conclusion A history of upper GI bleeding and low BMI may be poor prognostic factors of hemodialysis patients. Careful management of upper GI bleeding and a low BMI are required during the initiation of hemodialysis.

Utility and safety of the self-expandable metallic colonic stent in Japanese patients who received systemic chemotherapy or palliative treatment for obstructive primary advanced colorectal cancer: A retrospective single-center medical chart evaluation.

Background and Aim: The present study aimed to compare the utility and safety of the colonic self-expandable metallic stent between patients with obstructive primary colorectal cancer who underwent chemotherapy or palliative treatment care and patients bridging for surgery. Methods: The cases of 71 patients with colonic obstructive stenosis and in-dwelling stents who were hospitalized between May 2012 and April 2020 at Karatsu Red Cross Hospital were retrospectively analyzed. The patients were classified into three groups: bridging for curative surgery (group I), receiving systemic chemotherapy (group II-A), and receiving only palliative treatment (group II-B). Technical and clinical success rates and complication rates after stenting were evaluated. Results: No significant differences were observed in the technical (procedure) success rates (group I: 100%; group II, 97.6% [II-A: 100%; II-B: 95.8%]). The total clinical success rate was 85.9% (61/71) and did not vary significantly among the groups (group I: 82.8%; group II 88.0% [II-A: 83.3%; II-B: 91.6%]). No significant differences were observed in the early complication rates between groups I and II and in the late complication rates between groups II-A and II-B. Nutrition status, general condition, tumor staging, and 1-year survival were poorer in group II than in group I. Conclusion: The findings show that colonic stenting for malignant obstruction was performed successfully and safely both in patients who received systemic chemotherapy or palliative therapy and in patients bridging for curative surgery, regardless of risk status for malnutrition, poor general condition, cancer stage progression, and short survival.

Lifestyle- and comorbidity-related factors for the prescription of proton pump inhibitors after Helicobacter pylori eradication in Japan.

BACKGROUND AND AIM: The aim of the present study was to examine the lifestyle- and comorbidity-related determinant factors of the prescription of proton pump inhibitors (PPIs) for patients in whom Helicobacter pylori has been eradicated, and to evaluate the relationship between PPI prescription and the severity of endoscopic esophagitis. METHODS: This retrospective study included patients who underwent H. pylori eradication from May 2012 to September 2016 at Saiseikai Karatsu Hospital. All patients received upper gastrointestinal endoscopy before H. pylori eradication. Patients with open peptic ulcers and/or malignant diseases were excluded, and a final total of 389 patients were evaluated. Medical records were reviewed to determine the prescription of PPIs after H. pylori eradication, lifestyle-related factors, and comorbidities. Lifestyle-related factors were confirmed by a questionnaire. RESULTS: PPIs were administered to 124 of 389 patients (31.9%). The only lifestyle-related risk factor for the prescription of PPIs after H. pylori eradication was older age (P < 0.01). Hypertension increased the prescription of PPIs (P = 0.034). The prescription of PPIs was not influenced by the presence of grade A esophagitis, whereas the PPI prescription rate was significantly increased in patients with grades B/C/D endoscopic esophagitis (P < 0.01). The grade of chronic gastritis before H. pylori eradication had no effect on the prescription of PPIs. CONCLUSION: The lifestyle- and comorbidity-related risk factors for the prescription of PPIs after H. pylori eradication were older age and hypertension, while mild endoscopic esophagitis had no influence on PPI prescription.

Self-study of the non-extension sign in an e-learning program improves diagnostic accuracy of invasion depth of early gastric cancer.

Background and study aims We developed an e-learning program for endoscopic diagnosis of invasion depth of early gastric cancer (EGC) using a simple diagnostic criterion called non-extension sign, and the contribution of self-study quizzes to improvement of diagnostic accuracy was evaluated. Methods We conducted a prospective randomized controlled study that recruited endoscopists throughout Japan. After completing a pretest, the participants watched video lectures and undertook post-test 1. The participants were then randomly allocated to either the self-study or non-self-study group, and participants in the first group completed the self-study program that comprised 100-case quizzes. Finally, participants in both groups undertook post-test 2. The primary endpoint was the difference in post-test 2 scores between the groups. The perfect score for the tests was set as 100 points. Results A total of 423 endoscopists completed the pretest and were enrolled. Post-test 1 was completed by 415 endoscopists and 208 were allocated to the self-study group and 207 to the non-self-study group. Two hundred and four in the self-study group and 205 in the non-self-study group were included in the analysis. Video lectures improved the mean score of post-test 1 from 72 to 77 points. Participants who completed the self-study quizzes showed significantly better post-test 2 scores compared with the non-self-study group (80 vs. 76 points, respectively, P  < 0.0001). Conclusions Our e-learning program showed that self-study quizzes consolidated knowledge of the non-extension sign and improved diagnostic ability of endoscopists for invasion depth of EGC.

Correlation of Barrett's esophagus with colorectal polyps in Japanese patients: A retrospective chart review.

BACKGROUND AND AIM: Barrett's esophagus and colorectal polyps have several overlapping risk factors. Whereas several reports in Western countries have indicated a close relationship between Barrett's esophagus and colorectal polyps, the relationship between these two diseases remains unclear in Japan. This study was performed to determine whether the prevalence of Barrett's esophagus is related to that of colorectal polyps in Japanese patients. METHODS: The present retrospective chart review included 1582 Japanese patients who underwent both total colonoscopy and esophagogastroduodenoscopy from January 2010 to December 2016. The data on colorectal polyps and Barrett's esophagus were obtained from the endoscopic findings. The medical record of each patient was checked for age, sex, body mass index, smoking, alcohol drinking, use of acid suppression agents, and comorbidities including a history of diabetes, ischemic heart disease, gastroesophageal reflux disease, hiatal hernia, and Helicobacter pylori infection. RESULTS: Colorectal polyps were detected in 789 of the 1582 patients (49.9%). Barrett's esophagus was detected in 233 patients (14.7%), and most cases of Barrett's esophagus (n = 229) were classified as short-segment Barrett's esophagus. Colorectal polyps were more frequent in patients with than without Barrett's esophagus (odds ratio, 1.79; 95% confidence interval, 1.31-2.46; P < 0.001). In addition to Barrett's esophagus, the data indicated that old age, male sex, obesity, smoking, alcohol drinking, diabetes mellitus, and ischemic heart disease were independent risk factors for colorectal polyps. CONCLUSIONS: The present study revealed the correlation between the prevalence of Barrett's esophagus and colorectal polyps in Japanese patients.

Lower Rebleeding Rate after Endoscopic Band Ligation than Endoscopic Clipping of the Same Colonic Diverticular Hemorrhagic Lesion: A Historical Multicenter Trial in Saga, Japan.

Objective This historical control study was performed to evaluate i) the rebleeding rate of bleeding colon diverticula treated with endoscopic band ligation (EBL) versus endoscopic clipping (EC) and ii) risk factors for rebleeding of diverticula initially treated by endoscopic hemostasis. Methods From January 2010 to December 2012, 68 patients were treated with EC, and from January 2013 to August 2016, 67 patients were treated with EBL. All patients in each group were followed up for one year to check for rebleeding. Results The rebleeding rate was lower in the EBL group (7 of 67, 10%) than in the EC group (21 of 68, 31%; p<0.01). This difference was mainly due to the lower rebleeding rate from the same hemorrhagic diverticulum initially treated by hemostasis (EBL: 4 of 67, 6%; EC: 15 of 68, 22%; p<0.01). The time span until rebleeding in the EBL group was ≤1 week. A multivariate analysis indicated that bleeding from the diverticula on the right side of the colon was a high-risk factor for rebleeding from the diverticula (odds ratio, 4.48; 95% confidence interval, 1.22-16.46; p=0.02). Conclusion The low rebleeding rate in the EBL group was attributed to the low degree of rebleeding from the same diverticulum, indicating that EBL was superior to EC in preventing rebleeding of an initially treated diverticulum.

Is the eCura system useful for selecting patients who require radical surgery after noncurative endoscopic submucosal dissection for early gastric cancer? A comparative study.

BACKGROUND: We have established a risk-scoring system, termed the "eCura system," for the risk stratification of lymph node metastasis in patients who have received noncurative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We aimed to clarify whether this system contributes to the selection of patients requiring radical surgery after ESD. METHODS: Between 2000 and 2011, 1,969 patients with noncurative ESD for EGC were included in this multicenter study. Depending on the treatment strategy after ESD, we had patients with no additional treatment (n = 905) and those with radical surgery after ESD (n = 1,064). After the application of the eCura system to these patients, cancer recurrence and cancer-specific mortality in each risk category of the system were compared between the two patient groups. RESULTS: Multivariate Cox analysis revealed that in the high-risk category, cancer recurrence was significantly higher (hazard ratio = 3.13, p = 0.024) and cancer-specific mortality tended to be higher (hazard ratio = 2.66, p = 0.063) in patients with no additional treatment than in those with radical surgery after ESD, whereas no significant differences were observed in the intermediate-risk and low-risk categories. In addition, cancer-specific survival in the low-risk category was high in both patient groups (99.6 and 99.7%). A limitation of this study is that it included a small number of cases with undifferentiated-type EGC (292 cases). CONCLUSIONS: The eCura system is a useful aid for selecting the appropriate treatment strategy after noncurative ESD for EGC. However, caution is needed when applying this system to patients with undifferentiated-type EGC.

Survival Benefit of Additional Surgery After Non-curative Endoscopic Submucosal Dissection for Early Gastric Cancer: A Propensity Score Matching Analysis.

BACKGROUND AND PURPOSE: Previous studies comparing survival outcomes between patients who did and did not undergo additional surgery after non-curative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) were limited in that the baseline characteristics differed significantly between the groups. We aimed to address this limitation and compared survival outcomes between these two groups using propensity score matching analysis. METHODS: The study enrolled 1969 consecutive patients who underwent non-curative ESD for EGC between 2000 and 2011 at any of 19 institutions across Japan. Using propensity score matching analysis, patients who underwent additional surgery (n = 1064) were compared with patients who did not (n = 905). Overall survival (OS) and disease-specific survival (DSS) after ESD were compared between both groups. RESULTS: Propensity score matching analysis yielded 553 matched pairs and well-balanced baseline characteristics between the two groups. The 5-year OS rates were 91.0% in the additional surgery group and 75.5% in the no additional surgery group, and the 5-year DSS rates were 99.0 and 96.8%, respectively. OS and DSS in the additional surgery group were significantly higher than in the no additional surgery group (OS, p < 0.001; DSS, p = 0.013). In Cox proportional hazard analysis, additional surgery significantly reduced gastric cancer-related death after non-curative ESD for EGC (hazard ratio 0.33, 95% confidence interval 0.12-0.79, p = 0.012). CONCLUSIONS: Our findings suggest that additional surgery reduces mortality after non-curative ESD for EGC. We recommend additional surgery for patients after non-curative ESD for EGC.

A Scoring System to Stratify Curability after Endoscopic Submucosal Dissection for Early Gastric Cancer: "eCura system".

OBJECTIVES: Although radical surgery is recommended for patients not meeting the curative criteria for endoscopic submucosal dissection (ESD) of early gastric cancer (EGC) because of the potential risk of lymph node metastasis (LNM), this recommendation may be overestimated and excessive. We aimed to establish a simple scoring system for decision making after ESD. METHODS: This multicenter retrospective study consisted of two stages. First, the risk-scoring system for LNM was developed using multivariate logistic regression analysis in 1,101 patients who underwent radical surgery after having failed to meet the curative criteria for ESD of EGC. Next, the system was internally validated by survival analysis in another 905 patients who also did not meet the criteria and did not receive additional treatment after ESD. RESULTS: In the development stage, based on accordant regression coefficients, five risk factors for LNM were weighted with point values: three points for lymphatic invasion and 1 point each for tumor size >30 mm, positive vertical margin, venous invasion, and submucosal invasion ≥500 µm. Then, the patients were categorized into three LNM risk groups: low (0-1 point: 2.5% risk), intermediate (2-4 points: 6.7%), and high (5-7 points: 22.7%). In the validation stage, cancer-specific survival differed significantly among these groups (99.6, 96.0, and 90.1%, respectively, at 5 years; P<0.001). The C statistic of the system for cancer-specific mortality was 0.78. CONCLUSIONS: This scoring system predicted cancer-specific survival in patients who did not meet the curative criteria after ESD for EGC. ESD without additional treatment may be an acceptable option for patients at low risk.

The adenoma miss rate of blue-laser imaging vs. white-light imaging during colonoscopy: a randomized tandem trial.

Background and study aims The aim of the present study was to determine whether blue-laser imaging (BLI) reduced the miss rate of colon adenomatous lesions compared with conventional white-light imaging (WLI). Patients and methods This was a prospective randomized study of patients undergoing screening and/or surveillance colonoscopy at Saga Medical School, Japan. A total of 127 patients were randomized to tandem colonoscopy with BLI followed by WLI (BLI-WLI group) or WLI followed by WLI (WLI-WLI group). The main outcome measure was the adenoma miss rate. Results The proportion of patients with adenomatous lesions was 62.5 % (40 /64) in the BLI-WLI group and 63.5 % (40 /63) in the WLI-WLI group. The total number of adenomatous lesions detected in the first inspection of the BLI-WLI and WLI-WLI groups was 179 and 108, respectively, compared with 182 and 120 in the second inspection, respectively. The miss rate in the BLI-WLI group was (1.6 %), which was significantly less than that in the WLI-WLI group (10.0 %, P = 0.001). Conclusions Colonoscopy using BLI resulted in a lower colon adenoma miss rate than WLI.Trial registration UMIN 000015677.

Cronkhite-Canada Syndrome Complicated by Triple Primary Cancers.

We herein report a case of Cronkhite-Canada syndrome (CCS) complicated with triple primary cancers. The patient was diagnosed with CCS at 65 years of age. At 76 years of age, one of his colon polyps was diagnosed as adenocarcinoma. At 81 years of age, gastric carcinoma was detected. Weight loss and fatigue appeared one month before he visited our hospital. An examination revealed dilatation of the intrahepatic bile duct. Cholangiocarcinoma was diagnosed as a result of bile duct cytology. Patients with CCS should be monitored carefully for carcinoma of systemic organs as well as the gastrointestinal tract.

Effect of additional surgery after noncurative endoscopic submucosal dissection for early gastric cancer.

BACKGROUND AND STUDY AIMS: Endoscopic submucosal dissection (ESD) is a standard treatment for early gastric cancer (EGC) without lymph node metastasis. However, some patients undergo noncurative ESD. The aim of the present study was to assess the long-term clinical outcomes of noncurative ESD with or without additional surgery. PATIENTS AND METHODS: We investigated the chart data from all patients who had undergone ESD for EGC at Saga Medical School Hospital and Saga Prefectural Medical Centre Koseikan between 2001 and 2012. A total of 957 cases (1047 lesions) of EGC underwent ESD, and 99 had noncurative ESD. In total, 20 cases were excluded because their follow-up period was < 3 years. We divided the patients into observation and additional surgery groups, and we compared the survival rate and related factors between the groups. RESULTS: After noncurative ESD, 28 /79 patients (35.4 %) underwent additional surgery and 51/79 (64.6 %) were followed up without surgery. The average age of patients in the observation group was higher than that of the additional surgery group (75.9 vs. 71.6 years; P = 0.03). The incidence of hypertension was significantly higher in the observation group compared with the additional surgery group (51.0 vs. 25.9 %; P = 0.03). The overall survival rate of the additional surgery group was longer than that of the observation group. However, only one patient died from gastric cancer in the observation group. The disease-specific survival rate did not differ significantly between the groups. CONCLUSIONS: It might be acceptable to follow up without additional surgery for some patients with comorbidity and who were elderly after noncurative ESD for EGC.

Perforation and postoperative bleeding of endoscopic submucosal dissection in gastric tumors: analysis of 1190 lesions in low- and high-volume centers in Saga, Japan.

BACKGROUND: This retrospective study aimed to determine risk factors associated with serious complications of endoscopic submucosal dissection of gastric tumors in multicenters compared between high- and low-volume centers. METHODS: Between 2001 and 2010, gastric endoscopic submucosal dissection was performed in 1190 lesions of 1082 patients in five hospitals in Saga, three high-volume and two low-volume centers. Risk factors for serious complications were evaluated. Patients' background characteristics were evaluated, including anticoagulants use and underlying diseases. RESULTS: Postoperative bleeding was detected in 75 patients (6.9%), and perforation was detected in 40 patients (3.7%). Most postoperative bleeding and perforation cases were recovered with endoscopic procedures, although one case of each complication was treated by emergency surgery. Multivariate analysis indicated that risk factors for perforation were tumor location, massive submucusal invasion, endoscopists' experience of 100-149 cases and hypertension, and that risk factors for postoperative bleeding were tumor location, resected tumor size, and scar lesion. The serious complications were not different between high- and low-volume centers. CONCLUSIONS: The present study indicated that risk factors for perforation during endoscopic submucosal dissection were tumor, endoscopist and patient related, although risk factors for postoperative bleeding were tumor related. There was no difference in complications between high- and low-volume centers.

Two years' intensive training in endoscopic diagnosis facilitates detection of early gastric cancer.

OBJECTIVE: Early detection of gastric cancer by screening endoscopy facilitates endoscopic treatment in place of open surgery. The aim of this study was to evaluate whether 2 years intensive training improved the detection of gastric cancer by screening endoscopy. METHODS: An endoscopist who had trained for 6 years as a general physician, performed screening endoscopy at Imari Arita Kyoritsu Hospital before (group I) and after (group II) intensive training in the diagnosis of early gastric cancer in consecutive patients. RESULTS: Background characteristics, including age (61.6 vs. 62.2 years) and sex, did not differ between the groups. Before training, 10 gastric neoplasms were detected in 937 patients in group I: four early gastric cancers, one gastric adenoma, and five advanced gastric cancer. After training, 36 gastric neoplasms were detected in 937 patients in group II: 18 early gastric cancers, 11 gastric adenoma, five advanced gastric cancer, and one each of gastric carcinoid and malignant lymphoma. The detection rate for early gastric cancer was significantly improved by training [group I: 4/937 (0.4%) vs. group II: 18/937 (1.9%)], although the detection rate for advanced gastric cancer did not differ before and after training. The proportion of early gastric cancer + adenoma to advanced cancer was higher in group II (5/5 vs. 29/5 in group I). CONCLUSION: Intensive training in upper gastrointestinal endoscopy screening dramatically improved the detection rate for early gastric cancer, although the detection rate for advanced gastric cancer was not affected.