Novel quantitative assessment indicators for efficiency and precision of endoscopic submucosal dissection in animal training models by analyzing an electrical surgical unit.

OBJECTIVES: Although endoscopic submucosal dissection (ESD) training is important, quantitative assessments have not been established. This study aimed to explore a novel quantitative assessment system by analyzing an electrical surgical unit (ESU). METHODS: This was an ex vivo study. Step one: to identify the novel efficiency indicators, 20 endoscopists performed one ESD each, and we analyzed correlations between their resection speed and electrical status. Step two: to identify the novel precision indicators, three experts and three novices performed one ESD each, and we compared the stability of the electrical status. Step three: three novices in step two performed 19 additional ESDs, and we analyzed the learning curve using novel indicators. RESULTS: Step one: the percentage of total activation time (AT) of ESU in the procedure time (ß coefficient, 0.80; P < 0.01) and AT required for submucosal dissection (ß coefficient, -0.57; P < 0.01) were significantly correlated with the resection speed. Step two: coefficient of variation of the AT per one pulse (0.16 [range, 0.13-0.17] vs. 0.26 [range, 0.20-0.41], P = 0.049) and coefficient of variation of the peak electric power per pulse during mucosal incision (0.14 [range, 0.080-0.15] vs. 0.25 [range, 0.24-0.28], P = 0.049) were significantly lower in the experts than in the novices. Regarding the learning curve, the percentage of total AT of ESU in the procedure time and AT required for submucosal dissection had a trend of improvement. CONCLUSION: Novel indicators identified by analyzing ESU enable quantitative assessment for endoscopist's skill.

Impaired activity of daily living is a risk factor for high medical cost in patients of non-variceal upper gastrointestinal bleeding.

BACKGROUND: Non-variceal upper gastrointestinal bleeding (NVUGIB) is still a common and life-threatening disease, thus it would have a big impact on medical care cost. However, little is known about risk factors for increased medical care cost in NVUGIB patients. AIM: The purpose of the study was to clarify predictor of requiring high medical care cost in NVUGIB patients. Patients who underwent endoscopic hemostasis due to NVUGIB between April 2012 and March 2015 were included in this retrospective study. We analyzed the association between patients' background including activity of daily livings (ADL) and high medical care cost using logistic regression model. Medical care cost was calculated in reference to the "Diagnosis Procedure Combination" which is diagnosis-dominant case-mix system in Japan. The cutoff value of high medical care cost was defined as its first quartile. ADL was assessed according to Katz-6 score. We defined impaired ADL patient who revealed Katz-6 score more than 1. RESULTS: A total of 128 consecutive patients were included in this study. Median medical care cost was 5323 USD (IQR 3661-8172 USD). There were 13 patients (10%) in impaired ADL group. In univariate analysis, age and impaired ADL before admission revealed significant association with high cost. Of these, impaired ADL was an only independent risk factor [odds ratio 15.3 (95% CI 2.49-183)] in multivariate analysis. CONCLUSION: Impairment in ADL before admission was an independent predictor for high medical care cost with NVUGIB patients.

Evaluation of endoscopic ultrasound image quality is necessary in endosonographic assessment of early gastric cancer invasion depth.

We evaluated whether endoscopic ultrasonography (EUS) image quality affects the accuracy of diagnosing the vertical invasion depth of early gastric cancer (EGC). A total of 75 lesions in 75 patients suspected of having EGC were enrolled. All patients underwent EUS examination. Findings of EUS were compared with histopathologic results. We evaluated the effect of the following clinicopathologic factors: location, diameter, surface pattern, concomitant ulceration, histology type, and EUS image quality score. EUS image quality was scored based on detection repeatability, appropriate probe placement, and clarity of the five gastric wall layers including the lesion. Sixty-three lesions (84%) were pathologically mucosal and 12 lesions (16%) were submucosal cancer. Overall accuracy was 82.7%. Significantly more lesions in the upper and middle portions of the stomach were incorrectly diagnosed than in the lower portion (P = 0.0019). Lesion diameter was significantly larger among incorrectly diagnosed lesions (P = 0.0257). Low-quality images were significantly more often associated with incorrectly diagnosed lesions than with correctly diagnosed lesions (P = 0.0001). Multivariate analysis revealed that EUS image quality was associated with EUS staging accuracy (odds ratio, 21.8; 95% confidence interval, 4.5-137.6). Low-quality EUS images led to an incorrect diagnosis of invasion depth of EGC, independent of tumor location or size.