Factors predictive of inaccurate determination of horizontal extent of intestinal-type early gastric cancers during endoscopic submucosal dissection: a retrospective analysis.

BACKGROUND: Certain tumor characteristics may pose challenges when endoscopically determining the horizontal extent of early gastric cancers (EGC). In the present study, clinicopathological features related to inaccurate endoscopic evaluation of horizontal extent of intestinal-type EGC were analyzed. PATIENTS AND METHODS: We analyzed 431 lesions with intestinal-type EGC treated by endoscopic submucosal dissection (ESD) at our hospital. We focused on whether pretreatment demarcation was accurate by comparing positional relationships between marking dots and tumor edges in resected specimens, and factors related to inaccurate evaluation were analyzed. Gender, age, tumor size, location, circumference, depth, ulceration, macroscopic type, presence of a flat (0-IIb) component, predominant histological type, mixture of diffuse-type adenocarcinoma, mixed histology, and use of magnification endoscopy with narrow band imaging were analyzed. Reasons for inaccurate evaluation were also investigated by re-examining endoscopic images and prepared histological slides. RESULTS: Rate of inaccurate evaluation of horizontal extent was 7.4% (32/431 lesions). Multivariate analysis revealed the following significant independent variables contributing to inaccurate endoscopic evaluation: presence of a flat component, large size, and predominant histological findings of moderately differentiated adenocarcinoma. Re-examination of prepared histological slides of inaccurately evaluated cases revealed a marginal flat spreading area in 28 of the 32 lesions (87.5%). In 14 of the 32 lesions (43.8%), tumor margins were composed of moderately differentiated adenocarcinoma. CONCLUSIONS: For lesions with a flat component, large lesions, and moderately differentiated adenocarcinoma, determination of the horizontal extent can be challenging in EGC indicated for ESD, even with the best available endoscopic tools.

Lifestyle factors affecting gastroesophageal reflux disease symptoms: a cross-sectional study of healthy 19864 adults using FSSG scores.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a very common disorder worldwide, comprised of reflux esophagitis (RE) and non-erosive reflux disease (NERD). As more than half of GERD patients are classified into the NERD group, precise evaluation of bothersome epigastric symptoms is essential. Nevertheless, compared with many reports targeting endoscopic reflux esophagitis, large-scale studies focusing on GERD symptoms have been very scarce. METHODS: To elucidate lifestyle factors affecting GERD symptoms, 19,864 healthy adults in Japan were analyzed. Sub-analyses of 371 proton pump inhibitor (PPI) users and 539 histamine H2-receptor antagonist (H2RA) users were also performed. Using the FSSG (Frequency Scale for the Symptoms of GERD) score as a response variable, 25 lifestyle-related factors were univariately evaluated by Student's t-test or Pearson's correlation coefficient, and were further analyzed with multiple linear regression modelling. RESULTS: Average FSSG scores were 4.8 ± 5.2 for total subjects, 9.0 ± 7.3 for PPI users, and 8.2 ± 6.6 for H2RA users. Among the total population, positively correlated factors and standardized coefficients (ß) for FSSG scores are inadequate sleep (ß = 0.158), digestive drug users (ß = 0.0972 for PPI, ß = 0.0903 for H2RA, and ß = 0.104 for others), increased body weight in adulthood (ß = 0.081), dinner just before bedtime (ß = 0.061), the habit of midnight snack (ß = 0.055), lower body mass index (ß = 0.054), NSAID users (ß = 0.051), female gender (ß = 0.048), lack of breakfast (ß = 0.045), lack of physical exercise (ß = 0.035), younger age (ß = 0.033), antihyperglycemic agents non-users (ß = 0.026), the habit of quick eating (ß = 0.025), alcohol drinking (ß = 0.025), history of gastrectomy (ß = 0.024), history of cardiovascular disease (ß = 0.020), and smoking (ß = 0.018). Positively correlated factors for PPI users are female gender (ß = 0.198), inadequate sleep (ß = 0.150), lack of breakfast (ß = 0.146), antihypertensive agent non-users (ß = 0.134), and dinner just before bedtime (ß = 0.129), whereas those for H2RA users are inadequate sleep (ß = 0.248), habit of midnight snack (ß = 0.160), anticoagulants non-users (ß = 0.106), and antihypertensive agents non-users (ß = 0.095). CONCLUSIONS: Among many lifestyle-related factors correlated with GERD symptoms, poor quality of sleep and irregular dietary habits are strong risk factors for high FSSG scores. At present, usual dose of PPI or H2RA in Japan cannot fully relieve GERD symptoms.

Endoscopic mucosal resection with a ligation device or endoscopic submucosal dissection for rectal carcinoid tumors: an analysis of 24 consecutive cases.

AIMS: Endoscopic submucosal dissection (ESD) has several advantages over conventional endoscopic mucosal resection, including a higher en bloc resection rate and more accurate pathological estimation. However, ESD is a complex procedure that requires advanced endoscopic skills. The aim of our study is to evaluate the efficacy of endoscopic mucosal resection with a ligation device (EMR-L) compared to ESD for rectal carcinoid tumors. METHODS: Between September 2003 and April 2011, 24 rectal carcinoid tumors in 24 patients treated by ESD or EMR-L were retrospectively analyzed. The indications for endoscopic treatment were node-negative rectal carcinoid tumors. We compared the therapeutic outcomes of the ESD group (n = 13) and the EMR-L group (n = 11). RESULTS: Both groups had similar mean tumor sizes (ESD: 5.5 ± 2.1 mm; EMR-L: 4.4 ± 2.2 mm). The rates of en bloc and complete resection were, respectively, 100% and 92.3% for ESD, and 100% and 100% for EMR-L. Perforations did not occur in either group. Postoperative bleeding occurred in one EMR-L case, and it was endoscopically managed. However, there were no differences in therapeutic outcomes between the two groups. The mean procedure time was longer in the ESD group (28.8 ± 16.2 min) than in the EMR-L group (17.4 ± 4.4 min), without a significant difference. The mean hospitalization period was significantly shorter in the EMR-L group (1.8 ± 3.1 day) than in the ESD group (6.2 ± 2.1 day), and eight EMR-L cases were treated in an outpatient setting. CONCLUSIONS: EMR-L is a simple and effective procedure that compares favorably to ESD for small rectal carcinoid tumors.

Narrow band imaging with magnification can pick up esophageal squamous cell carcinoma more efficiently than lugol chromoendoscopy in patients after chemoradiotherapy.

Aim. Little is known about the usefulness of narrow band imaging (NBI) for surveillance of patients after chemoradiotherapy for esophageal neoplasia. Its usefulness in detecting esophageal squamous cell carcinoma (SCC) or high-grade intraepithelial neoplasia (HGIN) in these patients was retrospectively compared to Lugol chromoendoscopy. Patients and Methods. We assessed the diagnostic ability of NBI with magnification based on the biopsy specimens obtained from iodine-unstained lesions. Seventy-two iodine-unstained lesions were biopsied and consecutively enrolled for this study. The lesions were divided into NBI positive and NBI negative. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of NBI with magnification and PPV of Lugol chromoendoscopy was calculated using histological assessment as a gold standard. Results. Forty-six endoscopic examinations using NBI with magnification followed by Lugol chromoendoscopy were performed to 28 patients. The prevalence of SCC and HGIN was 21.4%. Sensitivity, specificity, PPV, NPV, and accuracy of NBI were 100.0%, 98.5%, 85.7%, 100%, and 98.6%, respectively. On the contrary, PPV of Lugol chromoendoscopy were 8.3%. Compared to Lugol chromoendoscopy, NBI with magnification showed equal sensitivity and significantly higher PPV (P < 0.0001). Conclusion. NBI with magnification would be able to pick up esophageal neoplasia more efficiently than Lugol chromoendoscopy in patients after chemoradiotherapy.

Evaluation of safety of endoscopic biopsy without cessation of antithrombotic agents in Japan.

BACKGROUND: Although guidelines in Japan recommend the cessation of antithrombotic agents before endoscopic biopsy, the safety of biopsy without the cessation of these agents has not been evaluated to date in this country. Therefore, we aimed to assess the feasibility of biopsy without cessation of antithrombotic agents in Japan. METHODS: This was a prospective single-arm study from a single institution. From May 2010 to November 2011, 112 outpatients who were receiving antithrombotic agents because of their high-risk status for a thromboembolic event (after implantation of coronary stent, after valve replacement, or a previous history of thromboembolic event or heart failure due to atrial fibrillation) were enrolled. We evaluated the rate of severe bleeding complications within 2 weeks after endoscopy and the endoscopic bleeding time (EBT) after biopsy in patients who underwent biopsy for endoscopic findings requiring pathology assessment. RESULTS: Among the 112 participants, 101 biopsies were performed for 48 and 12 outpatients who had had esophagogastroduodenoscopy and colonoscopy, respectively. All the biopsies provided enough specimens to evaluate pathologically. Hemostasis after biopsy was confirmed for all biopsies during endoscopic observation. No patients complained of any bleeding symptoms in the 2-week observation period after biopsy (0/101; 95% confidence interval [CI] 0-3.6%). Concerning the EBT (median 2.2 ± 1.8 min, range 0.5-9 min), there were no significant differences between patients receiving single antithrombotic agents and those receiving multiple agents (2.4 ± 1.4 vs. 2.1 ± 2.1 min), nor were there any significant differences between patients not receiving and receiving warfarin (2.3 ± 1.8 vs. 2.2 ± 1.8 min). CONCLUSION: Biopsy without cessation of antithrombotic agents, as recommended in Western guidelines, can also be acceptable for Japanese people if performed carefully.