Endoscopic placement of covered versus uncovered self-expandable metal stents for palliation of malignant gastric outlet obstruction.

OBJECTIVE: Stenting is an established endoscopic therapy for malignant gastric outlet obstruction (mGOO). The choice of stent (covered vs uncovered) has been examined in prior randomised studies without clear results. DESIGN: In a multicentre randomised prospective study, we compared covered (CSEMS) with uncovered self-expandable metal stents (UCSEMS) in patients with mGOO; main outcomes were stent dysfunction and patient survival, with subgroup analyses of patients with extrinsic and intrinsic tumours. RESULTS: Overall survival was poor with no difference between groups (probability at 3 months 49.7% for covered vs 48.4% for uncovered stents; log-rank for overall survival p=0.26). Within that setting of short survival, the proportion of stent dysfunction was significantly higher for uncovered stents (35.2% vs 23.4%, p=0.01) with significantly shorter time to stent dysfunction. This was mainly relevant for patients with extrinsic tumours (stent dysfunction rates for uncovered stents 35.6% vs 17.5%, p<0.01). Subgrouping was also relevant with respect to tumour ingrowth (lower with covered stents for intrinsic tumours; 1.6% vs 27.7%, p<0.01) and stent migration (higher with covered stents for extrinsic tumours: 15.3% vs 2.5%, p<0.01). CONCLUSIONS: Due to poor patient survival, minor differences between covered and uncovered stents may be less relevant even if statistically significant; however, subgroup analysis would suggest to use covered stents for intrinsic and uncovered stents for extrinsic malignancies.

Risk of colorectal cancer for fecal immunochemistry test-positive, average-risk patients after a colonoscopy.

BACKGROUND AND AIM: Because the risk of colorectal cancer has not been well examined in fecal immunochemistry test (FIT)-positive patients who previously underwent colonoscopy, this study aimed to investigate this topic. METHODS: This was a single-center, observational study of prospectively collected data in Japan. FIT-positive, average-risk patients who underwent colonoscopy were divided into groups as follows: those who never underwent colonoscopy in the past (no colonoscopy group), those with a history of colonoscopy between 6 months and 5 years (0.5- to 5-year colonoscopy group), and those with a history of colonoscopy more than 5 years ago (> 5-year colonoscopy group). We investigated the prevalence of advanced neoplasia and invasive cancer among these groups using multiple logistic regression analysis. RESULTS: Detection rates of advanced neoplasia in the no colonoscopy group, 0.5- to 5-year colonoscopy group, and > 5-year colonoscopy group were 14.8% (240/1626), 3.9% (13/330), and 6.9% (17/248), respectively. Detection rates of invasive cancer in each aforementioned group were 5.7% (92/1,626), 0.3% (1/330), and 1.2% (3/248), respectively. Odds ratios of advanced neoplasia in the 0.5- to 5-year colonoscopy group and > 5-year colonoscopy were 0.23 (95% confidence interval [CI]: 0.13-0.42) and 0.40 (95% CI: 0.24-0.68), respectively, in multivariate analysis. The odds ratios of invasive cancer in each aforementioned group were 0.05 (95% CI: 0.01-0.37) and 0.19 (95% CI: 0.06-0.61), respectively. CONCLUSION: Re-screening with the FIT should not be recommended for at least 5 years for average-risk patients after colonoscopy without high-risk neoplasms, because the risks of colorectal cancer are low in such patients.

Examination time as a quality indicator of screening upper gastrointestinal endoscopy for asymptomatic examinees.

BACKGROUND AND AIM: The significance of examination time of esophagogastroduodenoscopy (EGD) for asymptomatic examinees is yet to be established. We aimed to clarify whether endoscopists who allot more examination time can detect higher numbers of neoplastic lesions among asymptomatic examinees. METHODS: We reviewed a database of consecutive examinees who underwent EGD in our hospital from April 2010 to September 2015. Staff endoscopists were classified into fast, moderate, and slow groups based on the mean examination time of EGD without a biopsy. Neoplastic lesion detection rate among these groups was compared using multiple logistic regression. RESULTS: Of the 55 786 consecutive examinees who underwent EGD, 15 763 asymptomatic examinees who were screened by staff doctors were analyzed. Mean examination time of 13 661 EGD without biopsy was 6.2 min (range, 2-18 min). When cut-off times of 5 and 7 min were used, four endoscopists were classified into the fast (mean duration, 4.4 ± 1.0 min), 12 into the moderate (6.1 ± 1.4 min), and four into the slow (7.8 ± 1.9 min) groups. Neoplastic lesion detection rates in the fast, moderate, and slow groups were 0.57% (13/2288), 0.97% (99/10 180), and 0.94% (31/3295), respectively. Compared with that in the fast group, odds ratios for the neoplastic lesion detection rate in the moderate and slow groups were 1.90 (95% confidence interval [CI], 1.06-3.40) and 1.89 (95% CI, 0.98-3.64), respectively. CONCLUSION: Endoscopists who do not allot adequate examination time may overlook neoplastic lesions in the upper gastrointestinal tract.

Clinical usefulness of a short-type, prototype single-balloon enteroscope for endoscopic retrograde cholangiopancreatography in patients with altered gastrointestinal anatomy: preliminary experiences.

BACKGROUND AND AIM: A limited number of endoscopic retrograde cholangiopancreatography (ERCP) accessories are compatible with the conventional single-balloon enteroscope (SBE) because of the latter's dimensions. The aim of the present study was to assess the utility of a prototype SBE that has a shorter working length and a wider channel than the conventional SBE. METHODS: ERCP procedures carried out between January 2012 and July 2013 using the short SBE prototype were reconstructions such as Billroth II (B-II), post-gastrectomy with Roux-en-Y (RY-G), and post-choledochojejunostomy with Roux-en-Y (RY-CJ). We retrospectively analyzed the rate of reaching the blind end of the intestine, the diagnostic success rate, the interventional success rate, and the frequency of related complications. RESULTS: Twenty-seven ERCP procedures on 18 patients analyzed comprised two B-II, 15 RY-G, and 10 RY-CJ reconstructions. With a mean procedure time of 56 min (range 40-150 min), the rate of reaching the blind end, the diagnostic success rate, and the interventional success rate were 24/27 (89%), 20/27 (74%), and 19/27 (70%), respectively. There were no major ERCP-related complications in any patient. CONCLUSIONS: The prototype short-type SBE appears safe and effective for use in ERCP, and is compatible with conventional endoscopy accessories.

A case of colonic fecal impaction caused by excessive dietary fiber intake that was endoscopically treated with intra-fecal injection of a bowel-cleansing agent.

Background and Aim: A 75-year-old man who had eaten half a head of chopped raw cabbage (approximately 600 g) daily was suffering from the left lower pain, abdominal fullness, and constipation. He was diagnosed with colonic ileus and obstructive colitis due to a fecal impaction in the sigmoid-descending junction. During colonoscopy, a tapered catheter was repeatedly inserted into the impacted feces to inject a bowel-cleansing agent. Finally, the feces were broken to be fragmented enough to path the endoscope through. After the procedure, his symptoms were immediately relieved. Relevance for Patients: Excessive dietary fiber intake can induce fecal ileus. Endoscopic treatment with intra-fecal injection of a bowel-cleansing agent is useful and worth attempting for disimpaction of feces.

[A case of advanced gastric cancer found to be remaining by gastrectomy after a clinically complete response to chemotherapy].

The patient was a 72-year-old woman diagnosed with advanced gastric cancer, hepatic portal lymph node and para-aortic lymph node metastases. After five courses of S-1/CDDP combination therapy, both the primary tumor and lymph node metastases disappeared clinically. She wished to continue chemotherapy instead of having a resection. After three more courses of S-1/CDDP therapy, gastric cancer and lymph node metastases were still completely regressed, but complications of carcinoma of the gallbladder were suspected. Gastrectomy was performed with cholecystectomy, and a histopathological examination revealed cancer cells remaining in the gastric submucosa and xanthogranulomatous cholecystitis. We consider surgical therapy for clinically completely disappearing advanced gastric cancer by chemotherapy, in addition to case report.

Palliative Radiotherapy for Bleeding from Unresectable Gastric Cancer Using Three-Dimensional Conformal Technique.

Optimal regimens using recent radiotherapy (RT) equipment for bleeding gastric cancer (GC) have not been fully investigated yet. We retrospectively reviewed the clinical data of 20 patients who received RT for bleeding GC in our institution between 2016 and 2021. Three-dimensional conformal RT was performed. The effectiveness of RT was evaluated by the mean serum hemoglobin (Hb) level and the number of transfused red blood cell (RBC) units 1 month before and after RT. The median first radiation dose was a BED of 39.9 Gy. The treatment success rate was 95% and the rebleeding rate was 10.5%. There was a significant increase in the mean Hb level (8.0 ± 1.1 vs. 9.8 ± 1.3 g/dL, p = 0.01), and a significant decrease in the mean number of transfused RBC units (6.8 ± 3.3 vs. 0.6 ± 1.5 units, p < 0.01). Severe toxicity was observed in two patients (anorexia [n = 1] and gastrointestinal [GI] perforation [n = 1]). Reirradiation was attempted in three patients (for hemostasis [n = 2] and for mass reduction [n = 1]). The retreatment success rate for rebleeding was 100%. GI perforation occurred in two patients who had received hemostatic reirradiation. Palliative RT for bleeding GC using recent technology had excellent efficacy. However, it may be associated with a risk of GI perforation.

A Rare Case of COVID-19 Pneumonia Concomitant with Bleeding from Acute Gastric Mucosal Lesions.

A 70-year-old man was diagnosed with coronavirus disease 2019 (COVID-19) pneumonia. Twenty-six days after admission, he experienced hematemesis despite improvement in his respiratory symptoms. Contrast-enhanced computed tomography revealed edematous stomach wall thickening with neither ischemic findings in the gastric wall nor obstruction of the gastric artery. Emergent esophagogastroduodenoscopy showed diffuse dark-red mucosa accompanied by multiple easy-bleeding, irregularly shaped ulcers throughout almost the whole stomach without active bleeding or visible vessels. The clinical course, including the endoscopic findings, progressed favorably with conservative treatment. COVID-19 pneumonia can present with acute gastric mucosal lesion, which may be induced by microvascular thrombosis due to COVID-19-related coagulopathy.

Endoscopic ultrasonography for pre-operative local assessment and endoscopic ultrasonography-guided marking before gastrojejunostomy for duodenal obstruction using magnetic compression anastomosis.

BACKGROUND AND AIM: A 93-year-old woman who was bedridden with severe dementia was referred to our department with a 3-day history of repeated vomiting after meals. Computed tomography revealed significant dilatation of the duodenum up to the level of the third portion, which was compressed by a large, low-density mass. Upper gastrointestinal endoscopy showed narrowing of the third portion of the duodenum with edematous mucosa covered with multiple white spots, where the endoscope was able to pass through with mild resistance. B-cell lymphoma was histopathologically suspected from biopsy specimens of the mucosa. We performed gastrojejunostomy through the magnetic compression anastomosis (MCA) technique. We prepared two neodymium magnets: Flat plate shaped (15 × 3 mm) with a small hole 3 mm in diameter; a nylon thread was passed through each hole. We then confirmed the absence of no non-target tissue, including large vessels and intestine adjacent to the anastomosis where the magnets were to be placed using endoscopic ultrasonography (EUS) from the stomach. EUS-guided marking using biopsy forceps by biting the mucosa and placing a hemoclip was performed at the anastomosis site in the stomach. The magnet was pushed and delivered to the duodeno-jejuno junction, and another magnet was delivered to the marking point in the stomach. The magnets were attracted toward each other transmurally. The magnets fell into the colon by 11 days after starting the compression, and the completion of gastrojejunostomy was confirmed. RELEVANCE FOR PATIENTS: Endoscopic gastrojejunostomy using MCA is useful as a minimally invasive alternative treatment for duodenal obstruction. EUS for the pre-operative local assessment and EUS-guided marking can ensure the safety of the MCA procedure.

Post-endoscopic retrograde cholangiopancreatography pancreatitis assessed using criteria for acute pancreatitis.

BACKGROUND AND AIM: International consensus on the definition and classification of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) has been reached. However, the diagnosis and severity of PEP are often assessed according to the diagnostic criteria and classification for acute pancreatitis (AP). This study determined the incidence, severity, and risk factors of PEP diagnosed according to the diagnostic criteria and classification for AP in a large cohort. METHODS: This prospective, multicenter, observational cohort study conducted at five high-volume centers included 1932 patients who underwent ERCP-related procedures. The incidence, severity, and risk factors for PEP were evaluated. RESULTS: PEP occurred in 142 patients (7.3%); it was mild in 117 patients (6.0%) and severe in 25 patients (1.3%). According to the Cotton criteria, PEP occurred in 87 patients (4.5%); it was mild in 54 patients (2.8%), moderate in 20 patients (1.0%), and severe in 13 patients (0.7%). In the multivariate analysis, female sex (odds ratio [OR] 2.239; 95% confidence interval [CI] 1.546-3.243), naïve papilla (OR 3.047; 95% CI 1.803-5.150), surgically-altered gastrointestinal anatomy (OR 2.538; 95% CI 1.342-4.802), procedure time after reaching the papilla (OR 1.009; 95% CI 1.001-1.017), pancreatic duct injection (OR 2.396; 95% CI 1.565-3.669), and intraductal ultrasonography (OR 1.641; 95% CI 1.024-2.629) were independent risk factors. CONCLUSION: According to the diagnostic criteria and classification for AP, the incidence of PEP was higher than that according to the Cotton criteria and the severity of PEP tended to be severe.

Significance of fecal hemoglobin concentration for predicting risk of colorectal cancer after colonoscopy.

BACKGROUND AND AIM: As the significance of the quantitative fecal immunochemical test (FIT) in patients who previously underwent a colonoscopy is unknown, this study aimed at investigating the association between fecal hemoglobin concentration and the risk of colorectal cancer (CRC). METHODS AND RESULTS: We retrospectively analyzed FIT-positive patients who underwent a colonoscopy through our opportunistic annual screening program from April 2010 to March 2017 at the Kyoto Second Red Cross Hospital. We stratified them into no colonoscopy and past colonoscopy (>5 years or ≤5 years) groups based on whether they had a history of undergoing a colonoscopy and analyzed the correlation between fecal hemoglobin concentration and advanced neoplasia or invasive cancer detection in each group. We analyzed 1248 patients with positive FIT results. There were 748 (59.9%), 198 (15.9%), and 302 (24.2%) patients in the no colonoscopy, past colonoscopy (>5 years), and past colonoscopy (≤5 years) groups, respectively. In the no colonoscopy group, the advanced neoplasia detection rate significantly increased with the fecal hemoglobin concentration (P < 0.001). However, no significant trend was observed in the past colonoscopy (both >5 years and ≤5 years) group (P = 0.982). No invasive cancer was detected in the past colonoscopy (≤5 years) group. CONCLUSION: The risk of CRC might be low even if fecal hemoglobin concentration was high, especially in those who underwent colonoscopy within 5 years.

Association between hyperechogenic pancreas and pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasms.

PURPOSE: Pancreatic ductal adenocarcinoma (PDAC) may independently occur in the pancreas separate from an intraductal papillary mucinous neoplasm (IPMN). Therefore, identifying the characteristics of patients with IPMN who will likely develop PDAC is clinically important. Although a recent study found that fatty pancreas correlated with PDAC, no reports have examined this matter in patients with IPMN. A previous study showed that fatty pancreas increased the echogenicity; hence, this study aimed to investigate the association between hyperechogenic pancreas and PDAC in patients with IPMN. METHODS: We retrospectively collected data of patients with IPMN who underwent endoscopic ultrasonography (EUS) between January 2012 and November 2018. A case-control analysis was performed between patients with IPMN concomitant with PDAC (cases) and those without PDAC (controls). We identified controls by matching age and sex with cases. The echogenicity of the pancreas was determined using EUS by comparing it with the left kidney or spleen. Echogenicity was determined using transabdominal ultrasonography by comparison with that of the liver when it was difficult to determine using EUS. RESULTS: Among 400 patients with IPMN, 23 cases and 92 controls were identified. The proportion of patients with hyperechogenic pancreas was significantly greater in cases than in controls (91.3% vs. 65.2%, P = 0.02). Multivariate analysis, including family history of pancreatic cancer, multifocal cysts, and hyperechogenic pancreas, showed that hyperechogenic pancreas was correlated with PDAC concomitant with IPMN (odds ratio = 7.07; 95% confidence interval = 1.48-33.80; P = 0.01). CONCLUSION: Our analysis demonstrated that hyperechogenic pancreas was associated with concomitant PDAC in patients with IPMN.

Feasibility of Underwater Endoscopic Mucosal Resection for Colorectal Lesions: A Single Center Study in Japan.

BACKGROUND: Underwater endoscopic mucosal resection (U-EMR) has emerged as an alternative technique for the resection of colorectal lesions. This study aimed to evaluate our initial experience using U-EMR. METHODS: This is a single-center, retrospective case series study. We analyzed the clinical outcomes of consecutive patients who underwent U-EMR in our endoscopy center, from December 2015 to February 2017. RESULTS: Our analysis included 64 lesions, contributed by 38 patients, with a mean age of 68.6 years (range, 25 to 90 years). The study sample included 33 right-sided and 25 left-sided colon lesions, and seven rectal lesions, with an average size of 16.2 mm (6 - 40 mm). Of these, 46 lesions were polypoid and 18 ones non-polypoid. Histologically, 31 lesions were low-grade adenomas, eight ones were high-grade adenomas, 11 were mucosal cancers, four were submucosal cancers, and 10 were classified as "others". En bloc resection was achieved in 52 (81%) lesions, with an en bloc resection rate of 95% for lesions < 20 mm and 55% for lesions ≥ 20 mm. Complete resection of neoplastic epithelial lesions, defined by a negative pathological margin, was achieved in 32 of 59 neoplastic epithelial lesions (54%). We identified three cases (5%) of post-procedural bleeding and one case of perforation (2%). CONCLUSIONS: U-EMR can be feasibly used for resection of colonic lesions, including lesions ≥ 20 mm, although the en bloc resection rate for these lesions was lower than for lesions < 20 mm.

Palliation of malignant upper gastrointestinal obstruction with self-expandable metal stent.

OBJECTIVE: To assess the technical success, ability to eat, complications and clinical outcomes of patients with self-expandable metal stent (SEMS) placed for malignant upper gastrointestinal (GI) obstruction. MATERIALS AND METHODS: Data was collected retrospectively on patients who underwent SEMS placement for palliation of malignant upper GI obstruction by reviewing hospital charts from June 1998 to May 2011. Main outcome measurements were technical success, gastric outlet obstruction scoring system (GOOSS) score before and after treatment, complications, and survival. RESULTS: A total of 82 patients underwent SEMS placement with malignant upper GI obstruction. The initial SEMS placement was successful in 77 patients (93.9%). The mean GOOSS score was 0.56 before stenting and 1.92 (p < 0.001) after treatment. Complications arose in 12 patients (14.6%): stent migration in 1 patient (1.2%), perforation in 1 (1.2%), and obstruction of stent due to tumor ingrowth in 10 (12.2%). The median survival time after stenting was 52 days (6-445). CONCLUSION: SEMS placement is an effective and safe treatment for palliation of malignant upper GI obstruction. It provides lasting relief in dysphagia and improves the QOL of patients.