The safety and efficacy of Ringer's solution loading with rectal diclofenac for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: The RESOLUTION-PEP study.

Objectives: We evaluated the safety and efficacy of aggressive hydration with rectal non-steroidal anti-inflammatory drugs for the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Methods: This prospective, single-arm, multicenter trial was conducted at 12 institutions between October 2020 and August 2021. We enrolled 231 patients who had intact papillae and were scheduled to undergo ERCP. All patients were administered rectal diclofenac before ERCP. They received aggressive hydration with intravenous lactated Ringer's solution in an initial bolus of 5 ml/kg at the start of ERCP, followed by 3 ml/kg/h for 8 h after the procedure. The primary outcome was the occurrence of PEP. Secondary outcomes included PEP severity, hyperamylasemia, and adverse events. Results: The mean age of the patients was 68.8 ± 13.7 years, and 81 patients (35.1%) were 75 years or older. Thirteen patients developed PEP (5.6%, 95% confidence interval 3.0%-9.4%). There were 11 cases (4.8%) of mild pancreatitis and two cases (0.9%) of severe pancreatitis. Forty-five patients (19.5%) developed hyperamylasemia and one patient developed non-severe peripheral edema. Conclusions: Aggressive hydration combined with rectal diclofenac may be a promising strategy for the prevention of PEP. Furthermore, it is safe even for older individuals.

Peripancreatic Tuberculous Lymphadenitis with Biliary Obstruction Diagnosed by Endoscopic Ultrasound-guided Fine-needle Aspiration Biopsy.

A 57-year-old man with a history of tuberculosis (TB) was found to have a pancreatic head mass, accompanied by stenosis of the common bile duct. Due to the inherent difficulty in differentiating pancreatic carcinoma from an inflammatory mass, endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) was thus performed. The pathological findings confirmed granuloma with caseous necrosis, and the results of the QuantiFERON TB2G test were positive. Accordingly, the patient was diagnosed with peripancreatic TB and thereafter was successfully treated with anti-TB therapy. Based on the findings of this case, we conclude that EUS-FNAB is a useful modality for the diagnosis of pancreatic TB.

Human Equilibrative Nucleoside Transporter 1 Expression in Endoscopic Ultrasonography-Guided Fine-Needle Aspiration Biopsy Samples Is a Strong Predictor of Clinical Response and Survival in the Patients With Pancreatic Ductal Adenocarcinoma Undergoing Gemcitabine-Based Chemoradiotherapy.

OBJECTIVES: This study aimed to clarify whether pretreatment human equilibrative nucleoside transporter (hENT1) expressions in endoscopic ultrasonography-guided fine-needle aspiration biopsy (EUS-FNAB) specimens obtained from resectable, borderline resectable, and locally advanced unresectable pancreatic ductal adenocarcinoma (PDAC) are concordant with those in the resected specimen after gemcitabine-based chemoradiotherapy (Gem-CRT) and to validate the utility of hENT1 expression using EUS-FNAB samples as a prognostic marker. METHODS: We evaluated the relationship between hENT1 expressions assessed by immunohistochemical staining and clinical outcomes in 51 of 76 patients with PDAC who were diagnosed by EUS-FNAB and received preoperative Gem-CRT. RESULTS: The concordance rate of hENT1 expressions was 89.2% (K = 0.681). Median survival time (month) in the 51 whole patients and 37 patients with resection was significantly longer in hENT1 positive than in hENT1 negative: 25.0 and 30.0 versus 9.0 and 9.0, respectively. A multivariate analysis confirmed that hENT1 expression was an independent prognostic factor in both whole patients and those with resection. Regardless of T3 and T4, hENT1-positive patients with resection had significantly better prognosis than hENT1-negative patients, whose prognosis was similar to those without resection. CONCLUSIONS: The assessment of hENT1 expression using EUS-FNAB samples before Gem-CRT provides important information on patients with PDAC who can benefit from curative-intent resection.

Usefulness of Small Intestinal Endoscopy in a Case of Adult-onset Familial Mediterranean Fever Associated with Jejunoileitis.

A 66-year-old Japanese man consulted our institution due to paroxysmal and repetitive bouts of fever and abdominal pain that had persisted for more than one week. Capsule and double-balloon endoscopy (DBE) showed petal-shaped mucosal redness with white hemming in the jejunum and ileum, and histopathology of the biopsy specimens revealed villous atrophy and cryptitis with extensive severe neutrophil infiltration. A genetic examination disclosed compound heterozygous MEFV mutations (E84K, P369S), and familial Mediterranean fever was diagnosed. Treatment with colchicine and infliximab was very effective in inducing the complete disappearance of symptoms and normalization of the endoscopic findings. To the best of our knowledge, this is the first report to describe the findings of small intestinal endoscopic images obtained using capsule and DBE.

Endoscopic findings and lesion distribution in amebic colitis.

A retrospective cohort study was conducted in 55 symptomatic patients with amebic colitis that visited at St. Luke's International Hospital and Mie University Hospital from 1994 through 2013. To diagnose amebic colitis, 40 patients underwent total colonoscopy within 1 week after hospital visiting and before receiving any treatment. The percentage of characteristic endoscopic findings of amebic colitis including discrete ulcers or erosions with white or yellow exudates were 0% in terminal ileum, 93% in cecum, 28% in ascending, 25% in transverse, 15% in descending, 20% in sigmoid colon and 45% in rectum. The rectal lesions in 55% of patients with amebic colitis were nonspecific. The trophozoite identification rate by direct smear of intestinal tract washings performed during colonoscopy was 88%. The protozoan identification rate was 70% in biopsy specimens taken from the periphery of the characteristic discrete ulcers. Total colonoscopy should be considered for the diagnosis of amebic colitis.

Second and third-look endoscopy for the prevention of post-ESD bleeding.

The efficacy of 2nd-look esophagogastroduodenoscopy (EGD) with endoscopic hemostatic therapy (EHT) for the prevention of postendoscopic submucosal dissection (ESD) clinical bleeding remains controversial. The aim of this study was to estimate post-ESD bleeding rate using 2nd and 3rd-look strategy, and to determine risk factors for clinical bleeding, and for EHT at 2nd and 3rd-look EGDs.Three hundred forty-four consecutive patients with early gastric cancer or adenoma underwent ESD from January 2006 through March 2012. Second and 3rd-look EGDs were performed on day 1 (D1) and day 7 (D7), respectively, with EHT as needed.Post-ESD clinical bleeding rate was 2.6% (95% confidence interval [CI] 1.2%-4.9%). For clinical bleeding, adjusted odds ratios (ORs) for age <65 years and antithrombotic drug uses were 4.40 (95% CI 1.07-19.93) and 7.34 (95% CI 1.80-32.48), respectively. For D1 EHT, adjusted ORs of tumor location in the lower part of the stomach and maximum tumor diameter ≥60 mm were 2.16 (95% CI 1.35-3.51) and 2.20 (95% CI 1.05-4.98), respectively. For D7 EHT, adjusted OR of D1 EHT was 4.65 (95% CI 1.56-20.0).Post-ESD clinical bleeding rate was relatively low using 2nd and 3rd-look strategy. Age <65 years and antithrombotic drug use are significant risk factors for clinical bleeding. Regarding EHT, tumor location in the lower part of the stomach and maximum diameter of resected specimen ≥60 mm are significant predictors for D1 EHT. D1 EHT in turn is a significant risk factor for D7 EHT. The efficacy of sequential strategy for preventing post-ESD bleeding is promising.

The efficacy of rebamipide add-on therapy in arthritic patients with COX-2 selective inhibitor-related gastrointestinal events: a prospective, randomized, open-label blinded-endpoint pilot study by the GLORIA study group.

OBJECTIVE: We aimed to confirm the effect of combined treatment with celecoxib and rebamipide would be more effective than celecoxib alone for prevention of upper gastrointestinal (GI) events. METHODS: Patients with rheumatoid arthritis, osteoarthritis, and low back pain were enrolled in this study. Patients were randomized to two groups: a monotherapy group (100 mg celecoxib twice daily) and a combination therapy group (add on 100 mg of rebamipide three times a day). The GI mucosal injury was evaluated by endoscopic examination before treatment and at 3 months. The primary endpoint was to evaluate the preventive effect of the combination therapy group for GI events, endoscopic upper GI ulcers and intolerable GI symptoms, compared with the monotherapy group. RESULTS: Seventy-five patients were enrolled. Sixty-five patients were analyzed (16 males, 49 females; mean age: 67 ± 13 years). The prevalence of upper GI events, five of endoscopic GI ulcers and one of intolerable GI symptoms, were 6/34 (17.6%) in the monotherapy group and 0/31 in the combination therapy group, p = 0.0252. CONCLUSIONS: The combination therapy group was more effective than the monotherapy group for prevention of upper GI events in this study. Rebamipide might be a candidate for an option to prevent COX-2 selective inhibitor-induced upper GI events.

Usefulness of endoscopic submucosal dissection for the treatment of rectal carcinoid tumors.

BACKGROUND AND AIM: Various techniques of endoscopy have been developed to treat rectal carcinoids. This retrospective study aimed to evaluate the feasibility and efficacy of endoscopic submucosal dissection for the treatment of rectal carcinoids smaller than 10 mm in diameter. PATIENTS AND METHODS: A total of 18 consecutive patients were enrolled with 20 carcinoid tumors that had the following characteristics: the diagnosis of a rectal carcinoid smaller than 10 mm, no endoscopic evidence of muscularis propria invasion, and no evidence of lymph node or distant metastasis (11 men and seven women; median age, 69 years; median tumor size, 4 mm). Tumors were resected by endoscopic submucosal dissection with a needle knife and a hook knife. After marking, a one-third to one-half circumferential mucosal incision was made, and subsequently, the submucosa under the lesion was exfoliated. After the submucosa under the tumor was exfoliated, the residual mucosa was incised and the tumor was removed. Complete resection, complication rates, and operation time were evaluated. RESULTS: Complete resection was achieved in all cases (100%) without complications. The mean operation time was 34.2 min, which was acceptable in clinical practice. CONCLUSION: Endoscopic submucosal dissection with the strategy described above is feasible and efficacious for selected patients with a rectal carcinoid smaller than 10 mm.

Magnifying endoscopy for diagnosis of residual/local recurrent gastric neoplasms after previous endoscopic treatment.

BACKGROUND: Incomplete resection of gastric neoplasms by endoscopic treatment could lead to residual/local recurrence, which may be difficult to identify. This study aimed to evaluate the usefulness of magnifying endoscopy for identifying and demarcating residual/local recurrent gastric neoplasms after endoscopic treatment. METHODS: Between December 2004 and November 2010, magnifying endoscopy was performed in 15 patients with residual/local recurrent gastric neoplasms. All patients underwent conventional magnifying endoscopy (CME) and enhanced-magnification endoscopy with acetic acid instillation (EME) after conventional endoscopy (CE). Eleven patients additionally underwent magnifying endoscopy using narrow-band imaging (NBI-ME) and a combination of narrow-band imaging and acetic acid instillation (NBI-EME). For each procedure, it was recorded whether the location and circumferential demarcation of the lesions were identified. All lesions were resected by endoscopic submucosal dissection. RESULTS: Eleven lesions were identified using CE. However, two and four additional lesions were identified using CME and EME, respectively. In 11 cases, NBI-ME and NBI-EME were performed and all lesions were identified. Three lesions, which were identified by CME, were not demarcated circumferentially. All 15 lesions were well demarcated by EME and 11 by NBI-ME and NBI-EME. Of the resected specimens, histopathology indicated that ten lesions were differentiated tubular adenocarcinomas and five lesions were adenomas. The histopathological diagnosis of the location and demarcation of all neoplasms corresponded to endoscopic findings. CONCLUSIONS: Magnifying endoscopy techniques (CME, EME, NBI-ME, and NBI-EME) may be useful for identifying and demarcating residual/local recurrent gastric neoplasms after previous endoscopic treatment.

Risk for local recurrence of early gastric cancer treated with piecemeal endoscopic mucosal resection during a 10-year follow-up period.

BACKGROUND: Endoscopic mucosal resection (EMR) is a therapy for early gastric cancer (EGC) that can be provided relatively easily and safely in any institution. Identification of the resection margin is a problem in EMR, especially in cases of piecemeal EMR. Despite the long-standing widespread use of piecemeal EMR for EGC, its limitation and long-term outcomes in clinical practice have not been fully evaluated. This study aimed to determine the risk factors of piecemeal EMR, the local recurrence rates, and the mortality rate. METHODS: A cross-sectional, retrospective cohort study was performed to investigate the risks of piecemeal EMR for patients with the diagnosis of differentiated adenocarcinoma localized to the mucosa. Local recurrence of EGC was investigated by annual follow-up esophagogastroduodenoscopy (EGD) for 10 years. EMR was performed with snare electrocautery using a two-channel scope. When a resection margin was clearly positive for cancer, additional surgery was performed soon after the initial EMR. RESULTS: For the 149 EGC patients (mean age, 68.8 ± 9.8; male, 77%) who underwent EMR between 1995 and 2001, EMR was performed en bloc in 66 cases and piecemeal in 83 cases. The comorbid conditions existing in 34 of the 149 patients included other malignancies (n = 12), heart failure (n = 5), pulmonary disease (n = 7), liver cirrhosis (n = 4), and other illness (n = 6). However, EMR was completed without complication. The mean area (length × width) of the lesions was 404 ± 289 mm(2) in the piecemeal group and 250 ± 138 mm(2) in the en bloc groups. The en bloc and piecemeal EMR groups differed significantly in terms of unclear horizontal margins but not in terms of unclear vertical margins. Multiple logistic regression suggested that the adjusted odds ratio for maximum diameters exceeding 20 mm for piecemeal EMR was 2.71 (95% confidence interval [CI], 1.30-5.64). According to Kaplan-Meier estimates, the local recurrence rate was 30% (95% CI, 20-40%) at both 5 and 10 years. No recurrence was observed in the en bloc group. The adjusted hazard ratio of unclear horizontal margins for local recurrence was 1.63 (95% CI, 1.12-2.36). A total of 24 patients died after EMR because of comorbid conditions, including other malignancies (n = 11), cardiovascular disease (n = 6), pulmonary disease (n = 4), liver cirrhosis (n = 2), and traffic accident (n = 1). However, no patient died of gastric cancer during the 10-year follow-up period. CONCLUSIONS: An evaluation of horizontal margins in terms of local recurrence after piecemeal EMR is important, and en bloc resection is recommended. Close follow-up assessment is warranted, especially within 5 years in cases of unclear margin resection after piecemeal EMR. The use of EMR is safe even for patients with severe comorbid conditions.