Endoscopic Image 2 Hours after PuraStat® Application: A Case of Achieving Hemostasis Using PuraStat® for Postgastric Lesion Biopsy Bleeding after Hemostatic Clips Failed.

PuraStat® (3D Matrix, Tokyo, Japan) is a novel, self-assembling peptide hemostatic hydrogel that can be used endoscopically. Hemostasis can be physically obtained by covering bleeding points; however, there are no reports of how long PuraStat remains in the upper gastrointestinal tract. Herein, we report a case wherein esophagogastroduodenoscopy (EGD) was performed 2 hours after PuraStat application. A 73-year-old man underwent EGD for evaluation of lesions in the posterior wall of the stomach. A biopsy was then performed on the gastric lesions; however, massive bleeding occurred. A hemostatic clip was used to stop bleeding but failed; primary hemostasis was obtained by applying PuraStat. EGD performed 2 hours later to determine whether the patient could be discharged revealed that the white-turning PuraStat gel remained firmly in the applied area, confirming complete hemostasis. PuraStat is a hemostatic agent capable of physical hemostasis that reliably remains in the stomach even after a few hours of use and, thus, may replace some conventional hemostasis methods.

Comparison of the Ability of Artificial-Intelligence-Based Computer-Aided Detection (CAD) Systems and Endoscopists to Detect Colorectal Neoplastic Lesions on Endoscopy Video.

Artificial-intelligence-based computer-aided diagnosis (CAD) systems have developed remarkably in recent years. These systems can help increase the adenoma detection rate (ADR), an important quality indicator in colonoscopies. While there have been many still-image-based studies on the usefulness of CAD, few have reported on its usefulness using actual clinical videos. However, no studies have compared the CAD group and control groups using the exact same case videos. This study aimed to determine whether CAD or endoscopists were superior in identifying colorectal neoplastic lesions in videos. In this study, we examined 34 lesions from 21 cases. CAD performed better than four of the six endoscopists (three experts and three beginners), including all the beginners. The time to lesion detection with beginners and experts was 2.147 ± 1.118 s and 1.394 ± 0.805 s, respectively, with significant differences between beginners and experts (p < 0.001) and between beginners and CAD (both p < 0.001). The time to lesion detection was significantly shorter for experts and CAD than for beginners. No significant difference was found between experts and CAD (p = 1.000). CAD could be useful as a diagnostic support tool for beginners to bridge the experience gap with experts.

Safe and Efficient Procedures and Training System for Endoscopic Submucosal Dissection.

Recent improvements in endoscopists' skills and technological advances have allowed endoscopic submucosal dissection (ESD) to become a standard treatment in general hospitals. As this treatment entails a high risk of accidental perforation or hemorrhage, therapeutic procedures and training methods that enable ESD to be conducted more safely and efficiently are constantly being developed. This article reviews the therapeutic procedures and training methods used to improve the safety and efficiency of ESD and describes the ESD training system used in a Japanese university hospital at which the number of ESD procedures has gradually increased in a newly established Department of Digestive Endoscopy. During the establishment of this department, the ESD perforation rate was zero among all procedures, including those conducted by trainees.

A case of gastric antral vascular ectasia in which PuraStat, a novel self-assembling peptide hemostatic hydrogel, was effective.

Gastric antral vascular ectasia (GAVE) is a gastric hemorrhagic disease associated with chronic liver disease. Argon plasma coagulation is widely used to control gastrointestinal bleeding due to GAVE. Although argon plasma coagulation is a relatively safe endoscopic procedure, it is not suitable in some cases, such as in patients with pacemakers. We report a case of GAVE in which PuraStat, a novel self-assembling peptide hemostatic hydrogel, was effective. The patient was a 55-year-old man who had undergone Fontan surgery for tricuspid regurgitation more than 20 years prior. He developed hepatic cirrhosis as a complication following Fontan surgery. During upper gastrointestinal endoscopy to examine the cause of the progression of anemia and black stool, bleeding from GAVE was observed; PuraStat was applied to stop the bleeding. Postoperatively, the black stool disappeared, and his hemoglobin levels improved. Upper gastrointestinal endoscopy was performed 13 days after the surgery; the density of the capillaries in the antrum was significantly decreased, and a clear trend toward disappearance was observed. Therefore, the application of PuraStat may be useful in the treatment of GAVE.

Characteristics, Outcomes, and Risk Factors for Upper Gastrointestinal Bleeding in Inpatients - A Comparison with Outpatients.

Objective The study objectives were to clarify the clinical findings and the causes of intractability and mortality of upper gastrointestinal (UGI) bleeding in inpatients. Methods The patients were divided into Inpatient (Ip) and Outpatient (Op) onset groups, and their characteristics, clinical and bleeding data, and outcomes were compared. Patients Our study included 375 patients who developed UGI bleeding during hospitalization or were admitted after being diagnosed with UGI bleeding in an outpatient setting from January 1, 2015, to June 30, 2020. Results The Ip group had worse general condition; increased percentages of comorbidities; and more common use of proton pump inhibitor, anti-coagulant, and steroid than the Op group. Compared with the Op group, the Ip group had lower serum albumin levels and platelet counts at the onset of bleeding, whereas rebleeding, mortality, and bleeding-related death rates were higher. Multivariate analysis of the Ip group revealed that the risks of rebleeding included endoscopic high-risk stigmata, maintenance dialysis, and duodenal bleeding, whereas the risks of mortality were gastric ulcer and a Charlson Comorbidity Index update score of ≥3. Conclusion UGI bleeding in the Ip group was associated with higher rebleeding and mortality rates. Because of their poor general health condition, the pathology of UGI bleeding in these patients may differ from that of patients with common UGI bleeding. A different approach for the care and prevention of UGI bleeding in inpatients is required.

Gastric Signet-Ring Cell Carcinoma That Presented as an Elevated Lesion due to Fibromuscular Obliteration in the Lamina Propria.

The widespread use of Helicobacter pylori eradication therapy in recent years has reduced the H. pylori infection rate, indicating that gastric cancer cases diagnosed in the future may be H. pylori-naïve. The typical endoscopic presentation of signet-ring cell carcinoma, which accounts for the majority of H. pylori-naïve gastric cancer cases, is a discolored, flat, or depressed lesion; it is rarely presented as an elevated lesion. In this study, we treated a patient with elevated signet-ring cell carcinoma in an H. pylori-naïve stomach. Histopathological testing after endoscopic submucosal dissection showed proliferation of fibromuscular tissue in the tumor, which may have caused the formation of the elevated lesion.

Prevention and Management of Complications and Education in Endoscopic Submucosal Dissection.

Endoscopic submucosal dissection (ESD) is considered superior to endoscopic mucosal resection as an endoscopic resection because of its higher en bloc resection rate, but it is more difficult to perform. As ESD techniques have become more common, and the range of treatment by ESD has expanded, the number of possible complications has also increased, and endoscopists need to manage them. In this report, we will review the management of critical complications, such as hemorrhage, perforation, and stenosis, and we will also discuss educational methods for acquiring and improving ESD skills.

Emergency lower gastrointestinal endoscopy performed safely in a COVID-19 patient on extracorporeal membrane oxygenation (ECMO) with hemorrhagic shock.

Emergency endoscopy in coronavirus disease 2019 (COVID-19) patients should be avoided whenever possible to ensure the safety of medical staff; however, it may be unavoidable in some cases. We report a case of emergency lower gastrointestinal endoscopy performed with full personal protective equipment in a patient on extracorporeal membrane oxygenation with severe COVID-19 pneumonia admitted in a restricted area under negative pressure in the intensive care unit. To avoid the risk of fecal-oral transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the procedure, the patient's lower body was covered with a 2 m2 vinyl sheet with an aperture (diameter, approximately 2 cm). None of the medical staff involved exhibited any signs of SARS-CoV-2 infection after the procedure. Although patients with severe COVID-19 pneumonia on extracorporeal membrane oxygenation have a high risk of bleeding, we believe that emergency lower endoscopy can be safely performed in such patients by reducing exposure to dispersed feces and using full personal protective equipment.

Emergency upper gastrointestinal endoscopy performed safely in a patient with COVID-19 with suspected hemorrhagic shock.

Coronavirus disease 2019 caused by severe acute respiratory syndrome coronavirus 2 has spread explosively throughout the world and has since been declared a pandemic by the World Health Organization. Although it is recommended that upper gastrointestinal endoscopies either be postponed or canceled during the pandemic because of their high risk of aerosol generation, this does not apply in emergency cases, which may include patients with coronavirus disease. In this case report, we describe the safe undertaking of an emergency upper gastrointestinal endoscopy in a patient with suspected hemorrhagic shock who tested positive for the severe acute respiratory syndrome coronavirus 2 using the polymerase chain reaction. We performed the procedure in the contamination zone of a specialized coronavirus disease ward with prespecified zones. Full personal protective equipment was worn during the procedure, as recommended by various academic societies, and careful attention was paid to the sterilization of all equipment after the procedure. Thus, emergency endoscopies can be performed safely in patients with coronavirus disease in a suitable environment by using appropriate personal protective equipment and by handling the equipment appropriately.

A case of esophageal cancer with human immunodeficiency virus infection that progressed rapidly after neoadjuvant chemoradiotherapy.

While antiretroviral therapy has improved mortality in patients with human immunodeficiency virus (HIV) infections, deaths caused by non-acquired immunodeficiency syndrome-defining malignancies are increasing. A woman in her 70s with HIV infection who was receiving antiretroviral therapy presented with dysphagia. She was diagnosed with esophageal cancer (cT3N2M0, stage III). She received neoadjuvant chemotherapy (cisplatin and 5-fluorouracil) and radiotherapy. During treatment, we continued administering antiretroviral therapy and prophylaxis for opportunistic infections, with due attention to side effects and drug-drug interactions. No severe adverse events occurred. The primary lesion and metastatic lymph nodes decreased in size after treatment; however, 1 month later, her cancer spread to other organs; thus, surgery was canceled. Her general condition rapidly worsened. She eventually died of cancer cachexia and aspiration pneumonia. No previous reports have mentioned the treatment plan and management of esophageal cancer in HIV-positive patients. This report presents a case of esophageal cancer with HIV infection that progressed rapidly after neoadjuvant chemoradiotherapy.

Efficacy of an over-the-scope clip for preventing adverse events after duodenal endoscopic submucosal dissection: a prospective interventional study.

BACKGROUND: Duodenal endoscopic submucosal dissection (ESD) remains technically challenging, with a high risk of severe adverse events. Because exposure of the duodenal post-ESD mucosal defect to pancreatic juice and bile acid reportedly induces delayed perforation and bleeding, we examined whether defect closure using an over-the-scope clip (OTSC) system was useful for preventing postoperative adverse events. METHODS: From April 2016 to February 2017, a total of 50 consecutive patients with superficial non-ampullary duodenal epithelial tumors (SNADETs) larger than 10 mm, with no more than semi-circumferential spread, were prospectively enrolled in this study. All of the lesions were treated by experienced ESD operators and the post-ESD mucosal defect was closed using OTSCs. RESULTS: All of the SNADETs were completely removed by ESD, with an R0 resection rate of 88.0 %. The mean procedure and closure times were 67.3 ±â€Š58.8 minutes and 9.8 ±â€Š7.2 minutes, respectively. Although complete defect closure was achieved in 94.0 % of the patients (47/50), two patients required surgical conversion. Delayed perforation occurred in only one patient (2.1 %), who did not have successful closure of the defect, as misplacement of the OTSC exposed the muscle layer. Meanwhile, delayed bleeding occurred in three patients (6.3 %); however, the bleeding was easily controlled using endoscopic coagulation. The mean duration of postoperative hospitalization was 5.5 ±â€Š7.2 days. CONCLUSIONS: Prophylactic defect closure using OTSCs may be effective in reducing severe adverse events after duodenal ESD.

Usefulness of training using animal models for colorectal endoscopic submucosal dissection: is experience performing gastric ESD really needed?

BACKGROUND AND STUDY AIMS: Despite the clinical advantages of colorectal endoscopic submucosal dissection (ESD), an effective training system, especially for Western endoscopists, has been challenging to establish. Herein, we propose a novel training program using ex vivo animal models and evaluate the learning curve of colorectal ESD trainees without gastric ESD experience. PATIENTS AND METHODS: A total of 80 colorectal lesions were prospectively collected and removed by two novice operators. Before human ESD procedures, they received ESD training using an ex vivo porcine "proximal colon" model, which simulates a lumen with many folds and flexions. To assess the validity of our training system, the self-completion and en bloc R0 resection rates, the operation time, and prevalence of complications were compared between the first and latter period. Moreover the factors associated with prolonged operation time were evaluated. RESULTS: The overall rates of self-completion and en bloc R0 resection were 98 % (78/80) and 100 % (80/80), respectively. The operation time during the first period was significantly longer than that during the latter period (86 ±â€Š50 minutes vs. 60 ±â€Š36 minutes, P = 0.01). Regarding complications, only two cases of perforations and delayed hemorrhage were observed during the first period; however, all of the complications were successfully managed endoscopically. The presence of fibrosis was identified as a significant independent predictor of a prolonged operation time during the first period (coefficient, 5.90; 95 %CI, 2.36 - 9.44, P = 0.002). CONCLUSIONS: Our trainees achieved high rates of self-completion and R0 resection without severe complications even during the first 20 cases, suggesting that our training programs using ex vivo animal models are useful for trainees without gastric ESD experience. STUDY REGISTRATION: UMIN000013566.