Rebleeding Risk of Acute Hemorrhagic Rectal Ulcer: A Multicenter Retrospective Study.

Objective Acute hemorrhagic rectal ulcer (AHRU) is characterized by sudden, painless, and massive bleeding from rectal ulcers. To date, few studies have analyzed the risk factors for AHRU rebleeding. In this study, we clarified the risk factors of rebleeding after initial hemostasis of AHRU through a multicenter study. Methods A total of 149 patients diagnosed with AHRU between January 2015 and May 2020 at 3 medical centers were enrolled. We retrospectively investigated the following factors: age, sex, body mass index (BMI), performance status (PS), Charlson comorbidity index (CCI), comorbidities, medications, laboratory examinations, endoscopic findings, view of the entire rectum on endoscopy, hemostasis method, blood transfusion history, shock, instructions for posture change after initial hemostasis, and clinical course. Results Rebleeding was observed in 35 (23%) of 149 patients. A multivariate analysis showed that significant factors for rebleeding were PS 4 [odds ratio (OR), 5.23; 95% confidence interval (CI)], 1.97-13.9; p=0.001], a blood transfusion history (OR, 3.66; 95% CI, 1.41-9.51; p=0.008), low an estimated glomerular filtration rate (eGFR) levels (OR, 0.98; 95% CI, 0.97-0.99; p=0.001), poor view of the whole rectum on endoscopy (OR, 0.33; 95% CI, 0.12-0.90; p=0.030), and use of monopolar hemostatic forceps (OR, 4.89; 95% CI, 1.37-17.4; p=0.014). Conclusion Factors associated with rebleeding of AHRU were a poor PS (PS4), blood transfusion, a low eGFR, poor view of the whole rectum on endoscopy, and the use of monopolar hemostatic forceps.

Factors associated with long-term efficacy of lubiprostone for chronic constipation.

The prevalence of chronic constipation in Japan is increasing, and is presently almost 1 in 5 people. Because constipation is common, especially in older patients, to avoid adverse events and polypharmacy, simple treatments at low doses are generally desired. Although the chloride channel activator lubiprostone is candidate drug that may solve these problems, factors associated with the long-term efficacy of lubiprostone monotherapy for chronic constipation in treatment-naive patients remain unclear. We here retrospectively investigated the clinical characteristics and factors of patients who achieved long-term constipation improvement with lubiprostone monotherapy. Seventy-four patients with chronic constipation treated with lubiprostone monotherapy (24 or 48 µg/day) from January 2017 to August 2018 were reviewed. Patient characteristics and clinical time-courses were compared between those who sustained improvement for 6 months, and those who became refractory to treatment. In 54 patients (76.1%), constipation improved by lubiprostone administration for 6 months. On multivariate analysis, a significant clinical factor associated with sustained improvement was a starting lubiprostone dose of 24 µg/day (odds ratio: 5.791; 95% confidence interval: 1.032-32.498; p = 0.046). A starting lubiprostone dose of 24 µg/day has efficacy to improve chronic constipation and to prevent adverse events of nausea and diarrhea in Japanese patients.

Significance of rescue hybrid endoscopic submucosal dissection in difficult colorectal cases.

BACKGROUND/AIMS: Hybrid endoscopic submucosal dissection (ESD), in which an incision is made around a lesion and snaring is performed after submucosal dissection, has some advantages in colorectal surgery, including shorter procedure time and preventing perforation. However, its value for rescue resection in difficult colorectal ESD cases remains unclear. This study evaluated the utility of rescue hybrid ESD (RH-ESD). METHODS: We divided 364 colorectal ESD procedures into the conventional ESD group (C-ESD, n=260), scheduled hybrid ESD group (SH-ESD, n=69), and RH-ESD group (n=35) and compared their clinical outcomes. RESULTS: Resection time was significantly shorter in the following order: RH-ESD (149 [90-197] minutes) >C-ESD (90 [60-140] minutes) >SH-ESD (52 [29-80] minutes). The en bloc resection rate increased significantly in the following order: RH-ESD (48.6%), SH-ESD (78.3%), and C-ESD (97.7%). An analysis of factors related to piecemeal resection of RH-ESD revealed that the submucosal dissection rate was significantly lower in the piecemeal resection group (25% [20%-30%]) than in the en bloc resection group (40% [20%-60%]). CONCLUSION: RH-ESD was ineffective in terms of curative resection because of the low en bloc resection rate, but was useful for avoiding surgery.

Underwater endoscopic submucosal dissection for colorectal tumors decreases the incidence of post-electrocoagulation syndrome.

BACKGROUND AND AIMS: Underwater endoscopic submucosal dissection (U-ESD) is a recently developed procedure that has the potential to prevent post-ESD coagulation syndrome (PECS) owing to its heat-sink effect. We aimed to clarify whether U-ESD decreases the incidence of PECS compared with conventional ESD (C-ESD). METHODS: A total of 205 patients who underwent colorectal ESD (C-ESD: 125; U-ESD: 80) were analyzed. Propensity score matching analysis was performed to adjust for patient backgrounds. Ten C-ESD and two U-ESD patients with muscle damage or perforation during ESD were excluded when comparing PECS. The primary outcome was to compare the incidence of PECS between the U-ESD and C-ESD groups (54 matched pairs). Secondary outcomes were to compare procedural outcomes between the C-ESD and U-ESD groups (62 matched pairs). RESULTS: Among the 78 patients who underwent U-ESD, PECS occurred in only one patient (1.3%). Adjusted comparisons between the U-ESD and C-ESD groups demonstrated a significantly lower incidence of PECS in the U-ESD group (0% vs 11.1%; P = 0.027). Median dissection speed was significantly faster in the U-ESD than in the C-ESD group (10.9 mm2 /min vs 6.9 mm2 /min; P < 0.001). En bloc and complete resection rates were 100% in the U-ESD group. Although perforation and delayed bleeding occurred in one patient each (1.6%) as adverse events in the U-ESD group, there were no differences compared with the C-ESD group. CONCLUSIONS: Our study demonstrates that U-ESD effectively decreases the incidence of PECS and is a faster and safer method for colorectal ESD.

Visibility of early gastric cancers by texture and color enhancement imaging using a high-definition ultrathin transnasal endoscope.

We evaluated whether texture and color enhancement imaging (TXI) using a high-definition ultrathin transnasal endoscope (UTE) improves the visibility of early gastric cancer (EGC) compared with white-light imaging (WLI). This study included 31 EGCs observed by TXI mode 2 using a high-definition UTE prior to endoscopic submucosal dissection. The first outcome was to compare the color differences based on Commission Internationale de l'Eclairage L*a*b* color space between EGCs and the surrounding mucosa by WLI and TXI using the UTE (objective appearance of EGC). The second outcome was to assess the visibility of EGCs by WLI and TXI using the UTE in an image evaluation test performed on 10 endoscopists (subjective appearance of EGC). Color differences between EGCs and non-neoplastic mucosa were significantly higher in TXI than in WLI in all EGCs (TXI: 16.0 ± 10.1 vs. WLI: 10.2 ± 5.5 [mean ± standard deviation], P < 0.001). Median visibility scores evaluated by 10 endoscopists using TXI were significantly higher than those evaluated using WLI (TXI: 4 [interquartile range, 4-4] vs. WLI: 4 [interquartile range, 3-4], P < 0.001). TXI using high-definition UTE improved both objective and subjective visibility of EGCs compared with WLI.

Targeted Metabolomic Profiling of Plasma Samples in Gastric Cancer by Liquid Chromatography-Mass Spectrometry.

INTRODUCTION: As the high mortality rate of gastric cancer (GC) is due to delayed diagnosis, early detection is vital for improved patient outcomes. Metabolic deregulation plays an important role in GC. Although various metabolite-level biomarkers for early detection have been assessed, there is still no unified early detection method. We conducted a plasma metabolome study to assess metabolites that may distinguish GC samples from non-GC samples. METHODS: Blood samples were collected from 72 GC patients and 29 control participants (non-GC group) at the Tokyo Medical University Hospital between March 2020 and November 2020. Hydrophilic metabolites were identified and quantified using liquid chromatography-time-of-flight mass spectrometry. Differences in metabolite concentrations between the GC and non-GC groups were evaluated using the Mann-Whitney test. The discrimination ability of each metabolite was evaluated by the area under the receiver operating characteristic curve. A radial basis function (RBF) kernel-based support vector machine (SVM) model was developed to assess the discrimination ability of multiple metabolites. The selection of variables used for the SVM utilized a step-wise regression method. RESULTS: Of the 96 quantified metabolites, 8 were significantly different between the GC and non-GC groups. Of these, N1-acetylspermine, succinate, and histidine were used in the RBF-SVM model to discriminate GC samples from non-GC samples. The area under the curve (AUC) of the RBF-SVM model was higher (0.915; 95% CI: 0.865-0.965, p < 0.0001), indicating good performance of the RBF-SVM model. The application of this RBF-SVM to the validation dataset resulted from the AUC of the RBF-SVM model was (0.885; 95% CI: 0.797-0.973, p < 0.0001), indicating the good performance of the RBF-SVM model. The sensitivity of the RBF-SVM model was better (69.0%) than those of the common tumor markers carcinoembryonic antigen (CEA) (10.5%) and carbohydrate antigen 19-9 (CA19-9) (2.86%). The RBF-SVM showed a low correlation with CEA and CA19-9, indicating its independence. CONCLUSION: We analyzed plasma metabolomics, and a combination of the quantified metabolites showed high sensitivity for the detection of GC. The independence of the RBF-SVM from tumor markers suggested that their complementary use would be helpful for GC screening.

Using texture and colour enhancement imaging to evaluate gastrointestinal diseases in clinical practice: a review.

White light imaging (WLI) is the most common endoscopic technique used for screening of gastrointestinal diseases. However, despite the advent of a new processor that offers sufficient clear illumination and other advanced developments in endoscopic instrumentation, WLI alone is inadequate for detecting all gastrointestinal diseases with abnormalities in mucosal discoloration and morphological changes to the mucosal surface. The recent development of image-enhanced endoscopy (IEE) has dramatically improved the detection of gastrointestinal diseases. Texture and colour enhancement imaging (TXI) is a new type of IEE that enhances brightness, surface irregularities, such as elevations or depressions, and subtle colour changes. TXI with two modes, namely modes 1 and 2, can selectively enhance brightness in dark areas of an endoscopic image and subtle tissue differences such as slight morphological or colour changes while simultaneously preventing over-enhancement. Several clinical studies have investigated the efficacy of TXI for detecting and visualizing gastrointestinal diseases, including oesophageal squamous cell carcinoma (ESCC), Barret's epithelium, gastric cancer, gastric mucosal atrophy and intestinal metaplasia. Although TXI is often more useful for detecting and visualizing gastrointestinal diseases than WLI, it remains unclear whether TXI outperforms other IEEs, such as narrow-band imaging (NBI), in similar functions, and whether the performance of TXI modes 1 and 2 are comparable. Therefore, large-scale prospective studies are needed to compare the efficacy of TXI to WLI and other IEEs for endoscopic evaluation of patients undergoing screening endoscopy. Here, we review the characteristics and efficacy of TXI for the detection and visualization of gastrointestinal diseases.Key MessagesTXI mode 1 can improve the visibility of gastrointestinal diseases and qualitative diagnosis, especially for diseases associated with colour changes.The enhancement of texture and brightness with TXI mode 2 enables the detection of diseases, and is ideal for use in the first screening of gastrointestinal tract.

Efficacy of high-vision transnasal endoscopy using texture and colour enhancement imaging and narrow-band imaging to evaluate gastritis: a randomized controlled trial.

BACKGROUND: A new image-enhanced endoscopy method called texture and colour enhancement imaging (TXI) enhances brightness, surface irregularities, and subtle colour changes in endoscopic images. However, it is unclear whether TXI and narrow-band imaging (NBI) with third-generation high-vision transnasal ultrathin endoscopy are advantageous over white-light imaging (WLI) for detecting atrophy, intestinal metaplasia, map-like redness and gastric cancer. We investigated to compare the endoscopic efficacy for evaluation of gastritis between TXI and NBI with high-vision transnasal endoscopy and clarified the endoscopic efficacy of TXI and NBI compared to WLI. METHODS: We enrolled 60 patients who underwent high-vision transnasal endoscopy as part of a health check-up from March to November 2021 and randomized patients into two groups (the WLI-NBI group and the WLI-TXI group) using the minimization method based on Helicobacter pylori infection status, age and sex. Colour differences determined using the International Commission on Illumination 1976 (L∗, a∗, b∗) colour space was compared between WLI and TXI or NBI. RESULTS: No significant differences were observed in colour differences surrounding atrophy, intestinal metaplasia and map-like redness between NBI and TXI (p = .553, .057 and .703, respectively). Endoscopic scores based on the Kyoto classification of gastritis for atrophy, intestinal metaplasia, and map-like redness were similar between WLI and TXI. In contrast, NBI identified intestinal metaplasia at a significantly greater rate than WLI (p = .018). Further, colour differences surrounding atrophy and intestinal metaplasia on TXI and NBI were significantly greater than those on WLI (atrophy: TXI vs WLI p = .003, NBI vs WLI p < .001; intestinal metaplasia: TXI vs WLI p = .016, NBI vs WLI p < .001). However, TXI and NBI were not advantageous over WLI for detecting map-like redness. CONCLUSION: Third-generation high-vision transnasal ultrathin endoscopy using TXI and/or NBI is useful for detecting atrophic borders and intestinal metaplasia.Key MessagesHigh-vision transnasal endoscopy using TXI or NBI is useful for diagnosing and detecting atrophy and intestinal metaplasia.TXI and NBI increase colour differences surrounding atrophy and intestinal metaplasia, thereby increasing diagnostic efficiency to improve risk stratification for gastric cancer.The image quality and detection rate have improved markedly with the latest ultrathin high-vision transnasal endoscopes.

Endoscopic submucosal dissection using traction by a spring-and-loop with clip for a laterally spreading tumor in the inferior aspect of the cecum: a nonreferral center experience.

Video 1Endoscopic submucosal dissection using traction by a spring-and-loop with clip for a laterally spreading tumor in the inferior aspect of the cecum: a nonreferral center experience.

Empowering Children as Agents of Change to Foster Resilience in Community: Implementing "Creative Health" in Primary Schools after the Fukushima Nuclear Disaster.

The "Creative Heath" project, a participatory school activity to foster community resilience, was implemented in Fukushima, Japan, and children's experiences of the project were assessed both quantitatively and qualitatively. The project consists of three workshops: BODY, FOOD, and ACT, with activities to facilitate students' scientific and creative thinking, working in teams, presenting, and expressing their opinions. The first two schools participated with 105 students aged 9-11 years old. Before and after each workshop, students were given questionnaires to rate their satisfaction with their own health (BODY), local foods (FOOD), and the community at large (ACT) on a five-level scale, with space to add free comments. Ratings for BODY and FOOD changed significantly, and the proportion of students who increased their rating of an evaluation indicator after each workshop was 25% for BODY, 28% for FOOD, and 25% for ACT. Text analysis of free comments showed that students in the "increased" group appreciated presenting, measuring, learning connections between nutrition and health, and working collaboratively with peers. Children perceived their health and the foods in their community more positively after participating. Moreover, the Creative Health project could be a way to enhance children's creativity and autonomy as agents of change in the community.

New scoring system to distinguish deep invasive submucosal and muscularis propria colorectal cancer during colonoscopy: a development and global multicenter external validation study (e-T2 Score).

BACKGROUND AND AIMS: Diagnostics to differentiate deep submucosal invasive (invasion depth ≥1000 µm [T1b]) colorectal cancer (CRC) from muscularis propria invasive (T2) CRC are limited. We aimed to establish and validate a scoring system that differentiates T1b from T2. METHODS: A multicenter retrospective cross-validation study was performed. Four hundred sixty-one consecutive pathologically confirmed T1b or T2 CRCs were divided into the development (T1b, 222; T2, 189) and internal validation (T1b, 31; T2, 19) cohorts. Eight potential endoscopic findings were evaluated using the development cohort: loss of lobulation, deep depression, demarcated depressed area, protuberance within the depression, expanding appearance, fold convergency, erosion or white plaque, and Borrmann type 2 or 3 tumor. A scoring system that differentiates T1b from T2 was developed, and diagnostic performance was tested using the internal validation cohort by 8 endoscopists. External validation was conducted using 50 CRC images by 4 endoscopists from other institutions, including outside of Japan. RESULTS: Multivariate analysis identified the following 5 independent predictive endoscopic findings of T2 CRC: deep depression (odds ratio [OR], 2.08; 95% confidence interval [CI], 1.07-4.04), demarcated depressed area (OR, 4.40; 95% CI, 1.39-13.9), 4-fold convergency or more (OR, 3.41; 95% CI, 1.90-6.11), erosion or white plaque (OR, 8.28; 95% CI, 2.77-24.7), and Borrmann type 2 or 3 tumor (OR, 8.76; 95% CI, 3.58-21.5). The area under the receiver-operating characteristic curve (AUROC) was .90 (95% CI, .87-.93) in the development cohort, .80 (95% CI, .76-.85) in the internal validation, and .76 (95% CI, .69-.83) in the external validation. CONCLUSIONS: We established and validated a new scoring system to differentiate T1b from T2 CRC using 5 simple endoscopic findings.

Validation of the BEST-J score, a prediction model for bleeding after endoscopic submucosal dissection for early gastric cancer: a multicenter retrospective observational study.

BACKGROUND: A new scoring system, the BEST-J score, using ten risk factors to assign cases to different post-endoscopic submucosal dissection (ESD) risk groups for bleeding, has been shown to be accurate for risk stratification. We first aimed to validate the BEST-J score at four hospitals not specialized in performing ESD and then aimed to identify other risk factors for post-ESD bleeding. METHODS: We evaluated the incidence of post-ESD bleeding in 791 cases of early gastric cancer (EGC) between October 2013 and December 2020 as a retrospective, multi-center observational study conducted at four hospitals. Multivariate logistic regression models to examine the effect of independent variables on post-ESD bleeding firstly included ten possible factors raised by the BEST-J score and secondly included statistically significant (p < 0.01) in univariate analysis. The prediction accuracy of the model was evaluated by receiver-operating characteristic analysis and the areas under the curve (AUC). RESULTS: The incidence of post-ESD bleeding was 4.8% (38/791, 95% confidence interval [CI] 3.4-6.5%). On multivariate analysis, the risk factors were P2Y12 receptor antagonist (odds ratio [OR]: 5.870, 95% CI 1.624-21.219), warfarin (8.382, 1.658-42.322), direct oral anticoagulant (DOAC) (8.980, 1.603-50.322), and tumor location in lower third of stomach (2.151, 1.012-4.571), respectively. When we categorized cases into low-risk by BEST-J score, intermediate-risk, high-risk, and very high-risk groups, the bleeding rates were 2.8%, 7.3%, 12.8%, and 19.0%, respectively. The AUC for our cohort was 0.713 (95% CI 0.625-0.802) for the BEST-J score. In the multivariate analysis in our cohort, the risks were age, body mass index, P2Y12 receptor antagonist, warfarin, DOAC, respectively. DISCUSSION: The BEST-J score is equally accurate in risk stratification of patients with EGC for post-ESD bleeding at non-specialized facilities for ESD as in specialized hospitals. BMI and age may be helpful additional risk factors at hospitals not specialized.

Efficacy of endoscopic clip closure for nonperforated muscle layer exposure during esophageal endoscopic submucosal dissection.

Exposure of the muscle layer during endoscopic submucosal dissection (ESD) in the esophagus can lead to complications such as fever and pain. Although closure with endoscopic clips is widely used when perforation is a major complication, its value when the exposed muscle layer is not perforated is unclear. Data for 104 lesions in 104 patients who underwent esophageal ESD between 2008 and 2020 were retrospectively analyzed. Patients with multiple tumors, those who experienced procedure-related adverse events such as aspiration pneumonitis, perforation during ESD, or delayed bleeding, and those in whom the muscle layer was not exposed were excluded. The clinical course of inflammation after ESD in patients in whom the muscle layer was exposed was examined according to whether endoscopic clips were used for closure. A significantly greater number of patients had a temperature ≤ 37.5°C in the clip closure group than in the nonclip closure group (≤37.5°C/≥37.6°C, 47/14 vs. 25/18, respectively, P = 0.040). Furthermore, significantly more patients in the clip closure group had a white blood cell count ≤10,000/µL (≤10,000/µL/>10,000/µL, 51/10 vs. 21/22, P < 0.001) and a C-reactive protein level < 1.0 mg/dL (<1.0 mg/dL/≥1.0 mg/dL, 40/21 vs. 36/7, P = 0.040) in the 24 hour post-ESD. The results were not changed after propensity score matching. Closure with endoscopic clips reduces inflammation after esophageal ESD with nonperforated muscle layer exposure. Even if there is no obvious perforation during ESD, closure of the exposed muscle layer with endoscopic clips may contribute to the clinical course post-ESD.

Long-term Follow-up of Affected Residents After Lifting Evacuation Orders in Fukushima Prefecture, Japan: Findings from an Interview-Based Psychological Survey.

We examined the relationship between social support and psychological variables, and investigated the status of social support among villagers whose evacuation order had been lifted. The survey used for the analysis is the data of FY 2018 and 2019. In fiscal year 2018, a written questionnaire was posted to 4828 registered residents of Iitate Village and 1405 valid responses were received. The main finding (in joint assessment by local and external experts) was the 'need for professional support' (191 respondents, 13.6%). Multivariate analysis found that among those living in permanent housing outside the village, the need for support was significantly more likely for those without emotional support, or instrumental support, and those not providing support. The 2019 follow-up showed a slight improvement in perceived social support (PSS). The associations between perceived social support and living environment suggest the need to strengthen social support measures in areas where evacuation orders are yet to be lifted, which will provide useful information with which to examine the effects of future support efforts.

Diagnostic efficacy of the Japan NBI Expert Team classification with dual-focus magnification for colorectal tumors.

BACKGROUND AND AIMS: The Japan NBI Expert Team (JNET) classification is the first unified classification criteria for colorectal tumors using magnifying narrow-band imaging (NBI) in Japan. However, the diagnostic stratification ability of the JNET classification with dual-focus magnifying NBI (DF-JNET) has remained obscure. The aim of this study was to validate the diagnostic stratification ability of DF-JNET for colorectal tumors in two Japanese referral centers. METHODS: A multicenter retrospective image evaluation study was conducted by three experienced endoscopists, including an original JNET member who was also involved in establishing the diagnostic criteria. A total of two images, namely, one representative non-magnified white light image and one representative DF-NBI image for each of the 557 consecutive lesions were used in the evaluation study. The diagnostic value of DF-JNET was calculated based on the evaluation data. RESULTS: The sensitivity, specificity, positive and negative predictive values, and accuracy of DF-JNET Type 1 for differentiating between non-neoplastic and neoplastic lesions were 78.1%, 98.6%, 89.1%, 96.8%, and 95.9%, respectively; of Type 2A lesions for differentiating low-grade dysplasia from others were 98.0%, 76.5%, 94.9%, 89.7%, and 94.1%, respectively; of Type 2B lesions for differentiating high-grade dysplasia and shallow submucosal invasive carcinoma from others were 43.5%, 99.1%, 66.7%, 97.6%, and 96.8%, respectively; and of Type 3 lesions for differentiating deep submucosal invasive carcinoma from others were 83.3%, 99.5%, 62.5%, 99.8%, and 99.3%, respectively. CONCLUSIONS: All DF-JNET types had an over 90% diagnostic accuracy for the histological prediction of colorectal tumors. DF-JNET might contribute to appropriate treatment choices, such as endoscopic resection or surgery, not only in Japan but also in Western countries in which the use of optical zoom endoscopy is limited.