Preceding endoscopic submucosal dissection in submucosal invasive gastric cancer patients does not impact clinical outcomes.

Submucosal deep invasion of gastric cancer (T1b2; depth of submucosal invasion ≥ 500 µm) is a risk factor for lymph node metastasis and, thus, is one of the criteria for curative treatment. Our aim was to evaluate the specific influence of endoscopic submucosal dissection (ESD) on the prognosis of patients with T1b2 gastric cancer. This was a retrospective analysis of 248 consecutive patients, with 252 pT1b2 gastric cancer lesions, who underwent ESD prior to additional surgery (Group A, n = 101) or surgery only (Group B, n = 147). After propensity score-matching (for sex, age, tumor diameter and gross type), we compared pathological characteristics between the 2 groups and the prognosis over a follow-up period ≥ 60 months. Compared to Group B, patients in Group A were older, with a higher proportion of men. The proportion of depressed and undifferentiated type tumors was greater in Group B than A, with larger tumor size and depth of submucosal invasion as well. There was no incidence of local recurrence, but distant metastasis was identified in 5% of cases in Group A and 3% in Group B. After propensity score-matching, there were no difference in the 5-year overall survival rate between Group A and B (87.5% vs. 91.2%, respectively), nor in the 5-year disease-specific survival rate (96.3% vs. 96.4%, respectively). ESD prior to surgery for T1b2 gastric cancer did not adversely affect clinical outcomes after additional surgery.

Clinical significance of endoscopic ultrasonography in diagnosing invasion depth of early gastric cancer prior to endoscopic submucosal dissection.

BACKGROUND AND AIM: Endoscopic ultrasonography is a reliable diagnostic modality for determining indications of endoscopic submucosal dissection for early gastric cancer. We aimed to clarify the clinical significance of endoscopic ultrasonography in the invasion depth diagnosis of early gastric cancer. METHODS: We retrospectively assessed 1598 consecutive patients with 2001 early gastric cancers who underwent EUS before ESD or surgery between October 2010 and April 2019 at our institution. Lesions were classified according to endoscopic ultrasonography-determined invasion depth as EUS-M/SM1 (lesions confined to sonographic layers 1 and 2 or lesions with changes in sonographic layer 3; depth, < 1 mm) and EUS-SM2 (lesions with changes in sonographic layer 3; depth, ≥ 1 mm). We evaluated the invasion depth determination accuracy of endoscopic ultrasonography and analyzed the clinicopathological features of misdiagnosed early gastric cancer cases. RESULTS: The invasion depth determination accuracy was as follows: EUS-M/SM1: pathological T1a/T1b1 early gastric cancer, 97%; EUS-SM2: pathological T1b2 early gastric cancer, 79%. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 95%, 98%, 69%, 97%, and 79%, respectively. In EUS-M/SM1 early gastric cancer, tumor size of ≥ 15 mm, presence of ulceration, and undifferentiated histological type were significantly associated with endoscopic ultrasonography accuracy. In EUS-SM2 early gastric cancer, tumor size of ≥ 30 mm was significantly associated with endoscopic ultrasonography accuracy. CONCLUSIONS: Endoscopic ultrasonography is a useful modality in accurately determining the invasion depth of early gastric cancer before endoscopic submucosal dissection.

[A case of Salmonella bacteremia in an otherwise healthy young man].

A 19-year-old man was admitted to our hospital because of persistent fever of >38°C for 6 days and diarrhea for 4 days. Initially, he was treated for infectious enteritis, but on his second day in the hospital, the two sets of blood cultures came back positive. Cultures from the blood and stool yielded Salmonella sp. (Group O4). The patient's symptoms improved after treatment with fluoroquinolone-based antimicrobial agents for 14 days. Cases of nontyphoidal Salmonella bacteremia are rare;therefore, we reported this case with bibliographic consideration of the risk factors for Salmonella bacteremia.

Newly developed self-expandable Niti-S MD colonic metal stent for malignant colonic obstruction.

BACKGROUND: Colonic stents are increasingly used to treat acute malignant colonic obstructions. The WallFlex and Niti-S D type stents are the commonly used self-expandable metallic stents available in Japan since 2012. WallFlex stent has a risk of stent-related perforation because of its axial force, while the Niti-S D type stent has a risk of obstructive colitis because of its weaker radial force. Niti-S MD type stents not only overcome these limitations but also permit delivery through highly flexible-tipped smaller-caliber colonoscopes. AIM: To compare the efficacy and safety of the newly developed Niti-S MD type colonic stents. METHODS: This single-center retrospective observational study included 110 patients with endoscopic self-expandable metallic stents placed between November 2011 and December 2018: WallFlex (Group W, n = 37), Niti-S D type (Group N, n = 53), and Niti-S MD type (Group MD, n = 20). The primary outcome was clinical success, defined as a resolution of obstructive colonic symptoms, confirmed by clinical and radiological assessment within 48 h. The secondary outcome was technical success, defined as accurate stent placement with adequate stricture coverage on the first attempt without complications. RESULTS: The technical success rate was 100% in Groups W, N, and MD, and the overall clinical success rate was 89.2% (33/37), 96.2% (51/53), and 100% (20/20) in Groups W, N, and MD, respectively. Early adverse events included pain (3/37, 8.1%), poor expansion (1/37, 2.7%), and fever (1/37, 2.6%) in Group W and perforation due to obstructive colitis (2/53, 3.8%) in Group N (likely due to poor expansion). Late adverse events (after 7 d) included stent-related perforations (4/36, 11.1%) and stent occlusion (1/36, 2.8%) in Group W and stent occlusion (2/51, 3.9%) in Group N. The stent-related perforation rate in Group W was significantly higher than that in Group N (P < 0.05). No adverse event was observed in Group MD. CONCLUSION: In our early and limited experience, the newly developed Niti-S MD type colonic stent was effective and safe for treating acute malignant colonic obstruction.

Clinical outcomes of endoscopic resection for superficial non-ampullary duodenal tumors.

Background and study aims Because superficial non-ampullary duodenal epithelial tumors (SNADETs) are relatively rare, studies evaluating the outcomes of endoscopic resection (ER) for SNADETs are limited. Therefore, this study aimed to evaluate the clinical validity of ER for SNADETs. Patients and methods The study participants included 163 consecutive patients (108 men; mean age, 61.5 ±â€Š11.3 years) with 171 SNADETs, excluding patients with familial adenomatous polyposis resected by ER, at Hiroshima University Hospital between May 2005 and September 2016. Clinicopathological features and the outcomes of ER for 171 cases were retrospectively analyzed. Additionally, the prognosis of 135 patients with more than 12 months' follow-up was analyzed. Results Mean diameter of SNADETs was 10.7 ±â€Š7.2 mm. Most of the SNADET cases were classified as category 3 (71 %, 121/171), but some were category 5 (2 %, 3/171). En bloc resection rates were 93 % (146/157), 100 % (7/7), and 86 % (6/7) in endoscopic mucosal resection (EMR), polypectomy, and in endoscopic submucosal dissection (ESD) cases, respectively. Complete resection rates were 90 % (141/157), 100 % (7/7), and 71 % (5/7) in EMR, polypectomy, and ESD cases, respectively. Emergency surgery was performed in two patients with intraoperative perforation and in two with delayed perforation without artificial ulcer bed closure after ER. Since endoscopic closure of ulcer by clipping was performed, delayed perforation has not occurred. Local recurrence occurred in 1.2 %, but no metastasis to lymph nodes or other organs occurred after ER. No patient died of primary SNADETs. Conclusion Our data supported the clinical validity of ER for SNADETs. However, delayed perforation should be given much attention.

Clinical Usefulness of Dual Red Imaging in Gastric Endoscopic Submucosal Dissection: A Pilot Study.

BACKGROUND/AIMS: Dual red imaging (DRI) is a new, image-enhanced endoscopy technique. There are few reports about the usefulness of DRI during gastric endoscopic submucosal dissection (ESD). We aimed to examine the usefulness of DRI in endoscopic hemostasis during gastric ESD. METHODS: We enrolled a total of 20 consecutive patients who underwent gastric ESD. Five endoscopists compared DRI with white light imaging (WLI) for the visibility of blood vessels and bleeding points while performing endoscopic hemostasis. RESULTS: The visibility of blood vessels was increased in 56% (19/34) of the cases, and the visibility of bleeding points was improved in 55% (11/20) of the cases with the use of DRI compared with the use of WLI. CONCLUSION: DRI improved the visibility of blood vessels and bleeding points in cases with oozing bleeding, blood pooling around the bleeding points, and multiple bleeding points.

The Evaluation of Esophageal Motility Using Infusion Manometry with a Trans-nasal Endoscope: A Preliminary Study.

Objective The Chicago classification using high-resolution manometry (HRM) has been proposed for the diagnosis of esophageal motility disorders. However, HRM is expensive, and few patients are likely to benefit from this method. We established a method using a raised infusion catheter called "esophageal manometry using a trans-nasal endoscope". In this study, we examined the clinical utility of this new method for the assessment of patients with dysphagia. Methods We enrolled 124 consecutive patients who complained of dysphagia and were suspected of having esophageal motility disorders. Patients underwent manometry using a trans-nasal endoscope at Hiroshima University Hospital from September 2008 to December 2018. An esophageal biopsy was performed during the procedure from the thoracic esophagus to detect eosinophilic esophagitis. In addition, we examined the clinical courses of patients diagnosed with achalasia. Results The diagnostic ability of manometry using a trans-nasal endoscope was 98%, and no major complications associated with the procedure were recorded. About 30% of patients were diagnosed with achalasia, and most (77%) were well controlled by medications or balloon dilation. One patient was diagnosed with eosinophilic esophagitis. Conclusion Manometry using a trans-nasal endoscope is beneficial and can be used for the clinical management of patients with dysphagia.

Gastric Cancer with Submucosal Invasion after Successful Helicobacter pylori Eradication: A Propensity Score-Matched Analysis of Patients with Annual Patient Endoscopic Survey.

BACKGROUND AND AIM: The incidence of gastric cancer occurring after successful Helicobacter pylori eradication has been increasing. We aimed to clarify the influence of eradication therapy on the ability to diagnose early gastric cancer after successful H. pylori eradication in patients who underwent annual endoscopic screening. METHODS: A total of 220 patients (179 men; mean age 71.0 years) had differentiated-type early gastric cancer that was discovered through annual endoscopic screening. Patients were categorized into 2 groups: the H. pylori-eradicated group (n = 81) and the non-eradicated control group (n = 139). After matching patients by propensity scores, we retrospectively analyzed the clinicopathological characteristics of 162 patients (81 patients in each group). Furthermore, we compared the characteristics of gastric cancer with submucosal invasion between the 2 groups. RESULTS: The prevalence of early gastric cancer with submucosal invasion was significantly higher in the eradicated group than in the control group, both before propensity score matching (16.0 vs. 7.2%, respectively; p = 0.038) and after propensity score matching of 81 pairs (16.0 vs. 4.9%, respectively; p = 0.021). In the comparative analysis of gastric cancer with submucosal invasion, there was no difference between the 2 groups with respect to factors influencing the ability to diagnose its presence endoscopically. CONCLUSION: H. pylori eradication therapy increased the prevalence of differentiated-type gastric cancer with submucosal invasion despite patients' completion of annual endoscopic screening after eradication.

Taking Warfarin with Heparin Replacement and Direct Oral Anticoagulant Is a Risk Factor for Bleeding after Endoscopic Submucosal Dissection for Early Gastric Cancer.

BACKGROUND: Although bleeding after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) remains problematic, especially in patients taking anticoagulants, there are differing views on the ideal and optimal management for these patients. This study investigated the risk of bleeding after ESD in patients taking anticoagulants. METHODS: We enrolled 61 consecutive patients taking anticoagulants (anticoagulant group) and 968 patients taking no antithrombotic agents (non-antithrombotic group) treated with ESD for EGC between December 2010 and October 2016. We analyzed the risk factors for bleeding after ESD in relation to the various clinical factors. RESULTS: Incidences of bleeding after ESD were significantly higher (14%; 11/76) in the anticoagulant group compared to the non-antithrombotic group (3%; 40/1,167). Moreover, bleeding after ESD was significantly more common in patients in the warfarin monotherapy group (14%; 5/37) and in the direct oral anticoagulant (DOAC) monotherapy group (22%; 4/18), compared to the non-antithrombotic group. Multivariate analysis revealed that dialysis, the use of anticoagulants, and an operation time ≥75 min were independent risk factors for bleeding after ESD. CONCLUSIONS: Our data suggest that patients who take warfarin and receive heparin bridging, and those who take DOAC medication, are prone to bleeding after ESD for EGC.

Clinical Usefulness of the VS Classification System Using Magnifying Endoscopy with Blue Laser Imaging for Early Gastric Cancer.

BACKGROUND: Blue laser imaging (BLI) enables the acquisition of more information from tumors' surfaces compared with white light imaging. Few reports confirm the validity of magnifying endoscopy (ME) with BLI (ME-BLI) for early gastric cancer (EGC). We aimed to assess the detailed endoscopic findings from EGCs using ME-BLI. METHODS: We enrolled 386 consecutive patients with 417 EGCs that were diagnosed using ME-BLI and resected by endoscopic submucosal dissection. Using the VS classification system, three highly experienced endoscopists (HEEs) and three less experienced endoscopists (LEEs) evaluated the demarcation line (DL), microsurface pattern (MSP), and microvascular pattern (MVP) within the endoscopic images of EGCs obtained using ME-BLI, assigning high-confidence (HC) or low-confidence (LC) levels. We investigated the clinicopathological features associated with each confidence level. RESULTS: The HEEs' evaluations determined the presence of DL in 99%, irregular MSP in 96%, and irregular MVP in 96%, and the LEEs' evaluations determined the presence of DL in 98%, irregular MSP in 95%, and irregular MVP in 95% of the EGCs. When DL was present, HC levels in the Helicobacter pylori- (H. pylori-) eradicated group and noneradicated group were evident in 65% and 89%, a difference that was significant (p < 0.001). CONCLUSIONS: In the diagnosis of EGC with ME-BLI, the VS classification system with ME-NBI can be applied, but identifying the DL after H. pylori was difficult.