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A 32-year-old Japanese man presented with a gastric submucosal tumor. Esophagogastroduodenoscopy showed a sessile submucosal tumor measuring approximately 10 mm in diameter on the greater curvature of the gastric antrum. Endoscopic ultrasonography examination revealed a solid tumor with a diameter of 11.8 mm, which was located in the deep mucosal and submucosal layers. The internal echogenicity was homogenous and hypoechoic. Biopsy examinations were performed twice but were not diagnostic since only the intact mucosal layer was obtained. The patient was subsequently diagnosed with ectopic pancreas in the stomach by endoscopic submucosal dissection (ESD). This case underscores the usefulness of the ESD technique for the pathological diagnosis of gastric submucosal tumors. [ABSTRACT FROM AUTHOR]

Background and Aim Methods Results Conclusions The 2017 Japanese guidelines recommend continuing warfarin therapy during the perioperative period or discontinuing direct oral anticoagulants (DOACs) only on the day of endoscopic submucosal dissection for early gastric cancer. However, their safety has not been sufficiently explored. This study aimed to validate this management method.This retrospective, multicenter study analyzed the characteristics and outcomes of patients who underwent gastric endoscopic submucosal dissection between July 2017 and June 2019. The patients were categorized according to the use of warfarin or DOACs.Among the 62 eligible patients, 53 (85%) were male (median age, 76 years). Warfarin was used in 10 patients (16%) and DOACs in 52 patients (84%). Fourteen patients taking DOACs (27%) used concomitant antiplatelet agents, with seven patients (13%) continuing treatment at the time of the endoscopic procedure. No postprocedural bleeding occurred in patients receiving warfarin (0%), whereas 10 cases (19%) of bleeding occurred in patients receiving DOACs: rivaroxaban, 0% (0/22); dabigatran, 0% (0/2); edoxaban, 43% (6/14); and apixaban, 29% (4/14). The type of anticoagulant (P < 0.01) and continuation of antiplatelet therapy (P = 0.02) were risk factors for postprocedural bleeding in patients receiving DOACs. Intraprocedural bleeding requiring transfusion or symptomatic thromboembolic events were not reported.Continuous warfarin therapy is preferred. DOAC withdrawal 1 day before a procedure is associated with a high bleeding rate, which may differ for different types of anticoagulants. The continuation of antiplatelet medications in patients receiving DOACs carries a high risk of bleeding and is a future challenge. [ABSTRACT FROM AUTHOR]

Objectives: Long‐term outcomes of gastric subepithelial lesions have not been elucidated. To reveal the natural history, we initiated a prospective, 10‐year follow‐up of patients with small (≤20 mm) gastric subepithelial lesions in September 2014. Here, we report the results of an interim analysis of a prospective observational study. Methods: In total, 567 patients with 610 lesions were prospectively registered between September 2014 and August 2016. The location, size, morphology, and number of subepithelial lesions were recorded on a web‐based case report form. This study has been conducted as an Academic Committee Working Group of the Japan Gastroenterological Endoscopy Society. Results: The endoscopic follow‐up period was 4.60 ± 1.73 years (mean ± standard deviation), and survival data were investigated for 5.28 ± 1.68 years. This interim analysis revealed that the estimated cumulative incidence of a size increase ≥5 mm, after accounting for patients' death and resection of the tumor as competing risk events, was 4.5% at 5 years. In addition, the estimated cumulative incidence of lesion size increase ≥5 mm or resection of lesions was 7.9% at 5 years, and that of size increase ≥10 mm or resection of lesions was 4.5% at 5 years. Conclusion: These results indicate that approximately one in 13 patients with small (≤20 mm) gastric subepithelial lesions may require resection or further investigation for increased tumor size (≥5 mm) within 5 years. [ABSTRACT FROM AUTHOR]

Background: The details of gastric cancer in young patients remain unclear because of the low prevalence of the disease. This study aimed to clarify the clinicopathological features and prognosis of gastric cancer in young patients.Methods: From January 2007 to January 2016, patients in their 20s and 30s who were diagnosed with primary gastric cancer at 4 hospitals were enrolled. Their clinical characteristics and prognosis were evaluated.Results: The total number of patients was 72. The median age was 36 years, and the ratio of males to females was 1:1. The dominant histological type was undifferentiated type (66/72, 92%). Helicobacter pylori (H. pylori) was positive in 81% (54/67). Although there were some asymptomatic patients in stages I-III, all stage IV patients had some clinical symptoms at the diagnosis. The percentage of stage IV was significantly higher in patients in their 20s than in those in their 30s (75% vs. 25%, P < 0.001). The Kaplan-Meier method showed that the overall survival of patients in their 20s was significantly lower than that of patients in their 30s (P = 0.037).Conclusions: A high rate of H. pylori infection was revealed in young gastric cancer patients. The patients in their 20s had a worse prognosis than those in their 30s. We should consider examining the H. pylori infection status for young patients as well as older patients to identify high-risk populations. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented about protein-losing enteropathy.

Background: The Japan Gastroenterological Endoscopy Society updated its guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment in July 2012. However, the safety of endoscopic procedures in antithrombotic drug users has not been fully investigated.Aims: To evaluate the safety of upper gastrointestinal endoscopic procedures in antithrombotic drug users.Methods: From September 2013 to September 2015, patients who were taking antithrombotic drugs and who underwent upper gastrointestinal endoscopic procedures were prospectively enrolled at five hospitals. Incidences of bleeding and thrombosis during endoscopic procedures were evaluated.Results: A total of 270 patients [221 for endoscopic mucosal biopsy and 49 for endoscopic mucosal resection (EMR)/endoscopic submucosal dissection (ESD) were enrolled. The bleeding rate was 0.9% for endoscopic mucosal biopsy and 22% for EMR/ESD, respectively. The bleeding rate after endoscopic mucosal biopsy was not significantly high, even if antithrombotic drugs were continued (0 vs. 1%, P > 0.99), while it was significantly higher among multiple antithrombotic drug users than single drug users (5.9 vs. 0%, P < 0.05). The bleeding rate after EMR/ESD was also higher among multiple antithrombotic drug users than single drug users, but was not significantly different (33 vs. 14%, P = 0.17). Moreover, there were no differences in bleeding rates according to the cessation or continuance of antithrombotic drugs (20 vs. 25%, P = 0.74). There were no thromboembolisms in all cases.Conclusions: Upper gastrointestinal endoscopic procedures performed under the new guidelines appear acceptable. However, endoscopic procedures among multiple antithrombotic drug users show a greater potential for bleeding. [ABSTRACT FROM AUTHOR]

Background/Aims: Two studies have reported on the superiority of a proton pump inhibitor (PPI) compared with a histamine-2-receptor antagonist for the treatment of artificial ulcers after endoscopic submucosal dissection (ESD), but the optimal dose of PPI remains to be defined. The aim of this study was to evaluate the possibility of reducing the dose of PPI. The authors thus compared 30 mg (standard-dose) and 15 mg (half-dose) lansoprazole in terms of ulcer healing, prevention of bleeding and quality of life. Methods: 91 patients with gastric mucosal neoplasm were enrolled. All patients who underwent ESD were administered lansoprazole 30 mg daily during the first week, after which they were randomly assigned to either the standard-dose or half-dose group. Results: One patient in each group developed hematemesis. The stage of ulcers, ulcer reduction ratios and scores on the Gastrointestinal Symptom Rating Scale did not differ at 28 and 56 days. The costs of PPI for the half-dose group and standard-dose group were 7,326.5 and 11,698.4 JPY, respectively, i.e. a difference of 471.9 JPY. Conclusions: A reduced dose of PPI after 1 week of ESD was equivalent in treatment performance to the standard dose and cheaper. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

OBJECTIVES:The narrow-band imaging (NBI) system is a novel technology that enhances the visualization of microvasculature and mucosal patterns. The aim of this study was to assess the reliability of the NBI system for esophageal cancer screening in patients with head and neck cancers.METHODS:A total of 142 patients with head and neck squamous cell carcinoma (SCC) were examined by NBI endoscopy, followed by Lugol chromoendoscopy between April 2006 and June 2008 at the Okayama University Hospital, Okayama, Japan. Detection of SCC and high-grade intraepithelial neoplasia (HGIN) was conducted.RESULTS:The median age of the patients was 64 years (range: 29–86 years), and approximately three-fourths of all the patients were male. In total, 21 superficial lesions in 16 patients were detected by NBI endoscopy. Of these, 4 lesions were diagnosed histologically as SCC and 11 lesions as HGIN. An additional 22 Lugol-voiding lesions ≥5 mm were detected in 19 patients by Lugol chromoendoscopy. Although 1 of these lesions was diagnosed as HGIN, 21 lesions were diagnosed as low-grade intraepithelial neoplasia or lesions without atypical findings. The sensitivity of NBI endoscopy for detecting esophageal SCC and HGIN was 90.9% (95% confidence interval (CI), 58.7–99.8), specificity was 95.4% (95% CI, 90.3–98.3), and accuracy was 95.1% (95% CI, 90.1–98.0).CONCLUSIONS:NBI seems to be useful and reliable for screening for esophageal SCC in patients with head and neck cancers. [ABSTRACT FROM AUTHOR]

Background and Aim: Recent endoscopic imaging techniques for recognition of unclear lesions in the stomach (e.g. narrow band imaging, magnifying endoscopy) require special equipment and therefore are not commonly used. The aim of the present study was to estimate the accuracy of a new chromoendoscopic method using an acetic acid–indigo carmine mixture (AIM) in diagnosing early gastric cancers (EGC). Methods: Studied were 108 EGC lesions in 104 patients. EGC were initially observed by white light (WL) after which indigo carmine (IC) solution was sprinkled onto the gastric mucosa. Images by WL and IC observation were recorded by a digital filing system. After washing away IC solution with water, AIM solution was sprinkled onto the gastric mucosa and images were recorded. Margin lines of EGC determined by each observation were drawn on recorded images by graphic software for comparison with resected specimens. After lines were similarly drawn on images of resected specimens, the extent of the lesions was compared with that determined by endoscopic images. Results: Diagnostic accuracy of WL, IC, and AIM observations were 50.0%, 75.9% and 90.7%, respectively. No adverse events occurred with the AIM method. Conclusions: This chromoendoscopic method can be used to delineate the margin of EGC accurately, easily, safely and inexpensively. [ABSTRACT FROM AUTHOR]

Purpose: Anti-tumor activity can often be enhanced with combination therapy in managing patients with metastatic cancer. However, dose sequence and schedule of delivery can alter the pharmacokinetics, toxicity, and anti-tumor response. Therefore, attention to drug-drug interactions which may be sequence or schedule-dependent are necessary. Docetaxel and topotecan are non-cross-resistance cytotoxic agents with activity in a variety of malignancies. The goal of this study was to determine the maximum tolerated dose of docetaxel and continuous infusion topotecan using two sequences of administration. Experimental design: Patients were randomized to schedule A or B and enrolled in four escalating-dose cohorts. On schedule A, docetaxel was administered over 1 h and followed by topotecan administered over 72 h. On schedule B, topotecan was given as a 72 h continuous infusion followed by a 1 h infusion of docetaxel. While the doses for the docetaxel and topotecan were the same for schedule A and schedule B, the toxicities, and thus the determination of maximum tolerated dose (MTD), were assessed independently. The plasma pharmacokinetic disposition of topotecan and docetaxel were evaluated during the first cycle of each sequence to assess drug interactions. Results: Thirty patients, 20 males and 10 females were evaluable for toxicity and response. Four patients were chemonaive. Mean number cycles given were 3. Grade 3/4 thrombocytopenia and neutropenia were comparable on both schedules, as was the dose-limiting toxicity (DLT) for both schedules. There were no apparent differences in absolute neutrophil count or platelet nadirs between schedules A and B for three of the four cohorts. The principal non-hematologic toxicity was nausea and vomiting. The time of overlap of topotecan lactone or total concentrations and docetaxel concentrations were greater on schedule A as compared with schedule B and was associated with reduced clearance of docetaxel on schedule A as compared to schedule B. However, the mean clearance for docetaxel (18∀16 L h-1 m-2 and 29∀28 L h-1 m-2 on schedules A and B, respectively, and topotecan 16∀10 L h-1 m-2 and 7∀6 L h-1 m-2 on schedules A and B, respectively) were not statistically different (P>0.05). Conclusions: The observed toxicity was not sequence-dependent, despite the observed change in kinetics. Docetaxel and topotecan can be administered with acceptable toxicity at the recommended phase-II dose of docetaxel 60 mg m-2 and topotecan 0.85 mg m-2 day-1×3 days. [ABSTRACT FROM AUTHOR]