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Introduction: Few studies have focused on bleeding following endoscopic submucosal dissection (ESD) in surgically altered stomach. We aimed to reveal the bleeding risk in surgically altered stomach following ESD for early gastric cancer (EGC). Methods: We enrolled patients with ESD for EGC at 33 institutions between 2013 and 2016. In study 1, we evaluated bleeding risk following ESD in surgically altered stomach, compared with whole stomach. In study 2, we evaluated factors associated with bleeding following ESD in patients with surgically altered stomach. Results: Of 11,452 patients, 445 patients had surgically altered stomach with the bleeding rate following ESD of 4.9%. In study 1, the bleeding risk in surgically altered stomach was not significant (odds ratio [OR], 1.37; 95% confidence interval [CI], 0.87–2.17) in the multivariate logistic regression analysis. No significant results were obtained when the surgically altered stomach was subdivided into various types. In study 2, the multivariate logistic regression analysis revealed that independent risk factors for bleeding following ESD were ischemic heart disease (OR, 7.52; 95% CI, 2.00–28.25) and P2Y12 receptor antagonist (OR, 4.81; 95% CI, 1.21–19.14). Discussion/Conclusion: In this nationwide study, we found that the bleeding risk of surgically altered stomach following ESD for EGC did not significantly differ from that of whole stomach. The risk factors for ESD in patients with surgically altered stomach were ischemic heart disease and P2Y12 receptor antagonist.

Introduction: Although endocytoscopy (EC) with narrow-band imaging (NBI) is effective in diagnosing gastric cancer, no diagnostic system has been validated. We explored a specific diagnostic system for gastric cancer using EC with NBI. Methods: Equal numbers of images from cancerous and noncancerous areas (114 images each) were assessed by endoscopists with (development group: 33) and without (validation group: 28) specific training in magnifying endoscopy with NBI. Microvascular and microsurface patterns (MS) in each image were evaluated. Lesions were diagnosed as cancerous when patterns were deemed “irregular.” The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of a diagnosis according to patterns on EC with NBI (microvascular pattern [MV] alone, MS alone, and both) were evaluated and compared between groups to determine the diagnostic performance. Results: In the development and validation groups, diagnoses based on the MV alone had significantly higher accuracy (91.7% vs. 76.3%, p < 0.0001 and 92.5% vs. 67.5%, p < 0.0001, respectively) and sensitivity (88.6% vs. 68.3%, p < 0.0001 and 89.5% vs. 38.6%, p < 0.0001, respectively) than those based on the MS alone. In both groups, there were no significant differences in diagnostic accuracy between using the MV alone and both patterns. Discussion/Conclusion: Evaluation of the MV alone is a simple and accurate diagnostic method for gastric cancer. This system could find widespread applications in clinical practice.

Introduction: Curative rates of endoscopic treatment for undifferentiated-type early gastric cancer (EGC), particularly mixed poorly differentiated adenocarcinoma (MIXED-POR), are lower than those of endoscopic treatment for the differentiated type. Magnifying endoscopy with narrow-band imaging (ME-NBI) is useful for diagnoses of the histological type. This study aimed to investigate the detection rates of MIXED-POR among undifferentiated-type EGCs using biopsy and ME-NBI in order to improve curative rates through endoscopic treatment. Methods: We analyzed 267 lesions initially subjected to endoscopic submucosal resection (ESD) and histologically diagnosed as undifferentiated-type EGCs between July 2005 and December 2016 at our hospital. We obtained written informed consent from all participants. Biopsy and ME-NBI findings were compared to distinguish pure signet ring cell carcinoma (PURE-SIG) and MIXED-POR. ME-NBI findings were divided into 2 categories depending on the presence of irregular vessels. Results of biopsy and ME-NBI (combination method) were also analyzed, and detection rates of MIXED-POR and PURE-SIG were evaluated in terms of sensitivity, specificity, and accuracy. Results: Overall, 114 lesions were analyzed. Fifty-eight lesions (50.9%) were identified as MIXED-POR. With biopsy, the detection rate of MIXED-POR was significantly lower than that of PURE-SIG (p < 0.0001). ME-NBI detected significantly more MIXED-POR with irregular vessels than PURE-SIG (p < 0.0001). The combination method could detect significantly more MIXED-POR than PURE-SIG (p < 0.0001). The sensitivity and accuracy for MIXED-POR diagnosis were significantly higher with the combination method than with biopsy alone (p < 0.0001). Discussion/Conclusion: Combining biopsy and ME-NBI improved the accuracy of pretreatment diagnosis before ESD in undifferentiated-type cancer.

Introduction: We aimed to investigate the safety and efficacy of self-expandable metallic stent (SEMS) placement in patients with prior radiotherapy (RT) using the Niti-S stent, which is characterized by low radial force, in comparison to patients without prior RT. Methods: A consecutive series of 83 patients who were treated by SEMS placement using Niti-S stent for severe malignant esophageal obstruction or fistula were enrolled. The adverse event rates and efficacy were retrospectively compared between patients with/without prior RT before SEMS placement (RT group [n = 32] versus non-RT group [n = 51]). Results: The incidence rate of major adverse events in the RT group was 6.3% and was not significantly different from that in the non-RT group (5.9%, p = 0.95). Among the RT group, 84.4% were able to resume oral intake within a median of 2 days. Among the patients with fistula, 78.6% could resume oral intake and survive for 73 days after SEMS placement. Cox proportional hazard regression analysis identified significant factors affecting overall survival to be prior RT (hazard ratio [HR]: 1.96), low performance status (HR: 3.87), and subsequent anticancer treatment after SEMS placement (HR: 0.41). However, compared to the non-RT group, the RT group had received longer duration of anticancer treatment before SEMS placement and a lower rate of subsequent anticancer treatment after SEMS placement. Conclusions: With the Niti-S stent, the incidence of major adverse events was sufficiently low even for patients after RT. SEMS with low radial force would be an effective palliative treatment option for patients, regardless of prior RT.

Background: In recent years, effective outcomes of endoscopic submucosal dissection (ESD) for esophagogastric junction cancer including short-segment Barrett’s esophagus (SSBE) cancer have been reported. However, the efficacy of ESD for long-segment Barrett’s esophagus (LSBE) cancer is unknown. Aim: To clarify the treatment outcomes of ESD for LSBE cancer versus SSBE cancer. Methods: A total of 86 patients with 91 superficial Barrett’s esophageal adenocarcinomas who underwent ESD were enrolled; of these, 68 had underlying SSBE and 18 had LSBE. Procedure outcomes and prognosis were compared. Results: There was no significant difference in age and tumor diameter among patients. The only complication observed was stricture, but it was not significant (2 vs. 9%). No significant difference was observed in the negative horizontal margin rates (94.1 vs. 95.7%), R0 resection rates (83.8 vs. 82.6%), curative resection rates (72.1 vs. 73.9%), and noncurative factors. Both LSBE and SSBE cancer showed favorable 3-year overall survival rates (95.0 vs. 94.4%) in the median observation period of 28.5 months. Conclusions: ESD for LSBE cancer achieved procedure outcomes and short-term prognosis comparable to SSBE. ESD has the potential to be an effective therapeutic option for esophageal neoplasms in patients with LSBE.

Background: The factors associated with the pathogenesis of Helicobacter pylori-uninfected undifferentiated-type early gastric cancer (HPUGC) remain unclear. This study compared patient characteristics, including medical history and alcohol/tobacco use, of HPUGC patients with characteristics of patients with H. pylori-positive undifferentiated-type early gastric cancer (HPPGC) to clarify and gain understanding on those differences that could play a role in the pathogenesis. Methods: This retrospective study included 282 patients who were treated endoscopically from March 2005 to March 2014. This cohort consisted of 232 patients with HPPGC (82.3%) and 50 patients with HPUGC (17.7%). Patient characteristics were analyzed by subgroups of HPUGC vs. HPPGC, with comparisons for age, gender, cancer history, comorbidity of lifestyle diseases requiring medication (hypertension, type 2 diabetes, and dyslipidemia), cumulative amount of alcohol consumption, and smoking history (Brinkman index [BI]). Results: HPUGC patients were typically younger, had less frequent hypertension, and had higher BI values (p < 0.05 for all parameters). In a younger non-hypertensive subgroup, the OR for high BI (BI ≥340) in the HPUGC group vs. HPPGC group was 5.049 (95% CI 2.458–10.373, p < 0.0001). Conclusions: The investigation of clinical factors identified smoking history as being possibly contributing to the pathogenesis of HPUGC. Future research is necessary at the cellular and genetic levels.

Background and Aims: Endoscopic submucosal dissection (ESD) is a well-established minimally invasive treatment for early gastric cancer. To heal ESD-induced ulcers, we commonly prescribe proton pump inhibitors (PPIs). Vonoprazan is our new choice, which is reported to have a stronger and longer acid inhibitory effect than existing PPIs. Here, we aimed to evaluate the efficacy of vonoprazan for healing ESD-induced ulcers compared with rabeprazole. Methods: We reviewed 190 patients who underwent ESD before and after we switched the acid secretion inhibitor from rabeprazole to vonoprazan. We evaluated scarring and reduction rates at 4 weeks after ESD. Results: Scarring rates were not different between vonoprazan and rabeprazole (31.7 vs. 18.9%; p = 0.07). However, for ulcers ≤35 mm, vonoprazan was superior to rabeprazole (42.2 vs. 19.2%; p < 0.05). Reduction rates were superior for vonoprazan compared with rabeprazole (93.0 vs. 90.4%; p < 0.05). In multivariate analysis, vonoprazan was superior to rabeprazole for ulcer scarring (OR 2.21; p < 0.05), and ulcer location in the lower-third of the stomach had higher risk of incomplete scarring (OR 0.37; p < 0.05). Conclusion: Vonoprazan was superior to rabeprazole for healing ESD-induced ulcers.

The factors associated with the pathogenesis of Helicobacter pylori-uninfected undifferentiated-type early gastric cancer (HPUGC) remain unclear. This study compared patient characteristics, including medical history and alcohol/tobacco use, of HPUGC patients with characteristics of patients with H. pylori-positive undifferentiated-type early gastric cancer (HPPGC) to clarify and gain understanding on those differences that could play a role in the pathogenesis.This retrospective study included 282 patients who were treated endoscopically from March 2005 to March 2014. This cohort consisted of 232 patients with HPPGC (82.3%) and 50 patients with HPUGC (17.7%). Patient characteristics were analyzed by subgroups of HPUGC vs. HPPGC, with comparisons for age, gender, cancer history, comorbidity of lifestyle diseases requiring medication (hypertension, type 2 diabetes, and dyslipidemia), cumulative amount of alcohol consumption, and smoking history (Brinkman index [BI]).HPUGC patients were typically younger, had less frequent hypertension, and had higher BI values (p 0.05 for all parameters). In a younger non-hypertensive subgroup, the OR for high BI (BI ≥340) in the HPUGC group vs. HPPGC group was 5.049 (95% CI 2.458-10.373, p 0.0001).The investigation of clinical factors identified smoking history as being possibly contributing to the pathogenesis of HPUGC. Future research is necessary at the cellular and genetic levels.