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OBJECTIVES Guidelines for magnified endoscopic diagnosis of esophageal squamous cell carcinoma (SCC) have been proposed by the Japan Esophageal Society. Type B1, B2, and B3 reflect increasing tumor invasion depths (within mucosal epithelium or into lamina propria mucosa [T1a-EP/LPM], into muscularis mucosa or superficial invasion into submucosa [T1a-MM/T1b-SM1], and into submucosa [T1b-SM2], respectively). The diagnostic accuracy of type B1 and B3 is high, but accuracy of type B2 is low. We aimed to improve the diagnostic accuracy of type B2. METHODS We retrospectively reviewed 248 SCC lesions treated with endoscopic submucosal dissection between January 2012 and July 2018 and identified the B2 lesions. The maximum diameter of the area presenting B2 was measured and evaluated in relation to tumor invasion, for which receiver-operating characteristic (ROC) curves were generated. The optimal area size for distinguishing T1a-EP/LPM from T1a-MM or deeper invasion was determined. RESULTS There were 78 lesions with B2, of which 26 (33%) were T1a-MM or T1b-SM1 SCCs. ROC curve analysis indicated that the optimal cut-off for the target area showing B2 was 4 mm. The invasion depth (EP/LPM: MM/SM1: SM2) of B2 observed in an area with a diameter

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for early gastric carcinoma. Vitamin K antagonists and direct oral anticoagulants (DOAC) were reported to increase the risk of delayed bleeding after ESD. However, the evaluation of ESD cases taking anticoagulants is scarce. We analyzed the risk and characteristics of delayed bleeding after gastric ESD in patients on anticoagulants.We performed a retrospective observational study at a single center. Consecutive patients who underwent ESD for early gastric carcinoma and took anticoagulants, including warfarin, rivaroxaban, dabigatran, apixaban, and edoxaban, between January 2012 and December 2018, were analyzed. We also calculated delayed bleeding rates for those without anticoagulants.Of 1855 eligible patients who underwent gastric ESDs, 143 took anticoagulants. Delayed bleeding occurred in 30 (21.0%) cases taking anticoagulants, with 15 (19.5%) cases in the DOAC group [rivaroxaban, seven cases (21.2%); dabigatran, four cases (20.0%); apixaban, four cases (23.5%); and edoxaban, zero cases (0%)] and 15 cases (22.7%) in the warfarin group. Furthermore, 43/344 (12.5%) patients taking antiplatelets and 76/1368 (5.6%) patients without antithrombic drugs experienced delayed bleeding. Multivariable logistic analysis revealed post-heart valve replacement (OR, 6.56; 95% CI, 1.75-24.7;Anticoagulants were associated with a high incidence of severe delayed bleeding. Careful attention should be paid to patients on anticoagulants after gastric ESD, especially those on warfarin after heart valve replacement.

Background and Aim Recent studies have reported the usefulness of preoperative endoscopic ultrasonography-guided fiducial tattooing (EUS-tattooing) of the pancreas. However, problems of proper procedure, including markers and amounts, have not been resolved. The aim of the present study was to evaluate the feasibility of EUS-tattooing with a minuscule amount of marking solution using a new injector. Methods Six consecutive patients who underwent EUS-tattooing between June 2013 and April 2015 at our center were retrospectively analyzed (mean age, 60.7 years; males, 4). A 25-gauge needle was inserted into the surface of the pancreas near the tumor with EUS guidance. Then, 0.02 mL marking solution was injected three to five times (maximal total amount was defined as 0.1 mL). The marking solution used in this study was a compound of aqueous solution of sodium hyaluronate and India ink with proportions of 4 to 1. The newly developed injector for precise injection of minuscule amount of solution was used. Results All six patients were successfully injected with the intended amount of marking solution. The tattoo mark was easily detected during surgery and localized in a small area in five patients. In one patient, however, the tattoo mark was not detected during surgery. There were no adverse events, including bleeding, perforation, and acute pancreatitis, by EUS-tattooing. Conclusions EUS-tattooing with a minuscule amount of marking solution using the newly developed injector was feasible and seemed useful and relatively safe. Further studies are warranted to confirm the safety and efficacy of EUS-tattooing.

Endoscopic submucosal dissection (ESD) is technically one of the most complicated endoscopic procedures. Traction methods have been reported to be effective for ESD. A recent study revealed that the S–O clip allowed faster and safer colonic ESD. We assessed the efficacy and safety of gastric ESD with the S–O clip for gastric epithelial neoplasm. We performed a retrospective cohort study of patients treated for gastric ESD using the S–O clip between September and November 2016 (SO group, n = 48). The subjects were matched with patients treated with conventional gastric ESD from September 2015 to August 2016 (control group, n = 258) at Sendai Kousei Hospital, a tertiary endoscopic center. The primary outcome was procedure time. Multivariate logistic regression and propensity score matching analyses were performed to reduce the effects of selection bias for potential confounding factors differences like age, sex, lesion location, lesion position, presence of ulcer scarring, resected specimen size, and operator experiences. Forty-eight pairs were created after propensity score matching. The mean procedure time (including the S–O clip attachment time) was significantly shorter in the SO group (47.2 ± 24.6 vs. 69.2 ± 67.1 min, p = 0.035). The mean clip attachment time was 4.4 (range 2–15) min. There were no significant differences in other treatment outcomes (en-bloc resection rate: 100 vs. 100%, p = 1.000; perforation rate: 0 vs. 2.1%, p = 0.315; delayed bleeding rate: 2.1 vs. 4.3%, p = 0.558). The S–O clip improved the speed of gastric ESD by approximately 25%, without increasing adverse events.

A 56-year-old woman who was found to have a submucosal tumor (SMT) of the stomach in a medical check-up was admitted to our hospital for a detailed investigation of the SMT. Upper gastrointestinal endoscopy revealed an SMT of 20mm at the anterior wall of the antrum of the stomach. Endoscopic ultrasonography showed a hyperechoic tumor in the fourth layer of the stomach wall. CT examination showed a strongly enhancing tumor on arterial phase images and persistent enhancement on portal venous phase images. Laparoscopy endoscopy cooperative surgery was performed with a diagnosis of SMT of the stomach highly suspicious of a glomus tumor. Immunohistochemistry revealed expression of α-SMA but no expression of desmin, c-kit, CD34, or S-100. The tumor was finally diagnosed as a glomus tumor of the stomach.

The relationship between dilated blood vessels in the tumor periphery and the tumor invasion depth is unclear. Therefore, the present study aimed to clarify the relationship between dilated blood vessels and the invasion depth of small-sized (

Recent studies have reported the usefulness of preoperative endoscopic ultrasonography-guided fiducial tattooing (EUS-tattooing) of the pancreas. However, problems of proper procedure, including markers and amounts, have not been resolved. The aim of the present study was to evaluate the feasibility of EUS-tattooing with a minuscule amount of marking solution using a new injector.Six consecutive patients who underwent EUS-tattooing between June 2013 and April 2015 at our center were retrospectively analyzed (mean age, 60.7 years; males, 4). A 25-gauge needle was inserted into the surface of the pancreas near the tumor with EUS guidance. Then, 0.02 mL marking solution was injected three to five times (maximal total amount was defined as 0.1 mL). The marking solution used in this study was a compound of aqueous solution of sodium hyaluronate and India ink with proportions of 4 to 1. The newly developed injector for precise injection of minuscule amount of solution was used.All six patients were successfully injected with the intended amount of marking solution. The tattoo mark was easily detected during surgery and localized in a small area in five patients. In one patient, however, the tattoo mark was not detected during surgery. There were no adverse events, including bleeding, perforation, and acute pancreatitis, by EUS-tattooing.EUS-tattooing with a minuscule amount of marking solution using the newly developed injector was feasible and seemed useful and relatively safe. Further studies are warranted to confirm the safety and efficacy of EUS-tattooing.

A 59-year-old man was orally administered rabeprazole, a proton pump inhibitor (PPI), for gastroesophageal reflux disease, after which he gradually developed iron-deficiency anemia. The anemia did not improve following the administration of ferrous fumarate, and endoscopic screening of the entire gastrointestinal tract, including the small intestine, did not reveal any findings indicating the cause of the anemia. The patient was then switched from rabeprazole to famotidine and the anemia was cured within three months. There is much debate as to whether the long-term use of PPIs causes iron-deficiency. However, this case strongly suggests that PPIs can induce iron-deficiency anemia.

Histological diagnosis of upper gastrointestinal submucosal tumors (SMT) is a prerequisite for selecting the proper therapeutic approach. EUS-FNA has improved the evaluation of SMT. Endoscopic biopsy by mucosal incision (EBM) is a diagnostic procedure developed by Yokohata et al. The principal aim of this study was to examine the potential of EBM, as an alternative to the more expensive and technically-demanding EUS-FNA, in diagnosing SMT. This retrospective study included a consecutive series of 27 patients (15 males and 12 females, mean age 60.1 years) undergoing EBM and 11 patients (7 males and 4 females, mean age 65.7 years) undergoing EUS-FNA. The tumors had diameters of 15 mm or more, and were suspicious for continuity with the fourth layer as determined by EUS. We compared the diagnostic accuracy and the operating time of EBM with those of EUS-FNA. Results: The diagnostic accuracies of EBM and EUS-FNA were 85.2% (23/27) and 90.0% (9/10) respectively. The average operating time of EBM and EUS-FNA was 20 min and 41.0 min respectively. During our investigation no major complications were encountered in either group. Conclusion: EBM matches EUS-FNA in diagnostic accuracy of SMT and is more time and cost-efficient. Keywords: Submucosal tumor (SMT), Gastrointestinal stromal tumor (GIST), Leiomyoma, Schwannoma, Endoscopic biopsy by mucosal incision (EBM), EUS-FNA, Video

We conducted this study to clarify the effectiveness of aspiration endoscopic mucosal resection (EMR) using a cap-fitted scope for early gastric cancer in the C and M regions of the stomach. EMR was performed in 111 early gastric cancer patients with 123 lesions in the C and M regions. The patients were divided into three groups. The EMR-1CS group consisted of patients who had undergone EMR with a one-channeled scope, the EMR-2CS group those who had received EMR in which a two-channeled scope was utilized. The EMRC group consisted of patients who had undergone aspiration EMR with a cap-fitted scope. The rate of complete resection improved to a statistically significant degree in the EMRC group in comparison with that in the EMR-1CS group. In type lie, a statistically significant improvement was achieved in the EMRC group in comparison with the EMR-2CS group. In the M region or in lesions 10 mm or less in diameter, the rate of complete resection improved in the EMRC group as compared with that in the EMR-2CS group. Our results suggest that EMRC is useful for lesions of early gastric cancer in the C and M regions.

Preoperative endoscopic ultrasonography (EUS) was performed in 272 patients with advanced gastric cancer who underwent gastrectomy between December 1986 and December 1993. We divided the subjects into two groups: group A consisted of patients whose stomachs were filled with water for the EUS examination (water-filling method: 1986.12–1992. 10) and group B of patients in whom EUS was performed with the water-filled balloon compression method (balloon-compression method) in addition to the water-filling method (1992.11–1993. 12). A comparative study of EUS diagnostic efficacy, as regards the depth of invasion, was made between group A and group B. The following results were obtained: 1) In group A, the depth of invasion of mass-forming type carcinoma was accurately diagnosed by EUS in 59.3% of patients with mp cancer, in 28.8% of those with ss cancer, in 78.8% of those with se cancer, and in 83.3% of those with si cancer. The accuracy rate in diagnosing the depth of invasion of wall-thickening type carcinoma was 46.2% in patients with mp cancer, 68.0% in those with ss cancer, 59.1% in those with se cancer, and 66.7% in those with si cancer. 2) In group B, the depth of invasion of mass-forming type carcinoma was accurately diagnosed by EUS in 70.6% of patients with mp cancer, in 68.4% of those with ss cancer, in 92.3% of those with se cancer, and in 100% of those with si cancer. The accuracy rate in diagnosing the depth of invasion of wall-thickening type carcinoma was 75.0% in patients with mp cancer, 72.7% in those with ss cancer, 76.5% in those with se cancer, and 100% in those with si cancer. 3) These results suggest that the diagnostic efficacy of EUS utilizing both the balloon-compression method and the water-filling method is greater, as regards the depth of advanced gastric cancer invasion, than EUS utilizing only the water-filling method.

Endoscopic biliary drainage (EBD) is usually performed after endoscopic sphincterotomy (EST). In some patients, however, EBD without EST, so-called nonEST-EBD, is also effective. Thirty-four patients treated from 1983 to the present, were investigated to estimate the usefulness, safety, and drawbacks of nonEST-EBD. First, the reasons for adopting nonEST-EBD were reviewed in each patient. The most common reason was to reduce jaundice so as to preserve the function of the papilla of Vater in patients with choledocholithiasis who were to undergo surgery. However, such patients were treated in the early period of the investigation, and most would have undergone EST just after endoscopic retrograde cholangiography (ERC), had they been treated more recently. The most important reason, at present, was, thus, to avoid bleeding in patients with general or local hemorrhagic diathesis, who accounted for 20.6% (7/34 of our subjects). Next, the effect of drainage was examined. Drainage in seven patients was judged to be excellent, while that in 15 patients was determined to be effective. In 10 patients without jaundice, nonEST-EBD was performed to prevent jaundice. Therefore, in 91.7% of patients (22/24), nonEST-EBD was considered to be useful. Changes in the serum amylase level were investigated to estimate the safety of nonEST-EBD. Twenty-seven patients with nonEST-EBD, in whom the serum amylase level was within normal limits before treatment, and 57 patients with EBD after EST were evaluated. No statistically significant difference was recognized between these two groups in the degree of serum amylase elevation after drainage. NonEST-EBD is concluded to be an effective and safe method of reducing jaundice, if appropriate patients are selected.

This randomized controlled clinical trial was designed to compare the safety and effectiveness of different sequences of treatment with cisplatin (CDDP) and 5-fluorouracil (5-FU) in patients with unresectable advanced and post-operative recurrent gastric cancer. Patients with unresectable advanced or post-operative recurrent gastric cancer were randomly assigned by a registration center to group A or B. Group A received CDDP (80 mg/m(2)) as a continuous 2-h intravenous infusion on day 1 and 5-FU (700 mg/m(2)) as a continuous intravenous infusion on days 2-5. Group B was given 5-FU (700 mg/m(2)) as a continuous intravenous infusion on days 1-4, followed by CDDP (80 mg/m(2)) as a continuous 2-h intravenous infusion on day 5. Each course of chemotherapy was repeated every 28 days. A total of 74 patients were enrolled. One patient died accidentally, and 5 could not be evaluated. Response was assessable in 68 patients. The response rate was 31.3% (10/32) in group A as compared with 13.9% (5/36) in group B. Although the response rate was higher in Group A, the difference was not significant (p=0.085). The response rate in patients with diffuse type tumors was significantly lower in group B. There was no difference between the groups in response among patients with intestinal type tumors. The median overall survival was 239 and 174 days and time to progression was 175 and 140 days in group A and group B, respectively. Although there were trends toward longer survival and time to progression in group A, the differences between the groups were not statistically significant. There was also no difference in the type or incidence of adverse reactions. The results of this controlled study indicate that the overall response rate was slightly but not significantly higher in patients who received CDDP before 5-FU. Among patients with diffuse type tumors, the response rate was significantly lower when 5-FU was administered before CDDP. Our results suggest that CDDP should be given before 5-FU in patients with gastric cancer when treated with a combination of CDDP and 5-FU.