Hirotsugu Maruyama

Prediction of Poor Response to Modified Neuroleptanalgesia with Midazolam for Endoscopic Submucosal Dissection for Esophageal Squamous Cell Carcinoma

Background/Aims: Modified neuroleptanalgesia (m-NLA) with midazolam is often used for sedation and analgesia during endoscopic submucosal dissection (ESD) for gastrointestinal neoplasia. However, interruption due to poor response to midazolam is often experienced during ESD for esophageal squamous cell carcinoma (ESCC) because most patients with ESCC have a history of heavy alcohol intake. We examined the incidence and risk factors for poor response to m-NLA with midazolam and pethidine hydrochloride. Methods: This retrospective cross-sectional study was conducted at a single institution. Between April 2007 and July 2013, 151 patients with superficial ESCC who underwent ESD under sedation using m-NLA with midazolam and pethidine hydrochloride were enrolled. Poor response to sedation was defined as the use of a second drug when Ramsay Sedation Score 1-2. Results: Poor response to sedation occurred in 66.2% patients. Most cases of poor response were controlled by using additional flunitrazepam. Multivariate logistic regression analysis showed that cumulative alcohol intake and major specimen size were independent risk factors for poor response to sedation (OR 3.63, 95% CI 1.20-10.99, and OR 3.23, 95% CI 1.26-8.25). Conclusion: Our study indicated that cumulative alcohol intake and major specimen size were associated with poor response to m-NLA with midazolam and pethidine hydrochloride.

Celecoxib Oral Administration for Prevention of Post–Endoscopic Retrograde Cholangiopancreatography Pancreatitis: A Randomized Prospective Trial

Objectives Rectal nonsteroidal anti-inflammatory drugs have reported promising prophylactic activity in post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Conversely, cyclooxygenase-2 enzyme has been suggested to contribute to experimental acute pancreatitis. The aim of this study was to evaluate the efficacy of oral administration of celecoxib, a cyclooxygenase-2 inhibitor, for the prevention of PEP. Methods We performed a prospective randomized controlled study. Patients who were scheduled to undergo ERCP were randomized to receive either oral 400-mg celecoxib tablets 1 hour before ERCP and saline infusion (celecoxib group) or saline infusion only (control group). The primary outcome measure was the frequency of PEP. Results A total of 170 patients were randomized; 85 patients each in the celecoxib group and control group were analyzed. After the procedure, 23 patients (13.5%) developed PEP. There was no difference in the frequency of PEP between the 2 groups (control group vs celecoxib group, 15.3% (13/85) vs 11.7% (10/85); P = 0.65). The severity of PEP, asymptomatic hyperamylasemia, and post-ERCP pain were not significantly different between the 2 groups. There were no adverse events related to celecoxib treatment. Conclusions Oral administration of celecoxib had no beneficial preventive effect on PEP.

Heparin-bridging therapy is associated with post-colorectal polypectomy bleeding in patients whose oral anticoagulation therapy is interrupted

Abstract Objectives: The American and Japanese Societies for Gastrointestinal Endoscopy Guidelines recommend heparin-bridging therapy for patients whose oral anticoagulants are interrupted for endoscopic procedures. However, little is known about the potential association between heparin-bridging therapy and post-polypectomy bleeding (PPB). The aim was to investigate the incidence of PPB associated with heparin-bridging therapy administered to patients whose anticoagulants were interrupted. Materials and methods: This was a retrospective observational study using inverse propensity analysis. Between 2013 and 2015, 1004 patients with 2863 lesions were included. The primary outcomes were the rates of PPB and thromboembolism associated with heparin-bridging therapy. The risk factors associated with PPB were identified using multivariate logistic regression analysis involving probability of treatment weighting (IPTW). Results: The patients were categorized into a heparin-bridging therapy group (78 patients with 255 lesions) or a control group (926 patients with 2608 lesions). The PPB rate in the heparin-bridging therapy group (10.2%, 8/78) was significantly higher than in the control group (1.1%, 11/926) (p <.01). Thromboembolism occurred in one patient in the control group. The multivariate analysis revealed that heparin-bridging therapy was an independent risk factor associated with PPB (odds ratio [OR], 8.21; 95% confidence interval [95% CI], 2.32–29.10; p <.01). IPTW showed heparin-bridging therapy increased PPB (OR, 7.68; 95% CI, 1.83–32.28; p <.01). Conclusions: Heparin-bridging therapy administered to patients whose oral anticoagulants were interrupted was associated with an increased PPB risk.

Risk of pancreatitis after pancreatic duct guidewire placement during endoscopic retrograde cholangiopancreatography

Background & aims Advanced techniques have been developed to overcome difficult cannulation cases in endoscopic retrograde cholangiopancreatography (ERCP). Pancreatic duct guidewire placement method (PGW) is performed in difficult cannulation cases; it is possible that it places patients at risk of post-ERCP pancreatitis (PEP). The mechanism of PEP is still unclear, but pancreatic duct pressure and injury of pancreatic duct are known causes of PEP. Therefore, we hypothesized a relationship between pancreatic duct diameter and PEP and predicted that PGW would increase the risk of PEP in patients with non-dilated pancreatic ducts. This study aimed to investigate whether PGW increased the risk of PEP in patients with pancreatic duct diameter ≤ 3 mm. Methods We analyzed 332 patients with pancreatic duct ≤ 3 mm who performed first time ERCP session. The primary endpoint was the rate of adverse event of PEP. We evaluated the risk of PEP in patients who had undergone PGW compared to those who had not, using the inverse probability of treatment weighting (IPTW) analysis. Results PGW was found to be an independent risk factor for PEP by univariate analysis (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.12–5.38; p = 0.03) after IPTW in patients with pancreatic duct diameter ≤ 3 mm. Adjusted for all covariates, PGW remained an independent risk factor for PEP (OR, 3.12; 95% CI, 1.33–7.33; p = 0.01). Conclusion Our results indicate that PGW in patients with pancreatic duct diameter ≤ 3 mm increases the risk of PEP.

Brushing the distal biliary stricture in the surrounding of the papilla increased the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis: A retrospective study using propensity score analysis

Background and aims Brushing cytology is useful for diagnosing biliary strictures. With regard to biliary stricture brushing at the distal common bile duct in the surrounding of the papilla, the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis is unknown. Our study aimed to evaluate the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis by using this procedure. Methods A total of 150 endoscopic retrograde cholangiopancreatography-naïve patients undergoing endoscopic retrograde cholangiopancreatography including biliary stricture brushing were retrospectively analyzed. Patients were divided into two groups: the surrounding of the papilla group (n = 25) and the other group (n = 125). The primary outcome was the post-endoscopic retrograde cholangiopancreatography pancreatitis incidence. We analyzed the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis by using inverse probability of treatment weighting based on propensity scores to adjust for selection bias. Results The overall incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis was 11.3%, and post-endoscopic retrograde cholangiopancreatography pancreatitis of the surrounding of the papilla group occurred significantly more frequently than in the other group (32.0% vs 7.2%, p < 0.01). Multivariate analysis showed that this procedure was a risk factor for post-endoscopic retrograde cholangiopancreatography pancreatitis (odds ratio, 10.6; 95% confidence interval, 2.82–40.2; p < 0.01). In the propensity-weighted model, this procedure was an independent risk factor for post-endoscopic retrograde cholangiopancreatography pancreatitis (odds ratio, 8.42; 95% confidence interval, 2.12–32.4; p < 0.01) by multivariate analysis. Conclusions Biliary stricture brushing at the distal common bile duct in the surrounding of the papilla may increase the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis compared with brushing other portions.

Mo1104 Long-Term Outcome of Endoscopic Submucosal Dissection for Early Gastric Cancer in Patients With Severe Comorbidities: A Comparative Propensity Score Analysis

Background Recently, endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) has been performed on patients with severe comorbidities because it is less invasive, although little is known regarding long-term outcomes. This study aimed to assess the long-term outcomes of ESD for patients with severe and non-severe comorbidities.

Percutaneous cardiopulmonary support as a possible risk factor for symmetrical peripheral gangrene of the toes

on his third toe of the left foot, but histopathological examination of the lesion revealed melanophages but no dysplastic cells. Then, we tried left groin dissection, and resection of the left pelvic and para-aortic lymph nodes as much as possible using the inguinal and pararectal approach. However, a part of the left pelvic and para-aortic lymph nodes, which were swollen, were not removed because of possible nerve injury and excess bleeding. Atypical epithelioid cells, which were positive for HMB-45, were found in the large part of the inguinal, pelvic and para-aortic lymph nodes (Fig. 1c,d). Hence, we considered that the primary lesion on the third toe of the left foot had spontaneously regressed, and malignant melanoma stage IV (pTxpN3M1a) was diagnosed. A combination chemotherapy including CDDP, DTIC, ACNU and tamoxifen (DAC-Tam) was not effective. Next, we performed percutaneous ethanol injection therapy (PEIT) with computed tomography (CT) guidance into the para-aortic nodes once a month in addition to i.d. injection of OK-432 once a week for 3 months (from August to October 2007). As a result, 34% reduction of the long axis of the para-aortic lymph node was achieved. After starting PEIT/OK-432 treatment, white macules appeared on the surgical site on his left inguinal region, thigh and face. Because the patient refused further treatment, no further antitumor therapy was conducted. Positron emission tomography/CT performed in November 2013 showed no accumulation (Fig. 1b). The patient has been healthy, having white macules on his face until February 2014. This case suggests that PEIT/OK-432 treatment after mass reduction surgery becomes an effective treatment for advanced melanoma with para-aortic lymph node metastasis. This finding is well compatible with a previous report which describes the rapid destruction of human melanoma by percutaneous injection of absolute ethanol, and another case report of advanced melanoma successfully treated with OK-432. The underlying mechanism of getting a long-term remission in this patient may be due to induction of anti-melanoma immunity by destruction of melanoma cells in the metastatic lymph nodes. Immunohistochemical study of the metastatic lymph node revealed marked infiltration of CD11band PD-1-positive cells (Fig. 1e–h) around the melanoma cells into the lymph node, supporting the high anti-melanoma immunity in this patient. Now, nivolumab, a new biologic which targets PD-1, is available for the treatment of melanoma, indicating that immunotherapies may improve survival outcomes in melanoma.