Kenichiro Nakagawa

Comparison of the Long-Term Outcomes of Endoscopic Resection for Superficial Squamous Cell Carcinoma and Adenocarcinoma of the Esophagus in Japan

OBJECTIVES:Few studies have simultaneously evaluated the long-term outcomes of endoscopic resection (ER) for squamous cell carcinoma (SCC) and adenocarcinoma (AC) of the esophagus in Japan. The objective of this study was to evaluate the long-term outcomes of ER for superficial esophageal cancer in consecutive patients.METHODS:This was a retrospective study from a single institution. From April 2001 to June 2012, 204 patients with SCC and 26 patients with AC were included from a total of 355 consecutive patients who were treated by esophageal ER at the Tohoku University Hospital. Patients with submucosal invasion deeper than 200 μm and lymphovascular involvement were excluded. The intervention followed was endoscopic therapy.RESULTS:Overall survival, disease-free survival, and recurrence rates were evaluated as long-term outcomes. In the SCC group, during the median observation time of 36.5 months (range, 6–120 months), 22 (10.8%) patients experienced metachronous recurrence, 4 (2.0%) patients experienced local recurrence, and 27 (13.2%) patients died from causes unrelated to SCC. In the AC group, during the median observation time of 45.5 months (range, 6–131 months), one patient (3.8%) experienced metachronous recurrence and two (7.7%) died from causes unrelated to AC. The cumulative 5-year overall survival rates were not significantly different between SCC (75.9%) and AC (88.9%) (P=0.120). The cumulative 5-year disease-free survival rates of SCC (57.1%) were significantly lower than those of AC (85.2%; P=0.017). The cumulative 5-year recurrence rates of SCC (32.0%) were significantly higher than those of AC (4.2%; P=0.023).CONCLUSIONS:The rate of recurrence after ER was higher in patients with SCC than that in patients with AC. These findings suggest that, by detecting AC of the esophagus earlier, a satisfactory prognosis without recurrence can be expected after ER in Japan, and more rigorous endoscopic follow-up is necessary after ER in patients with SCC than in those with AC.

Endoscopic resection (endoscopic submucosal dissection/endoscopic mucosal resection) for superficial Barrett's esophageal cancer

Recently developed endoscopic resection (endoscopic submucosal dissection [ESD]/ endoscopic mucosal resection) has dramatically changed the therapeutic approach for Barretts esophageal cancer. The rationale for endoscopic resection is that lesions confined to the mucosal layer have negligible risk for developing lymph node metastasis and can be successfully eradicated by endoscopic treatment as a curative treatment with minimal invasiveness. According to some reports that analyzed the rate of lymph‐node involvement relative to the depth of mucosal or submucosal tumor infiltration, endoscopic resection is clearly indicated for intramucosal carcinoma and might be extended to lesions with invasion into the submucosa (<200 μm, sm1) because of the low risk for lymph node metastasis. MostJapanese experts recommend ESD for Barretts esophageal cancer after accurate diagnosis of the margin of cancer using narrow band imaging with magnifying endoscopy because of its high curative rate. However, few studies have evaluated the long‐term outcomes of endoscopic resection for Barretts esophageal cancer in Japan. Further investigations should be conducted to establish endoscopic resection for Barretts esophageal cancer.

Barrett's esophageal cancer in which magnifying narrow‐band imaging was useful for diagnosing extension under the squamous epithelium

A 36‐year‐old man complained of heartburn. Gastrointestinal endoscopies showed a reddish and slightly depressed lesion in the right‐anterior wall of the esophagogastric junction. With white light imaging, the area of the adenocarcinoma under the squamous epithelium was difficult to detect, but a slightly flat, elevated lesion appeared in the area of adenocarcinoma under the squamous epithelium. With narrow‐band imaging (NBI) in the area of the Barretts esophageal cancer under the squamous epithelium, a slight, brownish change could be observed. In addition, with the magnifying technique, irregular mesh‐like vessels were observed, suggesting the presence of differentiatedadenocarcinoma under the squamous epithelium. The lesion was resected en bloc by endoscopic submucosal dissection, and Barretts esophageal cancer under the squamous epithelium was histologically confirmed. In this case, NBI with magnifying endoscopy was very useful to diagnose the extension of Barretts esophageal cancer under the squamous epithelium.

Characteristics of symptomatic reflux episodes in Japanese proton pump inhibitor-refractory non-erosive reflux disease patients

AIM To clarify the pathogenesis of gastroesophageal reflux disease symptoms in non-erosive reflux disease (NERD) patients. METHODS Thirty-five NERD patients with persistent symptoms, despite taking rabeprazole 10 mg twice daily for at least 8 wk, were included in this study. All patients underwent 24 h combined impedance - pH on rabeprazole. The symptom index (SI) was considered to be positive if ≥ 50%, and proximal reflux episodes were determined when reflux reached 15 cm above the proximal margin of the lower esophageal sphincter. RESULTS In 14 (40%) SI-positive patients, with liquid weakly acid reflux, the occurrence rate of reflux symptoms was significantly more frequent in proximal reflux episodes (46.7%) than in distal ones (5.7%) (P < 0.001). With liquid acid reflux, there were no significant differences in the occurrence rate of reflux symptoms between proximal reflux episodes (38.5%) and distal ones (20.5%) (NS). With mixed liquid-gas weakly acid reflux, the occurrence rate of reflux symptoms in proximal reflux episodes was significantly more frequent (31.0%) than in distal reflux ones (3.3%) (P < 0.001). With mixed liquid-gas acid reflux, there were no significant differences in the occurrence rate of reflux symptoms between proximal reflux episodes (29.4%) and distal ones (14.3%) (NS). CONCLUSION The proximal extent of weakly acidic liquid and mixed liquid-gas reflux is a major factor associated with reflux perception in SI-positive patients on proton pump inhibitor therapy.

200ml Rapid Drink Challenge During High Resolution Manometry Predicts Oesophago-Gastric-JunctionObstruction Detected by Timed Barium Oesophagogram with High Sensitivity and Specificity

Introduction In patients with dysphagia, confirmation of obstruction at the oesophago-gastric junction (OGJ) is used to decide further endoscopic or surgical therapy. This is true for both untreated and treated patients with persistent dysphagia. A 200 ml rapid drink challenge (RDC) during high resolution manometry (HRM) may aid diagnosis of oesophageal motility disorders (Marin &Serra NGM 2016). Timed barium oesophagogram (TBO) detects impaired oesophageal emptying of liquids. We hypothesised that O-G pressure parameters during RDC could predict pathologic barium column in TBO. We aimed to assess the ability of RDC to diagnose obstruction at the OGJ in a group of untreated and treated patients with dysphagia. Method 30 patients with dysphagia (mean age 50y) were prospectively included. All patients underwent HRM (Medtronic; Sandhill) with standard protocol plus RDC followed by TBO. HRM analysis was in accordance with the Chicago Classification v3.0. Analysis of RDC included all parameters described by Marin & Serra 2016; cutoff points for each were determined using a ROC curve analysis. During TBO, oesophageal emptying was assessed at minutes 1, 3 and 5. Persistent barium column at 5 min was diagnostic of OGJ obstruction. Results Of 30 patients, 19 patients were untreated; 11 patients were previously treated (5 dilation, 6 myotomy). HRM diagnoses: 3 normal, 23 achalasia (type I=4, II=18, III=1), 1 aperistalsis, 1 distal oesophageal spasm. Overall, the RDC parameter that best predicted OGJ obstruction during TBO was IRP/200 ml (cutoff >17mmHg: sensitivity=75%, specificity=90%). Subgroup analysis: Prediction of obstruction during TBO by the RDC test further improved in the untreated group (sensitivity 100%; specificity 85.5%) but not for the treated group (sensitivity 50%; sensitivity 66%). Abstract PTH-138 Table 1 All patients (n=30) Abstract PTH-138 Table 2a Untreated population (n=19) Abstract PTH-138 Table 2b Treated population (n=11) Conclusion RDC during HRM is a useful adjuvant to improve diagnosis of OGJ obstruction, particularly in untreated dysphagia. Disclosure of Interest S. Sonmez: None Declared, J Arguero: None Declared, J Ooi: None Declared, K Nakagawa: None Declared, E Glasinovic: None Declared, P Woodland: None Declared, E Yazaki: None Declared, D Sifrim Conflict with: Reckitt Benckiser (Hull, UK); Sandhill Scientific (CO, USA)

Esomeprazole inhibits the pentagastrin-stimulated secretion of gastric acid in healthy Japanese volunteers.

Gastroesophageal reflux disease (GERD) is a common disease, in which the reflux of gastric acid causes mucosal damage of the esophagus and/or troublesome symptoms. Esomeprazole, a proton pump inhibitor, has been used for treatment of GERD in Japan since 2011; namely, only little is known about its effect on gastric acid secretion in Japanese. We, therefore, assessed the relationship between dose and timing of esomeprazole administration and gastric acid inhibition in 11 healthy male Japanese volunteers by directly examining gastric acid secretion capacity. In this randomized, open-label, three-way crossover study, the subjects were dosed with esomeprazole 10 mg or 20 mg once a day (q.d.), or 20 mg twice a day (b.i.d.) for 14 days, and pentagastrin-stimulated gastric acid secretion was measured by endoscopic gastrin test. At steady states, gastric acid inhibition rates were significantly higher in esomeprazole 20 mg b.i.d. (median 100.0%, interquartile range [IQR] 99.4-100%, P = 0.027) or 20 mg q.d. (100.0%, IQR 99.7-100%, P = 0.016), compared with 10 mg q.d. (98.4%, IQR 84.4-100%). At trough states, esomeprazole 20 mg b.i.d. showed significantly higher gastric acid inhibition (99.6%, IQR 99.0-100%) than did 20 mg q.d. (84.2%, IQR 76.4-88.8%, P = 0.002) or 10 mg q.d. (64.9%, IQR 59.1-76.7%, P = 0.001). Thus, esomeprazole 20 mg b.i.d. was sufficient to inhibit > 99% gastric acid secretion in healthy subjects. We propose that esomeprazole 20 mg b.i.d. is effective for treating Japanese patients with refractory GERD who require long-lasting gastric acid inhibition.