Kunihiro Kato

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.

Successful Treatment of Early-Diagnosed Primary Phlegmonous Gastritis.

A 64-year-old man presented with epigastralgia and nausea after an acute exacerbation of chronic pancreatitis. Abdominal computed tomography revealed remarkable thickening of the gastric wall and intramural hypodense areas. Esophagogastroduodenoscopy showed a large gastric ulcer surrounded by an edematous mucosa and mucopus. The results of a culture from a biopsy of the lesion indicated phlegmonous gastritis. The patient was successfully treated with an antibiotic without gastrectomy.

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.

A comparison between capsule endoscopy and double balloon enteroscopy using propensity score-matching analysis in patients with previous obscure gastrointestinal bleeding.

Abstract Background: Recently, diagnosis of obscure gastrointestinal bleeding (OGIB) has improved greatly due to introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE). However, the efficacy of CE over DBE in patients with previous OGIB remains unclear. This study aimed to compare, in terms of diagnostic yield, the efficacy of DBE with that of CE in patients with previous OGIB. Patients and methods: We enrolled 223 consecutive patients with previous OGIB who were treated between May 2007 and March 2012. We retrospectively evaluated the respective diagnostic yields of CE and DBE in patients with previous OGIB using propensity score-matching analysis. We compared the diagnostic yield of CE with that of DBE. Results: The diagnostic yields were 41.9% in DBE group and 11.6% in CE group, respectively (p < .01). On logistic regression analysis, DBE was significantly superior to CE after matching (Odds ratio [OR], 4.25; 95% confidence interval [CI], 1.43–12.6; p < .01), even after adjustment for propensity score (OR, 5.65; 95% CI, 1.56?20.5; p < .01). Conclusions: Our results indicate that DBE might be more useful and perhaps safer than CE in achieving a positive diagnosis in patients with previous OGIB.

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.

Successful treatment of betamethasone syrup on autoimmune esophagitis.

on the ridges of rugae and near the mucosal surface ( Figures 1 and 2 ). Th e majority of vessels contiguous with the ectatic network were of capillary size. Th e ectatic vessels oft en existed within an otherwise intact mucosal capillary bed. Ectatic vessels had occasional direct continuity with deeper arterioles and venules. Th e current three-dimensional studies illustrated and clarifi ed the relation of the ectatic vessels to neighboring vessels of the mucosal capillary network and ruled out the existence of submucosal vascular anomalies. Th e pictorial anatomy presented here may help calibrate the conjectural three-dimensional mental images held by the operator as these and other forms of ectasias are treated endoscopically. Our studies supported previous conceptions of GAVE, by which ectasias emerge within a developmentally normal mucosal vasculature due to a mechanical cause. Presumably, hypercontractility creates or exaggerates not only the abnormally prominent antral folding (and perhaps induces mucosal prolapse) but also generates extraordinary intraluminal pressure within the innermost vessels, those near the mucosal surface and the apices of the folds. Analogous to the pattern of infl ation of a long balloon, high intraluminal pressure would not initially produce prominent dilatation. Yet, once the limits of elastic distensibility were surpassed, focal weakening of the capillary structure would occur at the apical sites at which the pressure exceeded a threshold. Wall tension would increase geometrically (proportional to the fourth power of the increase in the luminal radius) with any increase in wall diameter, according to the law of LaPlace. Th is relationship initiates propagation of the dilatation for considerable distance along the vessel, as long as the wall tension exceeds the elastic threshold, but would not necessarily permit the ectasia to cross the vessel branch points at which distension (and therefore the propagation of the wall tension) may be structurally resisted. Vessel dilatations would not easily propagate beyond the apices of the mucosal fold, as a relatively higher tissue pressure at lower mucosal levels may counterbalance any increase in vascular intraluminal pressure produced by antral contractions. Such a schema would be consistent with the fi ndings of the current study. Th e bulk of the ectasias were superfi cial and readily accessed by luminal interventions. Some features of this examined case, however, may help explain treatment failure and bleeding complications of therapy, especially (1) the minority of vessels that had ectatic extension into some deep mucosal vessels and (2) the partial involvement of gastric rugal valleys and proximal duodenum in the extensive network of ectatic vessels. It seems readily apparent that this progressive ectatic process could continue post therapy among the remaining mucosal vessels, particularly if periodic episodes of high intraluminal pressure, perhaps attributable to hypercontractility, persist.