Shinji Nagata

Clinicopathologic features and endoscopic resection of early primary nonampullary duodenal carcinoma.

Early primary nonampullary duodenal carcinoma is an extremely rare disease with poorly defined clinicopathologic features; early detection of this carcinoma is not common. To clarify the clinicopathologic characteristics of early primary nonampullary duodenal carcinoma and retrospectively analyze methods of treatment. Seventeen early duodenal carcinomas identified between 1994 and 2001 in 15 patients were studied. Lesions were divided into 2 groups: sporadic carcinoma (10 cases in 10 patients) and familial adenomatous polyposis associated carcinoma (7 cases in 5 patients). Clinicopathologic features and methods of treatment were compared between groups. The mean age of patients with sporadic carcinoma (63.8 years) was significantly higher than that of patients with FAP-associated carcinoma (34.9 years). The incidence of sporadic carcinoma was significantly higher in men that in women (M:F ratio 9:1); the difference between sexes in the incidence of FAP-associated carcinoma (1:4) was not significant. There was no significant difference between both groups in relation to tumor size, location, gross appearance, or histopathology. Thirteen of the duodenal tumors were treated by endoscopic mucosal resection (EMR), two by polypectomy, and two by open surgery. Complications were encountered in 1 of 15 cases (6%); local bleeding occurred after one EMR, but hemostasis was achieved endoscopically. The mean follow-up period for all patients was 51.7 months. No patients experienced recurrence after resection. The significant differences between patients with sporadic and those with early FAP-associated duodenal carcinoma were in age and sex. Endoscopic resection appears to be a safe and efficient treatment of carefully selected patients with early primary nonampullary duodenal carcinoma.

Diagnosis of invasion depth in early colorectal carcinoma by pit pattern analysis with magnifying endoscopy

Background: The aim of this study was to clarify whether various pit patterns on the surface of colorectal tumors are associated with various levels of submucosal invasion.

ENDOSCOPIC HEMOSTASIS OF GASTRIC ULCER BLEEDING BY HEMOSTATIC FORCEPS COAGULATION

Endoscopic submucosal dissection (ESD) for early gastric carcinoma has been widely performed in Japan. In this technique, when hemorrhaging from vessels is observed, the bleeding point is coagulated using hemostatic forceps with the soft coagulation. There have been reports that using hemostatic forceps with soft coagulation is a safe and effective method of controlling upper gastrointestinal ulcer bleeding. However, there have been no reports regarding the comparative effectiveness of hemostatic forceps and clipping in upper gastrointestinal ulcer bleeding. Between April 2003 and December 2008, a total of 124 patients with gastric ulcer bleeding causing melena or hematochezia were treated with endoscopic hemostasis in our hospital. Two endoscopic hemostatic methods were used for different groups of patients: coagulation with hemostatic forceps was used for Group A and clipping was used for Group B. The rate of additional treatment required after the initial procedure was 28.6% (8/28) for Group A and 79.2% (76/96) for Group B, indicating a significantly lower rate for Group A than that for Group B (P < 0.01). Additional treatment consists of a hypertonic saline epinephrine injection. The rebleeding rate was 3.6% (1/28) for Group A and 8.3% (8/96) for Group B, again indicating a lower rate for Group A than for Group B. Finally, successful endoscopic hemostasis was 100% in both groups. Using the soft coagulation mode of hemostatic forceps is shown to be a safe, easy and effective method of controlling gastric ulcer bleeding in relation to clipping.

CURRENT MANAGEMENTS AND OUTCOMES OF PEPTIC AND ARTIFICIAL ULCER BLEEDING IN JAPAN

The recent trend of gastroduodenal ulcer bleeding in Japan has not been elucidated in detail and the data for a new categorized type, artificial ulcer bleeding, is completely lacking. The purpose of this paper is to elucidate current managements and outcomes of peptic and artificial ulcer bleeding in Japan. A retrospective multicenter study of consecutive case series was carried out during one year at nine departments of high‐volume hospitals in Japan. The study included 325 consecutive patients (239 with peptic ulcers and 86 with artificial ulcers) with bleeding nonmalignant gastroduodenal ulcers that were revealed by emergency endoscopy between January 2008 and December 2008. Hemostasis was carried out mainly using endoscopic treatments. Rates of successful initial hemostasis, rebleeding, transfer to surgery, and death were recorded according to peptic and artificial ulcer bleeding. Additionally, preferred endoscopic methods, concomitant use of antisecretory drugs, and timing of second‐look endoscopy were also measured. A total of 227 (99.1%) of 229 peptic ulcer patients with endoscopic treatment and all (100%) 84 artificial ulcer patients underwent successful tentative hemostasis. Rebleeding occurred in 23 peptic ulcer patients (10.1%) and 10 artificial ulcer patients (11.9%). One peptic ulcer patient and two artificial ulcer patients had final surgical rescue due to rebleeding. No death was observed. Monotherapy was predominant (around 65% of cases) in both types of ulcers. The coagulation forceps method was more frequently applied in artificial ulcers (P < 0.05). A per oral proton pump inhibitor was more frequently used in artificial ulcers (P < 0.05), although an intravenous proton pump inhibitor was used in the majority of patients in both types of ulcers. The frequency of second‐look endoscopy in peptic ulcers (88%) was significantly higher than that in artificial ulcers (71%) (P < 0.05). There seemed to be no rule as to the timing of second‐look endoscopy, although it was most frequently performed on the day after hemostasis. The recent outcomes of endoscopic treatment for nonmalignant gastroduodenal bleeding in Japan were excellent in both peptic and artificial ulcers with similar efficacies. Although they were minor findings, some differences in applied endoscopic methods, concomitant use of antisecretory drugs, and presence of second‐look endoscopy were observed.

RETROSPECTIVE MULTICENTER STUDY CONCERNING ELECTROCAUTERY FORCEPS WITH SOFT COAGULATION FOR NONMALIGNANT GASTRODUODENAL ULCER BLEEDING IN JAPAN

Electrocautery forceps with soft coagulation are actively used for treatment of bleeding and nonbleeding visible vessels during endoscopic submucosal dissection, but the usefulness of gastroduodenal ulcer bleeding has not been elucidated so far. The purpose of this paper is to elucidate the outcomes of electrocautery forceps with soft coagulation for peptic and artificial gastroduodenal ulcer bleeding. A retrospective multicenter study of consecutive case series during one year involved nine departments of high‐volume hospitals in Japan. The study included 128 consecutive patients (62 with peptic ulcers and 66 with artificial ulcers) with bleeding nonmalignant gastroduodenal ulcers that were revealed using emergency endoscopy between January 2008 and December 2008. Hemostasis was carried out using electrocautery forceps with soft coagulation. Rates of successful initial hemostasis, rebleeding, transfer to surgery, and death according to peptic and artificial ulcer bleeding were recorded. Successful initial endoscopic hemostasis was obtained in 61 peptic ulcer patients (98.4%) and 66 artificial ulcer patients (100%). Rebleeding was observed in seven peptic ulcer patients (11.5%) and five artificial ulcer patients (7.6%). Rates of successful management with endoscopic methods alone were 96.8% (60/62) and 100% (66/66) in peptic ulcer patients and artificial ulcer patients, respectively. There were no severe complications or deaths related to the management of gastroduodenal ulcer bleeding. The novel endoscopic method using electrocautery forceps with soft coagulation for gastroduodenal ulcer bleeding seems to provide safety and efficacy that is comparable with that of endoscopic hemostasis with other established hemostatic techniques.

Relationship between histopathological features and type V pit pattern determined by magnifying videocolonoscopy in early colorectal carcinoma

Background: The aim of the present study was to clarify the relationship between the histopathological features and type V pit pattern of early colorectal carcinoma.

Advanced colorectal carcinoma smaller than 10 mm in maximum diameter with special reference to clinicopathologic and molecular features: a report of 3 cases

Small, advanced-stage colorectal carcinoma (CRC) is being detected increasingly at routine colonoscopic examination.1,2 However, the frequency of these tumors, although rarely evaluated, may be low, accounting for only 0.05% of all CRCs.1 Small, advanced-stage CRCs have a malignant potential that is equivalent to that of large advanced-stage CRCs.1,2 They are therefore biologically and clinically significant with respect to the development and pathogenesis of CRC. Three cases of advanced-stage CRC, all smaller than 10 mm in maximum diameter, are described. The clinicopathologic characteristics of these cases are presented and assessed.

Evaluation of Individual Risk in Nonvariceal Gastrointestinal Bleeding Patients with NSAID Administration: A Multicenter Study in Japan

Backgrounds: Gastrointestinal (GI) toxicity is an undesirable effect of nonsteroidal anti-inflammatory drugs (NSAIDs). We conducted a multicenter study in Japan to clarify the GI risk grade in patients with NSAID-induced GI bleeding. Methods: Patients with emergent endoscopic hemostasis by nonvariceal bleeding were registered from 36 hospitals in Hiroshima. In cases with NSAID use, the GI risk grade (low, moderate, or high) was evaluated, and concomitant drugs were investigated. We asked 79 gastroenterologists and 234 orthopedists what concomitant drugs they would prescribe to 3 simulated patients. Results: A total of 1,350 patients were registered. NSAIDs were used in 278 cases (21%). Concerning the risk grade in each patient, the largest group was the moderate-risk group (203 patients; 73%), while the high-risk group comprised 10% of all NSAID users with bleeding. A proton pump inhibitor (PPI) or misoprostol was administrated to only 20 patients (7%). A small number of the gastroenterologists and orthopedists who responded to the questionnaire would prescribe PPI or misoprostol to simulated patients with short-term loxoprofen use. Conclusions: In NSAID users with GI bleeding, the moderate-risk group was the largest group for GI toxicity in Japan. In these cases, PPI or misoprostol was not commonly medicated in clinical practice.

Cardiac glands hyperplastic polyp of the stomach

Abstract  Reported herein is a very rare polyp in the gastric cardia of a 49‐year‐old man. He was referred because of a polyp detected by upper gastrointestinal examination in an affiliated hospital. Endoscopic examination revealed a polyp‐like submucosal tumor. Endoscopic ultrasonography revealed minute cystic dilatations and thickening of the submucosal layer. Accordingly, a preliminary diagnosis of cardiac gland hyperplasia was made. The lesion was removed successfully by snare polypectomy. Observed macroscopically, the polyp was 30 mm in diameter and covered with normal gastric mucosa. Examined histologically, the polyp comprised a hyperplastic submucosal cardiac gland.

Randomized study of lafutidine vs lansoprazole in patients with mild gastroesophageal reflux disease.

AIM To compare the clinical efficacy of the second-generation H2RA lafutidine with that of lansoprazole in Japanese patients with mild gastroesophageal reflux disease (GERD). METHODS Patients with symptoms of GERD and a diagnosis of grade A reflux esophagitis (according to the Los Angeles classification) were randomized to receive lafutidine (10 mg, twice daily) or lansoprazole (30 mg, once daily) for an initial 8 wk, followed by maintenance treatment comprising half-doses of the assigned drug for 24 wk. The primary endpoint was the frequency and severity of heartburn during initial and maintenance treatment. The secondary endpoints were the sum score of questions 2 and 3 in the Gastrointestinal Symptom Rating Scale (GSRS), and the satisfaction score. RESULTS Between April 2012 and March 2013, a total of 53 patients were enrolled, of whom 24 and 29 received lafutidine and lansoprazole, respectively. After 8 wk, the frequency and severity of heartburn was significantly reduced in both groups. However, lafutidine was significantly inferior to lansoprazole with regard to the severity of heartburn during initial and maintenance treatment (P = 0.016). The sum score of questions 2 and 3 in the GSRS, and satisfaction scores were also significantly worse in the lafutidine group than the lansoprazole group (P = 0.0068 and P = 0.0048, respectively). CONCLUSION The clinical efficacy of lafutidine was inferior to that of lansoprazole, even in Japanese patients with mild GERD.