Sho Suzuki

The Efficacy and Tolerability of a Triple Therapy Containing a Potassium-Competitive Acid Blocker Compared With a 7-Day PPI-Based Low-Dose Clarithromycin Triple Therapy.

OBJECTIVES:This study evaluated the efficacy and tolerability of potassium-competitive acid blocker (P-CAB), a new class of gastric acid inhibitory agents, as first-line H. pylori eradication treatment compared with 7-day proton pump inhibitor (PPI)-based triple therapy.METHODS:We retrospectively reviewed the medical records of 661 consecutive patients who received first-line H. pylori eradication treatment between January 2013 and October 2015. Patients who received 7-day P-CAB therapy (vonoprazan 20 mg+amoxicillin 750 mg+clarithromycin 200 mg twice/day; n=181) were compared with those who received 7-day PPI therapy (lansoprazole 30 mg/rabeprazole 20 mg+amoxicillin 750 mg+clarithromycin 200 mg twice/day; n=480) using propensity score matching analysis. The successful eradication and adverse event rates were compared between the two groups.RESULTS:The propensity score matching analysis yielded 175 matched pairs. Adjusted comparisons between the two groups showed a significantly higher eradication rate for the P-CAB than the PPI group in both intention-to-treat (89.1 vs. 70.9%; P<0.001) and per-protocol analyses (91.2 vs. 71.7%; P<0.001). There was no significant difference in the incidence of adverse events between the two therapies except skin rash. No patients discontinued H. pylori eradication treatment because of adverse events.CONCLUSIONS:Seven-day P-CAB-based triple therapy was more effective than 7-day PPI-based triple therapy as a first-line H. pylori eradication treatment. Seven-day P-CAB-based triple therapy was generally well-tolerated.

Risk factors for bleeding after endoscopic submucosal dissection of colorectal neoplasms

AIM To investigate the risk factors for delayed bleeding following endoscopic submucosal dissection (ESD) treatment for colorectal neoplasms. METHODS We retrospectively reviewed the medical records of 317 consecutive patients with 325 lesions who underwent ESD for superficial colorectal neoplasms at our hospital from January 2009 to June 2013. Delayed post-ESD bleeding was defined as bleeding that resulted in overt hematochezia 6 h to 30 d after ESD and the observation of bleeding spots as confirmed by repeat colonoscopy or a required blood transfusion. We analyzed the relationship between risk factors for delayed bleeding following ESD and the following factors using univariate and multivariate analyses: age, gender, presence of comorbidities, use of antithrombotic drugs, use of intravenous heparin, resected specimen size, lesion size, lesion location, lesion morphology, lesion histology, the device used, procedure time, and the presence of significant bleeding during ESD. RESULTS Delayed post-ESD bleeding was found in 14 lesions from 14 patients (4.3% of all specimens, 4.4% patients). Patients with episodes of delayed post-ESD bleeding had a mean hemoglobin decrease of 2.35 g/dL. All episodes were treated successfully using endoscopic hemostatic clips. Emergency surgery was not required in any of the cases. Blood transfusion was needed in 1 patient (0.3%). Univariate analysis revealed that lesions located in the cecum (P = 0.012) and the presence of significant bleeding during ESD (P = 0.024) were significantly associated with delayed post-ESD bleeding. The risk of delayed bleeding was higher for larger lesion sizes, but this trend was not statistically significant. Multivariate analysis revealed that lesions located in the cecum (OR = 7.26, 95%CI: 1.99-26.55, P = 0.003) and the presence of significant bleeding during ESD (OR = 16.41, 95%CI: 2.60-103.68, P = 0.003) were independent risk factors for delayed post-ESD bleeding. CONCLUSION Location in the cecum and significant bleeding during ESD predispose patients to delayed post-procedural bleeding. Therefore, careful and additional management is recommended for these patients.

Morphologic and Histologic Changes in Gastric Adenomas After Helicobacter pylori Eradication: A Long‐Term Prospective Analysis

Helicobacter pylori infection causes gastric neoplasia via development of chronic atrophic gastritis and intestinal metaplasia. The effect of H. pylori eradication on pre‐existing gastric neoplasias is still controversial. The aim of this study was to use long‐term observation to clarify morphologic and histologic changes in gastric adenomas following H. pylori eradication.

Ultrasound-guided vs endoscopic ultrasound-guided fine-needle aspiration for pancreatic cancer diagnosis

AIM To clarify the effectiveness and safety of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for the diagnosis of pancreatic cancer (PC). METHODS Patients who were diagnosed with unresectable, locally advanced or metastatic PC between February 2006 and September 2011 were selected for this retrospective study. FNA biopsy for pancreatic tumors had been performed percutaneously under extracorporeal ultrasound guidance until October 2009; then, beginning in November 2009, EUS-FNA has been performed. We reviewed the complete medical records of all patients who met the selection criteria for the following data: sex, age, location and size of the targeted tumor, histological and/or cytological findings, details of puncture procedures, time from day of puncture until day of definitive diagnosis, and details of severe adverse events. RESULTS Of the 121 patients who met the selection criteria, 46 had a percutaneous biopsy (Group A) and 75 had an EUS-FNA biopsy (Group B). Adequate cytological specimens were obtained in 42 Group A patients (91.3%) and all 75 Group B patients (P = 0.0192), and histological specimens were obtained in 41 Group A patients (89.1%) and 65 Group B patients (86.7%). Diagnosis of malignancy by cytology was positive in 33 Group A patients (78.6%) and 72 Group B patients (94.6%) (P = 0.0079). Malignancy by both cytology and pathology was found in 43 Group A (93.5%) and 73 Group B (97.3%) patients. The mean period from the puncture until the cytological diagnosis in Group B was 1.7 d, which was significantly shorter than that in Group A (4.1 d) (P < 0.0001). Severe adverse events were experienced in two Group A patients (4.3%) and in one Group B patient (1.3%). CONCLUSION EUS-FNA, as well as percutaneous needle aspiration, is an effective modality to obtain cytopathological confirmation in patients with advanced PC.

Underwater endoscopic mucosal resection for superficial nonampullary duodenal adenomas

BACKGROUND AND STUDY AIM Underwater endoscopic mucosal resection (UEMR) was recently developed in a Western country. A prospective cohort study to investigate the effectiveness of UEMR was conducted in patients with small superficial nonampullary duodenal adenomas. PATIENTS AND METHODS Patients with duodenal adenomas ≤ 20 mm were enrolled. After the duodenal lumen had been filled with physiological saline, UEMR was performed without submucosal injection. Endoclip closure was attempted for all mucosal defects after UEMR. Follow-up endoscopy with biopsy was performed 3 months later. The primary end point was the complete resection rate, defined as neither endoscopic nor histological residue of adenoma at the follow-up endoscopy. RESULTS 30 patients with 31 lesions were enrolled. The mean (SD) tumor size was 12.0 mm (7.3). The complete resection rate was 97 % (90 % confidence interval, 87 % - 99 %). The en bloc resection rate was 87 %. All mucosal defects were successfully closed by endoclips. No adverse events occurred except for one case of mild aspiration pneumonia. CONCLUSIONS UEMR is efficacious for the treatment of small duodenal adenomas, but further large-scale trials are warranted to confirm these results.

Efficacy and Safety of Endoscopic Resection Followed by Chemoradiotherapy for Superficial Esophageal Squamous Cell Carcinoma: A Retrospective Study.

OBJECTIVES: The reported 1‐ and 3‐year overall survival rates after esophagectomy for stage I superficial esophageal squamous cell carcinoma (SESCC) are 95–97% and 86%, and those after definitive chemoradiotherapy (CRT) are 98% and 89%, respectively. This study was performed to elucidate the efficacy and safety of another treatment option for SESCC: endoscopic resection (ER) followed by CRT. METHODS: We retrospectively reviewed the overall survival, recurrence, and grade ≥3 adverse events of consecutive patients who refused esophagectomy and underwent ER followed by CRT for SESCC from 1 January 2006 to 31 December 2012. RESULTS: In total, 66 patients with SESCC underwent ER followed by CRT during the study period, and complete follow‐up data were available for all patients. The median age was 67 (range, 45–82) years, and the median observation period was 51 (range, 7–103) months. Local and metastatic recurrences occurred in 2 (3%) and 6 (9%) patients, respectively, and 17 (26%) patients died. The 1‐, 3‐, and 5‐year overall survival rates were 98%, 87%, and 75%, respectively. One of the 23 patients with mucosal cancer and 5 of 43 with submucosal cancer developed metastatic recurrences (P=0.65). Five of the 61 patients with negative vertical resection margin and 1 of 5 with positive vertical resection margin developed metastatic recurrences (P=0.39). None of the 30 patients without lymphovascular involvement developed metastatic recurrences; however, 6 of 36 patients with lymphovascular involvement developed metastatic recurrences (P=0.0098). Grade ≥3 adverse events occurred in 21 (32%) patients and all adverse events were associated with CRT, hematological adverse events in 13 (20%), and non‐hematological adverse events in 9 (14%). CONCLUSIONS: ER followed by CRT provides survival comparable with that of esophagectomy or definitive CRT and has a low local recurrence rate. A particularly favorable outcome is expected for cancers without lymphovascular involvement.

Clinical impact of endoscopy position detecting unit (UPD-3) for a non-sedated colonoscopy.

AIM To evaluate whether an endoscopy position detecting unit (UPD-3) can improve cecal intubation rates, cecal intubation times and visual analog scale (VAS) pain scores, regardless of the colonoscopists level of experience. METHODS A total of 260 patients (170 men and 90 women) who underwent a colonoscopy were divided into the UPD-3-guided group or the conventional group (no UPD-3 guidance). Colonoscopies were performed by experts (experience of more than 1000 colonoscopies) or trainees (experience of less than 100 colonoscopies). Cecal intubation rates, cecal intubation times, insertion methods (straight insertion: shortening the colonic fold through the bending technique; roping insertion: right turn shortening technique) and patient discomfort were assessed. Patient discomfort during the endoscope insertion was scored by the VAS that was divided into 6 degrees of pain. RESULTS The cecum intubation rates, cecal intubation times, number of cecal intubations that were performed in < 15 min and insertion methods were not significantly different between the conventional group and the UPD-3-guided group. The number of patients who experienced pain during the insertion was markedly less in the UPD-3-guided group than in the conventional group. Univariate and multivariate analysis showed that the following factors were associated with lower VAS pain scores during endoscope insertion: insertion method (straight insertion) and UPD-3 guidance in the trainee group. For the experts group, univariate analysis showed that only the insertion method (straight insertion) was associated with lower VAS pain scores. CONCLUSION Although UPD-3 guidance did not shorten intubation times, it resulted in less patient pain during endoscope insertion compared with conventional endoscopy for the procedures performed by trainees.

Reasonable decision of anesthesia methods in patients who underwent endoscopic submucosal dissection for superficial esophageal carcinoma: A retrospective analysis in a single Japanese institution

BACKGROUND/AIMS Despite being a valuable therapeutic option, it has not yet been reported whether endoscopic submucosal dissection (ESD) for superficial esophageal carcinoma should be performed under general or non-general anesthesia (sedation). MATERIALS AND METHODS The clinicopathological factors (age, sex, histology, tumor size, tumor location, tumor macroscopic morphology, and adverse events) of 110 superficial esophageal carcinoma lesions (98 patients) treated by ESD at a single Japanese institution from January 2007 to December 2013 were retrospectively reviewed using medical records. RESULTS Among 110 lesions, 94 lesions were resected under general anesthesia, and 16 lesions were resected under non-general anesthesia by an experienced endoscopist. Although the number of complications was 12 in the group of general anesthesia and 1 in sedated patients, no significant differences between both groups were found in the incidence of adverse events (total adverse events: 12.2% versus 1.02%, p=0.456; mediastinal emphysema: 11.2% versus 1.02%, p=0.518; pulmonary atelectasis: 1.02% versus 0%, p=0.679). All of the events could be managed conservatively. CONCLUSION For ordered management of accidental events during esophageal ESD, general anesthesia might be a crucial option for a better clinical outcome even when administered by non-experienced operators.

Technical feasibility of line-assisted complete closure technique for large mucosal defects after colorectal endoscopic submucosal dissection

Background and study aims Complete closure of large mucosal defects after colorectal endoscopic submucosal dissection (C-ESD) is considered impossible in most cases because of the limited width of the open clip. We therefore invented a simple closure technique using clip-and-line, named “line-assisted complete closure (LACC)”, and assessed its technical feasibility. Patients and methods Between January and February 2016, we performed LACC in 11 patients after C-ESD and included them in this retrospective feasibility study. Outcome measures were procedural success rate, procedure time, and post-procedural complications. Results The median size of the resected specimen was 36 mm (range 30 – 72 mm). Procedural success was achieved in 10 of 11 cases (91 %). Those 10 cases required a median of 9 endoclips (range 6 – 12) for complete closure. Median procedure time for LACC was 14 minutes (range 6 – 22). No complications were observed in any of the cases after the procedure. Conclusion LACC is a simple and feasible technique for complete closure of large mucosal defects after C-ESD.

Clinical Backgrounds and Outcomes of Elderly Japanese Patients with Gastrointestinal Bleeding.

OBJECTIVE Elderly gastrointestinal bleeding (GIB) patients sometimes cannot be discharged home. In some cases, they die after hemostasis, even following appropriate treatment. This study investigates the clinical backgrounds and outcomes of elderly Japanese GIB patients. METHODS The medical records of 185 patients (123 men, 62 women; mean age 68.2 years; range 10-99 years) with GIB symptoms who underwent esophagogastroduodenoscopy or colonoscopy to detect or treat the source of GIB were retrospectively reviewed. We compared the outcomes between patients ≤70 (n=85) and >70 (n=100) years. The clinical backgrounds of the patients who died or changed hospitals to undergo rehabilitation or receive palliative care were evaluated, as were the association of four factors with these poor outcomes: GIB (re-bleeding or uncontrolled bleeding), endoscopic procedure-related complications, exacerbation of the pre-existing comorbidity, and any complications that were not directly related to GIB. RESULTS Of the patients ≤70 and >70 years of age, three (3.5%) and 17 (17.0%), respectively, were transferred to another hospital (p=0.003). One (1.2%) and five (5.0%), respectively, died (p=0.144). All three patients ≤70 years old that changed hospitals did so because their comorbidities became worse. The reasons for changing hospitals in the 17 patients >70 years of age included exacerbation of a pre-existing comorbidity (41.1%, 7/17), other complications (35.4%, 6/17), GIB itself (17.6%, 3/17), and endoscopic procedure-related complications (5.9%, 1/17). CONCLUSION Although non-elderly and elderly GIB patients had similar mortality rates, many more elderly patients could not be discharged home for various reasons.