Tatsuya Toyokawa

Risk factors for perforation and delayed bleeding associated with endoscopic submucosal dissection for early gastric neoplasms: Analysis of 1123 lesions

Background and Aim:  Endoscopic submucosal dissection (ESD) is a useful procedure for the treatment of early gastric neoplasms; however, this advanced technique has also resulted in an increase in serious complications such as perforation and delayed bleeding. This study aimed to elucidate the risk factors for these complications.

Eradication of Helicobacter pylori infection improved gastric mucosal atrophy and prevented progression of intestinal metaplasia, especially in the elderly population: a long-term prospective cohort study.

Background and Aims:  It still remains controversial whether gastric mucosal atrophy and intestinal metaplasia are reversible after eradication of Helicobacter pylori infection. The aims of this study were to evaluate the histological changes in gastric mucosa after H. pylori eradication during long‐term follow‐up periods, and to verify the propriety of H. pylori eradication for the elderly population.

Partial splenic embolization prior to combination therapy of interferon and ribavirin in chronic hepatitis C patients with thrombocytopenia

Aim:  A low platelet count leads to dose reduction of interferon (IFN) and is associated with failure to achieve a sustained virological response (SVR) in chronic hepatitis C patients. However, partial splenic embolization (PSE) is effective for treating thrombocytopenia resulting from hypersplenism.

Endoscopic submucosal dissection for cancers of the remnant stomach after distal gastrectomy

BACKGROUND Endoscopic submucosal dissection (ESD) of early gastric cancer is less invasive than surgical resection, and if technically feasible, it may result in less long-term morbidity than does incisional surgery. However, ESD is technically difficult in patients who have had a previous distal gastrectomy. OBJECTIVE Our purpose was to retrospectively assess the results of ESD of early gastric cancer in the remnant stomach. DESIGN Case series. SETTING AND PATIENTS A total of 31 lesions in 30 patients with early remnant gastric cancer were treated with ESD at Okayama University Hospital, Tsuyama Central Hospital, Hiroshima City Hospital, Kagawa Prefectural Central Hospital, and Mitoyo General Hospital from March 2001 to January 2007. INTERVENTION ESD. MAIN OUTCOME MEASUREMENTS En bloc resection rate, complete resection rate, operation time, and complications. RESULTS En bloc resection and complete resection were achieved in 30 (97%) and in 23 (74%) lesions, respectively. The median operation time required for ESD in the remnant stomach was 113 minutes (range 45-450 minutes). Perforation occurred in 4 (13%). The incidence of delayed bleeding requiring blood transfusion was 0%. LIMITATION Short duration of follow-up. CONCLUSIONS ESD is feasible in the remnant stomach but has a relatively high complication rate and should only be performed by experienced endoscopists.

Clinical outcomes of ESD for early gastric neoplasms in elderly patients

Eur J Clin Invest 2011; 41 (5): 474–478

Serum Antibodies to Helicobacter pylori and its Heat-Shock Protein 60 Correlate with the Response of Gastric Mucosa-Associated Lymphoid Tissue Lymphoma to Eradication of H. pylori

Background and aims.  Eradication of Helicobacter pylori leads to regression of mucosa‐associated lymphoid tissue (MALT) lymphomas. In this study, we measured serum antibodies to H. pylori and H. pylori‐recombinant heat‐shock protein 60 (rHSP60) in patients with gastric MALT lymphoma to determine whether humoral immune responses to the bacterial antigens correlate with the efficacy of eradication therapy.

Large waist circumference is a risk factor for reflux esophagitis in Japanese males.

Background/Aims: The prevalence of reflux esophagitis, which might lead to development of Barrett’s esophagus and esophageal adenocarcinoma, has been increasing. The aim of this study was to assess risk factors for reflux esophagitis. Methods: We conducted a cross-sectional study of 1,495 Japanese subjects undergoing health checkups (822 males and 673 females; median age 50 years) at a tertiary care center. Results: One hundred and twenty-seven subjects (8%) had reflux esophagitis and hiatal hernia was observed in 292 subjects (20%). Reflux esophagitis (13 vs. 3%) and hiatal hernia (28 vs. 9%) were more frequent in males than females. Significant differences in clinical backgrounds were observed between females and males. Multivariate logistic regression analyses revealed that hiatal hernia (OR 6.63, 95% CI 2.47–17.8; p = 0.0002) was associated with reflux esophagitis in females. In males, age (per 1-year increment: OR 0.96, 95% CI 0.94–0.99; p = 0.007), hiatal hernia (OR 3.16, 95% CI 2.05–4.87; p < 0.0001) and waist circumference (per 1-cm increase: OR 1.09, 95% CI 1.02–1.15; p = 0.006) were associated with reflux esophagitis. Conclusions: Abdominal obesity may be an important risk factor for reflux esophagitis in males compared with females.

Dual therapy for third-line Helicobacter pylori eradication and urea breath test prediction.

We evaluated the efficacy and tolerability of a dual therapy with rabeprazole and amoxicillin (AMX) as an empiric third-line rescue therapy. In patients with failure of first-line treatment with a proton pump inhibitor (PPI)-AMX-clarithromycin regimen and second-line treatment with the PPI-AMX-metronidazole regimen, a third-line eradication regimen with rabeprazole (10 mg q.i.d.) and AMX (500 mg q.i.d.) was prescribed for 2 wk. Eradication was confirmed by the results of the ¹³C-urea breath test (UBT) at 12 wk after the therapy. A total of 46 patients were included; however, two were lost to follow-up. The eradication rates as determined by per-protocol and intention-to-treat analyses were 65.9% and 63.0%, respectively. The pretreatment UBT results in the subjects showing eradication failure; those patients showing successful eradication comprised 32.9 ± 28.8 permil and 14.8 ± 12.8 permil, respectively. The pretreatment UBT results in the subjects with eradication failure were significantly higher than those in the patients with successful eradication (P = 0.019). A low pretreatment UBT result (≤ 28.5 permil) predicted the success of the eradication therapy with a positive predictive value of 81.3% and a sensitivity of 89.7%. Adverse effects were reported in 18.2% of the patients, mainly diarrhea and stomatitis. Dual therapy with rabeprazole and AMX appears to serve as a potential empirical third-line strategy for patients with low values on pretreatment UBT.

Risk factors for non-curative resection of early gastric neoplasms with endoscopic submucosal dissection: Analysis of 1,123 lesions

Although the frequency of residual disease and recurrence following endoscopic submucosal dissection (ESD) has markedly decreased, a few cases of residual disease and recurrence following ESD are still observed. The aims of the present study were to clarify the causes of non-curative resection and to investigate the risk factors. A total of 1,123 early gastric neoplasm lesions treated by ESD were investigated. Non-curative resection was defined as histological positivity of the resected margins, vascular invasion or failure of en bloc resection. Cases of non-curative resection were classified as being caused by one of three reasons: Inadequate technique, pre-procedural misdiagnosis or problems in the histological diagnosis. Following classification, the cases of non-curative and curative resection were compared based on a range of patient characteristics: Procedure time, and size, type and location of the lesions. The frequency of non-curative resection was 16% (182 lesions). Non-curative resection occurred due to inadequate technique in 59 cases, pre-procedural misdiagnosis in 88 cases and problems in the histological diagnosis in 35 cases. Multivariate analysis revealed that a large lesion size, long procedure time and inexperienced endoscopist were associated with a significantly higher risk of non-curative resection due to an inadequate technique. Furthermore, it was found that lesions located in the upper area of the stomach and cancer with submucosal invasion were associated with a significantly higher risk of non-curative resection due to pre-procedural misdiagnosis. In conclusion, the present study has shown that the major reasons for non-curative resection are an inadequate technique and pre-procedural misdiagnosis. The risk factors for these problems have been clarified.

Influence of Helicobacter pylori eradication on reflux esophagitis in Japanese patients.

The relationship between Helicobacter pylori eradication and reflux esophagitis is controversial. We analyzed the development of reflux esophagitis and the change in the grade of pre-existing reflux esophagitis after eradication. Enrolled were 559 Japanese patients who received eradication therapy for H. pylori. The grade of reflux esophagitis by endoscopy before and after therapy was evaluated retrospectively. No esophagitis was present before eradication in 526 patients. H. pylori was and was not eradicated in 429 and 97, respectively. Reflux esophagitis developed in 40 of the eradication group and in three of the treatment failure group, with prevalence higher with successful eradication (P = 0.04). Successful eradication and hiatus hernia were significant risk factors for reflux esophagitis development. Twenty-seven of 33 patients with pre-existing reflux esophagitis had successful eradication and six treatment failure. The reflux esophagitis grade worsened in two (Los Angeles classification from A to B) and improved in 14 patients after eradication. With treatment failure, reflux esophagitis worsened in none and improved in three patients. There showed no significant change in the grade of pre-existing reflux esophagitis after H. pylori eradication but the sample size was too small to evaluate the difference. In conclusion, the eradication of H. pylori increases the prevalence of reflux esophagitis, and hiatus hernia was a significant risk factor for the development of reflux esophagitis.