Tomoaki Matsumura

Indications for the use of endoscopic mucosal resection for early gastric cancer in Japan: a comparative study with endoscopic submucosal dissection

BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD) has been reported to produce excellent treatment results for early gastric cancer. In terms of lesions that previously met the criteria for endoscopic mucosal resection (EMR), there is now controversy about which of the two methods is superior, and whether the two methods are comparable. PATIENTS AND METHODS A total of 177 patients (202 lesions) with early gastric cancer who met the guidelines for EMR and who underwent either EMR or ESD were studied. The rates of en bloc resection, complete resection, local recurrence, and complications were compared between EMR and ESD. RESULTS The overall en bloc and complete resection rates were lower in patients undergoing EMR than in those undergoing ESD (en bloc: 53.8 % vs. 94.3 %, P < 0.001; complete: 37.5 % vs. 92.6 %, P < 0.001). The overall 5-year recurrence-free rate was lower in the EMR group than in the ESD group (82.5 % vs. 100 %; P < 0.001). However, with regard to the tumor size, the two groups did not differ in en bloc ( P = 1.0) or complete resection rate ( P = 0.8) for tumors < or = 5 mm and in 5-year recurrence-free rate ( P = 0.19) for tumors < or = 10 mm. The mean time required for resection was longer for ESD than for EMR ( P < 0.001). Perforation and bleeding requiring blood transfusion occurred in a small percentage in the ESD group, but in none in the EMR group. CONCLUSION In this study, EMR was comparable to ESD for the millimeter-sized lesions. We suggest that such small lesions might be well suited to treatment with EMR.

Rikkunshito improves the symptoms in patients with functional dyspepsia, accompanied by an increase in the level of plasma ghrelin.

BACKGROUND/AIMS Functional dyspepsia (FD) is a common disease but there is no established treatment. Rikkunshito is a traditional Japanese medicine that is widely used for treating upper gastrointestinal symptoms and its effect on ghrelin is of great interest. The aim of this study was to investigate the effect of rikkunshito on upper gastrointestinal symptoms and the levels of acylated ghrelin (AG) in patients with FD. METHODOLOGY This study was a paralleled, randomized controlled trial. Patients were treated with either rikkunshito (group R) or domperidone (group D) for 4 weeks. The overall change in dyspeptic symptoms was evaluated by the GSRS (Gastrointestinal Symptom Rating Scale) questionnaire score. RESULTS 27 patients were enrolled. There was a significant improvement in dyspeptic symptoms in both groups, based on the GSRS score. AG levels increased significantly in plasma in group R at 2 weeks after treatment (paired t-test, p<0.05). The improvements of reflux (Pearsons correlation test, r=-0.73, p=0.04) and indigestion (r=-0.76, p=0.03) symptoms in group R showed a good correlation with the increase of AG. CONCLUSIONS Rikkunshito improves upper gastrointestinal symptoms in patients with FD, accompanied by an increase in the levels of AG.

Subthalamic deep brain stimulation can improve gastric emptying in Parkinson's disease

It is established that deep brain stimulation of the subthalamic nucleus improves motor function in advanced Parkinsons disease, but its effects on autonomic function remain to be elucidated. The present study was undertaken to investigate the effects of subthalamic deep brain stimulation on gastric emptying. A total of 16 patients with Parkinsons disease who underwent bilateral subthalamic deep brain stimulation were enrolled. Gastric emptying was expressed as the peak time of (13)CO(2) excretion (T(max)) in the (13)C-acetate breath test and was assessed in patients with and without administration of 100-150 mg levodopa/decarboxylase inhibitor before surgery, and with and without subthalamic deep brain stimulation at 3 months post-surgery. The pattern of (13)CO(2) excretion curve was analysed. To evaluate potential factors related to the effect of subthalamic deep brain stimulation on gastric emptying, we also examined the association between gastric emptying, clinical characteristics, the equivalent dose of levodopa and serum ghrelin levels. The peak time of (13)CO(2) excretion (T(max)) values for gastric emptying in patients without and with levodopa/decarboxylase inhibitor treatment were 45.6 ± 22.7 min and 42.5 ± 13.6 min, respectively (P = not significant), thus demonstrating levodopa resistance. The peak time of (13)CO(2) excretion (T(max)) values without and with subthalamic deep brain stimulation after surgery were 44.0 ± 17.5 min and 30.0 ± 12.5 min (P < 0.001), respectively, which showed that subthalamic deep brain stimulation was effective. Simultaneously, the pattern of the (13)CO(2) excretion curve was also significantly improved relative to surgery with no stimulation (P = 0.002), although the difference with and without levodopa/decarboxylase inhibitor was not significant. The difference in peak time of (13)CO(2) excretion (T(max)) values without levodopa/decarboxylase inhibitor before surgery and without levodopa/decarboxylase inhibitor and subthalamic deep brain stimulation after surgery was not significant, although motor dysfunction improved and the levodopa equivalent dose decreased after surgery. There was little association between changes in ghrelin levels (Δghrelin) and changes in T(max) values (ΔT(max)) in the subthalamic deep brain stimulation trial after surgery (r = -0.20), and no association between changes in other characteristics and ΔT(max) post-surgery in the subthalamic deep brain stimulation trial. These results showed that levodopa/decarboxylase inhibitor did not influence gastric emptying and that subthalamic deep brain stimulation can improve the dysfunction in patients with Parkinsons disease possibly by altering the neural system that controls gastrointestinal function after subthalamic deep brain stimulation. This is the first report to show the effectiveness of subthalamic deep brain stimulation on gastrointestinal dysfunction as a non-motor symptom in Parkinsons disease.

Chromoendoscopy with indigo carmine dye added to acetic acid in the diagnosis of gastric neoplasia: a prospective comparative study

BACKGROUND Conventional endoscopy and chromoendoscopy with indigo carmine dye are usually performed for recognizing adequate tumor-negative lateral margins for successful endoscopic resection of gastric neoplasia. However, chromoendoscopy with indigo carmine dye added to acetic acid has not been used for this purpose. OBJECTIVE Our purpose was to compare the diagnostic performance of chromoendoscopy with indigo carmine dye added to acetic acid with that of conventional endoscopy and chromoendoscopy with indigo carmine dye or acetic acid alone. DESIGN Prospective study. SETTING Social Insurance Funabashi Central Hospital. PATIENTS Forty-seven consecutive patients (53 lesions) with early gastric cancer and gastric adenomas who underwent endoscopic submucosal dissection (ESD) from April 2006 to July 2007 were studied. INTERVENTIONS All the lesions were examined by the endoscopic modalities before ESD, and the resected specimens were analyzed histopathologically. MAIN OUTCOME MEASUREMENTS Two endoscopists independently evaluated the diagnostic performance of each image in terms of recognition of tumor borders with reference to macroscopic and histopathologic findings of resected specimens. We also conducted a substudy to assess interobserver variability. RESULTS There was good interobserver agreement between the 2 endoscopists in this study (kappa index = 0.764). The diagnostic performance of chromoendoscopy with indigo carmine dye added to acetic acid was significantly greater than that of any of the other modalities (vs each: P < .005). CONCLUSIONS The diagnostic performance of chromoendoscopy with indigo carmine dye added to acetic acid was better compared with conventional endoscopy and chromoendoscopy by using only indigo carmine dye or acetic acid. The applicability of this method for gastric neoplasia merits further investigation.

Clinical outcomes of endoscopic resection for nonampullary duodenal high-grade dysplasia and intramucosal carcinoma.

This study retrospectively analyzed the clinical outcomes of endoscopic resection of 26 sporadic (i. e., not associated with polyposis syndrome) nonampullary duodenal lesions representing high-grade dysplasia or intramucosal carcinoma (duodenal HGD/IMC) in 23 patients. No severe complications such as perforation were observed, but three cases of delayed bleeding were seen. The use of endoscopic clips significantly decreased the delayed bleeding rate (0/19, 0%) compared with cases in which clips were not used (3/7, 42.9%; P = 0.013, χ2 test). Eighteen lesions (69.2%) were removed by en bloc resection. The follow-up period after resection was 25.5 ± 23.3 months. Two lesions (7.7%) that recurred locally were detected at the first surveillance endoscopy 3 months after resection. These lesions were 22 and 15 mm in size respectively and were resected piecemeal. Endoscopic resection is an effective and safe procedure for treating duodenal HGD/IMC. En bloc resection and prophylactic clip usage are encouraged.

Factors Associated with Inadequate Tissue Yield in EUS-FNA for Gastric SMT

Aims. Our aim was to identify the factors that made the specimens inadequate and nondiagnostic in endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy of suspected submucosal tumors (SMTs). Methods. From August 2001 to October 2009, 47 consecutive patients with subepithelial hypoechoic tumors originating in the fourth sonographic layer of the gastric wall suspected as GIST by standard EUS in Chiba University hospital underwent EUS-FNA for histologic diagnosis. We evaluated patient age, sex, location of lesion, size, pattern of growth in a stomach, and pattern of echography retrospectively. We defined a case of gaining no material or an insufficient material for immunohistological diagnosis as nondiagnostic. Results. The diagnostic yield of EUS-FNA for the diagnosis of gastric SMTs was 74.5%. Multivariate logistic regression analysis identified that age of under 60 years (compared with patients older than 60 years: odds ratio [OR] = 11.91, 95% confidence interval [CI] = 1.761–80.48) and location of SMT at lower third area (compared with upper or middle third area: OR = 10.62, 95% CI = 1.290–87.42) were the predictive factors for inadequate tissue yield in EUS-FNA. Conclusions. The factors associated with inadequate tissue yield in EUS-FNA were younger age and the location of lesion at lower third area in stomach.

Vonoprazan is superior to proton pump inhibitors in healing artificial ulcers of the stomach post-endoscopic submucosal dissection: A propensity score-matching analysis.

Proton pump inhibitors (PPI) are effective at healing artificial ulcers after endoscopic submucosal dissection (ESD) for gastric neoplasms; however, the efficacy of vonoprazan is not completely understood. The aim of the present study was to determine the healing effect of vonoprazan on artificial ulcers post‐gastric ESD relative to PPI.

Efficacy of computed image modification of capsule endoscopy in patients with obscure gastrointestinal bleeding.

AIM To investigate whether flexible spectral color enhancement (FICE) improves diagnostic yields of capsule endoscopy (CE) for obscure gastro-intestinal bleeding (OGIB). METHODS The study subjects consisted of 81 patients. Using FICE, there were three different sets with different wavelengths. Using randomly selected sets of FICE, images of CE were evaluated again by two individuals who were not shown the conventional CE reports and findings. The difference between FICE and conventional imaging was examined. RESULTS The overall diagnostic yields in FICE sets 1, 2, 3 and conventional imaging (48.1%) were 51.9%, 40.7%, 51.9% and 48.1%, respectively, which showed no statistical difference compared to conventional imaging. The total numbers of detected lesions per examination in FICE imaging and conventional imaging were 2.5 ± 2.1 and 1.8 ± 1.7, respectively, which showed a significant difference (P = 0.01). CONCLUSION The diagnostic yield for OGIB is not improved by FICE. However, FICE can detect significantly more small bowel lesions compared to conventional imaging.

Predictive factors of response to intravenous ciclosporin in severe ulcerative colitis: the development of a novel prediction formula

When treating patients with severe ulcerative colitis (UC), accurate prediction of drug efficacy contributes to early clinical decision‐making.

Predictive factor of re‐bleeding after negative capsule endoscopy for obscure gastrointestinal bleeding: Over 1‐year follow‐up study

Capsule endoscopy (CE) is now widely accepted as a first‐line diagnostic modality for obscure gastrointestinal bleeding (OGIB), with a high diagnostic yield compared to other modalities. However, even after negative CE examination, re‐bleeding is often known to occur. The aim of the present study was to identify predictive factors of re‐bleeding after negative CE, and to clarify the clinical utility of double‐balloon enteroscopy (DBE) after negative CE for OGIB.