Tomohiro Iwai

Pancreatic cystic lesions with atypical steroid response should be carefully managed in cases of autoimmune pancreatitis

Pancreatic cysts have been reported in cases with autoimmune pancreatitis (AIP) and are often treated by corticosteroid; however, their response to steroid has not been determined fully. We aimed to see the incidence and steroid response of pancreatic cysts and the features of cysts without proper response in cases with AIP.

Efficacy of polyglycolic acid sheets and fibrin glue for prevention of bleeding after gastric endoscopic submucosal dissection in patients under continued antithrombotic agents

BackgroundA novel method for the prevention of bleeding after gastric endoscopic submucosal dissection (ESD) is necessary, as the numbers of patients taking antithrombotic agents have increased. This study aimed to assess the efficacy and safety of the covering method using polyglycolic acid (PGA) sheets and fibrin glue for ESD-induced ulcer in preventing post-ESD bleeding in patients under continued antithrombotic agents.MethodsOne hundred five consecutive gastric tumors among 84 patients who were treated by ESD under continued antithrombotic agents between April 2014 and September 2015 were enrolled in this study. The patients were classified into two groups, the covering group (52 lesions among 38 patients; those with ESD in whom PGA sheets and fibrin glue were used as the covering method) and the control group (53 lesions among 46 patients; ESD only), and their post-ESD bleeding rates were compared.ResultsNo significant differences were seen in the number and type of antithrombotic agents, lesion location, median procedure time, and median resected specimen size between the groups. ESD was completed in all cases, with no cases of uncontrollable bleeding during the procedure. Post-ESD bleeding occurred in 5.8% (3/52) and 20.8% (11/53) in the covering and control groups, respectively. The post-ESD bleeding rate significantly differed between the groups (Pxa0=xa00.04; odds ratio, 0.23; 95% confidential interval, 0.06–0.89). No adverse events were associated with the use of PGA sheets and fibrin glue.ConclusionsThe covering method using PGA sheets and fibrin glue has the potential to reduce post-ESD bleeding in patients receiving continued antithrombotic agents.

A simple endoscopic scoring system to differentiate between duodenal adenoma and carcinoma

Background and study aims u2002Diagnosis of nonampullary duodenal low grade adenoma (Vienna classification category 3, VCL 3) and high grade adenoma/carcinoma (VCL 4 or higher) is important for clinical management decisions. However, there are no criteria based on which endoscopic diagnosis can differentiate between VCL3 and VCL4 or higher. This study aimed to establish simple diagnostic criteria to differentiate between VCL3 and VCL4 or higher. Patients and methods u2002This retrospective study included patients with superficial nonampullary duodenal epithelial tumors (NADETs) who underwent tumor resection between June 2004 and November 2016 at a single cancer center hospital. Using patient demographics and endoscopic findings from 2004 to 2013, variables related to the final histology of VCL4 or higher were analyzed, and a predictive model was developed. Validation analysis was performed on patients treated between 2014 and 2016. Results u2002A total of 150 lesions in 134 patients were included. Lesion diameter, reddish color, depression, heterogeneous or no nodularity, and mixed or depressed macroscopic types were significantly predictive of VCL4 or higher. A predictive score model was developed and a score of 3 points was defined as an appropriate cutoff for predicting VCL4 or higher. In the validation analysis, the accuracy rate of VCL4 or higher diagnosis was 86u200a% when the score wasu200a≥u200a3 points. Scores between patients with VCL3 and VCL4 or higher were significantly different ( P u200a=u200a0.0004). Conclusions u2002A simple and useful endoscopic scoring system was developed to preoperatively differentiate between VCL3 and VCL4 or higher among superficial NADETs.

Endoscopic prediction of advanced histology in diminutive and small colorectal polyps: Small polyps with advanced histology

Most polyps detected during colonoscopies are diminutive or small, and they rarely have advanced histology. Real‐time prediction of advanced histology would help clinicians to assess the need for pathological evaluation. Here, we investigated endoscopic predictors of advanced histology in diminutive and small polyps.

Retroperitoneal choriocarcinoma diagnosed by endoscopic ultrasonography-guided fine needle aspiration biopsy

A 25-year-old man, with a retroperitoneal bulky mass invading the posterior pancreas head, was referred to investigate and treat his rapidly advancing disease. An endoscopic ultrasonography guided-fine needle aspiration biopsy (EUS-FNAB), performed the next day, and followed by immunostaining for human chorionic gonadotropin (hCG), led to a histological diagnosis of choriocarcinoma. An elevated level of serum hCG also supported the diagnosis. Systemic chemotherapy by etoposide and cisplatin was initiated within a week, with precautions taken to avoid tumour lysis syndrome and choriocarcinoma syndrome. EUS-FNAB enabled a prompt diagnosis and suitable treatment for choriocarcinoma and was considered as an effective diagnostic tool for rare tumours with rapid progression.

Natural History of Early Gastric Cancer: a Case Report and Literature Review

Early detection and treatment decrease the mortality rate associated with gastric cancer (GC). However, the natural history of GC remains unclear. An 85-year-old woman was referred to our hospital for evaluation of a gastric tumor. Esophagogastroduodenoscopy identified a 6 mm, flat-elevated lesion at the lesser curvature of the antrum. A biopsy specimen showed a well-differentiated tubular adenocarcinoma. The depth of the lesion was estimated to be intramucosal. Although the lesion met the indications for endoscopic resection, periodic endoscopic follow-up was performed due to the patients advanced age and comorbidities. The mucosal GC invaded into the submucosa 3 years later, and finally progressed to advanced cancer 5 years after the initial examination. The patient died of tumor hemorrhage 6.4 years after the initial examination. In this case, mucosal GC progressed to advanced GC, eventually leading to the patients death from GC. Early and appropriate treatment is required to prevent GC-related death.

A Rare Case of Ureteral Carcinoma with Recurrence in the Duodenum Requiring Double Stenting

A 61-year-old man who had undergone total nephrouretectomy eight months earlier for right ureteral carcinoma was referred for the investigation of elevated serum hepatobiliary enzymes. Computed tomography revealed a small mass invading the lower bile duct. Duodenoscopy revealed a central ulcerative tumor near the major papilla, and a biopsy histologically confirmed metastatic ureteral carcinoma. Endoscopic biliary stenting ameliorated the cholangitis, and gemcitabine-based chemotherapy was initiated. The patient was stable for a year until a duodenal stenosis developed and required duodenal stenting. Endoscopic procedures play important roles in the management of rare metastases to the duodenum.

Transpapillary biliary stenting is a risk factor for pancreatic stones in patients with autoimmune pancreatitis

Background and study aim: Pancreatic stones occasionally develop in autoimmune pancreatitis (AIP), often worsen endocrine and exocrine functions, and occasionally cause pain attacks. However, the risks of pancreatic stones in AIP have been poorly studied. The aim of this study was to analyze the risk factors associated with pancreatic stone formation in cases of AIP. Patients and methods: In total, 50 patients with AIP (39 males, 11 females; mean age 64.0 years), followed up for at least a year, were analyzed for their demographic and clinical findings and pancreatic stone occurrence. Results: In total, 50 patients were followed up for an average of 59.7 (12u200a–u200a120) months, with steroid treatment in 44 patients (88u200a%); pancreatic stones occurred in 14 (28u200a%) patients after the diagnosis of AIP and endoscopic treatment was needed in one patient with pain attack. The pancreatic stones appeared only in patients with long follow-up period (Pu200a<u200a0.001, 83.9 months vs. 49.6 months), biliary stenting (odds ratio [OR]: 8.40, Pu200a=u200a0.010), relapse (OR: 6.20, Pu200a=u200a0.023), jaundice (OR: 5.40, Pu200a=u200a0.019), and swelling of the duodenal major papilla (OR: 4.67, Pu200a=u200a0.040). Biliary stenting was placed for an average of 9.9 months in 27 patients. Multivariate analysis revealed a significant association only with biliary stenting (Pu200a=u200a0.011). The stones appeared relatively earlier in patients with stones in the main pancreatic duct or Santorini duct (22.1 months) than in patients where pancreatic stones developed elsewhere (53.4 months) (Pu200a=u200a0.018). Conclusions: The risk of pancreatic stone development should be taken into account when a biliary stent is placed in patients with AIP.