Yoshiyasu Kono

Propofol sedation with a target-controlled infusion pump and bispectral index monitoring system in elderly patients during a complex upper endoscopy procedure.

BACKGROUND AND AIMS Although the usefulness of propofol sedation during endoscopic submucosal dissection (ESD) for gastric neoplasms was reported previously, information is limited on its use in elderly patients. We investigated the safety and efficacy of propofol sedation with a target-controlled infusion (TCI) pump and bispectral index (BIS) monitoring system (TCI/BIS system) in elderly patients during gastric ESD. METHODS Included were 413 consecutive gastric ESD procedures involving 455 lesions (379 patients) performed in patients under propofol sedation with a TCI/BIS system between October 2009 and September 2013. Patients were divided into 3 groups: group A, age <70 years (n = 162); group B, age ≥70 and <80 years (n = 171); and group C, age ≥80 years (n = 80). We compared the propofol dose and adverse events (eg, hypotension and hypoxemia) during ESD. RESULTS Older groups required a lower target concentration of propofol (group A: median 2.1 μg/mL [interquartile range (IQR), 1.9-2.3]; group B: median 1.6 μg/mL [IQR, 1.3-1.8]; and group C: median 1.4 μg/mL [IQR, 1.2-1.6]; P < .0001). Hypotension tended to occur in the younger group, and hypoxemia occurred at a significantly higher rate in the older groups, although the number of cases was small. Low preoperative systolic blood pressure (≤125 mm Hg) was associated with hypotension (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.12-2.70; P = .013) and abnormal pulmonary function was associated with hypoxemia in groups B and C (OR, 4.54; 95% CI, 1.01-31.5; P = .048). CONCLUSIONS Elderly patients required lower doses of propofol with the TCI/BIS system than younger patients. Attention to hypoxemia is necessary in elderly patients, particularly patients with abnormal pulmonary function.

Linked color imaging (LCI), a novel image-enhanced endoscopy technology, emphasizes the color of early gastric cancer

Background and study aims  Linked color imaging (LCI) and blue laser imaging (BLI) are novel image-enhanced endoscopy technologies with strong, unique color enhancement. We investigated the efficacy of LCI and BLI-bright compared to conventional white light imaging (WLI) by measuring the color difference between early gastric cancer lesions and the surrounding mucosa. Patients and methods  Images of early gastric cancer scheduled for endoscopic submucosal dissection were captured by LCI, BLI-bright, and WLI under the same conditions. Color values of the lesion and surrounding mucosa were defined as the average of the color value in each region of interest. Color differences between the lesion and surrounding mucosa (ΔE) were examined in each mode. The color value was assessed using the CIE L*a*b* color space (CIE: Commission Internationale d’Eclairage). Results  We collected images of 43 lesions from 42 patients. Average ΔE values with LCI, BLI-bright, and WLI were 11.02, 5.04, and 5.99, respectively. The ΔE was significantly higher with LCI than with WLI ( P  < 0.001). Limited to cases of small ΔE with WLI, the ΔE was approximately 3 times higher with LCI than with WLI (7.18 vs. 2.25). The ΔE with LCI was larger when the surrounding mucosa had severe intestinal metaplasia ( P  = 0.04). The average color value of a lesion and the surrounding mucosa differed. This value did not have a sufficient cut-off point between the lesion and surrounding mucosa to distinguish them, even with LCI. Conclusion  LCI had a larger ΔE than WLI. It may allow easy recognition and early detection of gastric cancer, even for inexperienced endoscopists.

A Randomized Trial of Monopolar Soft-mode Coagulation Versus Heater Probe Thermocoagulation for Peptic Ulcer Bleeding.

Background and Aim: Endoscopic therapy has been demonstrated to be effective in achieving hemostasis for bleeding peptic ulcers. Thermal coagulation is one of the most commonly used methods, with a high success rate. Recently, endoscopic submucosal dissection for early gastric carcinoma was developed and hemostasis with soft coagulation using hemostatic forceps was introduced. The aim of this study was to compare the hemostatic efficacy of soft coagulation with heater probe thermocoagulation for peptic ulcer bleeding. Methods: Patients who visited our hospital with hematemesis or melena underwent emergency endoscopy. Inclusion criteria were presentation with an actively bleeding ulcer, a nonbleeding visible vessel, or an adherent clot. Patients were excluded if they were unwilling to give written informed consent or had a bleeding gastric malignancy. Patients were randomized to receive endoscopic hemostasis with soft coagulation (Group S) or heater probe thermocoagulation (Group H). The primary endpoint was the primary hemostasis rate and secondary endpoints were rebleeding rate, complications, and the procedure time. Results: Between May 2010 and February 2012, a total of 111 patients (89 gastric ulcers and 22 duodenal ulcers) were enrolled. Primary hemostasis was achieved in 54 patients (96%) in Group S and 37 (67%) in Group H (P<0.0001). Rebleeding occurred in 7 patients in Group H and none in Group S. Of these 7 patients, urgent surgery was performed in 1. Perforation occurred in 2 patients in Group H, which was managed conservatively. Conclusions: For patients with gastroduodenal ulcer bleeding, soft coagulation using monopolar hemostatic forceps is more effective than heater probe thermocoagulation for achieving hemostasis.

Intramucosal gastric mixed adenoneuroendocrine carcinoma completely resected with endoscopic submucosal dissection

Composite tumors in the stomach composed of adenocarcinoma and neuroendocrine carcinoma are rare. We herein report a case of intramucosal gastric mixed adenoneuroendocrine carcinoma (MANEC) that was treated with endoscopic submucosal dissection (ESD). A 77-year-old man who had previously received ESD for early gastric adenocarcinoma underwent esophagogastroduodenoscopy for screening, which showed a depressed lesion on the lesser curvature of the antrum. The tumor was removed en bloc via ESD and pathologically diagnosed as MANEC. The tumor was located within the mucosal layer, and no lymphovascular invasion was evident. Seven months after the ESD procedure, the patient is currently feeling well without recurrence or metastasis.

Chromoendoscopy of gastric adenoma using an acetic acid indigocarmine mixture.

AIM To investigate the usefulness of chromoendoscopy, using an acetic acid indigocarmine mixture (AIM), for gastric adenoma diagnosed by forceps biopsy. METHODS A total of 54 lesions in 45 patients diagnosed as gastric adenoma by forceps biopsy were prospectively enrolled in this study and treated by endoscopic submucosal dissection (ESD) between January 2011 and January 2012. AIM-chromoendoscopy (AIM-CE) was performed followed by ESD. AIM solution was sprinkled and images were recorded every 30 s for 3 min. Clinical characteristics such as tumor size (< 2 cm, ≥ 2 cm), surface color in white light endoscopy (WLE) (whitish, normochromic or reddish), macroscopic appearance (flat or elevated, depressed), and reddish change in AIM-CE were selected as valuables. RESULTS En bloc resection was achieved in all 54 cases, with curative resection of fifty two lesions (96.3%). Twenty three lesions (42.6%) were diagnosed as well-differentiated adenocarcinoma and the remaining 31 lesions (57.4%) were gastric adenoma. All adenocarcinoma lesions were well-differentiated tubular adenocarcinomas and were restricted within the mucosal layer. The sensitivity of reddish color change in AIM-CE is significantly higher than that in WLE (vs tumor size ≥ 2 cm, P = 0.016, vs normochromic or reddish surface color, P = 0.046, vs depressed macroscopic type, P = 0.0030). On the other hand, no significant differences were found in the specificity and accuracy. In univariate analysis, normochromic or reddish surface color in WLE (OR = 3.7, 95%CI: 1.2-12, P = 0.022) and reddish change in AIM-CE (OR = 14, 95%CI: 3.8-70, P < 0.001) were significantly related to diagnosis of early gastric cancer (EGC). In multivariate analysis, only reddish change in AIM-CE (OR = 11, 95%CI: 2.3-66, P = 0.0022) was a significant factor associated with diagnosis of EGC. CONCLUSION AIM-CE may have potential for screening EGC in patients initially diagnosed as gastric adenoma by forceps biopsy.

Does Helicobacter pylori Exacerbate Gastric Mucosal Injury in Users of Nonsteroidal Anti-Inflammatory Drugs? A Multicenter, Retrospective, Case-Control Study

Background/Aims The interaction between nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori remains controversial. We retrospectively investigated whether H. pylori infection exacerbates severe gastric mucosal injury among chronic NSAID users. Methods From January 2010 to December 2013, a total of 245 long-term NSAID (including low-dose aspirin) users who had undergone an esophagogastroduodenoscopy and had been evaluated for H. pylori infection were enrolled at Okayama University Hospital and Tsuyama Chuo Hospital. The degree of gastric mucosal injury was assessed according to the modified Lanza score (MLS). Severe gastric mucosal injury was defined as an MLS ≥4. Univariate and multivariate logistic regression analyses were performed. Results In the univariate analysis, age ≥75 years (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.3 to 4.2), H. pylori-positivity (OR, 2.0; 95% CI, 1.2 to 3.5), and the concomitant use of proton pump inhibitors (PPIs) (OR, 0.48; 95% CI, 0.26 to 0.86) were significantly associated with severe gastric mucosal injury. The multivariate analysis was adjusted by age and sex and demonstrated that H. pylori-positivity (OR, 1.8; 95% CI, 1.0 to 3.3) and the concomitant use of PPIs (OR, 0.53; 95% CI, 0.28 to 0.99) significantly contributed to severe gastric mucosal injury. Conclusions H. pylori infection exacerbates severe gastric mucosal injury among chronic NSAID users.

Clinical outcome of patients with obscure gastrointestinal bleeding during antithrombotic drug therapy

Background: The clinical outcome of patients with obscure gastrointestinal bleeding (OGIB) during antithrombotic drug therapy has not been fully investigated. Methods: Patients who underwent video capsule endoscopy (VCE) for the investigation of OGIB at Okayama University Hospital from January 2009 to March 2016 were enrolled. We evaluated the VCE findings, the patterns of OGIB, and the rate of rebleeding within 1 year in antithrombotic drug users and antithrombotic drug nonusers. Results: A total of 181 patients were enrolled. Among the antithrombotic drug users, the rate of VCE positivity in the patients with overt OGIB was significantly higher in comparison with patients with occult OGIB (45% versus 16%, p = 0.014), whereas there was no significant difference among the antithrombotic drug nonusers (27% versus 26%, p = 1.0). Among the antithrombotic drug users, the rate of rebleeding among the VCE-positive patients was significantly higher in comparison with the VCE-negative patients (50% versus 5.9%, p = 0.011). Moreover, among antithrombotic drug users who did not receive therapeutic intervention, the rate of rebleeding among the VCE-positive patients was significantly higher in comparison with the VCE-negative patients (75% versus 6.3%, p = 0.001). However, among the antithrombotic drug nonusers who did not receive therapeutic intervention, the rebleeding rate of the VCE-positive patients was not significantly different from that of the VCE-negative patients (20% versus 9.4%, p = 0.43). Conclusion: Therapeutic intervention should be considered for patients with overt OGIB who are VCE positive and who use antithrombotic drugs due to the high risk of rebleeding.

Postoperative bleeding risk after gastric endoscopic submucosal dissection during antithrombotic drug therapy

The safety of gastric endoscopic submucosal dissection (ESD) in the antithrombotic drug users remains controversial.

Evaluation of the bleeding risk with various antithrombotic therapies after gastric endoscopic submucosal dissection

Background and study aims  Patients receiving antithrombotic drugs have a higher risk of postoperative bleeding and thromboembolic events related to endoscopic procedures. The aim of this study was to evaluate the relationship between various antithrombotic therapies and bleeding after gastric endoscopic submucosal dissection (ESD) (post-ESD bleeding). Patients and methods  Among 529 consecutive gastric ESD procedures (483 patients with 579 legions), 100 patients with 121 lesions who underwent 108 procedures were on antithrombotic therapy (group A) and 382 patients with 458 lesions who underwent 421 procedures were not on antithrombotic therapy (group B). The ratio of post-ESD bleeding between the two groups and the bleeding risk related to various antithrombotic therapies were investigated. Results  Postoperative bleeding was more frequent in group A (11.1 %) than in group B (3.3 %). No thromboembolic events were reported in either group. Further investigation of antithrombotic therapies in group A demonstrated that various combinations of antithrombotic agents and heparin replacement were associated with a higher ratio of post-ESD bleeding. Multivariate analyses revealed that dual antiplatelet therapy (odds ratio [OR] 10.9, 95 % confidence interval [CI] 2.1 – 49.5; P  = 0.005) and heparin replacement (OR 34.4, 95 %CI 9.4 – 133.2; P  < 0.001) were associated with the increased risk of post-ESD bleeding. In patients on antiplatelet therapy, post-ESD bleeding tended to occur in the early postoperative period compared with patients on anticoagulant therapy. Conclusions  It is necessary to be cautious regarding post-ESD bleeding in patients requiring antithrombotic therapy, especially patients receiving dual antiplatelet therapy and heparin replacement. A further prospective study with a large sample will be needed to confirm these findings.

Underwater endoscopic mucosal resection for gastric polyp

Recently, the safety and efficacy of underwater endoscopic mucosal resection (UEMR) for superficial nonampullary duodenal adenomas and colorectal polyps has been reported [1-3]. However, there have been no reports on UEMR for the treatment of gastric polyps. We herein report two cases in which UEMR was useful for the treatment of gastric polyps (Video S1). One was the case of a polyp that had steadily been growing year by year (Figure 1), and the other was the case of a large gastric polyp (Figure 2). A diagnosis by a forceps biopsy was difficult in both cases, so endoscopic mucosal resection (EMR) for a total biopsy was considered. This article is protected by copyright. All rights reserved.