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Background: A 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.Methods: One 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.Results: No 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 (P = 0.04; 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.Conclusions: The covering method using PGA sheets and fibrin glue has the potential to reduce post-ESD bleeding in patients receiving continued antithrombotic agents. [ABSTRACT FROM AUTHOR]

Background: Although endoscopic submucosal dissection (ESD) represents a significant progress in therapeutic endoscopy, little is known about how trainees attain its technical proficiency. The aims of this study were to evaluate the learning curve and clinical outcomes of gastric ESD performed by trainee endoscopists.Methods: Between April 2009 and March 2014, 334 gastric ESD procedures were performed by seven trainees (42-50 consecutive cases per trainee). The learning curve for gastric ESD was evaluated using the cumulative sum (CUSUM) method. Long-term outcomes were also analyzed.Results: The calculated CUSUM learning curve comprised three phases: Phase I (the initial 15 cases), Phase II (the middle 15 cases), and Phase III (the final 20 cases). The resection speed was 5.7 ± 3.2 min/cm2 in Phase I, 4.7 ± 2.7 min/cm2 in Phase II, and 4.3 ± 2.2 min/cm2 in Phase III. The resection speed was significantly faster in Phase II than in Phase I (p = 0.019). The rate of self-completion reached more than 95% in Phases II and III. The overall complete resection rate was 95%, showing no significant differences between the three phases. Local recurrence was diagnosed in none of the patients during a median follow-up of 38 months.Conclusions: For the trainees, 30 cases were required to attain a higher technical level of competence in gastric ESD. After the learning curve phase, trainee operators could be expected to complete the procedure successfully with favorable long-term outcomes. [ABSTRACT FROM AUTHOR]

Background: Little is known about the specific risks of metastasis in esophageal adenocarcinoma in relation to invasion depth or other pathologic factors.Methods: We conducted a multicenter retrospective study in 13 high-volume centers in Japan from January 2000 to October 2014 to elucidate the risk of metastasis of esophageal adenocarcinoma. A total of 458 patients (217 surgically resected and 241 endoscopically resected) with esophageal adenocarcinoma or esophagogastric adenocarcinoma involving the esophagus were included. Metastasis was considered positive if there was histologically confirmed metastasis in the surgical specimen or clinically confirmed metastasis during follow-up. Metastasis was considered negative if no metastasis was identified in resected specimens and during follow-up in patients treated surgically or no metastasis during follow-up for >5 years in patients treated by endoscopic resection.Results: Metastasis was identified in 72 patients. Multivariate analysis confirmed lymphovascular involvement [odds ratio (OR) 6.20; 95 % confidence interval (CI) 3.12-12.32; p < 0.001], a poorly differentiated component (OR 3.69; 95 % CI 1.92-7.10; p < 0.001), and lesion size >30 mm (OR 3.12; 95 % CI 1.63-5.97; p = 0.001) as independent risk factors for metastasis. No metastasis was detected in patients with mucosal cancer without lymphovascular involvement and a poorly differentiated component (0/186 lesions) or in patients with cancer invading the submucosa (1-500 µm) without lymphovascular involvement, a poorly differentiated component, and ≤30 mm (0/32 lesions).Conclusions: Mucosal and submucosal cancers (1-500 µm invasion) without risk factors have a low incidence of metastasis and may thus be good candidates for endoscopic resection. [ABSTRACT FROM AUTHOR]

Background: Although a high incidence of bacteremia after esophageal endoscopic procedures has been reported, the incidence of bacteremia associated with esophageal endoscopic submucosal dissection (ESD) remains unknown. Therefore, we investigated the incidence of bacteremia associated with esophageal ESD.Methods: From April 2013 to March 2014, patients who underwent esophageal ESD were enrolled prospectively. Two sets of blood cultures were collected from patients at the following time points: (1) immediately after ESD; (2) the next morning; and (3) when fever ≥38 °C was present after ESD.Results: A total of 424 blood culture sets were collected from 101 patients. Six patients had positive blood cultures immediately after ESD (4 %, 7/202 sets). Another patient had a positive blood culture the next morning (0.5 %, 1/202 sets). Ten patients (10 %) developed a post-ESD fever ≥38 °C, and blood cultures from these patients were all negative (0/20 sets). The seven patients with positive blood cultures had no post-ESD fever or infectious symptoms. Growth of Bacteroides thetaiotaomicron was only observed in one patient (1 %) with positive blood cultures immediately after ESD, and this patient was diagnosed with transient bacteremia. The other six patients were considered to have contaminants in their blood cultures. Thus, the incidence of bacteremia after esophageal ESD was 1 % [95 % confidence interval (CI) 0-5 %]. No patient had infectious symptoms, and none required antibiotics after ESD.Conclusions: The incidence of bacteremia after esophageal ESD was low and post-ESD fever was not associated with bacteremia. We conclude that use of routine prophylactic antibiotics to patients undergoing esophageal ESD is unnecessary.Clinical Trial Registry Number: UMIN000012908. [ABSTRACT FROM AUTHOR]

Background: Endoscopic resection has been used to treat small rectal neuroendocrine tumors (NETs). However, the indication for additional surgery after endoscopic resection is unclear. The aim of this study was to identify risk factors for rectal NET metastasis and to determine the indication for additional surgery.Methods: Fifty-five patients with a total of 57 rectal NETs, treated between October 2003 and January 2013, were retrospectively divided into metastatic (11 lesions) and non-metastatic (46 lesions) groups. Tumor size, central depression, invasion depth, lymphatic and venous permeation, mitotic activity, nuclear abnormality, Ki-67 labeling index, and World Health Organization grading classification (G1 or G2) were compared between the groups. Patients underwent endoscopic submucosal resection with a ligation device, transanal full-thickness surgical resection, or radical surgery.Results: By univariate analysis, the odds ratios (OR) for a Ki-67 labeling index >3.0 %, positive lymphatic or venous permeation, World Health Organization grading classification G2, tumor size >10 mm, submucosal invasion >4000 μm, and central depression were 120 (P < 0.001), 67.6 (P < 0.001), 58.7 (P < 0.001), 9.8 (P = 0.0037), 6.8 (P = 0.012), and 5.7 (P = 0.018), respectively. Multivariate logistic regression analyses showed that vascular permeation (OR 111; P = 0.006) and a Ki-67 labeling index >3.0 % (OR 88; P = 0.012) were independent risk factors for metastasis.Conclusions: The Ki-67 labeling index and lymphatic/venous permeation were reliable predictors of rectal NET metastases. [ABSTRACT FROM AUTHOR]

Background: Providing appropriate tension to the lesion and securing a stable view of the submucosal layer is important for accomplishing successful endoscopic submucosal dissection (ESD) in gastric cancer. Dental floss clip traction (DFC), a new traction method, is proposed to reduce the difficulty of ESD. The objective of this pilot study was to investigate the efficacy of DFC for gastric ESD.Methods: From August to November 2014, a total of 95 patients with 104 gastric epithelial neoplasms underwent DFC-ESD (DFC group). Historical controls treated by conventional ESD (control group) were individually matched to cases at a 1:1 ratio by lesion location, ulcer findings, resected specimen size, and the proficiency of the operator (trainee/expert). The outcomes of the procedure in the two groups were then compared.Results: The mean ± SD procedure time was 43 ± 24 min in the DFC group and 52 ± 30 min in the control group (P < 0.01). Fewer lesions in the DFC group needed >80 min compared with the control group (3-vs-16 cases, P = 0.01). There were no significant differences in adverse events between the groups. Perforation and delayed bleeding occurred in one and four lesions, respectively, in the DFC group, and three and nine in the control group. En bloc resection was achieved in all cases. No significant differences were found regarding curability of ESD between the groups.Conclusions: DFC effectively reduced ESD procedure time without increasing adverse events. DFC is helpful for rapid, safe ESD. [ABSTRACT FROM AUTHOR]

Background: In cases of synchronous gastric cancers (SGC) that include one for surgical indication and another for endoscopic resection (ER) in two different regions of the stomach, patients can avoid total gastrectomy and undergo subtotal gastrectomy following successful pre-emptive ER. The aim of this study was to evaluate the feasibility and efficacy of pre-emptive endoscopic resection and surgery (PRES) with curative intent for such SGCs. Methods: Between September 2002 and December 2012, 34 patients with SGCs (72 lesions) underwent PRES. Our institutional principals of PRES ensure the following: (1) treatment with curative intent, (2) multiple lesions indicated for ER and surgery, (3) evasion of TG following successful pre-emptive ER, (4) exclusion of type 4 and large type 3 (>80 mm) tumors, and (5) nonemergent cases such as hemorrhage, perforation, and obstruction. Clinicopathological characteristics and technical data were evaluated for all patients, and long-term outcomes were analyzed in patients who obtained curative ER and underwent subtotal gastrectomy. Results: Curative ER was obtained in 31 patients (91.1 %), and subtotal gastrectomy was performed a median of 44 days after ER. Final stages were as follows: stage I, 25 patients (80.6 %); stage II, four patients (12.9 %); stage III, one patient (3.2 %); and stage IV, one patient (3.2 %). The 5-year overall and cause-specific survival rates were 96.3 % (95 % confidence interval 89.4-100 %) and 100 %, respectively. Conclusions: PRES was feasible and effective as the first treatment of choice for multiple SGCs. PRES enables minimally invasive surgery with promising oncological outcomes. [ABSTRACT FROM AUTHOR]

Background: Currently, granular-type laterally spreading tumors (LST-G) have been classified into uniform [LST-G (UNI)] and nodular mixed [LST-G (MIX)] subtypes. However, the progression pattern of each subtype has not been evaluated in detail. The present study was designed to assign adequate treatment strategies to each LST-G subtype, based on the progression pattern. Methods: This retrospective study included 457 consecutive patients with 482 LST-Gs that had been removed endoscopically or surgically in a tertiary cancer center between September 2002 and December 2011. We classified the tumors as LST-G (UNI) or LST-G (MIX) subtypes. We analyzed clinicopathological characteristics and submucosal invasion rates for both subtypes, and we determined the incidence of submucosal invasions associated with the largest nodules for each subtype. Results: We evaluated the histopathological data from 136 LST-G (UNI) and 316 LST-G (MIX) lesions with diameters of 10-19 mm (14 %), 20-29 mm (26 %), 30-39 mm (25 %), or >40 mm (35 %). Submucosal invasions were observed in 3 (1.8 %) LST-G (UNI) and 49 (15.5 %) LST-G (MIX) lesions. In LST-G (MIX) lesions, the submucosal invasion incidences (within a tumor-size category) were as follows: 5.8 % (10-19 mm), 11.1 % (20-29 mm), 14.7 % (30-39 mm), and 19.1 % (>40 mm), respectively. In LST-G (MIX) lesions that showed submucosal invasions, the invasive cancers were located under the largest nodule (69 %; 34/49), outside the largest nodule (25 %; 12/49), or in both sites (6 %; 3/49). Conclusions: Our results indicated that, for LST-G (UNI) lesions, piecemeal resections would be acceptable due to the low risk of submucosal invasion. For LST-G (MIX) lesions, particularly those with diameters ≥20 mm, en bloc removal in an endoscopic resection is preferable for sufficient histological evaluation. [ABSTRACT FROM AUTHOR]

Background: A few studies have shown promising results with endoscopic submucosal dissection (ESD) for adenocarcinoma at the esophagogastric junction (EGJAC). However, curative criteria on the histology of EGJAC have not been developed, and long-term clinical results are lacking. The purpose of this study was to validate the application of the Japanese curative criteria to EGJAC after ESD. Methods: Between September 2002 and March 2009, 1,350 superficial gastric neoplasms in 1,181 patients were treated by ESD at a single tertiary cancer center. For this retrospective cohort study, 49 patients with 50 superficial EGJACs were extracted from our database. Complications, en bloc resection rate, curative resection rate, overall survival, and cause-specific survival were evaluated in all patients. For assessment of curability, curative criteria proposed by the Japanese Gastric Cancer Association for early gastric carcinoma after endoscopic resection were used. Results: Delayed bleeding and postoperative stenosis each occurred in three (6 %) patients but were managed endoscopically. No other major complications were observed related to ESD. The en bloc resection rate was 98 % (49/50), and the curative resection rate was 72 % (36/50). With a median follow-up period of 47 (range 22-97) months, the overall survival rates and cause-specific survival rates at 5 years were 86.2 % [95 % confidence interval (CI) 76-97] and 100 % (95 % CI 91-100), respectively. Conclusions: Endoscopic submucosal dissection with application of the Japanese curative criteria may be a feasible and effective treatment for curative intent in patients with superficial EGJAC. [ABSTRACT FROM AUTHOR]

Background: With the widespread use of endoscopic submucosal dissection (ESD), more large early gastric cancers (EGC) have become candidates for endoscopic resection.A precise diagnosis of the extent of cancer is indispensable to obtain R0 resection. The aim of the present study was to clarify the factors related to lateral margin positivity for cancer in specimens resected by ESD for EGC. Methods: Among 1549 EGC treated by ESD during September 2002 to December 2008, lesions that were resected in an en-bloc fashion and resulted in a pathological diagnosis of lateral margin positive (LM+) for cancer, were extracted. The reason for LM+ and pathological characteristics of the lesions were studied and compared to lesions successfully resected with margins negative for cancer. Results: There were three types of lesion that resulted in LM+ resection: lesions with a flat spreading area, lesions with an unexpected nearby lesion, and lesions with lateral extension beneath a non-cancerous mucosa. Compared to lesions resected with margins negative for cancer, diameter of the tumor, recurrent-type cancer, submucosal cancer, and undifferentiatedtype cancer were factors significantly related to LM+ resection. Conclusion: Other than misdiagnosing a small portion of cancer extension, lateral margin positivity for cancer by ESD could result from a neighboring lesion and an unexpected lateral submucosal cancer extension.To avoid LM+ resection of EGC by ESD, one should be careful of unexpected lateral extension and simultaneous multi-lesions. [ABSTRACT FROM AUTHOR]

In Japan, the majority of esophageal cancers are squamous cell carcinomas. Because no lymph node metastasis was reported in squamous cell carcinomas limited to the intraepithelial layer (m1) or proper mucosal layer (m2), the Japanese Esophageal Association recommended endoscopic mucosal resection (EMR) as the treatment of choice for these cancers. However, these lesions often spread laterally, exceeding the limits of en bloc resectability with conventional EMR methods such as the EMR cap method. The lesions resected in piece-meal manner with conventional EMR methods are prone to recur locally. Therefore, we developed a method of mucosal resection with a hook-knife that enables endoscopic submucosal dissection safely and achieves a high rate of en bloc resection for larger lesions. The median size of the resected specimen and cancer by our method was 32 mm (range, 8–76 mm) and 28 mm (range, 4–64 mm), respectively. The en bloc resection rate was 95% (95 of 102) and the local recurrence rate was 0% (0 of 102). This procedure was safe, with only 6 cases (6%) of mediastinal emphysema, which improved with conservative treatment. Endoscopic submucosal dissection with the hook knife is a method of endoluminal surgery enabling large en bloc resections without increased surgical risks. [Copyright &y& Elsevier]