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Abstract Aim We conducted a multicenter study on classical laparoscopic and endoscopic cooperative surgery (LECS) and LECS‐related procedures to retrospectively clarify the safety, problems, and mid‐term outcomes of these methods after their coverage by the national health insurance. Methods A total of 201 patients who underwent classical LECS/LECS‐related procedures for gastric submucosal tumors (G‐SMTs) in 21 institutions affiliated with the Laparoscopy Endoscopy Cooperative Surgery Study Group from April 2014 to March 2016 were included. Data was retrospectively obtained from the patients' charts. Results The most common surgical procedure was classical LECS (155 patients, 77.1%), non‐exposed endoscopic wall inversion surgery (22 patients, 11.4%), a combination of laparoscopic and endoscopic approaches to neoplasia with non‐exposure technique (16 patients, 8%), and closed LECS (two patients, 1%). Only six (3%) patients underwent LECS with gastrostomy. The mean operative time and blood loss were 188.4 (70–462) minutes and 23.3 (0–793) g, respectively. Ten (5%) patients developed postoperative complications (Clavien–Dindo classification grade II or higher). Two patients needed reoperation due to postoperative bleeding or anastomotic leakage. All tumors were resected with negative margins. A total of 127 (63.2%) patients underwent follow‐up observations for over 36 months, one of whom had a recurrence of peritoneal dissemination and one had poor oral intake. Conclusion Classical LECS and LECS‐related procedures for G‐SMTs have favorable short/mid‐term outcomes.

Background/Aims: Asymptomatic esophageal eosinophilia (aEE), characterized by eosinophil infiltration in the esophagus without clinical symptoms, has been reported as a precursor of eosinophilic esophagitis (EoE). Nevertheless, no report exists on the long-term clinical course of the disease. Therefore, this study aimed to investigate the long-term clinical course of aEE over 5 years, including the symptomatic conversion rate and the effect of treatments. Methods: We reviewed 28 patients with aEE who had been followed up for over 5 years with endoscopic monitoring. The basal characteristics of patients were compared with those of 58 patients diagnosed with EoE during the same period. Patients’ clinicopathological findings were collected and examined. Results: No significant differences in basal characteristics and histopathological findings were observed between the patients with aEE and those with EoE. The median follow-up duration was 64 months. Among the 28 patients with aEE, seven were treated with proton pump inhibitor or potassium-competitive acid blocker and the remaining 21 opted for follow-up with no medication. Among the treated patients, six (85.7%) exhibited endoscopic and pathologic improvements. Among the cases followed up without medication, the findings worsened in two (9.5%), improved spontaneously in seven (33.3%), and were unchanged in 12 (57.1%), and three (14.3%) developed symptoms at a mean time of 40 months. Symptoms developed in cases where endoscopic and pathologic findings remained unchanged or worsened during follow-up. Conclusion : s: Some patients with aEE had improved findings without treatment, whereas others developed symptoms, emphasizing the importance of long-term monitoring and individualized treatment decisions.

Background/Aims: Asymptomatic esophageal eosinophilia (aEE) is considered to be a potential precursor of eosinophilic esophagitis (EoE). However, there are few clinical parameters that can be used to evaluate the disease. Therefore, we aimed to clarify the factors involved in the symptoms of EoE by examining the clinicopathological differences between aEE and EoE. Methods: We reviewed 41 patients with esophageal eosinophilia who underwent endoscopic ultrasonography and high-resolution manometry. They were divided into the aEE group (n=16) and the EoE group (n=25) using the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease score. The patients’ clinicopathological findings were collected and examined. Results: The median Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease score was 3.0 in the aEE group and 10.0 in the EoE group. There was no significant difference in patient characteristics, endoscopic findings and pathological findings. The cutoff value for wall thickening was 3.13 mm for the total esophageal wall thickness and 2.30 mm for the thickness from the surface to the muscular layer (total esophageal wall thickness: 84.0% sensitivity, 75.0% specificity; thickness from the surface to the muscular layer: 84.0% sensitivity, 68.7% specificity). The high-resolution manometry study was abnormal in seven patients (43.8%) in the aEE group and in 12 (48.0%) in the EoE group. The contractile front velocity was slower in the EoE group (p=0.026). Conclusions: The esophageal wall thickening in the lower portion of the esophagus is an important clinical factors related to the symptoms in patients with EoE.

The site of enterohepatic Helicobacter colonization/infection in humans is still unknown. We report microbiologically and histopathologically confirmed H. fennelliae localization in the large intestine in an immunocompromised patient in Japan. This case contributes to better understanding of the life cycle of enterohepatic Helicobacter species.

Abstract Objectives Gastric cancer can be diagnosed even in patients long after Helicobacter pylori eradication. Most cases involve intramucosal lesions; however, some are invasive and require surgery. To clarify appropriate long‐term surveillance methods, this study compared invasive gastric cancer diagnosed ≥10 and

Objectives: Recently, a newly designed short-type single-balloon enteroscope (SBE), SIF-H290S, has been developed with a smaller outer diameter and a longer working length than conventional colonoscopes. It has passive bending and high-force transmission, making insertion easier. However, it is difficult to perform rescue colonoscopy with an SBE after incomplete colonoscopy in the same session. Therefore, this study evaluated the feasibility of consecutive rescue colonoscopy using SIF-H290S without overtube after incomplete colonoscopy. Methods: This was a single-center retrospective study. We included 19 rescue colonoscopies (19 patients) with SIF-H290S without overtube performed by 11 endoscopists in the SIF group and 38 rescue colonoscopies (38 patients) using a small-caliber colonoscope (PCF-PQ260L) were randomly selected for the control group from procedures performed by the same 11 endoscopists. We compared the cecal intubation rate and other outcomes, such as insertion time, between the two groups. Results: The median age of the patients was 72 and 69 years, with 8 and 26 males in the SIF and control groups, respectively. The median body mass index was 21.6 and 22.7 kg/m2 in the SIF and control groups, respectively. There were no significant differences in the patient backgrounds between the groups, except for the reason for incomplete colonoscopy (p = 0.048). The cecal intubation rate was 78.9% (15/19 procedures) and 92.1% (35/38 procedures) in the SIF and control groups, respectively. Conclusions: This study revealed the real-world experience and feasibility of rescue colonoscopy using SIF-H290S, which could be a potential rescue device option after incomplete colonoscopy.

Abstract Objectives The coronavirus pandemic significantly impacted endoscopic practice. During lower gastrointestinal endoscopy, infectious substances disseminate; therefore, we developed an infection control device (STEP‐L) for lower gastrointestinal endoscopy and examined its usefulness. Methods STEP‐L wraps around the patient's buttocks and covers the endoscope. Using lower endoscopy training models, three endoscopists performed 18 colonoscopies with STEP‐L (group S) and without (group C). Endoscopic insertion time and pigmented areas of ​​gloves and diapers after the examination were compared between both groups. Results Insertion of the endoscope up to the cecum was possible in all 18 examinations. The insertion time to the cecum was 52.4 ± 19.0 s in group S and 53.9 ± 13.3 s in group C. The pigmented areas of the ​​gloves measured 39,108.0 ± 16,155.3 pixels in group C, but were significantly reduced to 2610.5 ± 4333.8 pixels in group S (p

Abstract Background Although almost all cases of gastric cancer are caused by Helicobacter pylori (HP) infection, there are some rare exceptions. Furthermore, the clinicopathological characteristics of gastric cancer may differ depending on HP infection status. This study aimed to determine the clinicopathological characteristics of undifferentiated-type gastric cancer (UD-GC) according to HP status. Methods The study involved 83 patients with UD-GC who were selected from 1559 patients with gastric cancer who underwent endoscopic resection at our hospital and whose HP infection status was confirmed. Clinicopathological characteristics were evaluated according to HP status (eradicated, n = 28; infected, n = 32; not infected, n = 23). Results In patients without HP infection, UD-GCs were

Background and study aims Endoscopic band ligation (EBL) has been reported to be effective for colorectal diverticular bleeding. However, current EBL devices have some limitations, and we have developed a novel EBL device. Methods This novel EBL device has a tapered hood attached to the tip of the endoscope and an outer cylinder that loads two EBL bands. Twelve EBL procedures were performed in a live porcine model alternately using a conventional EBL device (Group C) and the novel EBL device (Group N). Results EBL was successful in all cases in both groups. There were no cases of perforation in the 10 days after EBL. After ligation, the mean major axis of the ridge was significantly larger in Group N than Group C (9.7 ± 1.4 mm vs 7.2 ± 1.4 mm, P = 0.011). Pathological examination revealed disruption of the muscularis propria at four of the six ligation sites in Group C and at five of the six ligation sites in Group N. Conclusions Using this novel EBL device, it was possible to perform multiple ligation procedures in succession with a good field of view. No perforation was observed, but disruption of the muscularis propria was observed at approximately three-quarters of the ligation sites pathologically.

Gastric cancer without Helicobacter pylori infection accounts for less than 1% of all gastric cancers, and is generally considered to be less invasive. This report describes a rare case of H. pylori –uninfected gastric cancer with deep submucosal invasion and lymph node metastasis. Endoscopic submucosal dissection was performed, and pathological examination revealed tubular adenocarcinoma with deep submucosal invasion. We diagnosed foveolar-type gastric adenocarcinoma. While many cases of foveolar-type gastric adenocarcinoma, especially of the white elevated type, are reported as early stage gastric cancer, this case is very rare because it showed submucosal invasion and lymph node metastasis.

Introduction: Patients with ulcerative colitis (UC) have an increased risk of colorectal cancer. Some studies have recently investigated endoscopic resection of UC-associated neoplasia (UCAN), but the indications for endoscopic resection of UCAN remain controversial. This study sought to clarify the problems encountered in endoscopic submucosal dissection (ESD) for UCAN. Methods: Seventeen lesions in 12 patients with UCAN (UCAN group) and 913 epithelial lesions in 824 control patients without UC (non-UC group) were evaluated. Both groups underwent ESD between January 2010 and December 2017 at Toranomon Hospital, Tokyo, Japan. Treatment outcomes of the 2 groups were compared retrospectively. Results: Univariate analysis showed that the mean tumor size was significantly smaller in the UCAN group than in the non-UC group (25.1 ± 26.7 mm vs. 31.9 ± 19.0; p = 0.0023); however, the R0 resection rate was significantly lower in the UCAN group (70.6 vs. 92.9%; p = 0.001). Multivariate analysis showed a significantly lower negative horizontal margin rate in the UCAN group (odds ratio 11.3, 95% confidence interval 3.588–34.525; p = 0.000). Discussion/Conclusion: ESD for UCAN is associated with a low-negative horizontal margin rate. When performing ESD for UCAN, it is important to evaluate the accuracy of the UCAN demarcation line, especially for flat lesions, using white-light imaging and chromoendoscopy as well as other modalities, including biopsy of surrounding tissues.

A 57-year-old man with a 10-year history of proton pump inhibitor (PPI) use presented with multiple fundic gland polyps (FGPs) including one >20 mm, whitish, semi-pedunculated polyp. Black spots and cobblestone-like mucosa were also observed in the stomach upon endoscopy; therefore, the lesion was considered to result from long-term PPI administration. Endoscopically, we diagnosed this polyp as a neoplastic lesion with gastric phenotype rather than a non-neoplastic lesion. Biopsy revealed an atypical glandular lesion that was indeterminate for neoplasia; therefore, we performed en bloc resection via endoscopic submucosal dissection (ESD) of the 22 × 22 × 10 mm-sized polyp. Histologically, the polyp was composed of hyperplastic foveolar epithelia in the upper half of the mucosa and hyperplastic fundic glands in the lower half of the mucosa, with luminal dilatation and parietal cell protrusion. The pathological diagnosis for this ESD specimen was FGP associated with PPI administration. We herein describe this rare case of a large FGP in Helicobacter pylori-uninfected gastric mucosa associated with long-term PPI administration, which was mimicking gastric-type neoplasm and resected by endoscopy.

Background. Gastroesophageal reflux disease is diagnosed endoscopically based on the presence of mucosal breaks. However, mucosal breaks can be judged differently depending on the endoscopist, even in the same image. We investigated how narrow-band imaging (NBI) and magnified endoscopy affect the judgment of mucosal breaks. Methods. A total of 43 consecutive patients were enrolled who had suspected mucosal breaks on white-light images (WLI) and underwent nonmagnified NBI (N-NBI) and magnified NBI (M-NBI) by a single endoscopist. From WLI, N-NBI, and M-NBI, 129 image files were created. Eight endoscopists reviewed the image files and judged the presence of mucosal breaks. Results. The 8 endoscopists determined mucosal breaks were present in 79.4 ± 9.5% (67.4%–93.0%) on WLI, and 76.7 ± 12.7% (53.5%–90.7%) on N-NBI. However, the percentage of mucosal breaks on M-NBI was significantly lower at 48.8 ± 17.0% (18.6%–65.1%) (p

Background and study aims Infection control is essential when performing endoscopic procedures, especially during the COVID-19 pandemic. Therefore, we have developed a new shielding device called STEP for infection control in upper gastrointestinal endoscopy. Patients and methods STEP consists of a mask worn by the patient and a drape that is connected to the mask and covers the endoscope. A suction tube attached to the mask prevents aerosols from spreading. The endoscopist operates the endoscope through the drape. Three endoscopists performed a total of 18 examinations using an upper endoscopy training model with and without STEP. Endoscopic images were evaluated by three other endoscopists, using a visual analog scale. We also simulated contact, droplet, and aerosol infection and evaluated the utility of STEP. Results All examinations were conducted without a problem. Mean procedure time was 126.3 ± 11.6 seconds with STEP and 122.3 ± 10.0 seconds without STEP. The mean visual analog score was 90.7 ± 10.1 with STEP and 90.4 ± 10.0 without STEP. In the contact model, adherence of simulated contaminants was 4.9 ± 1.4 % without STEP and 0 % with STEP. In the droplet model, the number of simulated contaminants attached to the paper was 338 273 ± 90 735 pixels without STEP and 0 with STEP. In the aerosol model, the total number of particles was 346 837 ± 9485 without STEP and was significantly reduced to 222 ± 174 with STEP. Conclusions No effect on examination time or endoscopic image quality was observed when using STEP in upper gastrointestinal endoscopy. Using STEP reduced the diffusion of simulated contaminants in all three infection models.

Background and study aims Endoscopic submucosal dissection (ESD) is widely performed for superficial esophageal cancer, but stricture after extensive resection is a major clinical problem. Using an ultrathin endoscope would enable endoscopists to approach lesions beyond the stricture. We evaluated the feasibility of an ultrathin endoscope for esophageal ESD. Methods To perform ESD with an ultrathin endoscope, we developed a transparent hood and ESD knife. A total of 24 esophageal ESDs were performed by two endoscopists with excised and live porcine esophaguses. A GIF-Q260 J and Dual knife were used in the conventional group and the GIF-XP260NS and a newly developed knife were used in the ultrathin group. En bloc resection rates, perforation rates, and procedure times were compared. Results All 24 lesions were resected en bloc without perforation. The mean procedure time was longer in the ultrathin group, although not significantly so (274.3 ± 81.8 s vs 435.8 ± 313.9 s, respectively; P = 0.22). Conclusion Although the procedure time was longer in the ultrathin group, en bloc resection was performed without any perforation. The findings indicate that esophageal ESD with an ultrathin endoscope is feasible.

Objectives: The variable-stiffness colonoscope is reportedly useful for making colonoscope insertion easier. However, this function is not associated with all colonoscopes. We developed a variable-stiffness stylet that can be inserted into the endoscope instrumentation channel to change the rigidity of the endoscope. Methods: We developed a stylet with adjustable stiffness and investigated its utility in colonoscope insertion using an ex-vivo model. Four endoscopists performed 24 colonoscope insertions, alternating between using the stylet (Stylet method) and the conventional method. We assessed insertion rate, rate of applying abdominal compression, and insertion time between the two groups. Results: In all procedures, the endoscope was inserted up to the cecum. There were significantly fewer external abdominal compressions with the Stylet method (1/12, 8.3%) compared to the conventional method (6/12, 50%). The insertion time was shorter with the Stylet method (140.9 ± 53.7 s) compared to the conventional method (181.3 ± 64.9 s). Conclusions: Using the variable-stiffness stylet, currently under development, resulted in significantly fewer external abdominal compressions and tended to have shorter insertion time.

Background and Aims. Endoscopic submucosal dissection (ESD) is widely performed for early gastric cancer (EGC). We have sometimes encountered gastric cancer lesions for which ESD was performed and at which pathologically advanced cancer was found. In this study, we performed clinicopathological examination of lesions whose endoscopic diagnosis and pathology differed substantially. Methods. ESD was performed for 2,194 gastric cancer lesions (1,753 cases) in our institute from April 2005 through March 2015. The vertical margin was positive or status unknown in 51 lesions (2.3%); among these, muscularis propria (MP) or deeper infiltration was identified in 6 lesions from specimens obtained during subsequent surgery. In 1 lesion with MP invasion, the vertical margin was negative. We evaluated the clinicopathological features of these 7 lesions and retrospectively reviewed endoscopic indicators of submucosal invasion for EGC on white light imaging (WLI), narrow-band imaging magnifying endoscopy (NBI-ME), and endoscopic ultrasonography (EUS) performed previously. Results. Average age was 73.2±7.2 years, and all cases were men. The 7 lesions diagnosed as advanced cancer were 0.32% of 2,194 lesions and were all located in the U region (fundus). On retrospective review of endoscopic findings, 2 of 7 lesions on WBI, 3 of 6 lesions on NBI-ME, and 2 of 5 lesions on EUS met the criteria for indicating submucosal invasion of EGC. No lesions had findings on all 3 modalities. Conclusion. In rare cases, advanced gastric cancer could not be accurately diagnosed by endoscopy using various modalities. Each case had special characteristics making identification of deep infiltration difficult.

Background and study aims Delayed bleeding is one of the most serious adverse events of gastric endoscopic submucosal dissection (ESD), especially in patients taking antithrombotic therapy. This study aimed to evaluate the utility and safety of a shielding method with autologous fibrin glue and polyglycolic acid (PGA) sheets for patients undergoing gastric ESD who are receiving antithrombotic therapy. Patients and methods One hundred twenty-three patients who were treated with gastric ESD while receiving antithrombotic therapy between December 2014 and September 2017 were enrolled in this study. Patients who received the shielding method were classified into the shielding group. Others were classified into the conventional group. Various clinico-pathological factors were retrospectively compared between the two groups. Results The shielding group consisted of 38 patients, and the conventional group consisted of the remaining 85 patients. In the shielding group, the rate of continuation of antithrombotic therapy was significantly higher (68.4 % vs 41.2 %). Incidence of delayed bleeding was lower in the shielding group (2.6 %, 1/38) than in the conventional group (14.1 %, 12/85). In the propensity score-adjusted logistic regression analysis, the delayed bleeding rate in the shielding group tended to be lower than in the conventional group (P = 0.070). Allogeneic transfusion was performed in eight patients (8/85, 9.4 %) in the conventional group and none in the shielding group (P = 0.047). No adverse event associated with endoscopic shielding were observed in the shielding group. Conclusions This study suggests that a shielding method with autologous fibrin glue and PGA sheet effectively prevents delayed bleeding after gastric ESD in patients receiving antithrombotic therapy.

IntroductionPatients scheduled to undergo oesophageal, gastric and colorectal endoscopic submucosal dissection (ESD) are to be investigated to verify the efficacy of dual red imaging (DRI) for establishing haemostasis during ESD.Methods and analysisThe trial is designed as a multicentre, open-label randomised, parallel-group, controlled intervention study. Registered patients will be randomly assigned to DRI and white light imaging (WLI) groups. In the DRI group, the mucosal incision and submucosal dissection will be performed by WLI, and haemostasis will be managed by DRI when bleeding occurs. In the WLI group, the mucosal incision and submucosal dissection are to be performed by WLI and the haemostasis management is to be performed by WLI. The primary endpoint is the time from the recognition of bleeding up to the achievement of complete haemostasis (haemostasis time). The secondary endpoints are the operation time, the proportion of cases in which perforation occurs, and the psychological stress experienced by the endoscopist during haemostasis treatment.Ethics and disseminationThis trial was approved by the Keio University Review Board for Clinical Trials (5 December 2016).DiscussionThis will be the first multicentre collaborative research using DRI for haemostasis treatment during ESD. When the safety and simplicity of DRI as a treatment for haemostasis during ESD can be proven, the ESD procedure can be simplified and disseminated more widely in clinical practice.Trial registration numberUMIN000025134

Background and study aims Endoscopic submucosal dissection (ESD) is increasingly being used to treat superficial esophageal cancer in the elderly. However, data on clinical outcomes in this age group are limited. The aim of this study was to evaluate the safety and efficacy of ESD in treatment of superficial esophageal cancer and its effect on long-term outcome in the elderly. Patients and methods In total, 664 consecutive patients with a histological diagnosis of squamous cell carcinoma or high-grade intraepithelial neoplasia who underwent ESD between April 2008 and March 2016 at our institution were enrolled. Clinical outcomes and prognostic factors were compared retrospectively between those aged 75 years or older (n = 162) and those aged younger than 75 years (n = 502). Results There was no significant difference in post-ESD bleeding (0 vs. 0.8 %, P = 0.27) and perforation rates (1.8 vs. 1.2 %, P = 0.47) between the two age groups; however, stricture rate was higher in younger patients than in elderly patients (20.8 % vs 11 %; P = 0.036). There was no significant difference in the rate of locoregional recurrence between the two groups. Overall survival was significantly different between the two groups, but cause-specific survival was similar. Conclusion These findings confirm the efficacy of ESD for superficial esophageal cancer in selected elderly patients (75 years or older) who were fit for the treatment because they can achieve similar long-term survival to younger patients.

Background and study aims Many studies have shown the utility of rigid three-dimensional (3 D) endoscopes in surgery, but few have reported the utility of flexible 3 D endoscopes. This ex vivo study was intended to investigate whether a newly developed 3 D endoscope (GIF-Y0083; Olympus) improves diagnostic accuracy for superficial gastric tumor. Methods Twelve observers comprising experts, trainees, and novices (4 each) evaluated 2 D and 3 D images of 20 specimens resected by gastric ESD. Evaluation items were diagnostic accuracy of tumor extent and degree of confidence in assessing (a) tumor extent, (b) morphology, and (c) comprehensive recognition. The 2 D and 3 D endoscopy data were compared in a crossover analysis. Results Overall, diagnostic accuracy was significantly higher with 3 D images (88.1 %) than with 2 D images (84.2 %) (P

Background/Aims. Delayed bleeding is one of the most serious complications following gastric endoscopic submucosal dissection (ESD) under antithrombotic therapy. As a safety measure, for patients receiving antithrombotic therapy, we covered the ESD ulcer with autologous fibrin glue (prepared using autologous blood) alone or with polyglycolic acid (PGA) sheets. Methods. From July 2014 to November 2015, 20 patients with gastric neoplasms who were receiving antithrombotic therapy were enrolled in this study. After ESD, the ESD ulcers were covered with autologous fibrin glue alone or with PGA sheets. We prospectively evaluated the feasibility of this safety measure. Results. In total, 22 lesions in 20 patients were resected en bloc by ESD. The mean specimen size and tumor size were 31.5 ± 9.5 mm and 14.0 ± 8.8 mm, respectively. There were no cases of delayed bleeding or adverse events in this study. Attachment of autologous fibrin glue was observed in 81.8% (18/22) and 68.2% (15/22) of lesions at endoscopy performed 1 day and 7 days after ESD, respectively. Conclusion. No patient in this study had delayed bleeding or adverse events. This suggests that this measure may facilitate the safety of gastric ESD in patients receiving antithrombotic therapy. This trial is registered with UMIN000019386.

Background and study aims Cervical esophageal cancer (CEC) is a less common form of cancer and often locally advanced at the time of diagnosis; thus, survival rates for patients with CEC remain poor. However, no reports exist on results of endoscopic submucosal dissection (ESD) for superficial cancer at the cervical esophagus. The aim of this retrospective study was to elucidate the clinicopathological features and clinical outcomes of ESD for superficial CEC. Patients and methods ESD was performed on 891 lesions (in 662 patients) for superficial esophageal cancer from January 2008 to December 2015. Of these, 45 lesions (45 patients) were enrolled in the case group (CEC), and 405 lesions (375 patients) were enrolled in the control group (superficial cancer in the middle thoracic esophagus). The safety of ESD, including R0 resection rate and adverse events, and the efficacy, such as the local recurrence rate and overall survival rate, were evaluated. Results The R0 resection rate was 91.1 % in the case group and 96 % in the control group. The rate of esophageal stricture was significantly higher in the case group (20 %) than in the control group (6.6 %). There was no local recurrence, and the 3-year survival rate was 88.4 % in the case group and 96.7 % in the control group. Conclusions ESD for superficial cancer in the cervical esophagus was achieved safely, and successful local control was also confirmed. However, the esophageal stricture after ESD was more frequent.

Background and study aims Positive horizontal margins in resected specimens are sometimes encountered after endoscopic submucosal dissection (ESD) for early gastric cancers, and appropriate treatment strategies for these cases are not established. The aim of this study was to evaluate current empirical treatments for patients with positive horizontal or indeterminable margins after ESD. Patients and methods We performed a multicenter survey and data from 14 hospitals were collected. The pooled proportions of positive horizontal or indeterminable margins and those of patients followed up without early intervention were calculated using a logistic-normal random-effects model. For calculating pooled estimates, subgroup analyses of high- and non-high-volume centers were conducted. Results A total of 11,796 ESD cases were enrolled and 229 patients (2 %) had positive horizontal or indeterminable margins. Ninety-eight cases were treated within 30 days of ESD and 131 cases were followed up without early treatments. Pooled estimates of positive margins in high- and non-high-volume centers were 1 % (95 % CI: 1 % – 2 %) and 2 % (95 % CI: 1 % – 4 %), respectively, and were not heterogeneous (P = 0.191). The proportion of patients followed up without early intervention ranged from 30 % to 100 %. The pooled estimate was 68 % (95 % CI: 50 % – 83 %). The pooled estimates of high- and non-high-volume centers were 65 % (95 % CI: 38 % – 85 %) and 72 % (95 % CI: 44 % – 89 %), respectively, and were not heterogeneous (P = 0.692). Conclusion There was insufficient consensus regarding treatment strategies used for early gastric cancer with positive horizontal or indeterminable margins after ESD. Further studies are required to establish a consensus.

Background and Aims. We retrospectively investigated the incidence of acute graft-versus-host disease (GVHD) in the lower gastrointestinal (GI) tract and the diagnostic accuracy of endoscopy. Methods. Of 1231 patients who underwent allogeneic hematopoietic stem cell transplantation between January 2005 and December 2014, 186 of whom underwent colonoscopy and biopsy and had no cytomegalovirus infection. The endoscopic findings and histologic diagnosis from these 186 patients were retrospectively analyzed. Results. Based on the histopathological findings, 171 patients were diagnosed with GVHD, accounting for 13.9% of all transplant recipients. Useful endoscopic findings for the diagnosis of GVHD were atrophy of the ileocecal valve and villous atrophy in the terminal ileum and tortoise shell-like mucosae, edema, and low vascular permeability in the colon. Even when no mucosal abnormality was observed, the incidence of GVHD was 78.9% in the terminal ileum and 75.0% in the colon. Furthermore, patients with mucosal exfoliation, although infrequent, were all diagnosed with grade 3/4 GVHD. Conclusions. It is important to perform endoscopy proactively for the early diagnosis of GVHD, and biopsy should be performed even when no abnormality is observed. In addition, because patients with mucosal exfoliation are extremely likely to have grade 3/4 GVHD, early treatment should be initiated.

Background and study aims: The clinical benefit of endoscopic submucosal dissection (ESD) for superficial duodenal neoplasias has not yet been verified. The aims of this study were to validate the feasibility and long-term outcomes of ESD for nonampullary superficial duodenal neoplasias, larger than 20 mm. Patients and methods: 41 patients, with 41 nonampullary large superficial duodenal neoplasias, who underwent ESD between April 2005 to March 2013 were included in the study. The short- and long-term outcomes were retrospectively evaluated, related to tumor size, resection size, histological type, invasion depth, complete resection rate, operation time, perforation rate, delayed bleeding rate, local recurrence rate, distant metastasis, and survival rate. Results: ESD was successfully completed in 38 of 41 patients (92.7 %). The median sizes of tumors and resected specimens were, respectively, 26 mm (range 20 – 70 mm) and 36.5 mm (range 23 – 80 mm). Histopathological findings showed 13 adenocarcinomas (12 mucosal, 1 submucosal) and 28 adenomas (26 high grade dysplasia, 2 low grade dysplasia). The complete resection rate was 89.5 % (34 /38 tumors). The mean operation time was 128.3minutes. Perforation during ESD occurred in 39 % and delayed bleeding occurred in 18.4 %. The median observation period was 48 months (range 3.2 – 94.1 months), and no local recurrence or distant metastasis was seen during this time, representing a disease-free survival rate of 100 %. Conclusions: ESD for nonampullary large superficial duodenal adenocarcinoma/adenoma is feasible with favorable long-term outcomes. However, because of the high complication rate due to its technical difficulty, experience and skill of the operator, along with adequate perioperative management, are essential.

Aim. To determine whether 3D endoscopic images improved recognition accuracy for superficial gastrointestinal cancer compared with 2D images. Methods. We created an image catalog using 2D and 3D images of 20 specimens resected by endoscopic submucosal dissection. The twelve participants were allocated into two groups. Group 1 evaluated only 2D images at first, group 2 evaluated 3D images, and, after an interval of 2 weeks, group 1 next evaluated 3D and group 2 evaluated 2D images. The evaluation items were as follows: (1) diagnostic accuracy of the tumor extent and (2) confidence levels in assessing (a) tumor extent, (b) morphology, (c) microsurface structure, and (d) comprehensive recognition. Results. The use of 3D images resulted in an improvement in diagnostic accuracy in both group 1 (2D: 76.9%, 3D: 78.6%) and group 2 (2D: 79.9%, 3D: 83.6%), with no statistically significant difference. The confidence levels were higher for all items ((a) to (d)) when 3D images were used. With respect to experience, the degree of the improvement showed the following trend: novices > trainees > experts. Conclusions. By conversion into 3D images, there was a significant improvement in the diagnostic confidence level for superficial tumors, and the improvement was greater in individuals with lower endoscopic expertise.

We herein report a case of phlegmonous gastritis secondary to superior mesenteric artery syndrome. An 80-year-old woman visited the hospital emergency department with the chief complaints of epigastric pain and vomiting. She was hospitalized urgently following the diagnosis of superior mesenteric artery syndrome based on abdominal computed tomography findings. Conservative therapy was not effective, and phlegmonous gastritis was diagnosed based on the findings of upper gastrointestinal endoscopy and biopsy performed on the 12th day of the disease. Undernutrition and reduced physical activity were observed on hospital admission, and proactive nutritional therapy with enteral nutrition was started. An upper gastrointestinal series, performed approximately 1 month later, confirmed the persistence of strictures and impaired gastric emptying. Because conservative therapy was unlikely to improve oral food intake, open total gastrectomy was performed on the 94th day of the disease. Examination of surgically resected specimens revealed marked inflammation and fibrosis, especially in the body of the stomach. Following a good postoperative recovery, the patient was able to commence oral intake and left our hospital on foot approximately 1 month after surgery.

Background. Intraoperative bleeding is an important determinant for safety of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). This study aimed to prospectively evaluate the usefulness of endoscopic ultrasound (EUS) for predicting ESD safety. Methods. A total of 110 patients with EGC were divided into two groups based on EUS findings: group P, almost no blood vessels in submucosa, or ≤4 small vessels per field of view; group R, remaining patients. Primary endpoint was the decrease in Hb after ESD. Secondary endpoints included procedure time and the incidence of muscle injury and clip use. Results. A total of 89 patients were evaluated. Fifty were classified into group P and 39 into group R. Mean decrease in Hb was 0.27 g/dL in group P and 0.35 g/dL in group R, with no significant difference. Mean procedure time was significantly longer in group R (105.4 min) than in group P (65.5 min) (P

The prevalence of obesity in the Japanese population has been increasing dramatically in step with the Westernization of lifestyles and food ways. Our study demonstrated significant associations between obesity and a number of gastrointestinal disorders in a large sample population in Japan. We demonstrated that reflux esophagitis and hiatal hernia were strongly related to obesity (BMI > 25) in the Japanese. In particular, obesity with young male was a high risk for these diseases. On the other hand, it has been reported that obesity is also associated with Barrett’s esophagus and colorectal adenoma; however, obesity was not a risk factor for these diseases in our study. The difference of ethnicity of our subjects may partly explain why we found no data to implicate obesity as a risk factor for Barrett’s esophagus. Arterial sclerosis associated with advanced age and hyperglycemia was accompanied by an increased risk of colorectal adenoma.

Backgrounds. Magnifying endoscopy with narrow-band imaging (ME-NBI) has become essential for determining tumor margin in early gastric cancer (EGC). Here, we investigated the usefulness of ME-NBI for assessment of invasion depth in EGC. Methods. For 119 patients who had undergone ME-NBI and en bloc resection by endoscopic submucosal dissection, three physicians prospectively examined high-magnification ME-NBI images for clinical features such as presence or absence of dilated vessels (D vessels). Cases with D vessels verified by at least two physicians were assigned to group V, and others were assigned to group N. We then compared clinicopathological factors associated with the groups. Results. Groups V and N consisted of 18 and 101 patients, respectively. There were no significant differences in age, gender, tumor size, tumor location, gross morphology, or histological type. The percentage of submucosal cancer was 9.9% (10/101) in group N and significantly higher at 33.3% (6/18) in group V (). When the presence of D vessels was considered a diagnostic criterion for submucosal cancer, diagnostic accuracy, sensitivity, and specificity were 81.5, 37.5, and 88.3%, respectively. Conclusions. The results suggest that identification of D vessels using ME-NBI can assist in the assessment of invasion depth in EGC.