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Background: Esophagogastric junction (EGJ) cancers are not only located in regions anatomically difficult for endoscopic submucosal dissection (ESD), but they also have higher clinicopathological malignant potential than non-junctional gastric cancers (NJC). Despite this, no ESD-based comparative studies of junctional cancer (JC) and NJC have been conducted to date. The aims of this study were to clarify the clinicopathological characteristics of EGJ cancers and the short- and long-term outcomes after ESD. Methods: Between April 2005 and December 2010, ESD was performed on 1,463 lesions that were divided into the following three groups: Barrett’s adenocarcinoma (BA; n = 25); JC (n = 103), and NJC (n = 1,335). They were assessed for short-term outcomes, clinicopathological malignancy and long-term outcomes. Results: Rates of complete and curative resection were significantly lower for BA than for JC and NJC (64.0 vs. 96.1 and 96.0%; and 48.0 vs. 80.6 and 85.8%, respectively). The perforation rate was significantly higher for BA than for JC and NJC (20.0 vs. 2.9 and 2.7%). Clinicopathologically, submucosal invasion rates were higher in BA and JC than in NJC (32.0 and 30.1 vs. 13.6%), and positive rates of lymphatic and/or vascular invasion were remarkably higher in BA and JC versus NJC (24.0 vs. 9.7 vs. 4.8%, respectively). The 5-year survival rate in all patients with curative resection was 100%. Conclusion: This study confirmed the technical and theoretical validity of ESD for EGJ as a diagnostic treatment. However, we have to pay attention to the high rates of submucosal and lymphovascular invasive malignant potential of these cancers.

Aim: Owing to carelessness of endoscopists, invasive procedures, such as biopsy, are sometimes carried out inadvertently in patients receiving antithrombotic therapy. The aim of the present study was to retrospectively evaluate the actual status of such careless mistakes and the efficacy of new safety measures. Methods: A questionnaire survey was conducted in 34 endoscopists at Toranomon Hospital about experiences of careless mistakes and experiences of anxiety before and after the procedure. ‘Anxiety before procedure’ was defined as the experience of discontinuing a given procedure because endoscopists remembered that the patient was receiving antithrombotic therapy, and ‘anxiety after procedure’ was defined as the experience of feeling anxious about the status of medication after the invasive procedure. A new measure was introduced at Health Management Center in August 2009. In this measure, endoscopists directly interview each patient about the status of medication just before examination, and attach forceps valves of one of two colors depending on the status of medication. A blue forceps valve is attached for patients undergoing antithrombotic therapy, and a conventional black forceps valve is attached for patients not undergoing antithrombotic therapy. Six months after introduction, a questionnaire survey was conducted in 10 endoscopists in this center. Results: Approximately half of endoscopists (18/34) experienced such careless mistakes. ‘Anxiety’ had been experienced by approximately 80%. After introduction, there was no report of careless mistakes and frequency of ‘anxiety’ evaluated by visual analog scale score decreased significantly. Conclusion: This new safety measure is expected to facilitate safer gastrointestinal endoscopy in patients receiving antithrombotic therapy.

Background and Aim: Intraoperative bleeding is an important determining factor for the technical difficulty and safety of endoscopic submucosal dissection (ESD) for gastric neoplasms, which was previously difficult to predict before ESD. In the present study, we investigated whether endoscopic ultrasound (EUS) could be used to preoperatively predict intraoperative bleeding. Methods: The study included 106 patients who underwent EUS before ESD. EUS was used to evaluate the submucosal vascular structure. Patients who had at least 10 vascular structures per field of view or a vessel at least 500 µm in diameter were classified into the rich group (Group R), and others were classified into the non-rich group (Group N). The two groups were compared retrospectively with respect to procedure time, degree of anemia, frequency of clip use, and others. Results: There were 24 patients in Group R and 82 patients in Group N. Submucosal caner was found in 54.2% of patients in Group R and 18.3% in Group N. The reduction in hemoglobin was 5.8% in Group R and 3.45% in Group N. The procedure time was 151 min in Group R and 100 min in Group N. The frequency of clip use was 79.2% in Group R and 31.7% in Group N. A multivariate analysis revealed a significant difference in the depth of invasion and frequency of clip use between the two groups. Conclusions: The results suggest that identification of submucosal vascular structure by EUS might allow prediction of intraoperative bleeding during ESD.

Aims: The aims of the present study were to evaluate the feasibility of endoscopic submucosal dissection (ESD) as curative treatment for node-negative submucosal invasive early gastric cancer (EGC) and to consider further expansion of the curability criteria for submucosal invasive EGC. Methods: A total of 977 EGC in 855 patients treated by ESD were enrolled. They were divided into intramucosal cancer (M); minimally submucosal invasive cancer ( 500 µm from the muscularis mucosa) (SM2). The technical feasibility of ESD for SM1 and M were compared, and the clinical prognosis of SM1 was evaluated. Furthermore, the volume of carcinoma invading to the submucosal layer, which we called the SM volume index, was calculated virtually to analyze its correlation with lymphatic-vascular invasion. Results: There were no statistical differences in technical outcomes and complications between M and SM1. Curative resection rates were significantly better in M than in SM1 (M, 92.6%; SM1, 63.8%). No local recurrences and distant metastases were found in 48 SM1 patients declared to have undergone curative resections. Most cases (72.0%) with successful ESD but non-curative resection exceeded 30 mm in maximum size, and no local recurrences and metastases were found in these patients. The SM volume index of these cases was comparatively small. Conclusion: The technical and theoretical validity of ESD for SM1 was validated. The possibility of further expansion of the curability criteria for submucosal invasive cancers was suggested by the evaluation of the SM volume index.

Owing to carelessness of endoscopists, invasive procedures, such as biopsy, are sometimes carried out inadvertently in patients receiving antithrombotic therapy. The aim of the present study was to retrospectively evaluate the actual status of such careless mistakes and the efficacy of new safety measures.A questionnaire survey was conducted in 34 endoscopists at Toranomon Hospital about experiences of careless mistakes and experiences of anxiety before and after the procedure. 'Anxiety before procedure' was defined as the experience of discontinuing a given procedure because endoscopists remembered that the patient was receiving antithrombotic therapy, and 'anxiety after procedure' was defined as the experience of feeling anxious about the status of medication after the invasive procedure. A new measure was introduced at Health Management Center in August 2009. In this measure, endoscopists directly interview each patient about the status of medication just before examination, and attach forceps valves of one of two colors depending on the status of medication. A blue forceps valve is attached for patients undergoing antithrombotic therapy, and a conventional black forceps valve is attached for patients not undergoing antithrombotic therapy. Six months after introduction, a questionnaire survey was conducted in 10 endoscopists in this center.Approximately half of endoscopists (18/34) experienced such careless mistakes. 'Anxiety' had been experienced by approximately 80%. After introduction, there was no report of careless mistakes and frequency of 'anxiety' evaluated by visual analog scale score decreased significantly.This new safety measure is expected to facilitate safer gastrointestinal endoscopy in patients receiving antithrombotic therapy.

Intraoperative bleeding is an important determining factor for the technical difficulty and safety of endoscopic submucosal dissection (ESD) for gastric neoplasms, which was previously difficult to predict before ESD. In the present study, we investigated whether endoscopic ultrasound (EUS) could be used to preoperatively predict intraoperative bleeding.The study included 106 patients who underwent EUS before ESD. EUS was used to evaluate the submucosal vascular structure. Patients who had at least 10 vascular structures per field of view or a vessel at least 500 µm in diameter were classified into the rich group (Group R), and others were classified into the non-rich group (Group N). The two groups were compared retrospectively with respect to procedure time, degree of anemia, frequency of clip use, and others.There were 24 patients in Group R and 82 patients in Group N. Submucosal caner was found in 54.2% of patients in Group R and 18.3% in Group N. The reduction in hemoglobin was 5.8% in Group R and 3.45% in Group N. The procedure time was 151 min in Group R and 100 min in Group N. The frequency of clip use was 79.2% in Group R and 31.7% in Group N. A multivariate analysis revealed a significant difference in the depth of invasion and frequency of clip use between the two groups.The results suggest that identification of submucosal vascular structure by EUS might allow prediction of intraoperative bleeding during ESD.