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Objective Patient-reported outcomes (PROs) are important measures of the quality of life (QOL) and symptoms in patients with hepatitis C virus (HCV). We evaluated the PROs at the beginning of direct-acting antiviral (DAA) treatment and three years later. A low QOL in patients with chronic liver disease suggested a low muscle mass. We compared the relationship between the QOL and muscle mass.Methods DAAs were administered to 100 patients with HCV infection. The PROs included the cirrhosis-related symptom score (CSS), presence of restless legs syndrome, Pittsburg sleep quality index (PSQI) to evaluate sleep disturbance, SF-36 to measure the QOL, and calculated body muscle mass (CBMM) measured at the beginning of treatment and three years later. Computed tomography (CT) was used to screen 82 patients for hepatocellular carcinoma at the beginning of treatment and three years later. Cross-sectional CT images of the third lumbar vertebrae were analyzed to evaluate the body composition.Results The general health perception (GHN) of SF-36 was better at three years after DAA administration than at the beginning. Changes in the GHN (dGHN) were related to an improved sleep quality on the PSQI and CSS and increased CBMM. The dGHN was positively related to changes in the skeletal muscle. The sleep quality, sleep latency, fatigue, and abdominal fullness were related to dGHN. Conclusion The QOL is related to sleep disturbance and several other symptoms. Furthermore, in patients with an increased muscle volume after DAA treatment, increased muscle mass is associated with an improvement in the QOL., Internal medicine, 59(21), pp.2653-2660; 2020

A simple method is required to screen for sarcopenia in patients with chronic liver disease. In the present study, the value of the existing SARC-F questionnaire as well as calculated body muscle mass (CBMM) approaches were assessed for screening of sarcopenia. A total of 482 patients with chronic liver disease underwent CBMM, grip strength (GS) and SARC-F score assessments. Cross-sectional computed tomography images of the third lumbar vertebrae were analyzed to determine the skeletal muscle (SM) mass in 303 patients. Cutoff CBMM values for sarcopenia were

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 Conclusion Compared with 2 D images, 3 D images significantly improved both diagnostic accuracy of tumor extent and degree of confidence for diagnosing superficial gastric tumor. The utility of the 3 D endoscope was apparent among trainees and novices and for the diagnosis of type IIc lesions.

Background/Aims: Endoscopic submucosal dissection (ESD) for superficial esophageal cancer is sometimes extensive, and in our experience, patients not infrequently present with dysphagia after ESD even in the absence of esophageal stricture. The aim of this study was to evaluate esophageal motility using high-resolution manometry (HRM) in patients with and without dysphagia after extensive circumferential ESD. Methods: HRM was performed in a total of 52 patients who had undergone ESD for superficial esophageal cancer and a mucosal defect after ESD exceeded more than two-thirds of the esophageal circumference. The frequency and type of esophageal dysmotility and the relationship between esophageal motility and dysphagia were evaluated. Results: Esophageal dysmotility was observed in 13 patients (25%): jackhammer esophagus in 4, esophagogastric junction outflow obstruction in 4, absent contractility in 2, and distal esophageal spasm, ineffective esophageal motility, and fragmented peristalsis in 1 patient each. Of the 22 patients with dysphagia after ESD, 9 (41%) had esophageal dysmotility. Of the 30 patients without dysphagia after ESD, 4 (13%) had esophageal dysmotility. The relationship between dysmotility and dysphagia was significant (p = 0.025). Conclusions: Esophageal dysmotility exists in approximately one-quarter of patients after extensive circumferential ESD, which is associated with dysphagia in the absence of esophageal stricture.

Aim: Helicobacter pylori-naïve gastric cancers(GCs) have not been well documented. We aimed to characterize early H. pylori-naïve GCs. Subjects and Methods: Of 666 patients with GC resected by endoscopic submucosal dissection, H. pylori-naïve patients were extracted according to the definition: no H. pylori eradication history, negative for serum H. pylori-antibody and current H. pylori-infection tests, and no gastric atrophy by pepsinogen (PG) test, endoscopy, and histology. Results: It was found that 16 GCs were H. pylori-naïve, and classified into undifferentiated and differentiated type adenocarcinoma. All 9 undifferentiated type GCs were pale, depressed, mucosal pure signet ring cell adenocarcinoma except one of them and 7 differentiated type GCs were classified into 3 fundic gland type GCs and 4 foveolar type GCs. All fundic gland type GCs positive for PG-1 were cardia small submucosal tumor (SMT)-like protrusions with dilated vessels on the surface. All 4 foveolar type GCs were composed of dysplastic clear cells resembling foveolar epithelium, negative for PG-1 but positive for mucin 6 (MUC6) and MUC5AC. Endoscopically, all were laterally spreading elevations with papillary or villous surface. Conclusions: H. pylori-naïve GCs were infrequent at 2.5%, and classified into 3 types: a small pale depression of signet ring cell adenocarcinoma, a small SMT-like protrusion of fundic gland type GC, and a large laterally spreading elevation of foveolar type GC.

Hepatitis B virus (HBV) infection is associated with the risk of osteoporosis and bone mineral density (BMD) loss. Tenofovir alafenamide (TAF) is associated with a slightly lower degree of BMD loss compared with tenofovir disoproxil, without loss of the excellent anti‑HBV effects. The aim of the present study was to verify the effect of bone metabolism in patients with HBV treated with TAF. A total of 87 patients were treated with TAF. Of these, 32 patients were treatment naïve, and 55 patients were treated with entecavir (ETV) for at least 1 year, after which ETV was switched to TAF. At the start of TAF and after 1 year, BMD in the lumbar and neck of the femur, tartrate‑resistant acid phosphatase isoform 5b (TRACP‑5b) levels as a marker of bone metabolism and serum inorganic phosphorus (P) were compared to estimate bone metabolism. Serum creatinine (Cr), cystatin C, urine protein and β2 microglobulin levels were evaluated to estimate kidney function. Treatment with TAF for 1 year decreased TRACP‑5b levels, particularly in patients with bone disease, except for a minimal significant change (MSC; decrease of 12.4%) in TRACP‑5b levels. The change in rate of TRACP‑5b levels were positively associated with changes in P, Cr‑estimated glomerular filtration rate and TRACP‑5b levels at the start of TAF. Logistic regression analysis showed that increased BMD in the lumbar region contributed to the switch from ETV to TAF. TAF induced a decrease in TRACP‑5b levels in patients with HBV. Bone disease was a contributing factor for MSC. Since TRACP‑5b can be used as a marker of bone metabolism and fractures, TAF may exhibit potential in preventing fractures in patients with HBV., Biomedical Reports, 16(1), art. no. 6; 2022

Superficial non-ampullary duodenal epithelial tumors (SNADETs) are relatively rare, but they are now being detected more frequently due to advances in endoscopic technology. Nevertheless, the pathological nature of SNADETs remains unclear and a management strategy for these tumors has not been established. To elucidate the clinicopathological features, we conducted a retrospective analysis of 138 endoscopically resected SNADETs. Lesions were classified into two groups by histological grade according to the Vienna classification: category 3 (71 lesions, 51.4%) and category 4/5 (67 lesions, 48.6%). Compared with category 3 lesions, category 4/5 lesions were significantly more common in elderly patients (p

Background: Endoscopic submucosal resection (ESD) and endoscopic mucosal resection (EMR) are well established as curable and safety procedures for treating superficial tumors of the stomach, esophagus and colon. However, a majority of endoscopic resection strategies for non-ampullary superficial duodenal tumors (NASDTs) remains undefined. The aim of this study was to clarify which was the right method for NASDT treatment - EMR or ESD. Summary: We analyzed 129 consecutive endoscopic resection (74 ESD and 55 EMR) procedures performed with NADSTs and divided the ESD group into 49 large ESD groups (more than 20 mm in diameter) and 25 small ESD groups (less than 20 mm in diameter). With respect to the technical outcomes of EMR/ESD for small size NASDTs, EMR was safer than ESD, but its nature of curability was inferior to that of ESD. The rates of complication such as perforation or delayed bleeding were significantly higher in both ESD groups than in the EMR group. However, the prophylactic endoscopic closure of large mucosal defects after ESD was useful for resolving those complications. The limitations of our study were involvement of a single-center, limited sample size, short follow-up duration and the retrospective design, which may have introduced selection bias. However, the present findings suggest that adequate endoscopic treatment strategy for NASDTs can lead to favorable outcomes and an excellent prognosis. Key Message: It is necessary to select EMR or ESD adequately for R0 resection of small NASDTs, according to their size and location. For large NASDTs, duodenal ESD with essential management is feasible and useful as a therapeutic procedure.

Background/Aim: Clinical application of 3-dimensional (3D) technology for flexible endoscopes has not been reported. We developed a 3D flexible endoscope and conducted a feasibility study of endoscopic submucosal dissection (ESD) in porcine stomach. Methods: Four endoscopists used a 3D flexible endoscope to perform a total of 8 ESD procedures on resected porcine stomachs. We assessed the en bloc resection rate, perforation rate, and mechanical issues that arise during ESD. A visual analog scale (0, 2D superior; 100, 3D superior) was used to evaluate the depth perception, sense of security of the procedure, and eyestrain of 3D visualization. Results: En bloc resection was achieved in all cases and there were no cases of perforation or mechanical issues. Depth perception and sense of security were rated 85.5 ± 12.4 and 70.7 ± 9.7 respectively (mean ± SDs). Eyestrain was rated high for 3D visualization (mean ± SDs, 12.6 ± 8.6). Conclusions: ESD using a 3D flexible endoscope was technically feasible. The endoscopists reported good depth perception and a high sense of security when using 3D visualization but also noted strong eyestrain.

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: Superficial Barrett's esophageal adenocarcinoma (BEA) arising from short-segment Barrett's esophagus (SSBE) is visualized as a reddish lesion located on the right or anterior side wall of the esophagogastric mucosal junction (EGJ) and showing an elevated macroscopic appearance under conventional white light endoscopy (WLE). However, because the form and color are variable, misdiagnosis as reflux esophagitis or SSBE is frequent under WLE. The aim of this study is to clarify conventional WLE features of small superficial BEA. Summary: We retrospectively analyzed 30 lesions ≤20 mm in diameter in 30 patients who underwent endoscopic mucosal resection or endoscopic submucosal dissection at Toranomon Hospital between 2002 and 2014. Mean age of patients with small superficial BEA arising from SSBE was 64.3 ± 11.2 years, and mean tumor size was 12.0 ± 4.8 mm. Small superficial BEA fell into the following 4 categories based on WLE features: EGJ polyp type, 43.3% (13 of 30 lesions); triangular SSBE type, 43.3% (13 of 30 lesions); cardiac erosion type, 10.0% (3 of 30 lesions); and unclassified or mixed type, 3.4% (1 of 30 lesions). EGJ polyp-type tumors were located on the right or anterior side wall of the EGJ, and no tumors showed invasion to the submucosal layer. On the other hand, triangular SSBE-type tumors were located anywhere in the EGJ, and 38.5% showed submucosal invasion (5 of 13 lesions). Key Messages: We consider this classification significantly contributes to the detection of small superficial BEA arising from SSBE under WLE.

Esophageal adenocarcinoma arising from ectopic gastric mucosa (EGM) is extremely rare. We describe here two Japanese patients with adenocarcinoma of the cervical esophagus arising from EGM. Case 1 is a 62-year-old man who had slightly red EGM in the cervical esophagus on upper gastrointestinal endoscopy (UGE). Because the biopsy showed atypical glands that were suspicious for adenocarcinoma, endoscopic submucosal dissection was performed. Histopathological examination revealed that the lesion was a well-differentiated adenocarcinoma (pT1a MM). Lymphovascular invasion was absent, and the margins were free from carcinoma. Case 2 is a 57-year-old man who had an elevated lesion with a bleeding tendency in an area of EGM in the cervical esophagus on UGE. Adenocarcinoma was diagnosed in the biopsy. Because of the presence of enlarged lymph nodes (#106recL), preoperative chemoradiotherapy was performed to reduce the size of the adenocarcinoma and lymph nodes prior to resection of the cervical esophagus and reconstruction with free jejunal grafts. Histopathological examination revealed moderately differentiated adenocarcinoma (0-I, pT2N1M0, pStage II). In both cases, adenocarcinoma was surrounded by EGM, which led to the diagnosis of EGM-derived esophageal adenocarcinoma. Here, we report its immunohistochemical characteristics in the present cases and discuss the histogenesis.

Two-dimensional (2D) images lack depth information and thus provide probabilistic recognition that do not completely match the actual three-dimensional (3D) information. Here, we investigated the operability of 3D endoscopes. A 3D operation model was developed by passing 20 silk threads through upper and lower plates at 2-mm intervals in front and back rows separated by 1 mm. We evaluated accuracy and time of operating an electrosurgical knife. A successful operation was defined as pulling only a front-row thread; an unsuccessful operation was defined as pulling no thread (miss) or simultaneously pulling front- and back-row threads. Endoscopists (four experts, six trainees) repeated the operation under 2D and 3D conditions until individually accumulating 10 successful attempts under each condition. Operation accuracy was significantly higher for 3D compared with 2D in all endoscopists (88.5% vs. 61.3%; 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: In many endoscopic procedures, the operative view can be compromised when manipulating the treatment device because the endoscopists must release their hand from the endoscope. We have developed a new device called the Smart Shooter® (SS) for simultaneous manipulation of the endoscope and treatment device, and evaluated the utility of the SS compared with the conventional method. Methods: The SS is a semirigid, loop-shaped channel extender that enables endoscopists to manipulate the treatment device with the thumb of the right hand while holding the endoscope with the same hand. We conducted a comparative study of gastric endoscopic submucosal dissection (ESD) and esophageal injection sclerotherapy (EIS) in a porcine model to compare the utility of the SS method with the conventional method. Results: In gastric ESD, all lesions were resected en bloc with no perforation. The mean operative time was significantly shorter with the SS method than with the conventional method (287.5 ± 155.4 vs. 403.5 ± 215.6 s, p = 0.04). In esophageal EIS, 4 paravenous injections were given with the SS method and 5 were given using the conventional method. Similarly, the mean operative time was significantly shorter with the SS method than with the conventional method (19.0 ± 7.8 vs. 23.8 ± 10.0 s, p = 0.04). Conclusion: Use of the SS enabled a shorter operative time for gastric ESD and esophageal EIS with no adverse events. The present results suggest that the SS can contribute to safe and speedy endoscopic treatment.

Background and Aims Acute graft-versus-host disease (GVHD) occurring within 100 days post-transplant is one of critical factors influencing prognosis in transplant recipients. Among cases of GVHD of the gastrointestinal (GI) tract, GVHD rarely affects the upper GI. In this study, we retrospectively examined the frequency of upper GI GVHD and diagnostic accuracy. Patients and Methods From among 868 patients who underwent allogeneic hematopoietic stem cell transplantation at our hospital between January 2005 and June 2012, 115 of whom underwent biopsy for upper GI symptoms. The endoscopic findings and histologic diagnosis from these 115 patients were retrospectively analyzed. Results GVHD was histologically diagnosed in 85 patients overall (9.8% of all 868 transplant recipients). Although gastric mucosal exfoliation was not commonly observed, this endoscopic finding when used as a diagnostic predictor had both a specificity and positive predictive value (PPV) of 100%. When using redness, luster, and mucosal change as predictors, specificity and PPV were relatively high, suggesting that these gastric endoscopic findings are useful in the diagnosis of upper GI GVHD. Among the duodenal endoscopic findings, erosion as a diagnostic predictor had both a high specificity and PPV. The biopsy results often lead to a diagnosis of GVHD even in cases judged to be endoscopically normal. Conclusions Among the gastric endoscopic findings, mucosal exfoliation, although rare, and redness, luster, and mucosal change are likely to be useful diagnostic predictors of upper GI GVHD. GVHD was frequently diagnosed in patients with endoscopically normal duodenum, suggesting that biopsies are important for definitive diagnosis.

Background and Aim Duodenal endoscopic submucosal dissection (ESD) is technically challenging because of anatomical specificities and, to date, has not been validated concerning the high rate of complications such as perforation and delayed bleeding. In the present study, the risk factors for delayed bleeding after duodenal ESD are presented with the goal of establishing preventive measures. Methods We analyzed 63 patients with non-ampullary superficial duodenal neoplasias treated by ESD from April 2005 to March 2014. To analyze the risk factors of delayed bleeding after duodenal ESD, we divided the patients into a delayed bleeding group and a non-bleeding group. To verify the risk factors of delayed bleeding after duodenal ESD, we analyzed various patient-, lesion-, and treatment-related factors. Results Delayed bleeding was experienced in 11 patients (17.5%) Univariate analysis of patient-related risk factors of delayed bleeding indicated no significant risk factor. Univariate analysis of lesion-related and treatment-related risk factors indicated only endoscopic closure as a significant risk factor. Multivariate analysis also identified endoscopic closure (not done > done: P = 0.049) as an independent factor significantly associated with delayed bleeding after duodenal ESD. Hypertension (present > absent: P = 0.055) showed a non-significant tendency of association by multivariate analysis. Conclusions This retrospective evaluation found that endoscopic closure was associated with a reduced risk of delayed bleeding after duodenal ESD. Delayed bleeding after duodenal ESD might be prevented by prophylactic endoscopic closure.

Background and study aims: Endoscopists must maneuver both endoscope and treatment device during procedures, requiring them to release their hand from the scope to manipulate the treatment device. Aiming to improve this situation, we developed a new device called the Thumb Drive. Patients and methods: The Thumb Drive comprises a controller and catheter. After attaching the controller to the endoscope’s grip, the catheter is inserted into the forceps channel. The treatment device is then inserted into the Thumb Drive and fixed with its tip protruding from the endoscope tip. A single endoscopist resected 10 lesions in a porcine stomach by endoscopic submucosal dissection (ESD) using the Thumb Drive. Results: All lesions were resected en bloc using this new device without any perforations. The mean incision, dissection, and operative times were 97.2 ± 48.7 seconds, 121.6 ± 53.6 seconds, and 218.8 ± 67.8 seconds, respectively. Conclusions: The Thumb Drive enables the endoscopist to manipulate the treatment device with the thumb while handling the endoscope with the right hand during ESD. Its utility should be examined in in vivo studies as a next step.

Background Magnifying endoscopy with narrow band imaging (ME-NBI) is useful to diagnose invasion depth of superficial esophageal cancer. The purpose of this study was to evaluate the utility of ME-NBI of superficial pharyngeal cancer. Methods Between April 2008 and June 2012, 146 lesions in 104 patients who underwent ME-NBI and en bloc resection were retrospectively analyzed. Based on magnifying endoscopic classification, proposed by the Japan Esophageal Society, microvasculature type was classified into B1, B2, and B3. Results B1 alone, B2, and B3 were observed in 128, 14, and 4 lesions, respectively. The frequency of subepithelial cancer were 20.3% (26 of 128), 78.6% (11 of 14), and 100% (4 of 4), respectively (p < .05). Mean invasion distance were 650 μm, 720.0 μm, and 2256.5 μm. Positive and negative predictive value for diagnosing subepithelial cancer based on the presence of B2 or B3 was 83.3% (15 of 18) and 79.7% (102 of 128). Conclusion ME-NBI is useful to determining invasion depth of superficial pharyngeal cancer. © 2014 Wiley Periodicals, Inc. Head Neck 37: 846–850, 2015

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.

It is controversial whether antithrombotic therapy increases the risk of bleeding after endoscopic submucosal dissection (ESD). The aim of this study was to evaluate the effects of antithrombotic therapy on gastric ESD. Patients who underwent gastric ESD at Toranomon Hospital between April 2005 and July 2014 were enrolled. The risk of post-ESD bleeding was evaluated by multivariate logistic regression analysis. Of 1781 patients enrolled, 253 were taking an antithrombotic; 186 discontinued taking a single antithrombotic (n = 150) or multiple antithrombotics (n = 36) before ESD, whereas 15 continued taking a single antiplatelet agent and another 52 switched to heparin alternative therapy during the peri-ESD period. Post-ESD bleeding occurred in 101 patients (5.7 %): 68 patients (3.8 %) who did not take an antithrombotic, 11 patients (7.3 %) who discontinued taking a single antithrombotic, six patients (16.7 %) who discontinued taking multiple antithrombotics, one patient (6.7 %) who continued taking a single antiplatelet agent, and 15 patients (28.8 %) who switched to heparin therapy. In multivariate analysis, heparin alternative therapy [odds ratio (OR) 10.04, 95 % confidence interval (CI) 4.35–23.16], discontinuation of the use of multiple antithrombotics before ESD (OR 5.44, 95 % CI 2.00–14.79), tumor location in the lower third of the stomach (OR 2.17, 95 % CI: 1.32–3.58), and a long procedure time (100 min or greater; OR 2.00, 95 % CI 1.25–3.20) were independent risk factors for post-ESD bleeding. Among 52 subjects who switched to heparin therapy, one developed acute renal infarction and one developed cerebral bleeding. Because heparin alternative therapy significantly increases the risk of post-ESD bleeding and may not decrease the risk of thromboembolic events, other options should be considered for patients receiving anticoagulation therapy.

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.

Background and study aim: Endocytoscopy (ECS) enables in vivo microscopic imaging, which allows analysis of mucosal structures at the cellular level; however, limited data are available on the validity of ECS in the stomach. The aim of this study was to evaluate the feasibility of ECS in the diagnosis of early gastric cancer. Patients and methods: Gastric lesions that were the targets of histopathological diagnosis by endoscopic submucosal dissection or biopsy specimen were prospectively enrolled and evaluated using a single charge-coupled device-integrated endocytoscope, following double staining with crystal violet and methylene blue. High grade ECS atypia was defined according to specific irregularities in gland structure and cell nuclei. The primary end point was the accuracy of ECS diagnosis for gastric cancer, using histopathological diagnosis as the gold standard. Results: A total of 82 lesions were investigated, including 23 early gastric cancers, 10 gastric adenomas, and 49 non-neoplastic lesions. Ten lesions could not be clearly observed by ECS because of poor staining due to viscous mucus or plaque; thus, assessability rates with ECS were 88 % in total and 91 % for gastric cancer. High grade ECS atypia was observed in 86 % of assessable gastric cancers, but not in any cases of gastric adenomas or non-neoplastic lesions. The sensitivity, specificity, positive and negative predictive values of high grade ECS atypia as the criterion for the diagnosis of gastric cancer were 86 %, 100 %, 100 %, and 94 %, respectively. No serious complications occurred during or after the examinations. Conclusion: ECS is a clinically feasible modality to obtain in vivo histology, with high diagnostic accuracy in gastric cancer.

Background and aim: High-grade atypia demonstrated by endocytoscopy may be a key criterion for the diagnosis of gastric cancer. We therefore sought to verify whether endocytoscopic atypia can provide satisfactory levels of diagnostic accuracy and concordance among trainee and expert endoscopists. Method: A total of 100 lesions evaluated by endocytoscopy and histopathology were enrolled to create an endocytoscopic image catalog (44 early cancers, 10 low-grade adenomas, 46 non-neoplastic lesions). Four endoscopists (two trainees and two experts) independently reviewed the catalog images and evaluated each of them for the presence or absence of endocytoscopic atypia. High-grade endocytoscopic atypia, as a criterion for cancer diagnosis, was defined as the consistent observation of any of the following features: lumen absence, lumen fusion, and irregular nuclei showing the three typical features (heterogeneous shape, swelling, and disarrangement). Results: High-grade endocytoscopic atypia was observed in 78 %, 18 %, and 4 % of cancers, adenomas, and non-neoplastic lesions, respectively. The sensitivity, specificity, accuracy, and positive and negative predictive values for cancer diagnosis by endocytoscopy were 78.4 %, 93.3 %, 87.3 %, 85.4 %, and 87.3 %, respectively. The concordance rate for the results of high-grade endocytoscopic atypia was good among the four endoscopists (κ value 0.682). No significant difference in diagnostic accuracy or concordance was observed between trainee and expert endoscopists. Conclusion: Using the defined high-grade atypia as a diagnostic criterion of cancer, endocytoscopy provided a satisfactory level of accuracy and concordance for the diagnosis of early gastric cancer, regardless of endoscopic expertise.

Acute graft-versus-host disease (GVHD) occurring within 100 days post-transplant is one of critical factors influencing prognosis in transplant recipients. Among cases of GVHD of the gastrointestinal (GI) tract, GVHD rarely affects the upper GI. In this study, we retrospectively examined the frequency of upper GI GVHD and diagnostic accuracy.From among 868 patients who underwent allogeneic hematopoietic stem cell transplantation at our hospital between January 2005 and June 2012, 115 of whom underwent biopsy for upper GI symptoms. The endoscopic findings and histologic diagnosis from these 115 patients were retrospectively analyzed.GVHD was histologically diagnosed in 85 patients overall (9.8% of all 868 transplant recipients). Although gastric mucosal exfoliation was not commonly observed, this endoscopic finding when used as a diagnostic predictor had both a specificity and positive predictive value (PPV) of 100%. When using redness, luster, and mucosal change as predictors, specificity and PPV were relatively high, suggesting that these gastric endoscopic findings are useful in the diagnosis of upper GI GVHD. Among the duodenal endoscopic findings, erosion as a diagnostic predictor had both a high specificity and PPV. The biopsy results often lead to a diagnosis of GVHD even in cases judged to be endoscopically normal.Among the gastric endoscopic findings, mucosal exfoliation, although rare, and redness, luster, and mucosal change are likely to be useful diagnostic predictors of upper GI GVHD. GVHD was frequently diagnosed in patients with endoscopically normal duodenum, suggesting that biopsies are important for definitive diagnosis.

Magnifying endoscopy with narrow band imaging (ME-NBI) is useful to diagnose invasion depth of superficial esophageal cancer. The purpose of this study was to evaluate the utility of ME-NBI of superficial pharyngeal cancer.Between April 2008 and June 2012, 146 lesions in 104 patients who underwent ME-NBI and en bloc resection were retrospectively analyzed. Based on magnifying endoscopic classification, proposed by the Japan Esophageal Society, microvasculature type was classified into B1, B2, and B3.B1 alone, B2, and B3 were observed in 128, 14, and 4 lesions, respectively. The frequency of subepithelial cancer were 20.3% (26 of 128), 78.6% (11 of 14), and 100% (4 of 4), respectively (p.05). Mean invasion distance were 650 μm, 720.0 μm, and 2256.5 μm. Positive and negative predictive value for diagnosing subepithelial cancer based on the presence of B2 or B3 was 83.3% (15 of 18) and 79.7% (102 of 128).ME-NBI is useful to determining invasion depth of superficial pharyngeal cancer.

Tu1714 Gastric Cancer: Are WE Missing the Opportunity of Early Diagnosis? Ramiro Tapia-Sosa*, Luis Uscanga Gastroenterology, Instituto de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico Background/Aims: Gastric Cancer (GC) is the third-leading cause of death from Cancer in Mexico. Based on the diagnosis and treatment guidelines of this country, the upper gastrointestinal endoscopy (UGE) with biopsy is the most efficient procedure to identify this disease. We aim to know the number of patients, and their clinical features, who have had at least one UGE before the definitive diagnosis of GC. Methods: All the patient medical files with GC who were admitted to a health Institute in Mexico City in a period of 5 years were reviewed. The total subjects were divided into: Group A, those with only one UGE performed to establish the GC diagnosis, and Group B, those patients who had more than one procedure before the identification of GC within a maximum period of 24 months. Results: One hundred and twelve patients with GC were diagnosed with GC. Group A was 70% (78/112) of the total population under study and Group B consisted of the remaining 30% (34/112). The time between the onset of symptoms and the diagnosis of this disease was statistically significantly (p!0.05) greater in the latter group (Table 1). Twenty-six of the 34 patients of Group B had an endoscopic view consistent with neoplasm; however, they were not histologically confirmed. The remaining eight were not suspected of neoplasm neither endoscopically nor microscopically. An important number of patients (11%) of the study group had a delayed diagnosis due to a time between studies greater than 6 months. The variable that implied a risk for delayed diagnosis of GC was the use of proton pump inhibitors (HR 3.2, CI 95% 1.4 7.2) which also has an effect on prognosis (Table 2). Conclusions: The majority of patients with a previous UGE had a macroscopic image that suggested GC which forces the physician to recheck the tissue under microscope or, if it were the case, repeat the study. Table 1. Univariate analysis: Group A vs B