Bleeding after endoscopic submucosal dissection: Risk factors and preventive methods

Endoscopic submucosal dissection(ESD) has become widely accepted as a standard method of treatment for superficial gastrointestinal neoplasms because it enables en block resection even for large lesions or fibrotic lesions with minimal invasiveness, and decreases the local recurrence rate. Moreover, specimens resected in an en block fashion enable accurate histological assessment. Taking these factors into consideration, ESD seems to be more advantageous than conventional endoscopic mucosal resection(EMR), but the associated risks of perioperative adverse events are higher than in EMR. Bleeding after ESD is the most frequent among these adverse events. Although post-ESD bleeding can be controlled by endoscopic hemostasis in most cases, it may lead to serious conditions including hemorrhagic shock. Even with preventive methods including administration of acid secretion inhibitors and preventive hemostasis, post-ESD bleeding cannot be completely prevented. In addition high-risk cases for post-ESD bleeding, which include cases with the use of antithrombotic agents or which require large resection, are increasing. Although there have been many reports about associated risk factors and methods of preventing post-ESD bleeding, many issues remain unsolved. Therefore, in this review, we have overviewed risk factors and methods of preventing post-ESD bleeding from previous studies. Endoscopists should have sufficient knowledge of these risk factors and preventive methods when performing ESD.

Endoscopic submucosal dissection for superficial esophageal neoplasms

Endoscopic submucosal dissection(ESD) is currently accepted as the major treatment modality for superficial neoplasms in the gastrointestinal tract including the esophagus.An important advantage of ESD is its effectiveness in resecting lesions regardless of their size and severity of fibrosis.Based on excellent outcomes for esophageal neoplasms with a small likelihood of lymph node metastasis,the number of ESD candidates has increased.On the other hand,ESD still requires highly skilled endoscopists due to technical difficulties.To avoid unnecessary complications including perforation and postoperative stricture,the indications for ESD require careful consideration and a full understanding of this modality.This article,in the highlight topic series,provides detailed information on the indication,procedure,outcome,complications and their prevention in ESD of superficial esophageal neoplasms.

Curative ESD for intraepithelial esophageal carcinoma with leiomyoma mimicking submucosal invasive carcinoma

This case report presents a 65-year-old man who developed early esophageal cancer with leiomyoma treated by endoscopic submucosal dissection(ESD).There have been several reports of co-existing superficial esophageal cancer and leiomyoma treated by endoscopic mucosal resection.However,there is no previous report describing the co-existing lesion treated by ESD.In order to determine treatment strategies for esophageal cancer,accurate endoscopic evaluation of the cancerous depth is essential.In the present case,the combination of endoscopic ultrasonography and narrow-band imaging system with magnifying endoscopy was extremely useful to evaluate the superficial esophageal cancer with leiomyoma,which lead to the appropriate treatment,ESD.

Sessile serrated adenoma detection rate is correlated with adenoma detection rate

AIM To investigated the association between adenoma detection rate(ADR) and sessile serrated ADR(SSADR) and significant predictors for sessile serrated adenomas(SSA) detection.METHODS This study is a retrospective, single-center analysis. Total colonoscopies performed by the gastroenterologists at the University of Tokyo Hospital between January and December 2014 were retrospectively identified. Polyps were classified as low-grade or high-grade adenoma, cancer, SSA, or SSA with cytological dysplasia, and the prevalence of each type of polyp was investigated. Predictors of adenoma and SSA detection were examined using logistic generalized estimating equation models. The association between ADR and SSADR for each gastroenterologist was investigated by calculating a correlation coefficient weighted by the number of each gastroenterologist's examination.RESULTS A total of 3691 colonoscopies performed by 35 gastroenterologists were assessed. Overall, 978 (26.5%) low-and 84 (2.2%) high-grade adenomas, 81 (2.2%) cancers, 66 (1.8%) SSAs, and 2 (0.1%) SSAs with cytological dysplasia were detected. Overall ADR was 29.5%(men 33.2%, women 23.8%) and overall SSADR was 1.8%(men 1.7%, women 2.1%). In addition, 672 low-grade adenomas (68.8% of all the detected lowgrade adenomas), 58 (69.9%) high-grade adenomas, 29 (34.5%) cancers, 52 (78.8%) SSAs, and 2 (100%) SSAs with cytological dysplasia were found in the proximal colon. Adenoma detection was the only significant predictor of SSA detection (adjusted OR: 2.53, 95%CI: 1.53-4.20; P < 0.001). The correlation coefficient between ADR and SSADR weighted by the number of each gastroenterologist's examinations was 0.606(P < 0.001).CONCLUSION Our results demonstrated that ADR is correlated to SSADR. In addition, patients with adenomas had a higher prevalence of SSAs than those without adenomas.

Ultrathin endoscope flexibility can predict discomfort associated with unsedated transnasal esophagogastroduodenoscopy

AIM: To evaluate the effects of choice of insertion route and ultrathin endoscope types. METHODS: This prospective study (January-June 2012) included 882 consecutive patients who underwent annual health checkups. Transnasal esophagogastroduodenoscopy (EGD) was performed in 503 patients and transoral EGD in 235 patients using six types of ultrathin endoscopes. Patients were given a choice of insertion route, either transoral or transnasal, prior to EGD examination. For transoral insertion, the endo-scope was equipped with a thin-type mouthpiece and tongue depressor. Conscious sedation was not used for any patient. EGD-associated discomfort was assessed using a visual analog scale (VAS; no discomfort 0maximum discomfort 10). RESULTS: Rates of preference for transnasal insertion were significantly higher in male (male/female 299/204 vs 118/117) and younger patients (56.8 ± 11.2 years vs 61.3 ± 13.0 years), although no significant difference was found in VAS scores between transoral and transnasal insertion (3.9 ± 2.3 vs 4.1 ± 2.5). Multivariate analysis revealed that gender, age, operator, and endoscope were independent significant predictors of VAS for transnasal insertion, although gender, age, and endoscope were those for transoral insertion. Further analysis revealed only the endoscopic flexibility index (EFI) as an independent significant predictor of VAS for transnasal insertion. Both EFI and tip diameter were independent significant predictors of VAS for transoral insertion. CONCLUSION: Flexibility of ultrathin endoscopes can be a predictor of EGD-associated discomfort, especially in transnasal insertion.

Subserosal injection of hyaluronic acid may prevent perforation after endoscopic resection

AIM:To investigate the protective effect of subserosal injection of hyaluronic acid(HA) after endoscopic resection(ER) using ex vivo and in vivo studies.METHODS:As the first examination,technical application of subserosal injection was tested 10 times using resected porcine stomachs.As the second examination,ER was applied to make six mucosal defects per stomach in three live minipigs and thermal damage was given on the proper muscle layer by using hemostatic forceps.Following the thermocoagulation,1 mL of normal saline and HA,respectively,was injected targeting the subserosal layer in two mucosal defects each and the rest kept no injection as the control.The minipigs were recovered from the anesthesia and kept fasting until euthanasia which was carried out around 24 h after the procedures.RESULTS:Ex vivo study revealed that complete and partial subserosal injection was possible two(20%) and four(40%) times,respectively.In vivo study revealed that no postoperative perforation occurred at any point of the thermocoagulation.Apparent retention of hyaluronic acid was identified at only two(33%) points where HA was injected.CONCLUSION:This study failed to show preventative effects of subserosal injection of HA on postoperative perforation due to technical faults.However,this concept has a possibility to change strategy of ER with further technical innovation.

Evaluation of preferable insertion routes for esophagogastroduodenoscopy using ultrathin endoscopes

AIM:To evaluate the discomfort associated with esophagogastroduodenoscopy(EGD)using an ultrathin endoscope through different insertion routes.METHODS:This study(January 2012-March 2013)included 1971 consecutive patients[male/female(M/F),1158/813,57.5±11.9 years]who visited a single institute for annual health checkups.Transnasal EGD was performed in 1394 patients and transoral EGD in 577.EGD-associated discomfort was assessed using a visual analog scale score(VAS score:0-10).RESULTS:Multivariate analysis revealed gender(M vs F:4.02±2.15 vs 5.06±2.43)as the only independent predictor of the VAS score in 180 patients who underwent EGD for the first time;whereas it revealed gender(M vs F 3.60±2.20 vs 4.84±2.37),operator,age group(A:<39 years;B:40-49 years;C:50-59years;D:60-69 years;E:>70 years;A/B/C/D/E:4.99±2.32/4.34±2.49/4.19±2.31/3.99±2.27/3.63±2.31),and type of insertion as independent predictors in the remaining patients.Subanalysis for gender,age group,and insertion route revealed that the VAS score decreased with age regardless of gender and insertion route,was high in female patients regardless of age and insertion route,and was low in males aged over60 years who underwent transoral insertion.CONCLUSION:Although comprehensive analysis revealed that the insertion route may not be an independent predictor of the VAS score,transoral insertion may reduce EGD-associated discomfort in elderly patients.

Preservation and management of a World Heritage site Tajima Yahei Sericulture Farm and its buffer zone

Tajima Yahei Sericulture Farm,one of the four components of the UNESCO World Heritage Site Tomioka Silk Mill and Related Sites inscribed in 2014,was the starting point for advancements in sericulture farmhouses,emphasizing the importance of ventilation.Through Yahei’s experimentation surrounding the ideal space to breed silkworms,a new sericulture theory was invented,and a sericulture farmhouse architecture was formed.For the purpose of preserving this cultural heritage for future generations,it is important to understand the idea that led to the cultural and industrial advancement of the village of Shimamura and to revise the preservation plans prepared by stakeholders.This paper will discuss the development of the sericulture theory,seiryō-iku theory,and the formation of a sericulture farmhouse architecture;describe the adaptation of former sericulture farmhouses and the surrounding landscapes in terms of the industry and environment;outline the plans and efforts for the preservation and revitalization of Tajima Yahei Sericulture Farm,its surrounding area and its underlying issues;and propose a direction for future preservation plans.