Diagnosis of boundary in early gastric cancer

Endoscopic submucosal dissection (ESD) is an advanced therapeutic endoscopic technique,which allowsresection of larger superficial tumors in the esophagus,stomach,and colon.Precise diagnosis of the boundary between tumor and the non-tumorous surrounding portion is especially important before starting ESD,because too much resection can potentially take more time and can induce a higher complication rate,while too little resection can result in a non-curative resection.The boundary diagnosis is often difficult for early gastric cancer,mainly because of the underlying condition of chronic gastritis.Due to recent developments in endoscopy,including magnified endoscopy and narrow band endoscopy,the boundary diagnosis is becoming easy and more accurate.We have also applied magnified endoscopy combined with narrow band imaging to fresh specimens immediately after resection using thetiling method and XY stage.

Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones

Current guidelines for treating asymptomatic common bile duct stones(CBDS)recommend stone removal,with endoscopic retrograde cholangiopan-creatography(ERCP)being the first treatment choice.When deciding on ERCP treatment for asymptomatic CBDS,the risk of ERCP-related complications and outcome of natural history of asymptomatic CBDS should be compared.The incidence rate of ERCP-related complications,particularly of post-ERCP pancreatitis for asymptomatic CBDS,was reportedly higher than that of symptomatic CBDS,increasing the risk of ERCP-related complications for asymptomatic CBDS compared with that previously reported for biliopancreatic diseases.Although studies have reported short-to middle-term outcomes of natural history of asymptomatic CBDS,its long-term natural history is not well known.Till date,there are no prospective studies that determined whether ERCP has a better outcome than no treatment in patients with asymptomatic CBDS or not.No randomized controlled trial has evaluated the risk of early and late ERCP-related complications vs the risk of biliary complications in the wait-and-see approach,suggesting that a change is needed in our perspective on endoscopic treatment for asymptomatic CBDS.Further studies examining long-term complication risks of ERCP and wait-and-see groups for asymptomatic CBDS are warranted to discuss whether routine endoscopic treatment for asymptomatic CBDS is justified or not.

Endoscopic retrograde cholangiopancreatography for bile duct stones in patients with a performance status score of 3 or 4

BACKGROUND As the aging population grows worldwide,the rates of endoscopic retrograde cholangiopancreatography(ERCP)for common bile duct stones(CBDS)in older patients with a poor performance status(PS)have been increasing.However,the data on the safety and efficacy of ERCP for CBDS in patients with a PS score of 3 or 4 are lacking,with only a few studies having investigated this issue among patients with poor PS.AIM To examine the safety and efficacy of ERCP for CBDS in patients with a PS score of 3 or 4.METHODS This study utilized a retrospective multi-centered design of three institutions in Japan for 8 years to identify a total of 1343 patients with CBDS having native papillae who underwent therapeutic ERCP.As a result,1113 patients with a PS 0-2 and 230 patients with a PS 3-4 were included.One-to-one propensity-score matching was performed to compare the safety and efficacy of ERCP for CBDS between patients with a PS 0-2 and those with a PS 3-4.RESULTS The overall ERCP-related complication rates in all patients and propensity score-matched patients with a PS 0-2 and 3-4 were 9.0%(100/1113)and 7.0%(16/230;P=0.37),and 4.6%(9/196)and 6.6%(13/196;P=0.51),respectively.In the propensity score-matched patients,complications were significantly more severe in the group with a PS 3-4 than in the group with a PS 0-2 group(P=0.042).Risk factors for complications were indications of ERCP and absence of antibiotics in the multivariate analysis.Therapeutic success rates,including complete CBDS removal and permanent biliary stent placement,in propensity score-matched patients with a PS 0-2 and 3-4 were 97.4%(191/196)and 97.4%(191/196),respectively(P=1.0).CONCLUSION ERCP for CBDS can be effectively performed in patients with a PS 3 or 4.Nevertheless,the indication for ERCP in such patients should be carefully considered with prophylactic antibiotics.

Possibilities of interventional endoscopic ultrasound

Since endoscopic ultrasound (EUS) was developed in the 1990s, EUS has become widely accepted as an imaging tool. EUS is categorized into radial and linear in design. Radial endoscopes provide cross-sectional imaging of the mediastinum, gastrointestinal tract, liver, spleen, kidney, adrenal gland, and pancreas, which has highly accuracy in the T and N staging of esophageal, lung, gastric, rectal, and pancreatic cancer. Tumor staging is common indication of radial-EUS, and EUSstaging is predictive of surgical resectability. In contrast, linear array endoscope uses a side-viewing probe and has advantages in the ability to perform EUSguides fine needle aspiration (EUS-FNA), which has been established for cytologic diagnosis. For example, EUS-FNA arrows accurate nodal staging of esophageal cancer before surgery, which provides more accurate assessment of nodes than radial-EUS imaging alone. EUS-FNA has been also commonly used for diagnose of pancreatic diseases because of the highly accuracy than US or computed tomography. EUS and EUS-FNA has been used not only for TNM staging and cytologic diagnosis of pancreatic cancer, but also for evaluation of chronic pancreatitis, pancreatic cystic lesions, and other pancreatic masses. More recently, EUS-FNA has developed into EUS-guided fine needle injection including EUS-guided celiac plexus neurolysis, celiac plexus block, and other "interventional EUS" procedures. In this review, we have summarized the new possibilities offered by "interventional EUS".

Clinical impact of gastrointestinal endoscopy on the early detection of pharyngeal squamous cell carcinoma: A retrospective cohort study

BACKGROUND In recent years,with the growing availability of image-enhanced gastrointestinal endoscopy,gastroenterologists have contributed to the early detection of pharyngeal squamous cell carcinomas(SCC).AIM To clarify the clinical characteristics of pharyngeal SCCs detected by gastrointestinal endoscopy.METHODS This is a retrospective cohort study conducted in a single-center,a university hospital in Japan.We retrospectively assessed the clinical records of 522 consecutive patients with oropharyngeal or hypopharyngeal SCC who were examined in our hospital between 2011 and 2018.The lesions were classified into two groups:Group GE(detected by gastrointestinal endoscopy)and Group non-GE(detected by means other than gastrointestinal endoscopy).The clinical characteristics were compared between the two groups.Continuous data were compared using the Mann–Whitney U test.Pearson’sχ2 test or Fisher's exact test was used to analyze the categorical data and compare proportions.The Kaplan–Meier method was used to estimate the cumulative patient survival rates.RESULTS In our study group,the median age was 65 years and 474 patients(90.8%)were male.One hundred and ninety-six cases(37.5%)involved the oropharynx and 326 cases(62.5%)involved the hypopharynx.Three hundred and ninety-five cases(75.7%)had some symptoms at the time of diagnosis.One hundred and forty-five(27.8%)cases had concurrent ESCC or a history of ESCC.One hundred and sixtyfour(31.4%)cases were detected by gastrointestinal endoscopy and classified as Group GE.The proportions of asymptomatic cases,cTis-1 cases and cases with no lymph node metastasis were significantly higher in Group GE than Group non-GE(61.6%vs 7.3%,P<0.001,32.9%vs 12.0%,P<0.001 and 69.5%vs 19.0%,P<0.001).Endoscopic laryngo-pharyngeal surgery or endoscopic submucosal dissection were performed in only 0.6%of the lesions in Group non-GE but in 21.3%of the lesions in Group GE(P<0.001).Overall survival was significantly longer in Group GE than in Group non-GE(P=0.018).The 2-year and 4-year survival rates were 82.5%and 70.7%in Group GE,and 71.5%and 59.0%in Group non-GE,respectively.CONCLUSION Gastrointestinal endoscopy plays an important role in the early detection and improving the prognosis of pharyngeal SCCs.