Publications by authors named "Dai Hirasawa"

43 Publications

Automatic anatomical classification of colonoscopic images using deep convolutional neural networks.

Gastroenterol Rep (Oxf) 2021 Jun 7;9(3):226-233. Epub 2020 Dec 7.

Tada Tomohiro Institute of Gastroenterology and Proctology, Saitama, Japan.

Background: A colonoscopy can detect colorectal diseases, including cancers, polyps, and inflammatory bowel diseases. A computer-aided diagnosis (CAD) system using deep convolutional neural networks (CNNs) that can recognize anatomical locations during a colonoscopy could efficiently assist practitioners. We aimed to construct a CAD system using a CNN to distinguish colorectal images from parts of the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum.

Method: We constructed a CNN by training of 9,995 colonoscopy images and tested its performance by 5,121 independent colonoscopy images that were categorized according to seven anatomical locations: the terminal ileum, the cecum, ascending colon to transverse colon, descending colon to sigmoid colon, the rectum, the anus, and indistinguishable parts. We examined images taken during total colonoscopy performed between January 2017 and November 2017 at a single center. We evaluated the concordance between the diagnosis by endoscopists and those by the CNN. The main outcomes of the study were the sensitivity and specificity of the CNN for the anatomical categorization of colonoscopy images.

Results: The constructed CNN recognized anatomical locations of colonoscopy images with the following areas under the curves: 0.979 for the terminal ileum; 0.940 for the cecum; 0.875 for ascending colon to transverse colon; 0.846 for descending colon to sigmoid colon; 0.835 for the rectum; and 0.992 for the anus. During the test process, the CNN system correctly recognized 66.6% of images.

Conclusion: We constructed the new CNN system with clinically relevant performance for recognizing anatomical locations of colonoscopy images, which is the first step in constructing a CAD system that will support us during colonoscopy and provide an assurance of the quality of the colonoscopy procedure.
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http://dx.doi.org/10.1093/gastro/goaa078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8309686PMC
June 2021

Diagnostic utility of a novel magnifying endoscopic classification system for superficial Barrett's esophagus-related neoplasms: a nationwide multicenter study.

Esophagus 2021 Oct 30;18(4):713-723. Epub 2021 May 30.

Department of Endoscopy, Saku Central Hospital Advanced Care Center, Nagano, Japan.

Background: Currently, no classification system using magnification endoscopy for the diagnosis of superficial Barrett's esophagus (BE)-related neoplasia has been widely accepted. This nationwide multicenter study aimed to validate the diagnostic accuracy and reproducibility of the magnification endoscopy classification system, including the diagnostic flowchart developed by the Japan Esophageal Society-Barrett's esophagus working group (JES-BE) for superficial Barrett's esophagus-related neoplasms.

Methods: The JES-BE acquired high-definition magnification narrow-band imaging (HM-NBI) images of non-dysplastic and dysplastic BE from 10 domestic institutions. A total of 186 high-quality HM-NBI images were selected. Thirty images were used for the training phase and 156 for the validation (test) phase. We invited five non-experts and five expert reviewers. In the training phase, the reviewers discussed how to correctly predict the histology based on the JES-BE criteria. In the validation phase, they evaluated whether the criteria accurately predicted the histology results according to the diagnostic flowchart. The validation phase was performed immediately after the training phase and at 6 weeks thereafter.

Results: The sensitivity and specificity for all reviewers were 87% and 97%, respectively. Overall accuracy, positive predictive value, and negative predictive value were 91%, 98%, and 83%, respectively. The overall strength of inter-observer and intra-observer agreements for dysplastic histology prediction was κ = 0.77 and κ = 0.83, respectively. No significant difference in diagnostic accuracy and reproducibility between experts and non-experts was found.

Conclusion: The JES-BE classification system, including the diagnostic flowchart for predicting dysplastic BE, is acceptable and reliable, regardless of the clinician's experience level.
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http://dx.doi.org/10.1007/s10388-021-00841-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8387266PMC
October 2021

Risk of metastatic recurrence after endoscopic resection for esophageal squamous cell carcinoma invading into the muscularis mucosa or submucosa: a multicenter retrospective study.

J Gastroenterol 2021 Jul 21;56(7):620-632. Epub 2021 Apr 21.

National University Corporation Hirosaki University, Hirosaki, Japan.

Background: We aimed to elucidate the risk of metastatic recurrence after endoscopic resection (ER) without additional treatment for esophageal squamous cell carcinomas (ESCCs) with tumor invasion into the muscularis mucosa (pT1a-MM) or submucosa (T1b-SM).

Methods: We retrospectively enrolled patients with pT1a-MM/pT1b-SM ESCC after ER at 21 institutions in Japan between 2006 and 2017. We compared metastatic recurrence between patients with and without additional treatment, stratified into category A (pT1a-MM with negative lymphovascular invasion [LVI] and vertical margin [VM]), B (tumor invasion into the submucosa ≤ 200 µm [pT1b-SM1] with negative LVI and VM), and C (others). Subsequently, using multivariate Cox analysis, we evaluated risk factors for metastatic recurrence after ER without additional treatment.

Results: We enrolled 593 patients, and metastatic recurrence occurred in 38 patients. Metastatic recurrence after additional treatment was significantly lower than that after no additional treatment in category C (9.1% vs. 23.6% in 5 years, p = 0.001), whereas no significant difference was noted in categories A (0.0% vs. 2.6%) and B (0.0% vs. 4.3%). In patients without additional treatment after ER, risk factors for metastatic recurrence were lymphatic invasion (hazard ratio [HR], 5.61), positive VM (HR, 4.55), and tumor invasion into the submucosa > 200 μm (HR, 3.25), and, but near half of the patients with metastatic recurrence had no further recurrence after salvage treatment, resulting in excellent 5-year disease-specific survival in categories A (99.6%) and B (100.0%).

Conclusions: Closed follow-up with no additional treatment may be an acceptable option after ER in pT1a-MM/pT1b-SM1 ESCC with negative LVI and VM.
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http://dx.doi.org/10.1007/s00535-021-01787-yDOI Listing
July 2021

A case of duodenal polyp at superior duodenal angle successfully treated by cap-assisted endoscopic mucosal resection.

VideoGIE 2020 Dec 20;5(12):681-683. Epub 2020 Aug 20.

Department of Gastroenterology, Sendai Kousei Hospital, Miyagi, Japan.

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http://dx.doi.org/10.1016/j.vgie.2020.07.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7730507PMC
December 2020

Cancer of unknown primary inside the gastric wall identified by endoscopic submucosal dissection.

Clin J Gastroenterol 2021 Apr 18;14(2):506-510. Epub 2020 Nov 18.

Department of Gastroenterology, Sendai Kousei Hospital, 4-15, Hirose-machi, Aoba-ku, Sendai, Miyagi, 980-0873, Japan.

We report the rare and interesting case of cancer of unknown primary (CUP) detected by endoscopic submucosal dissection (ESD). A 67-year-old man with a gastric adenoma was referred to our hospital for endoscopic treatment. Esophagogastroduodenoscopy revealed a 15-mm submucosal tumor (SMT) at the lesser curvature of the lower gastric body, near the gastric adenoma. Both lesions were resected by ESD. Pathological examination showed that the SMT was a poorly differentiated adenocarcinoma with lymphatic tissue. Additional surgical resection was performed, and the lymph nodes were found to have the same pathological findings as the SMT. These lesions were diagnosed as CUP because the obvious primary site was not detected with additional examination. The patient has been followed up for 24 months without recurrence.
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http://dx.doi.org/10.1007/s12328-020-01297-zDOI Listing
April 2021

The risks and characteristics of the delayed bleeding after endoscopic submucosal dissection for early gastric carcinoma in cases with anticoagulants.

Scand J Gastroenterol 2020 Oct 14;55(10):1253-1260. Epub 2020 Sep 14.

Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Japan.

Background: Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for early gastric carcinoma. Vitamin K antagonists and direct oral anticoagulants (DOAC) were reported to increase the risk of delayed bleeding after ESD. However, the evaluation of ESD cases taking anticoagulants is scarce. We analyzed the risk and characteristics of delayed bleeding after gastric ESD in patients on anticoagulants.

Methods: We performed a retrospective observational study at a single center. Consecutive patients who underwent ESD for early gastric carcinoma and took anticoagulants, including warfarin, rivaroxaban, dabigatran, apixaban, and edoxaban, between January 2012 and December 2018, were analyzed. We also calculated delayed bleeding rates for those without anticoagulants.

Results: Of 1855 eligible patients who underwent gastric ESDs, 143 took anticoagulants. Delayed bleeding occurred in 30 (21.0%) cases taking anticoagulants, with 15 (19.5%) cases in the DOAC group [rivaroxaban, seven cases (21.2%); dabigatran, four cases (20.0%); apixaban, four cases (23.5%); and edoxaban, zero cases (0%)] and 15 cases (22.7%) in the warfarin group. Furthermore, 43/344 (12.5%) patients taking antiplatelets and 76/1368 (5.6%) patients without antithrombic drugs experienced delayed bleeding. Multivariable logistic analysis revealed post-heart valve replacement (OR, 6.56; 95% CI, 1.75-24.7;  < .05) as a risk for delayed bleeding in warfarin-taking patients, while no statistically significant factor was found in DOAC-taking patients.

Conclusions: Anticoagulants were associated with a high incidence of severe delayed bleeding. Careful attention should be paid to patients on anticoagulants after gastric ESD, especially those on warfarin after heart valve replacement.
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http://dx.doi.org/10.1080/00365521.2020.1817542DOI Listing
October 2020

Massive esophageal hemorrhage after a MitraClip procedure successfully treated by balloon compression.

Clin J Gastroenterol 2020 Oct 25;13(5):693-696. Epub 2020 Jun 25.

Department of Gastroenterology, Sendai Kousei Hospital, 4-15, Hirose-machi, Aoba-ku, Sendai, Miyagi, 980-0873, Japan.

MitraClip procedure is an effective treatment for mitral regurgitation, performed globally. During the MitraClip procedure, transesophageal echocardiography is an essential modality to perform the operation safely. Although a few transesophageal echocardiography-related complications, such as esophageal hematoma, have been reported, there are no reports on massive esophageal bleeding after the MitraClip procedure. We present the first case of massive esophageal hemorrhage caused by transesophageal echocardiography after a MitraClip procedure and the successful treatment by balloon compression using a Sengstaken-Blakemore tube.
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http://dx.doi.org/10.1007/s12328-020-01160-1DOI Listing
October 2020

A case of gastric adenocarcinoma considered to originate from a sporadic fundic gland polyp in a Helicobacter pylori-uninfected stomach.

Clin J Gastroenterol 2020 Oct 28;13(5):740-745. Epub 2020 May 28.

Department of Gastroenterology, Sendai Kousei Hospital, 4-15 Hirosemachi, Aoba-ku, Sendai-shi, Miyagi-ken, 980-0873, Japan.

We encountered a rare case of gastric adenocarcinoma considered to arise from a sporadic fundic gland polyp (FGP). A woman in her 70 s, who had been prescribed a proton pump inhibitor for 5 years, was referred to our institution for further investigation and treatment of a gastric lesion. White light endoscopy showed numerous isochromatic FGPs in the greater curvature of the gastric body and a 15-mm reddish polypoid lesion with uneven surface characteristics. Magnifying endoscopy with narrow band imaging revealed an irregular granular microsurface structure with irregular microvessels, which is suggestive of cancer. The absence of atrophic changes in the entire gastric mucosa was confirmed endoscopically and histologically, and multiple Helicobacter pylori (HP) tests were negative. An en bloc resection was performed by polypectomy. The specimen showed adenocarcinoma that was thought to arise from an FGP. The lesion consisted of cystically dilated fundic glands in the basal part and neoplastic cells with nuclear atypia and high nuclear-cytoplasmic ratio in the foveolar part; on the basis of these findings, noninvasive adenocarcinoma was diagnosed. Although both adenocarcinoma in an HP-uninfected stomach and epithelial high-grade dysplasia in a sporadic FGP are extremely rare, this possibility should be considered when performing esophagogastroduodenoscopy.
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http://dx.doi.org/10.1007/s12328-020-01139-yDOI Listing
October 2020

Posterior Mediastinitis Caused by Esophageal Anisakiasis.

Clin Gastroenterol Hepatol 2021 07 30;19(7):A30. Epub 2020 Apr 30.

Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Japan.

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http://dx.doi.org/10.1016/j.cgh.2020.04.063DOI Listing
July 2021

The sub-classification of type B2 vessels according to the magnifying endoscopic classification of the Japan Esophageal Society.

Dig Endosc 2020 Jan 20;32(1):49-55. Epub 2019 Aug 20.

Department of Gastroenterology, Sendai Kousei Hospital, Miyagi, Japan.

Objectives: Guidelines for magnified endoscopic diagnosis of esophageal squamous cell carcinoma (SCC) have been proposed by the Japan Esophageal Society. Type B1, B2, and B3 reflect increasing tumor invasion depths (within mucosal epithelium or into lamina propria mucosa [T1a-EP/LPM], into muscularis mucosa or superficial invasion into submucosa [T1a-MM/T1b-SM1], and into submucosa [T1b-SM2], respectively). The diagnostic accuracy of type B1 and B3 is high, but accuracy of type B2 is low. We aimed to improve the diagnostic accuracy of type B2.

Methods: We retrospectively reviewed 248 SCC lesions treated with endoscopic submucosal dissection between January 2012 and July 2018 and identified the B2 lesions. The maximum diameter of the area presenting B2 was measured and evaluated in relation to tumor invasion, for which receiver-operating characteristic (ROC) curves were generated. The optimal area size for distinguishing T1a-EP/LPM from T1a-MM or deeper invasion was determined.

Results: There were 78 lesions with B2, of which 26 (33%) were T1a-MM or T1b-SM1 SCCs. ROC curve analysis indicated that the optimal cut-off for the target area showing B2 was 4 mm. The invasion depth (EP/LPM: MM/SM1: SM2) of B2 observed in an area with a diameter <4 mm (B2-Narrow) and those with diameter ≥4 mm (B2-Broad) was 46:11:1 and 1:15:4, respectively. To predict T1a-MM or deeper invasion, B2-Broad had a sensitivity, specificity, positive predictive value, and negative predictive value of 61%, 98%, 95%, and 79%, respectively.

Conclusion: The diagnostic accuracy of type B2 was improved by evaluating the area of type B2.
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http://dx.doi.org/10.1111/den.13459DOI Listing
January 2020

Long-term outcomes of endoscopic resection and metachronous cancer after endoscopic resection for adenocarcinoma of the esophagogastric junction in Japan.

Gastrointest Endosc 2019 06 18;89(6):1120-1128. Epub 2018 Dec 18.

Department of Endoscopy, Saku Central Hospital Advanced Care Center, Nagano, Japan.

Background And Aims: Endoscopic resection (ER) of superficial adenocarcinoma of the esophagogastric junction (AEGJ) has been shown to be safe and effective. However, long-term data in patients undergoing ER for superficial AEGJ in Japan are still limited. The aim of this study was to determine the effect of ER on survival and occurrence of metachronous cancer of patients with superficial AEGJ.

Methods: A retrospective analysis of patients who underwent or endoscopic submucosal dissection (ESD) for superficial AEJG in 13 centers in Japan was performed. The patients were classified as either low risk or high risk for lymph node metastasis based on histologic features. The incidence of metachronous AEGJ as well as overall survival and disease-specific survival rates were calculated.

Results: A total of 372 patients who underwent ER were included, in which 277 patients were low risk and 95 high risk for lymph node metastasis. Five-year cumulative incidences of local recurrence were 13% and .5% in the EMR and ESD groups, respectively (P < .01). Six AEGJ deaths were observed in the high-risk group and none in the low-risk group. The 5-year overall survival rates in the low-risk group without additional treatment, the high-risk group with additional treatment, and the high-risk group without additional treatment were 93.9%, 77.7%, and 81.6%, respectively. The 5-year disease-specific survival rates in the 3 groups were 100%, 94.4%, and 92.8%, respectively. The 5-year cumulative incidence of metachronous AEGJ in 316 patients without additional treatment was 1.1%.

Conclusions: Favorable long-term outcomes with ER were observed in patients with AEGJ who met the low-risk criteria for lymph node metastasis. ESD was a reasonable and effective treatment in Japanese patients.
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http://dx.doi.org/10.1016/j.gie.2018.12.010DOI Listing
June 2019

Newly developed magnifying endoscopic classification of the Japan Esophageal Society to identify superficial Barrett's esophagus-related neoplasms.

Esophagus 2018 Jun 19. Epub 2018 Jun 19.

Department of Endoscopy, Saku Central Hospital Advanced Care Center, Nagano, Japan.

Aim And Methods: The Japan Esophageal Society created a working committee group consisting of 11 expert endoscopists and 2 pathologists with expertise in Barrett's esophagus (BE) and esophageal adenocarcinoma. The group developed a consensus-based classification for the diagnosis of superficial BE-related neoplasms using magnifying endoscopy.

Results: The classification has three characteristics: simplified, an easily understood classification by incorporating the diagnostic criteria for the early gastric cancer, including the white zone and demarcation line, and the presence of a modified flat pattern corresponding to non-dysplastic histology by adding novel diagnostic criteria. Magnifying endoscopic findings are composed of mucosal and vascular patterns, and are initially classified as "visible" or "invisible." Morphologic features were evaluated for "visible" patterns, and were subsequently rated as "regular" or "irregular," and the histology, non-dysplastic or dysplastic, was predicted.

Conclusion: We introduce the process and outline of the magnifying endoscopic classification.
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http://dx.doi.org/10.1007/s10388-018-0623-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6021472PMC
June 2018

Usefulness of the S-O clip for gastric endoscopic submucosal dissection (with video).

Surg Endosc 2018 Feb 21;32(2):908-914. Epub 2017 Jul 21.

Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan.

Background: Endoscopic submucosal dissection (ESD) is technically one of the most complicated endoscopic procedures. Traction methods have been reported to be effective for ESD. A recent study revealed that the S-O clip allowed faster and safer colonic ESD. We assessed the efficacy and safety of gastric ESD with the S-O clip for gastric epithelial neoplasm.

Methods: We performed a retrospective cohort study of patients treated for gastric ESD using the S-O clip between September and November 2016 (SO group, n = 48). The subjects were matched with patients treated with conventional gastric ESD from September 2015 to August 2016 (control group, n = 258) at Sendai Kousei Hospital, a tertiary endoscopic center. The primary outcome was procedure time. Multivariate logistic regression and propensity score matching analyses were performed to reduce the effects of selection bias for potential confounding factors differences like age, sex, lesion location, lesion position, presence of ulcer scarring, resected specimen size, and operator experiences.

Results: Forty-eight pairs were created after propensity score matching. The mean procedure time (including the S-O clip attachment time) was significantly shorter in the SO group (47.2 ± 24.6 vs. 69.2 ± 67.1 min, p = 0.035). The mean clip attachment time was 4.4 (range 2-15) min. There were no significant differences in other treatment outcomes (en-bloc resection rate: 100 vs. 100%, p = 1.000; perforation rate: 0 vs. 2.1%, p = 0.315; delayed bleeding rate: 2.1 vs. 4.3%, p = 0.558).

Conclusions: The S-O clip improved the speed of gastric ESD by approximately 25%, without increasing adverse events.
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http://dx.doi.org/10.1007/s00464-017-5765-9DOI Listing
February 2018

Prediction of the invasion depth of superficial squamous cell carcinoma based on microvessel morphology: magnifying endoscopic classification of the Japan Esophageal Society.

Esophagus 2017 6;14(2):105-112. Epub 2016 Apr 6.

Department of Endoscopy, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461 Japan.

Predicting invasion depth of superficial esophageal squamous cell carcinoma is crucial in determining the precise indication for endoscopic resection because the rate of lymph node metastasis increases in proportion to the invasion depth of the carcinoma. Previous studies have shown a close relationship between microvascular patterns observed by Narrow Band Imaging magnifying endoscopy and invasion depth of the superficial carcinoma. Thus, the Japan Esophageal Society (JES) developed a simplified magnifying endoscopic classification for estimating invasion depth of superficial esophageal squamous cell carcinomas. We conducted a prospective study to evaluate the diagnostic values of type B vessels in the pretreatment estimation of invasion depth of superficial esophageal squamous cell carcinomas utilizing JES classification, the criteria of which are based on the degree of irregularity in the microvascular morphology. Type A microvessels corresponded to noncancerous lesions and lack severe irregularity; type B, to cancerous lesions, and exhibit severe irregularity. Type B vessels were subclassified into B1, B2, and B3, diagnostic criteria for T1a-EP or T1a-LPM, T1a-MM or T1b-SM1, and T1b-SM2 tumors, respectively. We enrolled 211 patients with superficial esophageal squamous cell carcinoma. The overall accuracy of type B microvessels in estimating tumor invasion depth was 90.5 %. We propose that the newly developed JES magnifying endoscopic classification is useful in estimating the invasion depth of superficial esophageal squamous cell carcinoma.
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http://dx.doi.org/10.1007/s10388-016-0527-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5362661PMC
April 2016

Duodenal endoscopic submucosal dissection with traction method using the S-O clip.

Dig Endosc 2017 Jul 30;29(5):635. Epub 2017 May 30.

Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Japan.

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http://dx.doi.org/10.1111/den.12860DOI Listing
July 2017

"Small white sign" in Barrett's esophageal cancer under the squamous epithelium.

Gastrointest Endosc 2017 07 21;86(1):231-233. Epub 2016 Dec 21.

Department of Gastroenterology, Sendai Kousei Hospital, Sendai City, Japan.

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http://dx.doi.org/10.1016/j.gie.2016.12.011DOI Listing
July 2017

Risk of metastasis in adenocarcinoma of the esophagus: a multicenter retrospective study in a Japanese population.

J Gastroenterol 2017 Jul 18;52(7):800-808. Epub 2016 Oct 18.

Department of Gastroenterological Surgery, Tokai University School of Medicine, Isehara, Japan.

Background: Little is known about the specific risks of metastasis in esophageal adenocarcinoma in relation to invasion depth or other pathologic factors.

Methods: We conducted a multicenter retrospective study in 13 high-volume centers in Japan from January 2000 to October 2014 to elucidate the risk of metastasis of esophageal adenocarcinoma. A total of 458 patients (217 surgically resected and 241 endoscopically resected) with esophageal adenocarcinoma or esophagogastric adenocarcinoma involving the esophagus were included. Metastasis was considered positive if there was histologically confirmed metastasis in the surgical specimen or clinically confirmed metastasis during follow-up. Metastasis was considered negative if no metastasis was identified in resected specimens and during follow-up in patients treated surgically or no metastasis during follow-up for >5 years in patients treated by endoscopic resection.

Results: Metastasis was identified in 72 patients. Multivariate analysis confirmed lymphovascular involvement [odds ratio (OR) 6.20; 95 % confidence interval (CI) 3.12-12.32; p < 0.001], a poorly differentiated component (OR 3.69; 95 % CI 1.92-7.10; p < 0.001), and lesion size >30 mm (OR 3.12; 95 % CI 1.63-5.97; p = 0.001) as independent risk factors for metastasis. No metastasis was detected in patients with mucosal cancer without lymphovascular involvement and a poorly differentiated component (0/186 lesions) or in patients with cancer invading the submucosa (1-500 µm) without lymphovascular involvement, a poorly differentiated component, and ≤30 mm (0/32 lesions).

Conclusions: Mucosal and submucosal cancers (1-500 µm invasion) without risk factors have a low incidence of metastasis and may thus be good candidates for endoscopic resection.
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http://dx.doi.org/10.1007/s00535-016-1275-0DOI Listing
July 2017

Carbon dioxide insufflation in esophageal endoscopic submucosal dissection reduces mediastinal emphysema: A randomized, double-blind, controlled trial.

World J Gastroenterol 2016 Aug;22(32):7373-82

Yuki Maeda, Dai Hirasawa, Tetsuya Ohira, Yoshihiro Harada, Taku Yamagata, Yoshiki Koike, Kenjirou Suzuki, Department of Gastroenterology, Sendai City Medical Center, Sendai 983-0824, Japan.

Aim: To assess the efficacy of CO2 insufflation for reduction of mediastinal emphysema (ME) immediately after endoscopic submucosal dissection (ESD).

Methods: A total of 46 patients who were to undergo esophageal ESD were randomly assigned to receive either CO2 insufflation (CO2 group, n = 24) or air insufflation (Air group, n = 22). Computed tomography (CT) was carried out immediately after ESD and the next morning. Pain and abdominal distention were chronologically recorded using a 100-mm visual analogue scale (VAS). The volume of residual gas in the digestive tract was measured using CT imaging.

Results: The incidence of ME immediately after ESD in the CO2 group was significantly lower than that in the Air group (17% vs 55%, P = 0.012). The incidence of ME the next morning was 8.3% vs 32% respectively (P = 0.066). There were no differences in pain scores or distention scores at any post-procedure time points. The volume of residual gas in the digestive tract immediately after ESD was significantly smaller in the CO2 group than that in the Air group (808 mL vs 1173 mL, P = 0.013).

Conclusion: CO2 insufflation during esophageal ESD significantly reduced postprocedural ME. CO2 insufflation also reduced the volume of residual gas in the digestive tract immediately after ESD, but not the VAS scores of pain and distention.
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http://dx.doi.org/10.3748/wjg.v22.i32.7373DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4997641PMC
August 2016

Submucosal fibrosis detected by endoscopic ultrasonography may predict incomplete endoscopic submucosal dissection.

Dig Endosc 2015 Apr;27 Suppl 1:24

Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan.

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http://dx.doi.org/10.1111/den.12452DOI Listing
April 2015

Usefulness of the thread-traction method in esophageal endoscopic submucosal dissection: randomized controlled trial.

Dig Endosc 2015 Mar 1;27(3):303-9. Epub 2014 Dec 1.

Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan.

Background And Aim: To assess the usefulness of the thread-traction method (TT method) in esophageal endoscopic submucosal dissection (ESD).

Methods: A total of 40 lesions that were scheduled to be treated by esophageal ESD were included in the study. The TT method was used for 20 lesions (group TT) and conventional ESD was used for 20 lesions (group C) after randomization. The hook-knife method was used in all cases. In group TT, after circumferential mucosal incision, a clip with thread was attached to the oral edge of the lesion.

Results: ESD was carried out in all cases. Effective countertraction was created by the TT method, and it was possible to carry out an efficient dissection operation. Significant shortening of dissection time was achieved in group TT compared with group C (19.8 min vs 31.8 min, P = 0.044). Mean number of local injections during dissection was significantly less in group TT compared with that in group C (0.6 times vs 2.2 times, P < 0.001). As for the amount of local injection, group TT required significantly less compared with group C (2.6 mL vs 7.5 mL, P < 0.01). No complications were encountered.

Conclusion: The TT method in esophageal ESD was safe and contributed to shortening of dissection time. The TT method is expected to become widespread as a safe and useful procedure.
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http://dx.doi.org/10.1111/den.12396DOI Listing
March 2015

Efficacy and safety of a WallFlex enteral stent for malignant gastric obstruction.

Dig Endosc 2013 Jul 1;25(4):386-91. Epub 2012 Nov 1.

Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan.

Aim: The aim of the present study was to investigate the efficacy and safety of a newly available enteral WallFlex stent for malignant gastric outlet obstruction (GOO).

Methods: Twenty-one consecutive patients with symptomatic (unable to take solids) malignant GOO treated by a WallFlex stent from April 2010 to February 2012 were included and analyzed retrospectively. Main outcome measurements were technical success, early complications, clinical response (elimination of the need for nasogastric tube drainage), clinical success (improvement of oral intake to a GOO score of 2 or 3), and duration of sustaining a GOO score of 2 or 3 after clinical success (median duration until reworsening of GOO score to <2 by the Kaplan-Meier method). A four-point GOO scoring system (0-3) was used for estimation of oral intake.

Results: Technical success rate was 100%. Bleeding and perforation after stent placement and stent dislocation/migration in the follow-up period did not occur in any patients, whereas one patient (5%) developed moderate post-procedural pancreatitis. Clinical response and clinical success was achieved in all patients and in 81% (17/21), respectively. In 17 patients whose GOO score had improved to 2 or 3 after stent placement, eight (47%) developed reworsening of the GOO score to <2 with a median time of 148 days (95% confidence interval [CI], 0-328; Kaplan-Meier method). Median survival time after the initial intervention was 61 days (95% CI, 40-82).

Conclusion: Placement of an enteral WallFlex stent in patients with malignant GOO is safe and effective.
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http://dx.doi.org/10.1111/j.1443-1661.2012.01396.xDOI Listing
July 2013

Clinicopathological study on endocrine cell micronests associated with early gastric cancer.

Intern Med 2013 ;52(12):1311-6

Department of Gastroenterology, Sendai City Medical Center, Japan.

Objective: The purpose of this study was to review cases of early gastric cancer associated with Endocrine cell micronests (ECM) and investigate the incidence and characteristics of these lesions.

Methods: A total of 482 patients who had undergone endoscopic or surgical resection for gastric epithelial neoplasms from April 2008 to March 2010 were enrolled in this study. After detection of ECM in the lamina propria mucosa by histological examination of the resected specimens with hematoxilin-eosin staining, immunostaining was also performed. Clinical manifestation and endoscopic findings, as well as histological findings, were examined.

Results: Among the 482 patients, 5 (1.0%) had ECM. The histological type of gastric epithelial cancers associated with ECM was tubular adenocarcinoma and carcinoma in situ (Tis) in the WHO classification in all 5 cases. ECM were round to oval or trabecular and located within the area of the early gastric cancer in all the 5 cases. The background gastric mucosa was Type A gastritis in 2 patients and ordinary atrophic gastritis in 2 patients. In the other case, it was difficult to determine the type of gastritis.

Conclusion: ECM developed not only from the background of Type A gastritis but also from ordinary atrophic gastritis. ECM coexistent with gastric cancer were present in 1.0% of resectable gastric epithelial neoplasms.
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http://dx.doi.org/10.2169/internalmedicine.52.9229DOI Listing
February 2014

Small Barrett's adenocarcinoma, 3 mm in size, in long-segment Barrett's esophagus detected after 4 years of follow up.

Dig Endosc 2013 May;25 Suppl 2:196-200

Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan.

We herein report a rare case of very small Barrett's adenocarcinoma. A 65-year-old man underwent surveillance esophagogastroduodenoscopy (EGD) 3 years after endoscopic submucosal dissection (ESD) for superficial Barrett's adenocarcinoma, which revealed a very small reddish area in the mucosa, 2 mm in diameter, in long-segment Barrett's esophagus. The EGD carried out 1 year later confirmed slight enlargement of the lesion, from 2 mm to 3 mm in diameter. Macroscopic type changed from flat type to slightly depressed type. On narrow-band imaging with magnifying endoscopy, an irregular microstructure and irregular microvasculature became recognizable. It was resected by ESD and diagnosed as mucosal adenocarcinoma with a diameter of only 3 mm.
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http://dx.doi.org/10.1111/den.12110DOI Listing
May 2013

Current status of endoscopic diagnosis and treatment of superficial Barrett's adenocarcinoma in Asia-Pacific region.

Dig Endosc 2013 May;25 Suppl 2:146-50

Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan.

The incidence of Barrett's adenocarcinoma has increased dramatically over the past few decades in most Western countries. While Barrett's esophagus is uncommon and adenocarcinoma is still rare in Asian populations, several Asian studies have indicated that the prevalence of esophageal adenocarcinoma is gradually increasing. Therefore, in order to determine the best way to treat superficial Barrett's adenocarcinoma, 12 expert endoscopists and a pathologist from the Asia-Pacific region conducted a session entitled 'The current status of endoscopic diagnosis and treatment of superficial Barrett's adenocarcinoma'. After three keynote lectures, three Japanese panels presented cases of superficial Barrett's adenocarcinomas diagnosed by image-enhanced endoscopy (IEE). We then confirmed the results of a questionnaire on the diagnosis and treatment of superficial Barrett's adenocarcinomas. Finally, a panel introduced an Asia-Pacific international study on simplified narrow-band imaging (NBI) classification of Barrett's esophagus and neoplasias. After a discussion, we proposed consensus statements on endoscopic diagnosis and treatment of superficial Barrett's adenocarcinoma as follows. Representative characteristics by conventional white light endoscopy are a reddish area or a lesion located on the anterior to right side wall. IEE may be useful for characterizing the tumor and diagnosing lateral tumor extension. Superficial Barrett's adenocarcinoma adjacent to the squamocolumnar junction is sometimes associated with subsquamous tumor extension. IEE may be useful to detect the subsquamous tumor extension especially when using NBI or an acetic acid-spraying method. Endoscopic mucosal resection or endoscopic submucosal dissection for mucosal carcinomas could provide excellent prognosis.
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http://dx.doi.org/10.1111/den.12093DOI Listing
May 2013

A case of mucosal cancer of the stomach treated by endoscopic submucosal dissection after which nodal metastasis became evident.

Case Rep Med 2013 27;2013:853849. Epub 2013 Feb 27.

Department of Gastroenterology, Sendai City Medical Center, 5-22-1, Tsurugaya, Miyagino-ku, Sendai 983-0824, Japan.

An 82-year-old male was referred to our institution for evaluation and treatment of a protruding lesion in the stomach. Esophagogastroduodenoscopy (EGD) showed a small protruding lesion and a large superficial elevated lesion on the lesser curvature of the stomach (macroscopic type: 0-I and 0-IIa, resp.). CT and endoscopic ultrasonography (EUS) visualized a small round lymph node (LN) 11 mm in size near the lesser curvature, although submucosal invasion was not evident. These two lesions were resected en bloc by endoscopic submucosal dissection (ESD). Pathological examination of the resected specimen showed moderately differentiated tubular adenocarcinoma (tub2) and well-differentiated tubular adenocarcinoma (tub1), respectively, which were limited to the mucosal layer. Because lymphatic-vascular involvement was not detected by hematoxylin and eosin (HE) staining, additional gastrectomy was not performed. Two months after ESD, follow-up EUS and CT showed an enlarged LN. EUS-guided fine needle aspiration (EUS-FNA) for the LN revealed metastasis. Therefore, total gastrectomy with LN dissection was performed. His postoperative course was uneventful. After discharge, he has been followed up at the outpatient department without any sign of recurrence for 5 years. Histological reexamination of the ESD specimen using immunohistochemistry showed lymphatic invasion of cancer cells in the lamina propria of the 0-I lesion 13 mm in size.
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http://dx.doi.org/10.1155/2013/853849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3600226PMC
March 2013

Prospective evaluation of contrast-enhanced computed tomography for the detection of colonic diverticular bleeding.

Dig Dis Sci 2013 Jul 17;58(7):1985-90. Epub 2013 Mar 17.

Department of Gastroenterology, Sendai City Medical Center, 5-22-1, Tsurugaya, Miyagino-ku, Sendai, Miyagi 983-0824, Japan.

Background And Aims: To prospectively evaluate the role of contrast-enhanced computed tomography (CE-CT) in the detection of colonic diverticular bleeding (CDB).

Patients And Methods: Consecutive patients who presented with hematochezia and were clinically suspected of CDB were prospectively enrolled. Those who could undergo both CE-CT and total colonoscopy, and who were finally diagnosed as CDB, were included in the analysis.

Results: Fifty-two cases were finally included in the analysis. The detection rate of CDB by CT was 15.4 % (8/52). Univariate analysis showed that the interval from the latest episode of hematochezia to the performance of CT and the presence of a past history of CDB were contributing factors for detection. The interval was 1.6 ± 4.6 h (mean ± SD) in patients detected by CT, and 3.4 ± 3.2 h in those without detection. The detection rate of CDB by total colonoscopy was 38.5 % (20/52). The overall detection rate was 46.2 % (24/52), which was superior to what CT or colonoscopy alone achieved.

Conclusions: CE-CT may play a complementary role to colonoscopy in patients with suspected CDB, but is not recommended for all cases due to its low detection rate. Patients who can be examined within 2 h of last hematochezia would be candidates for urgent CT.
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http://dx.doi.org/10.1007/s10620-013-2629-6DOI Listing
July 2013

Efficacy of acetic acid-spraying method in diagnosing extension of Barrett's cancer under the squamous epithelium.

Dig Endosc 2012 Sep 15;24(5):309-14. Epub 2012 Mar 15.

Department of Gastroenterology, Sendai City Medical Center, Japan.

Aim: Endoscopic diagnosis of the lateral extension of Barrett's cancer under the squamous epithelium (BCUS) is sometimes difficult because the cancer is unobservable in the esophageal lumen. The aim of the present study was to clarify the endoscopic features of the extension of BCUS and verify the usefulness of the acetic acid-spraying method (AAS) for diagnosis.

Methods: A total of 25 patients with Barrett's cancer who had undergone endoscopic resection were included in this study. Histological examination of patients' resected specimens was performed to identify the presence of BCUS. Then, the endoscopic images of the BCUS cases were reviewed to summarize the findings and to evaluate the feasibility of diagnosing the extent of BCUS with each imaging technique.

Results: Of the 25 patients, 10 (40%) had BCUS. With white-light imaging, subtle reddish change was observed in the area of BCUS in 80% of the patients, and a flat elevated lesion was recognized in 30%. With narrow band imaging, slight brownish change was observed in the area of BCUS in 86% of the patients. Slight white changes were visualized in all cases with AAS. The extension of BCUS was correctly diagnosed by white-light imaging, narrow band imaging and AAS in 50%, 43% and 100% of the cases, respectively. Histology verified the opening of cancerous glands, which extended under the squamous epithelium, into the esophagus in the area showing slight white changes by AAS.

Conclusion: AAS can be useful for diagnosing the extension of BCUS.
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http://dx.doi.org/10.1111/j.1443-1661.2012.01239.xDOI Listing
September 2012

[Hook knife method of ESD for early esophageal cancer].

Nihon Rinsho 2011 Aug;69 Suppl 6:248-54

Department of Gastroenterology, Sendai City Medical Center.

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August 2011

Efficacy of propofol sedation for endoscopic submucosal dissection (ESD): assessment with prospective data collection.

Intern Med 2011 15;50(14):1455-60. Epub 2011 Jul 15.

Department of Gastroenterology, Sendai City Medical Center, Japan.

Objective: The indications for endoscopic treatment in early stage cancer of the digestive tract are expanding with the emergence and technical development of endoscopic submucosal dissection (ESD). ESD requires longer term stable sedation than conventional endoscopic procedures due to the necessity of meticulous control of the devices during the procedure. Propofol has a very short half-life and can be administered continuously, which is advantageous for long-term sedation. Propofol, thus, is likely to be useful for sedation during ESD.

Methods: Fifty consecutive patients who underwent ESD for early gastric cancer with propofol sedation (Group P) and those with midazolam sedation (Group M) were included in this study. Cardiorespiratory suppression rate and the condition of arousal were compared between the groups. A questionnaire survey on the satisfaction of endoscopists, anesthesiologists, endoscopy nurses, and ward nurses with the use of propofol was also carried out.

Results: Respiratory suppression was observed in 50% in Group M and in 20% in Group P (p<0.05). Hypotension was seen in 14% and 36% in Groups M and P, respectively (p<0.05). No sedation-related complications were encountered in either of the groups. Arousal rates 1 hour and 3 hours after the procedure were 23% and 60% in group M and 86% and 100% in Group P (p<0.05). As for the questionnaire survey, most respondents, in particular the ward nurses, supported the use of propofol.

Conclusion: Our data suggest that propofol is safe and useful during ESD as compared with midazolam.
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http://dx.doi.org/10.2169/internalmedicine.50.4627DOI Listing
November 2011
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