Publications by authors named "Motohiko Kato"

110 Publications

Water pressure method overcomes the gravitational side in endoscopic submucosal dissection for gastric cancer.

VideoGIE 2021 Oct 21;6(10):457-459. Epub 2021 Jul 21.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

Video 1Extensive gastric endoscopic submucosal dissection using the water pressure method, which made it easy to process the greater curvature of the gastric body.
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http://dx.doi.org/10.1016/j.vgie.2021.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8503939PMC
October 2021

Endoscopic resection of the rectal mucosal bridge after surgery for Hirschsprung's disease.

Gastrointest Endosc 2021 Oct 11. Epub 2021 Oct 11.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

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http://dx.doi.org/10.1016/j.gie.2021.10.006DOI Listing
October 2021

Outcomes of endoscopic resection for superficial duodenal tumors: 10 years' experience in 18 Japanese high-volume centers.

Endoscopy 2021 Sep 8. Epub 2021 Sep 8.

Cancer Center, School of Medicine, Keio University, Tokyo, Japan.

Background And Study Aim: There is no enough data for endoscopic resection (ER) of superficial duodenal epithelial tumors (SDETs) due to its rarity. There are two main kinds of ER techniques for SDETs: EMR and ESD. In addition, modified EMR techniques, underwater EMR (UEMR) and cold polypectomy (CP), are getting popular. We conducted a large-scale retrospective multicenter study to clarify detailed outcomes of duodenal ER.

Patients And Methods: Patients with SDETs who underwent ER at 18 institutions from January 2008 to December 2018 were included. The rates of en bloc resection and delayed adverse events (AEs) (defined as delayed bleeding or perforation) were analyzed. Local recurrence was analyzed using Kaplan-Meier method.

Results: In total, 3107 patients (including 1017 receiving ESD) were included. En bloc resection rates were 79.1%, 78.6%, 86.8%, and 94.8%, and delayed AE rates were 0.5%, 2.2%, 2.8%, and 7.3% for CP, UEMR, EMR and ESD, respectively. The delayed AE rate was significantly higher for ESD group than non-ESD group among lesions less than 19 mm (7.4% vs 1.9%, p<0.0001), but not among lesions larger than 20 mm (6.1% vs 7.1%, p=0.6432). The local recurrence rate was significantly lower in ESD group than non-ESD group (p<0.001). Furthermore, for lesions larger than 30 mm, the cumulative local recurrence rate at 2 years was 22.6% in non-ESD group compared to only 1.6% in ESD group (p<0.0001).

Conclusions: ER outcomes for SDETs were generally acceptable. ESD by highly experienced endoscopists might be an option for very large SDETs.
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http://dx.doi.org/10.1055/a-1640-3236DOI Listing
September 2021

A Case of Large Duodenal Lymphangioma as Struggled to Diagnose Because of Well Localized Morphology.

Am J Gastroenterol 2021 09;116(9):1824

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

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http://dx.doi.org/10.14309/ajg.0000000000001178DOI Listing
September 2021

Spurting delayed bleeding on postoperative day six after cold snare polypectomy for small superficial duodenal epithelial tumor.

Dig Endosc 2021 Aug 31. Epub 2021 Aug 31.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

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http://dx.doi.org/10.1111/den.14123DOI Listing
August 2021

Three separate sessions of endoscopic submucosal dissection for long-segment Barrett's esophagus prevent severe esophageal stricture.

Dig Endosc 2021 Aug 26. Epub 2021 Aug 26.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

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http://dx.doi.org/10.1111/den.14117DOI Listing
August 2021

Efficacy of partial injection underwater endoscopic mucosal resection for superficial duodenal epithelial tumor: Propensity score-matched study (with video).

Dig Endosc 2021 Aug 9. Epub 2021 Aug 9.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

Background And Aim: Underwater endoscopic mucosal resection (UEMR) has been reported as effective endoscopic treatment for superficial duodenal epithelial tumors (SDETs). However, it has been reported that a notable problem of UEMR for SDETs is that en bloc resection rate is relatively low. Therefore, we proposed a novel technique to improve en bloc resection rate: UEMR combining partial submucosal injection (PI-UEMR). The aim of this study is to evaluate efficacy and safety of PI-UEMR for SDETs by comparing to UEMR.

Methods: This is a retrospective observational study in a single center. The patients who underwent UEMR or PI-UEMR from June 2010 to August 2020 were included in this study. Eligible patients were selected from included patients in a 1:1 ratio using propensity score matching. The clinical outcomes of endoscopic resection (procedure time, en bloc resection rate, complication rate [immediate perforation, delayed bleeding, delayed perforation]), and histopathological diagnosis (adenoma/cancer) were compared between each group.

Results: Two hundred and twenty-eight patients were included in this study. Of included patients, 47 patients were selected in each group by propensity score matching. There were no statistical differences in procedure time (11 ± 1.2 min vs. 9 ± 1.2 min, P = 0.30), complication rate (immediate perforation [0% vs. 2%, P = 0.12], delayed bleeding [0% vs. 2%, P = 0.12], and no delayed perforation) and histopathological diagnosis (adenoma; 100% vs. 96%, P = 0.14) in each group. However, en bloc resection rate of PI-UEMR was significantly higher than UEMR (96% vs. 83%, P < 0.05).

Conclusion: Partial submucosal injection UEMR might be superior procedure for en bloc resection in SDETs compare to UEMR.
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http://dx.doi.org/10.1111/den.14103DOI Listing
August 2021

Gastric epithelial neoplasm of fundic-gland mucosa lineage: proposal for a new classification in association with gastric adenocarcinoma of fundic-gland type.

J Gastroenterol 2021 Sep 15;56(9):814-828. Epub 2021 Jul 15.

Department of Gastroenterology, National Hospital Organization Hakodate National Hospital, Hokkaido, Japan.

Background: Gastric adenocarcinoma of fundic-gland type (GA-FG) is a rare variant of gastric neoplasia. However, the etiology, classification, and clinicopathological features of gastric epithelial neoplasm of fundic-gland mucosa lineage (GEN-FGML; generic term of GA-FG related neoplasm) are not fully elucidated. We performed a large, multicenter, retrospective study to establish a new classification and clarify the clinicopathological features of GEN-FGML.

Methods: One hundred GEN-FGML lesions in 94 patients were collected from 35 institutions between 2008 and 2019. We designed a new histopathological classification of GEN-FGML using immunohistochemical analysis and analyzed via clinicopathological, immunohistochemical, and genetic evaluation.

Results: GEN-FGML was classified into 3 major types; oxyntic gland adenoma (OGA), GA-FG, and gastric adenocarcinoma of fundic-gland mucosa type (GA-FGM). In addition, GA-FGM was classified into 3 subtypes; Type 1 (organized with exposure type), Type 2 (disorganized with exposure type), and Type 3 (disorganized with non-exposure type). OGA and GA-FG demonstrated low-grade epithelial neoplasm, and GA-FGM should be categorized as an aggressive variant of GEN-FGML that demonstrated high-grade epithelial neoplasm (Type 2 > 1, 3). The frequent presence of GNAS mutation was a characteristic genetic feature of GEN-FGML (7/34, 20.6%; OGA 1/3, 33.3%; GA-FG 3/24, 12.5%; GA-FGM 3/7, 42.9%) in mutation analysis using next-generation sequencing.

Conclusions: We have established a new histopathological classification of GEN-FGML and propose a new lineage of gastric epithelial neoplasm that harbors recurrent GNAS mutation. This classification will be useful to estimate the malignant potential of GEN-FGML and establish an appropriate standard therapeutic approach.
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http://dx.doi.org/10.1007/s00535-021-01813-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370942PMC
September 2021

Pathogenesis and management of gastrointestinal inflammation and fibrosis: from inflammatory bowel diseases to endoscopic surgery.

Inflamm Regen 2021 Jul 14;41(1):21. Epub 2021 Jul 14.

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.

Gastrointestinal fibrosis is a state of accumulated biological entropy caused by a dysregulated tissue repair response. Acute or chronic inflammation in the gastrointestinal tract, including inflammatory bowel disease, particularly Crohn's disease, induces fibrosis and strictures, which often require surgical or endoscopic intervention. Recent technical advances in endoscopic surgical techniques raise the possibility of gastrointestinal stricture after an extended resection. Compared to recent progress in controlling inflammation, our understanding of the pathogenesis of gastrointestinal fibrosis is limited, which requires the development of prevention and treatment strategies. Here, we focus on gastrointestinal fibrosis in Crohn's disease and post-endoscopic submucosal dissection (ESD) stricture, and we review the relevant literature.
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http://dx.doi.org/10.1186/s41232-021-00174-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8278771PMC
July 2021

Endoscopic hand suturing for mucosal defect closure after gastric endoscopic submucosal dissection may reduce the risk of postoperative bleeding in patients receiving antithrombotic therapy.

Dig Endosc 2021 May 21. Epub 2021 May 21.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

Objectives: Endoscopic hand suturing (EHS) is expected to decrease the risk of post-endoscopic submucosal dissection (ESD) bleeding by closing mucosal defects. We investigated the efficacy of EHS after gastric ESD in patients with antithrombotic agents.

Methods: In this prospective single-arm trial, patients taking antithrombotic agents for cardiovascular disease, arrhythmia, cerebrovascular disease and/or peripheral arterial disease and having <3-cm gastric neoplasms were recruited. The mucosal defects after ESD were closed by EHS in which the needle was delivered through an overtube, and the mucosal rim of the defect was continuously sutured in a linear fashion by manipulating the needle grasped with the needle holder, followed by cutting the remnant suture and retrieval of the needle. The primary endpoint was the incidence of postoperative bleeding within 4 weeks after ESD.

Results: Twenty-two lesions in 20 patients (continuing antiplatelet agents in 11, anticoagulant agents in eight, both in one) underwent ESD followed by EHS. All defects (median size, 30 mm; range, 12-51 mm) were completely closed by EHS and remained closed on postoperative day 3. The median number of stitches was six (range, 4-8) and median suturing time was 36 (range, 24-60) min. There were no adverse events during/after EHS or postoperative bleeding.

Conclusions: Postoperative bleeding was not observed in patients taking antithrombotic agents without perioperative cessation. EHS appears to be useful for prevention of post-gastric ESD bleeding in high-risk patients. (Clinical registration number: UMIN000024184).
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http://dx.doi.org/10.1111/den.14045DOI Listing
May 2021

Predictors of technical difficulty for complete closure of mucosal defects after duodenal endoscopic resection.

Gastrointest Endosc 2021 Oct 27;94(4):786-794. Epub 2021 Apr 27.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

Background And Aims: It has been reported that the prophylactic closure of mucosal defects after duodenal endoscopic resection (ER) can reduce delayed adverse events; however, under certain circumstances, this can be technically challenging. Therefore, the aim of this study was to determine the predictors of difficulty during the complete closure of mucosal defects after duodenal ER.

Methods: This was a retrospective study of duodenal lesions that underwent ER between July 2010 and May 2020. We reviewed the endoscopic images and analyzed the relationships between the degree of closure or closure time and clinical features of the lesions using univariate and multivariate analyses.

Results: We analyzed 698 lesions. The multivariate analysis revealed that lesion location in the medial or anterior wall (odds ratio, 2.8; 95% confidence interval, 1.36-5.85; P < .01) and a large lesion size (odds ratio, 1.4; 95% confidence interval, 1.07-1.89; P = .03) were independent predictors of an increased risk of incomplete closure. Moreover, a large lesion size (β coefficient, .304; P < .01), an occupied circumference over 50% (β coefficient, .178; P < .01), intraoperative perforation (β coefficient, .175; P < .01), treatment period (β coefficient, .143; P < .01), and treatment with endoscopic submucosal dissection (β coefficient, .125; P < .01) were independently and positively correlated with a prolonged closure time in the multiple regression analysis.

Conclusions: This study revealed that lesion location in the medial or anterior wall and lesion size affected the incomplete closure of mucosal defects after duodenal ER, and lesion size, occupied circumference, intraoperative perforation, treatment period, and treatment method affected closure time.
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http://dx.doi.org/10.1016/j.gie.2021.04.017DOI Listing
October 2021

Superficial nonampullary duodenal epithelial tumor: a rare case accompanied by cancer component as subepithelial lesion.

Gastrointest Endosc 2021 08 12;94(2):427-428. Epub 2021 Jun 12.

Department of Research and Development for Minimal Invasive Treatment, Cancer Center, Keio University, Tokyo, Japan.

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http://dx.doi.org/10.1016/j.gie.2021.04.001DOI Listing
August 2021

Successful endoscopic submucosal dissection using the water pressure method for cervical esophageal cancer.

Dig Endosc 2021 Jul 31;33(5):e93-e94. Epub 2021 Mar 31.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

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http://dx.doi.org/10.1111/den.13973DOI Listing
July 2021

Feasibility Study of Partial Submucosal Injection Technique Combining Underwater EMR for Superficial Duodenal Epithelial Tumors.

Dig Dis Sci 2021 Mar 15. Epub 2021 Mar 15.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.

Background And Aims: Endoscopic mucosal resection (EMR) and Underwater EMR have been reported as effective endoscopic treatment for superficial duodenal tumor (SDET). However, a notable problem of EMR for SDET is technical difficulty for the lesion with non-lifting sign, and it of UEMR is that en bloc resection rate is relatively low. Therefore, we performed partial submucosal injection combining UEMR (PI-UEMR). The aim of this study is to evaluate feasibility and safety of this technique for duodenal tumor.

Methods: This is a prospective observational study from tertiary care hospital. We performed PI-UEMR in patients with SDET that is 13-20 mm in diameter, or less than 13 mm with technical difficulty for EMR and UEMR from January 2019 to March 2020. Primary outcome was en bloc resection rate. Secondary outcomes were R0 resection rate, mean total procedure time, intra- and post-procedure complication.

Results: Thirty patients were included in this study. Mean age was 62 ± 12 years old. Three fourths lesions were located at anal side from major papilla. Median lesion size was 12 mm [IQR 10-16 mm]. Twenty-four cases were taken endoscopic biopsy in prior hospital and observed biopsy scar. En bloc resection rate was 97%. Ro resection rate was 83%. Mean total procedure time was 17 ± 12 min. And there was an only one case of complication, intra-procedure bleeding that was controllable endoscopically.

Conclusions: PI-UEMR might be very useful and safe technique of endoscopic resection for SDET including relatively large lesions.
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http://dx.doi.org/10.1007/s10620-021-06925-3DOI Listing
March 2021

Underwater endoscopic mucosal resection for a sporadic adenoma located at severe longitudinal ulcer scars in ulcerative colitis.

Endoscopy 2021 Feb 22. Epub 2021 Feb 22.

Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan.

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http://dx.doi.org/10.1055/a-1368-3796DOI Listing
February 2021

Retroflexion technique in the descending part of the duodenum for endoscopic mucosal resection.

Dig Endosc 2021 Mar 28;33(3):e45-e46. Epub 2021 Jan 28.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

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http://dx.doi.org/10.1111/den.13920DOI Listing
March 2021

Usefulness of an artificial intelligence system for the detection of esophageal squamous cell carcinoma evaluated with videos simulating overlooking situation.

Dig Endosc 2021 Jan 27. Epub 2021 Jan 27.

AI Medical Service Inc, Tokyo, Japan.

Objectives: Artificial intelligence (AI) systems have shown favorable performance in the detection of esophageal squamous cell carcinoma (ESCC). However, previous studies were limited by the quality of their validation methods. In this study, we evaluated the performance of an AI system with videos simulating situations in which ESCC has been overlooked.

Methods: We used 17,336 images from 1376 superficial ESCCs and 1461 images from 196 noncancerous and normal esophagi to construct the AI system. To record validation videos, the endoscope was passed through the esophagus at a constant speed without focusing on the lesion to simulate situations in which ESCC has been missed. Validation videos were evaluated by the AI system and 21 endoscopists.

Results: We prepared 100 video datasets, including 50 superficial ESCCs, 22 noncancerous lesions, and 28 normal esophagi. The AI system had sensitivity of 85.7% (54 of 63 ESCCs) and specificity of 40%. Initial evaluation by endoscopists conducted with plain video (without AI support) had average sensitivity of 75.0% (47.3 of 63 ESCC) and specificity of 91.4%. Subsequent evaluation by endoscopists was conducted with AI assistance, which improved their sensitivity to 77.7% (P = 0.00696) without changing their specificity (91.6%, P = 0.756).

Conclusions: Our AI system had high sensitivity for the detection of ESCC. As a support tool, the system has the potential to enhance detection of ESCC without reducing specificity. (UMIN000039645).
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http://dx.doi.org/10.1111/den.13934DOI Listing
January 2021

Continuous warfarin administration versus heparin bridging therapy in post colorectal polypectomy haemorrhage: a study protocol for a multicentre randomised controlled trial (WHICH study).

Trials 2021 Jan 7;22(1):33. Epub 2021 Jan 7.

Department of Gastroenterology and Hepatology, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan.

Background: Endoscopic removal of colorectal adenoma is considered an effective treatment for reducing the mortality rates associated with colorectal cancer. Warfarin, a type of anticoagulant, is widely used for the treatment and prevention of thromboembolism; however, bleeding may increase with its administration after polypectomy. In recent times, a high incidence of bleeding after endoscopic polypectomy has been reported in patients receiving heparin bridge therapy. However, previous studies have not compared the bleeding rate after endoscopic colorectal polypectomy between patients who continued with anticoagulant therapy and those who received heparin bridge therapy. We hypothesised that endoscopic colorectal polypectomy under the novel treatment with continuous warfarin is not inferior to endoscopic colorectal polypectomy under standard treatment with heparin bridge therapy with respect to the rate of postoperative bleeding. This study aims to compare the efficacy of endoscopic colorectal polypectomy with continuous warfarin administration and endoscopic colorectal polypectomy with heparin bridge therapy with respect to the rate of postoperative bleeding.

Methods: We will conduct a prospective multicentre randomised controlled non-inferiority trial of two parallel groups. We will compare patients scheduled to undergo colorectal polypectomy under anticoagulant therapy with warfarin. There will be 2 groups, namely, a standard treatment group (heparin bridge therapy) and the experimental treatment group (continued anticoagulant therapy). The primary outcome measure is the rate of postoperative bleeding. On the contrary, the secondary outcomes include the rate of cumulative bleeding, rate of overt haemorrhage (that does not qualify for the definition of haemorrhage after endoscopic polypectomy), incidence of haemorrhage requiring haemostasis during endoscopic polypectomy, intraoperative bleeding during endoscopic colorectal polypectomy requiring angiography, abdominal surgery and/or blood transfusion, total rate of bleeding, risk factors for postoperative bleeding, length of hospital stay, incidence of thromboembolism, prothrombin time-international ratio (PT-INR) 28 days after the surgery, and incidence of serious adverse events.

Discussion: The results of this randomised controlled trial will provide valuable information for the standardisation of management of anticoagulants in patients scheduled to undergo colorectal polypectomy.

Trial Registration: UMIN-CTR UMIN000023720 . Registered on 22 August 2016.
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http://dx.doi.org/10.1186/s13063-020-04975-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7791998PMC
January 2021

Helicobacter pylori eradication prevents secondary gastric cancer in patients with mild-to-moderate atrophic gastritis.

J Gastroenterol Hepatol 2021 Aug 1;36(8):2083-2090. Epub 2021 Feb 1.

Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan.

Background And Aim: Whether Helicobacter pylori eradication prevents metachronous recurrence after endoscopic resection (ER) of early gastric cancer remains controversial. This multicenter retrospective study aimed to evaluate the long-term (> 5 years) effects of H. pylori eradication by stratifying patients' baseline degrees of atrophic gastritis.

Methods: A total of 483 H. pylori-positive patients who had undergone ER for early gastric cancer were divided into two groups-(i) those having undergone successful H. pylori eradication within 1 year after ER (eradicated group, n = 294) and (ii) those with failed or not attempted H. pylori eradication (non-eradicated group, n = 189). The cumulative incidences of metachronous gastric cancer between the two groups were compared for all patients, for patients with mild-to-moderate atrophic gastritis (n = 182), and for patients with severe atrophic gastritis (n = 301).

Results: During a median follow-up of 5.2 years (range 1.1-14.8), metachronous cancer developed in 52 (17.7%) patients in the eradicated group and in 35 (18.5%) patients in the non-eradicated group (P = 0.11, log-rank test). In patients with mild-to-moderate atrophic gastritis (111 and 71 in the eradicated and non-eradicated groups, respectively), the cumulative incidence of metachronous cancer was significantly lower in the eradicated group than that in the non-eradicated group (P = 0.03, log-rank test). However, no significant intergroup difference was observed in patients with severe atrophic gastritis (P = 0.69, log-rank test).

Conclusions: Helicobacter pylori eradication had a preventive effect on the development of metachronous gastric cancer in patients with mild-to-moderate atrophic gastritis.
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http://dx.doi.org/10.1111/jgh.15396DOI Listing
August 2021

External drainage of bile and pancreatic juice after endoscopic submucosal dissection for duodenal neoplasm: Feasibility study (with video).

Dig Endosc 2021 Sep 4;33(6):977-984. Epub 2021 Jan 4.

Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

Background And Aims: Endoscopic submucosal dissection (ESD) for superficial duodenal epithelial tumors (SDETs) is technically difficult and has a high risk of adverse events. Endoscopic nasobiliary and nasopancreatic duct drainage (ENBPD) may reduce the risk of delayed adverse events by preventing exposure of the post-ESD mucosal defect to bile and pancreatic juice. This study was performed to evaluate the safety and feasibility of ENBPD after duodenal ESD.

Methods: Patients who underwent ESD for SDETs from July 2010 to March 2020 were included. We collected data on the success rate of ENBPD, adverse events due to insertion of a side-viewing endoscope, and pancreatitis after ENBPD. We also collected the clinical outcomes of duodenal ESD, including the incidence rate of delayed adverse events (defined as bleeding or perforation found after the endoscopic procedure).

Results: Among 70 patients without complete closure of the post-ESD mucosal defect, ENBPD was successfully performed in all 25 patients including 21 cases inserted immediately after ESD and four cases inserted later. There were no adverse events associated with ENBPD procedure intraoperatively, while pancreatitis after ENBPD occurred in four patients (16.0%). No patients who underwent immediate ENBPD required intervention for an intra-abdominal abscess or delayed perforation, whereas 3 of 49 patients (6.1%) who did not undergo immediate ENBPD required surgery or drainage of an abscess.

Conclusions: Endoscopic nasobiliary and nasopancreatic duct drainage is technically feasible and might provide effective prophylaxis for delayed adverse events, even if a large mucosal defect is present after ESD.
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http://dx.doi.org/10.1111/den.13907DOI Listing
September 2021

Significance of endoscopic deep small bowel evaluation using balloon-assisted enteroscopy for Crohn's disease in clinical remission.

J Gastroenterol 2021 Jan 19;56(1):25-33. Epub 2020 Oct 19.

Division of Gastroenterology and Hepatology, Department of Internal Medicine, School of Medicine, Keio University, Tokyo, Japan.

Background: Small bowel lesions of Crohn's disease (CD) are known to be associated with a poor prognosis; however, endoscopic healing leads to favorable patients' outcome. The aim of this study was to clarify the clinical impact of assessing deep small bowel lesions (DSB) using balloon-assisted enteroscopy (BAE) on CD patients in clinical remission.

Methods: From January 2012 to July 2018, a total of 100 CD patients in clinical remission were enrolled to undergo trans-anal enteroscopy using single-balloon enteroscope. Endoscopic evaluations at the terminal ileum (TI) were performed using a partial Simple Endoscopic Score for CD (pSES-CD). Endoscopic evaluations at the DSB used a modified partial SES-CD (mpSES-CD). We evaluated the factors associated with relapse, and the correlation of endoscopic score between the TI and DSB. For this study, relapse was defined as hospitalization within a year from enteroscopy.

Results: 30 patients (30.0%) relapsed within a year from enteroscopy. Multivariate logistic regression analysis revealed that the Harvey-Bradshaw Index (OR 1.77, 95% CI 1.18-2.65; p = 0.003) and an mpSES-CD at DSB (OR 3.10, 95% CI 1.86-5.15; p = 0.001) were independent predictors for relapse, whereas a SES-CD at the TI did not exhibit independence. There was a significant correlation trend between the relapse rate and greater than 5 points of an mpSES-CD at DSB; however, there was no correlation between the relapse rate and pSES-CD at the TI.

Conclusion: Even when Crohn's disease is in remission, it is important to evaluate DSB using BAE to assess endoscopic mucosal healing.
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http://dx.doi.org/10.1007/s00535-020-01737-0DOI Listing
January 2021

The incidence of non-ampullary duodenal cancer in Japan: The first analysis of a national cancer registry.

J Gastroenterol Hepatol 2021 May 9;36(5):1216-1221. Epub 2020 Oct 9.

Department of Surgery, Nara Medical University, Nara, Japan.

Background And Aim: Although duodenal cancer is rare, no epidemiological research on this disease has been conducted in Asian countries. We aimed to elucidate the incidence and clinical features of duodenal cancer in Japan using a large-scale national database.

Methods: Data of patients with primary duodenal cancer diagnosed from January 1, 2016, to December 31, 2016, were extracted from the Japanese national cancer registry. Excluding malignant neoplasm of the Vater's ampulla, we calculated the incidence among the population as a crude number of patients with duodenal cancer divided by the total Japanese population in 2016. We performed multivariate analyses using logistic regression models to identify risk factors for advanced cancer, defined as metastatic cancer or local invasion to adjacent organs.

Results: Data on 3005 patients were included. The incidence of duodenal cancer was 23.7 per 1 000 000 person-years. In total, 56.4% of cases were detected at the localized stage. In the localized cancer group, endoscopic resection was more frequently performed (48.0%), whereas in the advanced cancer group, surgery and chemotherapy were the major treatment options (39.3% and 41.5%, respectively). Multivariate analyses identified age ≥80 years (odds ratio [OR], 1.489; 95% confidence interval [CI], 1.113-1.992; P = 0.007), incidental detection (OR, 2.325; CI, 1.623-3.331; P < 0.0001), and precise examination for symptomatic patients (OR, 10.561; CI, 7.416-15.042; P < 0.0001) as independent risk factors for advanced cancer.

Conclusions: Our study revealed the incidence of duodenal cancer in Japan. However, localized cancer was the major tumor stage at detection, resulting in a high rate of endoscopic resection.
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http://dx.doi.org/10.1111/jgh.15285DOI Listing
May 2021

Suturing the mucosal defect after ESD.

Endosc Int Open 2020 Sep 31;8(9):E1218-E1219. Epub 2020 Aug 31.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

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http://dx.doi.org/10.1055/a-1216-1717DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458746PMC
September 2020

Water pressure method for duodenal endoscopic submucosal dissection (with video).

Gastrointest Endosc 2021 04 25;93(4):942-949. Epub 2020 Aug 25.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.

Background And Aims: Duodenal endoscopic submucosal dissection (ESD) is considered technically challenging and has a high risk of adverse events. However, we recently made some progress with the ESD technique and device by introducing 2 features: a water pressure (WP) method and a second-generation ESD knife (DualKnife) with a water jet function (DualKnife J). The present study aimed to assess whether these changes improved the clinical outcomes of duodenal ESD.

Methods: This was a retrospective observational study. Among all patients who underwent ESD for superficial duodenal epithelial tumors from June 2010 to December 2018, patients in whom a single expert performed the procedure were included in this study. Various factors, including the use of the WP method and ESD devices (DualKnife or DualKnife J) and the treatment phase (early, mid, and late), were analyzed to determine whether they were associated with intraprocedural perforation and procedure time. Treatment phase was assigned by dividing the study population equally into 3 subgroups according to the treatment phase.

Results: The procedure time was significantly shorter, and the proportion of patients with intraprocedural perforations was the lowest in the late phase. Multivariate analysis of the use of the WP method revealed that it significantly decreased the intraprocedural perforation rate (odds ratio, 0.39; 95% confidence interval, 0.16-0.96), and analysis of the use of both the WP method (β coefficient, -0.40; P < .01) and the DualKnife J (β coefficient, -0.10; P = .032) revealed they were independently and negatively correlated with procedure time.

Conclusion: The present study reveals that the WP method significantly reduced the intraprocedural perforation rate and that both the WP method and the DualKnife J significantly shortened procedure times for duodenal ESD.
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http://dx.doi.org/10.1016/j.gie.2020.08.018DOI Listing
April 2021

Efficacy of endoscopic preventive procedures to reduce delayed adverse events after endoscopic resection of superficial nonampullary duodenal epithelial tumors: a meta-analysis of observational comparative trials.

Gastrointest Endosc 2021 02 22;93(2):367-374.e3. Epub 2020 Aug 22.

Department of Surgery, Nara Medical University, Nara, Japan.

Background And Aims: Although various procedures have been used to prevent serious adverse events after endoscopic resection of the duodenum, their effectiveness has not been determined. In this study, we conducted a systematic review and meta-analysis to determine whether endoscopic preventive procedures reduce delayed adverse events.

Methods: Studies on endoscopic treatment for superficial nonampullary duodenal tumors were selected. We compared the following 2 groups: the closure group, which underwent mucosal sutures and coverage of mucosal defects after resection, and the unclosed group, which did not. The primary outcome was the rate of delayed adverse events, including perforation and bleeding. The pooled risk ratios (RRs) of all outcomes investigated, the 95% confidence intervals (CIs), and P values were calculated.

Results: A total of 438 patients from 4 studies were included in the meta-analysis. The pooled overall adverse event rates in the closure group and unclosed group were 3.6% and 21.1%, respectively. This rate was significantly lower in the closure group (RR, 0.19; 95% CI, 0.10-0.38; P < .01; I = 0%), and the rate of delayed bleeding was significantly lower in the closure group (RR, 0.14; 95% CI, 0.06-0.33; P < .01; I = 0%). Regarding delayed perforation, the RR in the closure group was 0.39 (95% CI, 0.12-1.32; P = .13; I = 0%).

Conclusions: Preventive procedures significantly reduced the risk of delayed adverse events by more than 80%. After endoscopic resection of the duodenum, the implementation of preventive procedures, including mucosal sutures and coverage of mucosal defects, to delay adverse events is strongly recommended.
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http://dx.doi.org/10.1016/j.gie.2020.08.017DOI Listing
February 2021

A Case of Duodenal Tumor Adjacent to the Diverticulum That Was Resected by the Technique of Partial Submucosal Injection Combined with Underwater Endoscopic Mucosal Resection.

Dig Dis 2021 11;39(1):70-74. Epub 2020 Jun 11.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan.

A 66-year-old male was referred to our hospital for treatment of duodenal tumor. The most difficult part was that the lesion was adjacent to duodenal diverticulum. Endoscopic mucosal resection (EMR) was difficult because submucosal injection spread broadly and quickly and makes it difficult to visualize the diverticulum edge of the lesion. Simple underwater EMR (UEMR) had risk for perforation at the diverticulum part because duodenal diverticulum is spurious diverticulum that defects the proper muscle layer. Therefore, to make sufficient distance between diverticulum and the lesion, we performed partial submucosal injection into only the diverticulum side of the lesion combined with simple UEMR. The lesion was resected en bloc without any adverse events. Histopathological diagnosis was tubular adenoma with moderate atypia and surgical margin negative. Partial submucosal injection combined with simple UEMR might be useful for duodenal tumor that has any technical difficulties as in this case.
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http://dx.doi.org/10.1159/000509323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7949217PMC
February 2021

Endoscopic and Clinicopathological Features of Superficial Non-Ampullary Duodenal Tumor Based on the Mucin Phenotypes.

Digestion 2021 9;102(5):663-670. Epub 2020 Jun 9.

Department of Gastroenterology, Juntendo University School of Medicine, Tokyo, Japan.

Aims: We aimed to clarify the endoscopic/clinicopathological features of superficial non-ampullary duodenal epithelial tumors (SNADETs) based on their mucin phenotypes.

Methods: We analyzed 62 SNADET lesions and classified them based on mucin phenotypic expression. Endoscopic and clinicopathological findings were compared according to mucin phenotypes.

Results: Eleven lesions had the gastric phenotype (GP) and 43 lesions had the intestinal phenotype (IP). All GP lesions were located in the first portion of the duodenum, while most IP lesions (72.1%) were located in the second portion (p < 0.01). Tumor size was significantly larger in the GP than in the IP group (14.4 mm vs. 10.2 mm, p < 0.05). Reddish color (72.7% in GP vs. 37.2% in IP, p < 0.05), type 0-I (72.7% vs. 11.6%, p < 0.01), lobular/granular pattern (81.8% vs. 4.7%, p < 0.01), and category 4/5 in Vienna classification (81.8% vs. 30.2%, p < 0.01) were observed significantly more often in the GP than in the IP group. Regarding findings of magnifying endoscopy with narrow-band imaging (M-NBI), white opaque substance (22.2% in GP vs. 89.7% in IP, p < 0.01) and light blue crest (0% vs. 43.6%, p < 0.05) were significantly less frequently observed in the GP group. Oval-shaped marginal epithelium (66.7% vs. 17.9%, p < 0.01), dense pattern (55.6% vs. 2.6%, p < 0.01), and dilatation of the intervening part (100% vs. 12.8%, p < 0.01) were more frequently observed in the GP group.

Conclusions: SNADETs showed distinct endoscopic/clinicopathological features according to the mucin phenotype. Tumor location, coloration, macroscopic type, and endoscopic findings including M-NBI are useful to distinguish the mucin phenotypes of SNADETs.
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http://dx.doi.org/10.1159/000508040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8491506PMC
September 2021

Efficacy of a new image-enhancement technique for achieving hemostasis in endoscopic submucosal dissection.

Gastrointest Endosc 2020 Sep 1;92(3):667-674. Epub 2020 Jun 1.

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University, School of Medicine, Tokyo, Japan.

Background And Aims: Hemostasis during endoscopic submucosal dissection (ESD) can sometimes be challenging and stressful for the endoscopist. Therefore, we aimed to assess the usefulness of dual red imaging (DRI), a new image enhancement technique that uses 3 wavelengths (540, 600, and 630 nm) to visualize bleeding points and to examine the efficacy of DRI in shortening the time required to achieve hemostasis (hemostasis time) during ESD.

Methods: DRI and white-light imaging (WLI) were used alternately for managing 378 bleeding events in 97 patients undergoing ESD. Hemostasis time for each hemostasis event was measured. Using portable eye-tracking glasses, 4 experienced endoscopists were shown random videos of intraoperative bleeding during ESD (20 cases each on WLI and DRI) and identified the bleeding point in each video. The mean distances of eye movement per unit of time until the bleeding point were identified in each video and compared between the WLI and DRI groups.

Results: Average hemostasis time was significantly shorter in the DRI group. The mean distance of eye movement was significantly shorter in the DRI group than in the WLI group for all endoscopists.

Conclusions: DRI can offer useful images to help in clearly detecting bleeding points and in facilitating hemostasis during ESD. It is feasible and may help in successfully performing ESD that is safer and faster than WLI. (Clinical trial registration number: UMIN000018309.).
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http://dx.doi.org/10.1016/j.gie.2020.05.033DOI Listing
September 2020

Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer.

Dig Endosc 2020 May;32(4):452-493

Japan Gastroenterological Endoscopy Society, Tokyo, Japan.

The Japan Gastroenterological Endoscopy Society has developed endoscopic submucosal dissection/endoscopic mucosal resection guidelines. These guidelines present recommendations in response to 18 clinical questions concerning the preoperative diagnosis, indications, resection methods, curability assessment, and surveillance of patients undergoing endoscopic resection for esophageal cancers based on a systematic review of the scientific literature.
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http://dx.doi.org/10.1111/den.13654DOI Listing
May 2020
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