Publications by authors named "Naohisa Yahagi"

227 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

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

What is important for a smooth implementation of endoscopic submucosal dissection?

Gastrointest Endosc 2021 07;94(1):145-147

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.2021.04.007DOI Listing
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

Is artificial intelligence ready to replace expert endoscopists?

Authors:
Naohisa Yahagi

Endoscopy 2021 05 22;53(5):478-479. Epub 2021 Apr 22.

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-1308-2121DOI Listing
May 2021

Demarcated redness associated with increased vascular density/size: a useful marker of flat-type dysplasia in patients with ulcerative colitis.

Endosc Int Open 2021 Apr 12;9(4):E552-E561. Epub 2021 Apr 12.

Center for Preventive Medicine, Keio University School of Medicine, Tokyo, Japan.

Recent advances in endoscopic equipment and diagnostic techniques have improved the detection of dysplasia in the inflamed mucosa of patients with ulcerative colitis (UC). However, it remains difficult to endoscopically identify flat-type dysplasia which has been formerly recognized as invisible dysplasia. In this retrospective, single-center study, we endoscopically identified 10 cases of flat-type-predominant dysplasia by targeted biopsy among 38 intramucosal dysplasia lesions from patients with UC who underwent surgical or endoscopic resection from 2007 to 2017. Their endoscopic and histological features were examined, including color changes, intramucosal vascular density/size, and vascular endothelial growth factor (VEGF) expression. All flat-type-predominant dysplasias were endoscopically recognized as demarcated red-colored areas and histologically diagnosed as low- (LGDs) or high-grade dysplasias (HGDs). Immunohistochemical examination using resected specimens revealed that flat-type dysplasia was characterized by significantly increased CD34-positive vascular density (LGDs, 1.7-fold, P < 0.01; HGDs, 2.2-fold,  < 0.01) and size (LGDs, 1.03-fold,  < 0.01; HGDs, 1.11-fold,  < 0.01) in the mucosa, compared to adjacent non-neoplastic areas. Increased numbers of vessels were observed at the base of the mucosa in LGDs, whereas HGDs contained increased/enlarged vessels throughout the mucosa. Moreover, VEGF expression was elevated in all dysplastic epithelia. Demarcated red-colored areas, histologically characterized by an increased vascular density/size in the mucosa, are an endoscopic sign of formerly invisible flat-type dysplasia in patients with UC and should be considered for targeted biopsy. Prospective studies focusing on the mucosal color change for their early detection would be desirable in the future.
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http://dx.doi.org/10.1055/a-1352-2709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041573PMC
April 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

Closure of gastric perforations during endoluminal resection using a novel biodegradable collagen sol: A feasibility survival study on porcine model (with video).

Dig Endosc 2021 Feb 21. Epub 2021 Feb 21.

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

Objective: A prior study using porcine colon demonstrated the feasibility of a novel injectable, temperature-responsive, and biodegradable collagen sol (ICS) that transforms from a liquid to a gel state in response to body temperature for endoscopic closure of perforation during endoscopic resection (ER). This study aims to report the acute and survival outcomes of ICS for gastric perforations during ER.

Methods: In two experiments using nine live pigs under general anesthesia, four and six perforations (3-5 mm) were created using an electrosurgical knife in acute and survival experiments, respectively. ICS was delivered to the perforations using an endoscopic catheter. In Experiment 1, a leak test and histopathology were performed on all explanted stomachs after euthanization. In Experiment 2, perforation sites were assessed by gastroscopy and histopathology 7, 14 and 28 days post-procedure.

Results: In Experiment 1, gastroscopy confirmed complete closure of the perforations with ICS and no evidence of leak. Subsequent histopathology revealed a fixation of collagen gel (CG) as a sealant agent at the perforation sites. There were no adverse effects related with ESD or the use of ICS. In Experiment 2, histopathology revealed a fixation of CG as a sealant agent, replacement with granulation tissue and no CG; and fibrotic tissue at 7, 14 and 28 days, respectively.

Conclusions: This study presents a novel method using ICS, demonstrating promising efficacy and safety profile for endoscopic closure of perforations during ER. Further studies are necessary before translating to clinical use.
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http://dx.doi.org/10.1111/den.13962DOI Listing
February 2021

Response.

Gastrointest Endosc 2021 03;93(3):780

Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan.

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http://dx.doi.org/10.1016/j.gie.2020.12.027DOI Listing
March 2021

Long-term follow-up after colorectal endoscopic submucosal dissection in 182 cases.

Endosc Int Open 2021 Feb 3;9(2):E258-E262. Epub 2021 Feb 3.

Department of Medicine and Gastroenterology, Gemeinschaftskrankenhaus Bonn, Academic Teaching Hospital, University of Bonn, Bonn, Germany.

 We previously reported a case series of our first 182 colorectal endoscopic submucosal dissections (ESDs). In the initial series, 155 ESDs had been technically feasible, with 137 en bloc resections and 97 en bloc resections with free margins (R0). Here, we present long-term follow-up data, with particular emphasis on cases where either en bloc resection was not achieved or en bloc resection resulted in positive margins (R1).  Between September 2012 and October 2015, we performed 182 consecutive ESD procedures in 178 patients (median size 41.0 ± 17.4 mm; localization rectum vs. proximal rectum 63 vs. 119). Data on follow-up were obtained from our endoscopy database and from referring physicians.  Of the initial cohort, 11 patients underwent surgery; follow-up data were available for 141 of the remaining 171 cases (82,5 %) with a median follow-up of 2.43 years (range 0.15-6.53). Recurrent adenoma was observed in 8 patients (n = 2 after margin positive en bloc ESD; n = 6 after fragmented resection). Recurrence rates were lower after en bloc resection, irrespective of involved margins (1.8 vs. 18,2 %; P < 0.01). All recurrences were low-grade adenomas and could be managed endoscopically.  The rate of recurrence is low after en bloc ESD, in particular if a one-piece resection can be achieved. Recurrence after fragmented resection is comparable to published data on piecemeal mucosal resection.
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http://dx.doi.org/10.1055/a-1321-1271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857971PMC
February 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

Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer (second edition).

Dig Endosc 2021 Jan 9;33(1):4-20. Epub 2020 Dec 9.

Japan Gastroenterological Endoscopy Society, Tokyo, Japan.

In response to the rapid and wide acceptance and use of endoscopic treatments for early gastric cancer, the Japan Gastroenterological Endoscopy Society, in collaboration with the Japanese Gastric Cancer Association, produced "Guidelines for Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection for Early Gastric Cancer" in 2014, as a set of basic guidelines in accordance with the principles of evidence-based medicine. At the time, a number of statements had to be established by consensus (the lowest evidence level), as evidence levels remained low for many specific areas in this field. However, in recent years, the number of well-designed clinical studies has been increasing. Based on new findings, we have issued the revised second edition of the above guidelines that cover the present state of knowledge. These guidelines are divided into the following seven categories: indications, preoperative diagnosis, techniques, evaluation of curability, complications, long-term postoperative surveillance, and histology.
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http://dx.doi.org/10.1111/den.13883DOI Listing
January 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

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

Recovery of endoscopy services in the era of COVID-19: recommendations from an international Delphi consensus.

Gut 2020 11 14;69(11):1915-1924. Epub 2020 Aug 14.

Department of Gastroenterology, Pirogov Russian National Research Medical University, Moscow, Russian Federation.

The COVID-19 pandemic has had a profound impact on provision of endoscopy services globally as staff and real estate were repurposed. As we begin to recover from the pandemic, a cohesive international approach is needed, and guidance on how to resume endoscopy services safely to avoid unintended harm from diagnostic delays. The aim of these guidelines is to provide consensus recommendations that clinicians can use to facilitate the swift and safe resumption of endoscopy services. An evidence-based literature review was carried out on the various strategies used globally to manage endoscopy during the COVID-19 pandemic and control infection. A modified Delphi process involving international endoscopy experts was used to agree on the consensus statements. A threshold of 80% agreement was used to establish consensus for each statement. 27 of 30 statements achieved consensus after two rounds of voting by 34 experts. The statements were categorised as pre-endoscopy, during endoscopy and postendoscopy addressing relevant areas of practice, such as screening, personal protective equipment, appropriate environments for endoscopy and infection control precautions, particularly in areas of high disease prevalence. Recommendations for testing of patients and for healthcare workers, appropriate locations of donning and doffing areas and social distancing measures before endoscopy are unique and not dealt with by any other guidelines. This international consensus using a modified Delphi method to produce a series of best practice recommendations to aid the safe resumption of endoscopy services globally in the era of COVID-19.
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http://dx.doi.org/10.1136/gutjnl-2020-322329DOI Listing
November 2020

COVID-19 and endoscopic management of superficial gastrointestinal neoplastic lesions: a multinational cross-sectional survey.

Endoscopy 2021 Feb 11;53(2):173-177. Epub 2020 Aug 11.

Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal.

Introduction: We aimed to report the impact of the pandemic lockdown period on the treatment and prognosis of superficial gastrointestinal neoplastic lesions.

Methods: A survey was completed by 11 centers from four continents regarding postponements during the early lockdown period of the pandemic, and the same period in 2019.

Results: In 2020, 55 % of the scheduled procedures were deferred, which was 11 times higher than in 2019; the main reasons were directly related to COVID-19. In countries that were highly affected, this proportion rose to 76 % vs. 26 % in those where there was less impact. Despite the absolute reduction, the relative distribution in 2019 vs. 2020 was similar, the only exception being duodenal lesions (affected by a 92 % reduction in mucosectomies). Although it is expected that the majority of postponements will not affect the stage (based on the results from biopsies and/or endoscopic appearance), 3 % of delayed procedures will probably require surgery.

Conclusions: The lockdown period caused by the SARS-CoV-2 pandemic led to a substantial reduction in the number of endoscopic resections for neoplastic lesions. Nevertheless, based on clinical judgment, the planned median delay will not worsen the prognosis of the affected patients.
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http://dx.doi.org/10.1055/a-1237-5221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869031PMC
February 2021

Nursing Record Innovations Aimed at Harmonizing Structured Clinical Knowledge Among Doctors and Nurses.

Stud Health Technol Inform 2020 Jun;270:638-642

The University of Tokyo.

Hospitalization expenses account for a high proportion of national medical care expenditure in Japan. In 2015, the total national medical care expenditure in Japan was 42.4 trillion yen, and hospitalization expenses were 15.6 trillion yen (36.8%). Therefore, it is necessary to reduce hospitalization expenses. The labor cost of physicians and nurses accounted for about 1/3rd of all expenditure of general hospitals in 2015. Moreover, the personnel cost of nurses accounted for about 1/5th of all expenditure, indicating that it has a marked impact on hospital management. Nurses spend a lot of time completing descriptive records; however, the quality of such records is poor. It is necessary to improve nurse's records to make them highly accessible and reduce the amount of time nurses spend producing records. The objective of this study was to improve the processes underlying record-keeping by nurses in order to harmonize structured clinical knowledge among doctors and nurses. We created 778 Patient Condition Adaptive Path System (PCAPS) items, covering all of the clinical departments that were registered for the PCAPS content master. The resultant masters will be standardized by sharing them with hospitals that adopt the "Team Compass" application. We were able to summarize all of the information in clinical progress sheets because we could link the information described in electronic medical records with that described in Team Compass. Therefore, it became easy to collect information by linking information about clinical orders. The system also made it possible for foundational nursing plans to be created in collaboration with doctors instead of being developed by nurses alone because it allowed information regarding patients' problems, the clinical process, and observation selection to be shared smoothly with doctors. We implemented Team Compass in May 2019. On the first day, PCAPS-based care pathways were used to treat 580 of 623 inpatients. Approximately 4,000 patients were treated using this system from May to August 2019. No major problems have arisen since the implementation of Team Compass.
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http://dx.doi.org/10.3233/SHTI200238DOI Listing
June 2020

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

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
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