Publications by authors named "Noboru Hanaoka"

71 Publications

Transoral surgery for superficial head and neck cancer: National Multi-Center Survey in Japan.

Cancer Med 2021 Jun 15;10(12):3848-3861. Epub 2021 May 15.

Department of Gastroenterology, Kobe City Medical Center General Hospital, Kobe, Japan.

Head and neck cancers, especially in hypopharynx and oropharynx, are often detected at advanced stage with poor prognosis. Narrow band imaging enables detection of superficial cancers and transoral surgery is performed with curative intent. However, pathological evaluation and real-world safety and clinical outcomes have not been clearly understood. The aim of this nationwide multicenter study was to investigate the safety and efficacy of transoral surgery for superficial head and neck cancer. We collected the patients with superficial head and neck squamous cell carcinoma who were treated by transoral surgery from 27 hospitals in Japan. Central pathology review was undertaken on all of the resected specimens. The primary objective was effectiveness of transoral surgery, and the secondary objective was safety including incidence and severity of adverse events. Among the 568 patients, a total of 662 lesions were primarily treated by 575 sessions of transoral surgery. The median tumor diameter was 12 mm (range 1-75) endoscopically. Among the lesions, 57.4% were diagnosed as squamous cell carcinoma in situ. The median procedure time was 48 minutes (range 2-357). Adverse events occurred in 12.7%. Life-threatening complications occurred in 0.5%, but there were no treatment-related deaths. During a median follow-up period of 46.1 months (range 1-113), the 3-year overall survival rate, relapse-free survival rate, cause-specific survival rate, and larynx-preservation survival rate were 88.1%, 84.4%, 99.6%, and 87.5%, respectively. Transoral surgery for superficial head and neck cancer offers effective minimally invasive treatment. Clinical trials registry number: UMIN000008276.
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http://dx.doi.org/10.1002/cam4.3927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8209601PMC
June 2021

Endoscopic appearance of esophageal xanthoma.

Endosc Int Open 2019 Oct 1;7(10):E1214-E1220. Epub 2019 Oct 1.

Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka 541-8567, Japan.

 Esophageal xanthomas are considered to be rare, and their endoscopic diagnosis has not been fully elucidated. The aim of the present study was to determine the characteristics of the endoscopic appearance of esophageal xanthomas.  This was a retrospective study of consecutive patients with histologically diagnosed esophageal xanthomas at a referral cancer center in Japan. The endoscopic appearance, by magnifying or image-enhanced endoscopy, and histological findings of esophageal xanthomas were investigated.  Seven patients (six men and one woman) were enrolled. All of the patients had a solitary lesion, and the median size was 2 mm (range, 1 - 5 mm). Conventional white-light endoscopy showed the lesions as flat areas with yellowish spots in four cases and slightly elevated yellowish lesions in three cases. Magnifying endoscopy, performed in six patients, revealed the lesions as areas with aggregated minute yellowish spots with tortuous microvessels inside. Magnifying narrow-band imaging contrasted the yellowish spots and microvessels better than white-light endoscopy. In all lesions, histological examination showed that the yellowish spots corresponded to papillae filled with foam cells. The foam cells were strongly immunopositive for CD68, and in all lesions, CD34-positive intrapapillary capillaries surrounded the aggregated foam cells. The different morphologies of the flat and slightly elevated lesions corresponded to different densities of papillae filled with foam cells.  Magnifying endoscopy revealed minute yellowish spots with tortuous microvessels inside. These correspond well with histological findings and so may be useful in the diagnosis of esophageal xanthomas.
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http://dx.doi.org/10.1055/a-0966-8544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773585PMC
October 2019

Differentiation between duodenal neoplasms and non-neoplasms using magnifying narrow-band imaging - Do we still need biopsies for duodenal lesions?

Dig Endosc 2020 Jan 20;32(1):84-95. Epub 2019 Aug 20.

Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan.

Objectives: Endoscopic biopsies for nonampullary duodenal epithelial neoplasms (NADENs) can induce submucosal fibrosis, making endoscopic resection difficult. However, no biopsy-free method exists to distinguish between NADENs and non-neoplasms. We developed a diagnostic algorithm for duodenal neoplasms based on magnifying endoscopy findings and evaluated the model's diagnostic ability.

Methods: Magnified endoscopic images and duodenal lesion histology were collected consecutively between January 2015 and April 2016. Diagnosticians classified the surface patterns as pit, groove or absent. In cases of nonvisible surface patterns, the vascular pattern was evaluated to determine regularity or irregularity. The correlation between our algorithm (pit-type or absent with irregular vascular pattern) and the lesion histology were evaluated. Four evaluators, who were blinded to the histology, also classified the endoscopic findings and evaluated the diagnostic performance and interobserver agreement.

Results: Endoscopic images of 114 lesions were evaluated (70 NADENs and 44 non-neoplasms, 31 in the superior and 83 in the descending and horizontal duodenum). Of the NADEN surface patterns, 88% (62/70) were pit-type, while 79% (35/44) of the non-neoplasm surface patterns were groove-type. Our diagnostic algorithm for differentiating NADENs from non-neoplasms was high (sensitivity 96%, specificity 95%) in the descending and horizontal duodenum. The evaluators' diagnostic performances were also high, and interobserver agreement for the algorithm was good between each diagnostician and evaluator (κ = 0.60-0.76).

Conclusion: Diagnostic performance of our algorithm sufficiently enabled eliminating endoscopic biopsies for diagnosing the descending and horizontal duodenum.
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http://dx.doi.org/10.1111/den.13485DOI Listing
January 2020

Efficacy of Endoscopic Resection and Selective Chemoradiotherapy for Stage I Esophageal Squamous Cell Carcinoma.

Gastroenterology 2019 08 20;157(2):382-390.e3. Epub 2019 Apr 20.

Department of Therapeutic Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan. Electronic address:

Background & Aims: Esophagectomy is the standard treatment for stage I esophageal squamous cell carcinoma (ESCC). We conducted a single-arm prospective study to confirm the efficacy and safety of selective chemoradiotherapy (CRT) based on findings from endoscopic resection (ER).

Methods: We performed a prospective study of patients with T1b (SM1-2) N0M0 thoracic ESCC from December 2006 through July 2012; 176 patients underwent ER. Based on the findings from ER, patients received the following: no additional treatment for patients with pT1a tumors with a negative resection margin and no lymphovascular invasion (group A); prophylactic CRT with 41.4 Gy delivered to locoregional lymph nodes for patients with pT1b tumors with a negative resection margin or pT1a tumors with lymphovascular invasion (group B); or definitive CRT (50.4 Gy) with a 9-Gy boost to the primary site for patients with a positive vertical resection margin (group C). Chemotherapy comprised 5-fluorouracil and cisplatin. The primary end point was 3-year overall survival in group B, and the key secondary end point was 3-year overall survival for all patients. If lower limits of 90% confidence intervals for the primary and key secondary end points exceeded the 80% threshold, the efficacy of combined ER and selective CRT was confirmed.

Results: Based on the results from pathology analysis, 74, 87, and 15 patients were categorized into groups A, B, and C, respectively. The 3-year overall survival rates were 90.7% for group B (90% confidence interval, 84.0%-94.7%) and 92.6% in all patients (90% confidence interval, 88.5%-95.2%).

Conclusions: In a prospective study of patients with T1b (SM1-2) N0M0 thoracic ESCC, we confirmed the efficacy of the combination of ER and selective CRT. Efficacy is comparable to that of surgery, and the combination of ER and selective CRT should be considered as a minimally invasive treatment option. UMIN-Clinical Trials Registry no.: UMIN000000553.
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http://dx.doi.org/10.1053/j.gastro.2019.04.017DOI Listing
August 2019

Endoscopic Balloon Dilation Followed By Intralesional Steroid Injection for Anastomotic Strictures After Esophagectomy: A Randomized Controlled Trial.

Am J Gastroenterol 2018 10 4;113(10):1468-1474. Epub 2018 Sep 4.

Department of Gastroenterology, Osaka Red Cross Hospital, Osaka, Japan. Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan. Department of Surgery, Osaka General Medical Center, Osaka, Japan. Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan. Department of Gastroenterology, Osaka Rosai Hospital, Sakai, Japan. Department of Gastroenterology, National Hospital Organization Osaka National Hospital, Osaka, Japan. Department of Surgery, Osaka International Cancer Institute, Osaka, Japan. Department of Cancer Epidemiology and Prevention, Center for Cancer Control and Statistics, Osaka International Cancer Institute, Osaka, Japan. Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan. Department of Gastroenterology, Kaizuka City Hospital, Kaizuka, Japan. Department of Gastroenterology, Obihiro-Kosei General Hospital, Obihiro, Japan. Department of Gastroenterology, Itami City Hospital, Itami, Japan.

Objective: Endoscopic balloon dilation (EBD) is a standard treatment for anastomotic strictures after esophagectomy, and requires multiple dilations. We conducted a randomized controlled trial to assess the efficacy of adding a steroid injection to EBD to reduce restricture.

Methods: Patients were randomized to receive EBD combined with either triamcinolone or placebo injection. The primary endpoint was the number of dilations required to resolve the stricture. The secondary endpoints were restricture-free survival and adverse events. Patients with a dysphagia symptom score of ≥2 after esophagectomy with an endoscopy-confirmed anastomotic stricture were included. A total of 50 mg of triamcinolone acetonide (50 mg/5 mL) or an identical volume of normal saline solution as a placebo was injected per site using a 25-gauge needle immediately after EBD. Both the patient and treating physician were blinded to the treatment given.

Results: During the 4-year study period, 65 patients were randomized to either the steroid group (n = 33) or placebo group (n = 32). The median number of EBDs required to resolve strictures was 2.0 (interquartile range, 1.0-2.5) in the steroid group and 4.0 (interquartile range, 2.0-6.8) in the placebo group (p < 0.001). After 6 months of follow-up, 39% of patients who had received steroid injections remained recurrence free compared with 16% of those who had received saline injections (p = 0.002). No adverse events occurred during follow-up.

Conclusions: Steroid injection shows promising results for the prevention of stricture recurrence in patients who underwent EBD for anastomotic strictures.
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http://dx.doi.org/10.1038/s41395-018-0253-yDOI Listing
October 2018

Efficacy of vonoprazan in prevention of bleeding from endoscopic submucosal dissection-induced gastric ulcers: a prospective randomized phase II study.

J Gastroenterol 2019 Feb 25;54(2):122-130. Epub 2018 Jun 25.

Clinical Study Support Center, Wakayama Medical University, Wakayama, Japan.

Background: Vonoprazan, potassium-competitive acid blocker, is expected to reduce incidence of delayed bleeding after gastric endoscopic submucosal dissection (ESD); however, preliminary data to design a large-scale comparative study are lacking. This study aimed to assess the efficacy of vonoprazan in preventing delayed bleeding after gastric ESD.

Methods: In this single-center randomized phase II trial, a modified screened selection design was used with a threshold non-bleeding rate of 89% and an expected rate of 97%. In this design, Simon's optimal two-stage design was first applied for each parallel group, and efficacy was evaluated in comparison with the threshold rate using binomial testing. Patients were randomly assigned in a 1:1 ratio to receive either vonoprazan 20 mg (VPZ group) or lansoprazole 30 mg (PPI group) for 8 weeks from the day before gastric ESD. The primary endpoint was the incidence of delayed bleeding, defined as endoscopically confirmed bleeding accompanied by hematemesis, melena, or a decrease in hemoglobin of ≥ 2 g/dl.

Results: Delayed bleeding occurred in three of 69 patients (4.3%, 95% CI 0.9-12.2%, p = 0.047) in the VPZ group, and four of 70 (5.7%, 95% CI 1.6-14.0%, p = 0.104) in the PPI group. As only vonoprazan showed significant reduction in delayed bleeding compared with the threshold rate, it was determined to be efficacious treatment.

Conclusions: Vonoprazan efficaciously reduced the delayed bleeding rate in patients with an ESD-induced gastric ulcer. A large-scale, randomized, phase III study is warranted to definitively test the effectiveness of vonoprazan compared with proton pump inhibitors.
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http://dx.doi.org/10.1007/s00535-018-1487-6DOI Listing
February 2019

Line-assisted complete closure for a large mucosal defect after colorectal endoscopic submucosal dissection decreased post-electrocoagulation syndrome.

Dig Endosc 2018 Sep 29;30(5):633-641. Epub 2018 Apr 29.

Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan.

Background And Aim: The incidence of post-endoscopic submucosal dissection (ESD) coagulation syndrome (PECS) can be decreased by closing mucosal defects. However, large mucosal defects after colorectal ESD cannot be closed endoscopically. We established line-assisted complete clip closure (LACC), a novel technique for large mucosal defects after colorectal ESD. We evaluated the prophylactic efficacy of LACC for preventing PECS.

Methods: Sixty-one consecutive patients on whom LACC after colorectal ESD was attempted from January 2016 to August 2016 were analyzed. After exclusion of patients with incomplete LACC and adverse events during ESD, 57 patients comprised the LACC group. In contrast, 495 patients who did not undergo closure of a mucosal defect comprised the control group. Propensity score matching was used to adjust for patients' backgrounds. Treatment outcomes were evaluated between the groups.

Results: Median resected specimen size in the LACC-attempted group was 35 mm (range, 20-72 mm), and LACC success rate was 95% (58/61). Median procedure time of LACC was 14 min. In the LACC group, incidence of PECS was only 2%, and no delayed bleeding or perforation occurred. Propensity score matching created 51 matched pairs. Adjusted comparisons between the LACC and control groups showed a lower incidence of PECS (0% vs 12%, respectively; P = 0.03) and shorter hospitalization (5 vs 6 days, respectively; P < 0.001) in the LACC group.

Conclusion: This study suggests that LACC can effectively reduce the incidence of PECS, although further large-scale studies are warranted.
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http://dx.doi.org/10.1111/den.13052DOI Listing
September 2018

Sporadic Minute Pharyngeal Xanthomas Detected Incidentally During Esophagogastroduodenoscopy: A Case Series.

Head Neck Pathol 2019 Jun 19;13(2):277-280. Epub 2018 Mar 19.

Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 3-1-69, Otemae, Chuo-ku, Osaka, 541-8567, Japan.

Pharyngeal xanthomas are considered rare, and no reports have described their endoscopic appearance under magnifying or image-enhanced endoscopy. We report three cases of asymptomatic sporadic pharyngeal xanthoma that were detected incidentally during routine esophagogastroduodenoscopy. All the patients were men and had a solitary lesion of about 1 mm in size. Two of the lesions were located in the oropharynx, while one was in the hypopharynx. Non-magnifying endoscopy showed yellowish lesions, and magnifying endoscopy showed an aggregation of minute yellowish nodules with tortuous microvessels on their surface. Histopathological examination revealed foam cells filling the intraepithelial papillae. The foam cells were strongly immunopositive for cluster of differentiation (CD) 68. Immunohistochemical staining for CD34 showed intrapapillary capillaries around the foam cells. This characteristic magnifying endoscopic appearance corresponded to the histopathological findings of pharyngeal xanthomas. The present cases reveal the relationship between the endoscopic appearance and histopathological findings of pharyngeal xanthomas.
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http://dx.doi.org/10.1007/s12105-018-0911-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513931PMC
June 2019

Impact of electrosurgical unit mode on post esophageal endoscopic submucosal dissection stricture in an in vivo porcine model.

Endosc Int Open 2018 Mar 7;6(3):E376-E381. Epub 2018 Mar 7.

Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan.

Background And Aim:  Strictures are a major complication of esophageal endoscopic submucosal dissection (ESD) for superficial esophageal carcinoma. Post ESD, stricture develops during the process of scar formation, which is related to inflammation caused by ESD. We planned a study to evaluate whether certain electrosurgical unit modes could attenuate strictures after esophageal ESD.

Methods:  A total of 16 ESD, three-quarters of the esophageal circumference, were performed in four live pigs. A ball-tip Flush knife was used for mucosal incision. Submucosal dissection was performed using a Hook knife in monopolar mode and a ball-tip Jet B-knife in bipolar mode. Applied electrosurgical unit modes were FORCED COAG, SWIFT COAG, SPRAY COAG, ENDO CUT in monopolar mode, and FORCED COAG in bipolar mode. One month after ESD, the pigs were killed humanely and the severity of strictures and fibrosis was assessed.

Results:  The resected site in the esophagus showed complete mucosal regrowth and scar formation in all pigs. The quotients of stricture following ENDO CUT, SWIFT COAG, FORCED COAG effect2, FORCED COAG effect3, FORCED COAG effect4, SPRAY COAG, and Bipolar FORCED COAG mode were 16 %, 28 %, 38 %, 33 %, 51 %, 39 %, and 47 %, respectively. The equivalent quotients of fibrosis were 7 %, 28 %, 31 %, 30 %, 35 %, 63 %, and 100 %, respectively. ENDO CUT mode was associated with the lowest mean quotients of stricture and fibrosis.

Conclusion:  ENDO CUT mode showed promising results to attenuate fibrosis and strictures after esophageal ESD.
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http://dx.doi.org/10.1055/s-0043-122883DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842068PMC
March 2018

Efficacy of traction-assisted colorectal endoscopic submucosal dissection using a clip-and-thread technique: A prospective randomized study.

Dig Endosc 2018 Jul 11;30(4):467-476. Epub 2018 Mar 11.

Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan.

Background And Aim: Colorectal endoscopic submucosal dissection (ESD) remains challenging because of technical difficulties, long procedure time, and high risk of adverse events. To facilitate colorectal ESD, we developed traction-assisted colorectal ESD using a clip and thread (TAC-ESD) and conducted a randomized controlled trial to evaluate its efficacy.

Methods: Patients with superficial colorectal neoplasms (SCN) ≥20 mm were enrolled and randomly assigned to the conventional-ESD group or to the TAC-ESD group. SCN ≤50 mm were treated by two intermediates, and SCN >50 mm were treated by two experts. Primary endpoint was procedure time. Secondary endpoints were TAC-ESD success rate (sustained application of the clip and thread until the end of the procedure), self-completion rate by the intermediates, and adverse events.

Results: Altogether, 42 SCN were analyzed in each ESD group (conventional and TAC). Procedure time (median [range]) for the TAC-ESD group was significantly shorter than that for the conventional-ESD group (40 [11-86] min vs 70 [30-180] min, respectively; P < 0.0001). Success rate of TAC-ESD was 95% (40/42). The intermediates' self-completion rate was significantly higher for the TAC-ESD group than for the conventional-ESD group (100% [39/39] vs 90% [36/40], respectively; P = 0.04). Adverse events included one intraoperative perforation in the conventional-ESD group and one delayed perforation in the TAC-ESD group.

Conclusion: Traction-assisted colorectal endoscopic submucosal dissection reduced the procedure time and increased the self-completion rate by the intermediates (UMIN000018612).
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http://dx.doi.org/10.1111/den.13036DOI Listing
July 2018

Safety of cold snare polypectomy for duodenal adenomas in familial adenomatous polyposis: a prospective exploratory study.

Endoscopy 2018 05 19;50(5):511-517. Epub 2018 Jan 19.

Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan.

Background: Cold snare polypectomy (CSP) to remove multiple duodenal adenomas (MDAs) in patients with familial adenomatous polyposis (FAP) could be an effective and less invasive method than more extensive surgery. The aim of the present study was to determine the safety of this procedure.

Methods: This prospective exploratory study included 10 consecutive patients with FAP and MDAs who underwent CSP for as many as 50 duodenal adenomas. The primary outcome was the incidence of severe adverse events.

Results: 10 patients were enrolled and underwent 332 CSPs from June 2016 to January 2017. The median procedure time was 33 minutes (range 25 - 53), and the median number of polyps removed during a single session was 35 (range 10 - 50). Most of the removed polyps were ≤ 10 mm. None of the 10 patients experienced a severe adverse event. One patient developed arterial bleeding during the procedure, but it was easily managed using hemoclips.

Conclusions: CSP for MDAs in patients with FAP was safe. The long-term efficacy of this procedure should be investigated.
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http://dx.doi.org/10.1055/s-0043-124765DOI Listing
May 2018

Underwater endoscopic mucosal resection for superficial nonampullary duodenal adenomas.

Endoscopy 2018 02 29;50(2):154-158. Epub 2017 Sep 29.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

Background And Study Aim: Underwater endoscopic mucosal resection (UEMR) was recently developed in a Western country. A prospective cohort study to investigate the effectiveness of UEMR was conducted in patients with small superficial nonampullary duodenal adenomas.

Patients And Methods: Patients with duodenal adenomas ≤ 20 mm were enrolled. After the duodenal lumen had been filled with physiological saline, UEMR was performed without submucosal injection. Endoclip closure was attempted for all mucosal defects after UEMR. Follow-up endoscopy with biopsy was performed 3 months later. The primary end point was the complete resection rate, defined as neither endoscopic nor histological residue of adenoma at the follow-up endoscopy.

Results: 30 patients with 31 lesions were enrolled. The mean (SD) tumor size was 12.0 mm (7.3). The complete resection rate was 97 % (90 % confidence interval, 87 % - 99 %). The en bloc resection rate was 87 %. All mucosal defects were successfully closed by endoclips. No adverse events occurred except for one case of mild aspiration pneumonia.

Conclusions: UEMR is efficacious for the treatment of small duodenal adenomas, but further large-scale trials are warranted to confirm these results.
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http://dx.doi.org/10.1055/s-0043-119214DOI Listing
February 2018

Efficacy and Safety of Endoscopic Resection Followed by Chemoradiotherapy for Superficial Esophageal Squamous Cell Carcinoma: A Retrospective Study.

Clin Transl Gastroenterol 2017 Aug 3;8(8):e110. Epub 2017 Aug 3.

Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan.

Objectives: The reported 1- and 3-year overall survival rates after esophagectomy for stage I superficial esophageal squamous cell carcinoma (SESCC) are 95-97% and 86%, and those after definitive chemoradiotherapy (CRT) are 98% and 89%, respectively. This study was performed to elucidate the efficacy and safety of another treatment option for SESCC: endoscopic resection (ER) followed by CRT.

Methods: We retrospectively reviewed the overall survival, recurrence, and grade ≥3 adverse events of consecutive patients who refused esophagectomy and underwent ER followed by CRT for SESCC from 1 January 2006 to 31 December 2012.

Results: In total, 66 patients with SESCC underwent ER followed by CRT during the study period, and complete follow-up data were available for all patients. The median age was 67 (range, 45-82) years, and the median observation period was 51 (range, 7-103) months. Local and metastatic recurrences occurred in 2 (3%) and 6 (9%) patients, respectively, and 17 (26%) patients died. The 1-, 3-, and 5-year overall survival rates were 98%, 87%, and 75%, respectively. One of the 23 patients with mucosal cancer and 5 of 43 with submucosal cancer developed metastatic recurrences (P=0.65). Five of the 61 patients with negative vertical resection margin and 1 of 5 with positive vertical resection margin developed metastatic recurrences (P=0.39). None of the 30 patients without lymphovascular involvement developed metastatic recurrences; however, 6 of 36 patients with lymphovascular involvement developed metastatic recurrences (P=0.0098). Grade ≥3 adverse events occurred in 21 (32%) patients and all adverse events were associated with CRT, hematological adverse events in 13 (20%), and non-hematological adverse events in 9 (14%).

Conclusions: ER followed by CRT provides survival comparable with that of esophagectomy or definitive CRT and has a low local recurrence rate. A particularly favorable outcome is expected for cancers without lymphovascular involvement.
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http://dx.doi.org/10.1038/ctg.2017.36DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5587838PMC
August 2017

Investigation of mucosal pattern of gastric antrum using magnifying narrow-band imaging in patients with chronic atrophic fundic gastritis.

Ann Gastroenterol 2017 21;30(3):302-308. Epub 2017 Mar 21.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka (Yasushi Yamasaki, Noriya Uedo, Hiromitsu Kanzaki, Minoru Kato, Kenta Hamada, Kenji Aoi, Yusuke Tonai, Noriko Matsuura, Takashi Kanesaka, Takeshi Yamashina, Tomofumi Akasaka, Noboru Hanaoka, Yoji Takeuchi, Koji Higashino, Ryu Ishihara, Hiroyasu Iishi).

Background: Magnifying narrow-band imaging (M-NBI) can reportedly help predict the presence and distribution of atrophy and intestinal metaplasia in the gastric corpus. However, the micro-mucosal pattern of the antrum shown by M-NBI differs from that of the corpus. We studied the distribution and histology of the micro-mucosal pattern in the antrum based on magnifying endoscopy.

Methods: Endoscopic images of the greater curvature of the antrum were evaluated in 50 patients with chronic atrophic fundic gastritis (CAFG). The extent of CAFG was evaluated by autofluorescence imaging. The micro-mucosal pattern was evaluated by M-NBI and classified into groove and white villiform types. The localization of white villiform type mucosa was classified into three types in relation to the : null, central, and segmental types. Biopsies were taken from regions showing different micro-mucosal patterns. Associations among the extent of CAFG, micro-mucosal pattern, and histology were examined.

Results: As the extent of CAFG increased, the proportion of white villiform type mucosa increased, whereas that of groove type mucosa decreased (P=0.022). In patients with extensive CAFG, most of the was composed of the segmental or central type of white villiform type mucosa (P=0.044). The white villiform type mucosa had significantly higher grades of atrophy (P=0.002) and intestinal metaplasia (P<0.001) than did the groove type mucosa.

Conclusion: White villiform type mucosa is indicative of atrophy and intestinal metaplasia in the gastric antrum. It extends to the whole or central part of the as CAFG becomes more extensive.
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http://dx.doi.org/10.20524/aog.2017.0134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5411380PMC
March 2017

Technical feasibility of line-assisted complete closure technique for large mucosal defects after colorectal endoscopic submucosal dissection.

Endosc Int Open 2017 Jan;5(1):E11-E16

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

Complete closure of large mucosal defects after colorectal endoscopic submucosal dissection (C-ESD) is considered impossible in most cases because of the limited width of the open clip. We therefore invented a simple closure technique using clip-and-line, named "line-assisted complete closure (LACC)", and assessed its technical feasibility. Between January and February 2016, we performed LACC in 11 patients after C-ESD and included them in this retrospective feasibility study. Outcome measures were procedural success rate, procedure time, and post-procedural complications. The median size of the resected specimen was 36 mm (range 30 - 72 mm). Procedural success was achieved in 10 of 11 cases (91 %). Those 10 cases required a median of 9 endoclips (range 6 - 12) for complete closure. Median procedure time for LACC was 14 minutes (range 6 - 22). No complications were observed in any of the cases after the procedure.  LACC is a simple and feasible technique for complete closure of large mucosal defects after C-ESD.
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http://dx.doi.org/10.1055/s-0042-121002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5361877PMC
January 2017

Incomplete resection rate of cold snare polypectomy: a prospective single-arm observational study.

Endoscopy 2017 Mar 13;49(3):251-257. Epub 2017 Feb 13.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

 Cold snare polypectomy (CSP) is considered to be safe for the removal of subcentimeter colorectal polyps. This study aimed to determine the rate of incomplete CSP resection for subcentimeter neoplastic polyps at our center.  Patients with small or diminutive adenomas (diameter 1 - 9 mm) were recruited to undergo CSP until no polyp was visible. After CSP, a 1 - 3 mm margin around the resection site was removed using endoscopic mucosal resection. The polyps and resection site marginal specimens were microscopically evaluated. Incomplete resection was defined as the presence of neoplastic tissue in the marginal specimen. We also calculated the frequency at which the polyp lateral margins could be assessed for completeness of resection.  A total of 307 subcentimeter neoplastic polyps were removed from 120 patients. The incomplete resection rate was 3.9 % (95 % confidence interval [CI] 1.7 % - 6.1 %); incomplete resection was not associated with polyp size, location, morphology, or operator experience. The polyp lateral margins could not be assessed adequately for 206 polyps (67.1 %). Interobserver agreement between incomplete resection and lateral polyp margins that were inadequate for assessment was poor (κ = 0.029, 95 %CI 0 - 0.04). Female sex was an independent risk factor for incomplete resection (odds ratio 4.41, 95 %CI 1.26 - 15.48;  = 0.02).  At our center, CSP resection was associated with a moderate rate of incomplete resection, which was not associated with polyp characteristics. However, adequate evaluation of resection may not be routinely possible using the lateral margin from subcentimeter polyps that were removed using CSP.Trial registered at University Hospital Medical Information Network (UMIN 000010879).
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http://dx.doi.org/10.1055/s-0043-100215DOI Listing
March 2017

Endoscopic imaging modalities for diagnosing invasion depth of superficial esophageal squamous cell carcinoma: a systematic review and meta-analysis.

BMC Gastroenterol 2017 Feb 2;17(1):24. Epub 2017 Feb 2.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi Higashinari-ku, Osaka, 537-8511, Japan.

Background: Diagnosis of cancer invasion depth is crucial for selecting the optimal treatment strategy in patients with gastrointestinal cancers. We conducted a meta-analysis to determine the utilities of different endoscopic modalities for diagnosing invasion depth of esophageal squamous cell carcinoma (SCC).

Methods: We conducted a comprehensive search of MEDLINE, Cochrane Central, and Ichushi databases to identify studies evaluating the use of endoscopic modalities for diagnosing invasion depth of superficial esophageal SCC. We excluded case reports, review articles, and studies in which the total number of patients or lesions was <10.

Results: Fourteen studies fulfilled our criteria. Summary receiver operating characteristic curves showed that magnified endoscopy (ME) and endoscopic ultrasonography (EUS) performed better than non-ME. ME was associated with high sensitivity and a very low (0.08) negative likelihood ratio (NLR), while EUS had high specificity and a very high (17.6) positive likelihood ratio (PLR) for the diagnosis of epithelial or lamina propria cancers. NLR <0.1 provided strong evidence to rule out disease, and PLR >10 provided strong evidence of a positive diagnosis.

Conclusions: EUS and ME perform better than non-ME for diagnosing invasion depth in SCC. ME has a low NLR and is a reliable modality for confirming deep invasion of cancer, while EUS has a high PLR and can reliably confirm that the cancer is limited to the surface. Effective use of these two modalities should be considered in patients with SCC.

Trial Registration: PROSPERO (International Prospective Register of Systematic Reviews); number 42015024462 .
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http://dx.doi.org/10.1186/s12876-017-0574-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5288972PMC
February 2017

Line-assisted complete closure of duodenal mucosal defects after underwater endoscopic mucosal resection.

Endoscopy 2017 Feb 9;49(S 01):E37-E38. Epub 2017 Jan 9.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

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http://dx.doi.org/10.1055/s-0042-120707DOI Listing
February 2017

Scissor-type knife significantly improves self-completion rate of colorectal endoscopic submucosal dissection: Single-center prospective randomized trial.

Dig Endosc 2017 May 20;29(3):322-329. Epub 2017 Jan 20.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

Background And Aim: Colorectal endoscopic submucosal dissection (C-ESD) is recognized as a difficult procedure. Recently, scissors-type knives were launched to reduce the difficulty of C-ESD. The aim of this study was to evaluate the efficacy and safety of the combined use of a scissors-type knife and a needle-type knife with a water-jet function (WJ needle-knife) for C-ESD compared with using the WJ needle-knife alone.

Methods: This was a prospective randomized controlled trial in a referral center. Eighty-five patients with superficial colorectal neoplasms were enrolled and randomly assigned to undergo C-ESD using a WJ needle-knife alone (Flush group) or a scissor-type knife-supported WJ needle-knife (SB Jr group). Procedures were conducted by two supervised residents. Primary endpoint was self-completion rate by the residents.

Results: Self-completion rate was 67% in the SB Jr group, which was significantly higher than that in the Flush group (39%, P = 0.01). Even after exclusion of four patients in the SB Jr group in whom C-ESD was completed using the WJ needle-knife alone, the self-completion rate was significantly higher (63% vs 39%; P = 0.03). Median procedure time among the self-completion cases did not differ significantly between the two groups (59 vs 51 min; P = 0.14). No fatal adverse events were observed in either group.

Conclusions: In this single-center phase II trial, scissor-type knife significantly improved residents' self-completion rate for C-ESD, with no increase in procedure time or adverse events. A multicenter trial would be warranted to confirm the validity of the present study.
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http://dx.doi.org/10.1111/den.12784DOI Listing
May 2017

Pethidine hydrochloride is a better sedation method for pharyngeal observation by transoral endoscopy compared with no sedation and midazolam.

Dig Endosc 2017 Jan 21;29(1):39-48. Epub 2016 Oct 21.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

Background And Aim: Standard surveillance methods for pharyngeal cancer have not been established. We conducted a randomized controlled trial to investigate the best sedation method for pharyngeal observation using transoral endoscopy.

Methods: In total, 120 patients who underwent surveillance or diagnostic examinations for esophageal cancer were enrolled and divided equally into three groups (no sedation, midazolam, or pethidine hydrochloride). In the midazolam group, midazolam was given i.v. maintaining a Ramsay score of 3. In the pethidine group, pethidine hydrochloride (35 mg) given i.v. Seven sites in five pharyngeal regions were observed on insertion of the endoscope, and graded (0 = poor, 1 = good). After examination, the five pharyngeal regions were scored using a seven-point scale. Primary endpoint was the total score from the five pharyngeal regions. Secondary endpoints were the proportion of the perfect score using the seven-point scale, discomfort score, and adverse events.

Results: Mean total scores for the no sedation group, the midazolam group and the pethidine group were 5.7, 5.5, and 6.8, respectively (P < 0.0001). Proportion of patients with a perfect score for the no sedation group, the midazolam group and the pethidine group were 53%, 35%, and 89%, respectively (P < 0.0001). The pethidine group had better results than the other two groups. Discomfort score and adverse events were low in the pethidine group.

Conclusion: Pethidine hydrochloride is a feasible and safe sedation method, and was superior to no sedation and midazolam regarding pharyngeal observation of esophageal cancer patients.
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http://dx.doi.org/10.1111/den.12746DOI Listing
January 2017

First reports of esophageal adenocarcinoma with white globe appearance in Japanese and Caucasian patients.

Endosc Int Open 2016 Oct 14;4(10):E1075-E1077. Epub 2016 Sep 14.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

Better endoscopic diagnosis in case of Barrett's esophagus is still needed. White globe appearance (WGA) is a novel endoscopic marker for gastric adenocarcinoma, with high sensitivity for differentiating between gastric cancer/high-grade dysplasia and other lesions. We report 2 cases of esophageal adenocarcinoma with WGA. In Case 1, esophagogastroduodenoscopy (EGD) revealed a 10-mm esophageal adenocarcinoma in a 48-year-old Japanese woman with short-segment Barrett's esophagus. A small (< 1 mm) white globular lesion, typical of WGA, was observed under the epithelium by magnifying narrow-band imaging. A dilated neoplastic gland with eosinophilic material and necrotic epithelial fragments was identified at the site of the WGA by histologic examination. In Case 2, EGD revealed a 5-mm esophageal adenocarcinoma in a 60-year-old Caucasian man with long-segment Barrett's esophagus. A typical WGA was observed by magnifying narrow-band imaging and similar histologic findings were identified at the site of the WGA. WGA could be a reliable endoscopic finding for target biopsy in esophageal adenocarcinoma, if its specificity is as high as in gastric cancer. The clinical implications of WGA in patients with Barrett's esophagus should be investigated further.
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http://dx.doi.org/10.1055/s-0042-114983DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5063742PMC
October 2016

"Take your polyp for a walk": endoscopic retrieval of multiple colon polyps using a clip and line.

Endoscopy 2016 14;48 Suppl 1:E291-2. Epub 2016 Sep 14.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

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http://dx.doi.org/10.1055/s-0042-115563DOI Listing
August 2017

Endoscopic surveillance of head and neck cancer in patients with esophageal squamous cell carcinoma.

Endosc Int Open 2016 Jul 21;4(7):E752-5. Epub 2016 Jun 21.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

Background And Study Aims: Multiple squamous cell carcinomas (SCCs) frequently arise in the upper aerodigestive tract, referred to as the field cancerization phenomenon. The aim of this study was to elucidate the detailed clinical features of second primary head and neck (H&N) SCCs arising in patients with esophageal SCC.

Patients And Methods: A total of 818 patients underwent endoscopic resection for superficial esophageal cancer between January 2006 and December 2013. Of these, 439 patients met our inclusion criteria, and we retrospectively investigated the incidence, primary sites, and stages of second primary H&N SCCs in these patients.

Results: A total of 53 metachronous H&N SCCs developed in 40 patients after a median follow-up period of 46 months (range 9 - 109). The cumulative incidence rates of metachronous H&N SCCs at 3, 5, and 7 years were 5.3 %, 9.7 %, and 17.2 %, respectively. These lesions were frequently located at pyriform sinus or in the posterior wall of the pharynx (70 %, 37/53 lesions). Most of the lesions were detected at an early stage, though 4 lesions were associated with lymph node metastasis when their primary sites were detected (1 postcricoid area, 2 posterior wall of hypopharynx, and 1 lateral wall of oropharynx).

Conclusions: Patients with esophageal SCC should undergo careful inspection of the pyriform sinus and posterior wall of the pharynx for detection of H&N SCCs. Methods to open the hypopharyngeal space, such as the Valsalva maneuver, should be included in the surveillance program.
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http://dx.doi.org/10.1055/s-0042-106720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4993894PMC
July 2016

A comparative study of grasping-type scissors forceps and insulated-tip knife for endoscopic submucosal dissection of early gastric cancer: a randomized controlled trial.

Endosc Int Open 2016 Jun 12;4(6):E654-60. Epub 2016 May 12.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

Background And Study Aims: Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is technically difficult for beginners. Few comparative studies of technical feasibility, efficacy, and safety using various devices have been reported. This study evaluated the feasibility, efficacy, and safety of ESD for EGC < 2 cm using grasping-type scissors forceps (GSF) or insulated-tip knife (IT2) for three resident endoscopists.

Patients And Methods: This was a randomized phase II study in a cancer referral center. A total of 108 patients with 120 EGCs were enrolled with the following characteristics: differentiated-type mucosal EGC, without ulcers or scars, < 2 cm (86 men, 22 women; median age 72 years). All lesions were stratified according to operator and tumor location (antrum or corpus), assigned randomly to two groups (GSF or IT2), and resected by ESD. Self-completion rate, complete resection rate, procedure time, and adverse events were evaluated as main outcome measures.

Results: There was no difference in self-completion rate between the IT2 group (77 %, 47/61, P = 0.187) and the GSF group (66 %, 37/56). Also, there were no differences in en bloc resection rate (98 %, 60/61 vs. 93 %, 52/56, P = 0.195) and adverse events (3.3 %, 2/61 vs. 7.1 %, 4/56, P = 0.424). Median (min [range]) procedure time in the IT2 group (47 [33 - 67], P = 0.003) was shorter than that in the GSF group (66 [40 - 100]). Limitations of this study were the small sample size and single center design.

Conclusions: ESD with GSF did not show a statistically significant advantage in improvement of self-completion rate over IT2. (

Study Registration: UMIN 000005048).
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http://dx.doi.org/10.1055/s-0042-105870DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4993886PMC
June 2016

Prospective small bowel mucosal assessment immediately after chemoradiotherapy of unresectable locally advanced pancreatic cancer using capsule endoscopy: a case series.

Ann Gastroenterol 2016 Jul-Sep;29(3):386-8. Epub 2016 Feb 15.

Gastrointestinal Oncology (Takeshi Yamashina, Noriya Uedo, Tomofumi Akasaka, Noboru Hanaoka, Yoji Takeuchi, Koji Higashino, Ruy Ishihara, Hiroyasu Iishi), Osaka, Japan.

In this case series, three consecutive patients with unresectable locally advanced pancreatic cancer (ULAPC) underwent capsule endoscopy (CE) before and after chemoradiotherapy (CRT) to evaluate duodenal and jejunal mucosa, and to examine the relationship between CE findings and dose distribution. CE after CRT showed duodenitis and proximal jejunitis in all three patients. The most inflamed region was the third part of the duodenum, and in dose distribution, this was the closest region to the center of irradiation. This case series shows that CE can safely diagnose acute duodenitis and proximal jejunitis caused by CRT for ULAPC, and that dose distribution is possible to predict the degree of duodenal and jejunal mucosal injuries.
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http://dx.doi.org/10.20524/aog.2016.0063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4923833PMC
July 2016

Refractory strictures despite steroid injection after esophageal endoscopic resection.

Endosc Int Open 2016 Mar 11;4(3):E354-9. Epub 2016 Feb 11.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

Background: Although steroid injection prevents stricture after esophageal endoscopic submucosal dissection (ESD), some patients require repeated sessions of endoscopic balloon dilation (EBD). We investigated the risk for refractory stricture despite the administration of steroid injections to prevent stricture in patients undergoing esophageal ESD. Refractory stricture was defined as the requirement for more than three sessions of EBD to resolve the stricture. In addition, the safety of steroid injections was assessed based on the rate of complications.

Patients And Methods: We analyzed data from 127 consecutive patients who underwent esophageal ESD and had mucosal defects with a circumferential extent greater than three-quarters of the esophagus. To prevent stricture, steroid injection was performed. EBD was performed whenever a patient had symptoms of dysphagia.

Results: The percentage of patients with a tumor circumferential extent greater than 75 % was significantly higher in those with refractory stricture than in those without stricture (P = 0.001). Multivariate analysis adjusted for age, sex, history of radiation therapy, tumor location, and tumor diameter showed that a tumor circumferential extent greater than 75 % was an independent risk factor for refractory stricture (adjusted odds ratio [OR] 5.49 [95 %CI 1.91 - 15.84], P = 0.002). Major adverse events occurred in 3 patients (2.4 %): perforation during EBD in 2 patients and delayed perforation after EBD in 1 patient. The patient with delayed perforation underwent esophagectomy because of mediastinitis.

Conclusions: A tumor circumferential extent greater than 75 % is an independent risk factor for refractory stricture despite steroid injections. The development of more extensive interventions is warranted to prevent refractory stricture.
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http://dx.doi.org/10.1055/s-0042-100903DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4798940PMC
March 2016

Polyglycolic acid sheets for closure of refractory esophago-pulmonary fistula after esophagectomy.

Endoscopy 2016 7;48 Suppl 1 UCTN:E78-9. Epub 2016 Mar 7.

Department of Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

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http://dx.doi.org/10.1055/s-0042-102452DOI Listing
October 2016

Feasibility of Simple Traction Technique for Rectal Endoscopic Submucosal Dissection.

Dig Dis Sci 2016 07 25;61(7):2127-31. Epub 2016 Jan 25.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinari-ku, Osaka, 537-8511, Japan.

Background And Aims: Rectal endoscopic submucosal dissection (ESD) is a highly effective procedure that achieves high en bloc resection regardless of lesion size or location. However, rectal ESD has a higher risk of intraoperative and postoperative bleeding and still difficult for beginners. Therefore, we designed a novel traction technique "traction-assisted rectal ESD using a clip-with-line (TAREC)," and investigated its feasibility.

Methods: Between December 2014 and July 2015, ten patients with rectal neoplasms (median size 36 mm; range 20-125 mm) were treated using the TAREC technique.

Results: In all lesions, good visibility of the submucosal layer was obtained, and the submucosal layer was dissected easily under direct visualization. All lesions were removed en bloc, and there were no procedure-related adverse events including postoperative bleeding. In particular, we experienced no intraoperative bleeding, which may be difficult to stop in some circumstances.

Conclusions: The TAREC technique is a simple and generally applicable procedure. This technique is feasible for rectal ESD.
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http://dx.doi.org/10.1007/s10620-016-4036-2DOI Listing
July 2016

Traction-assisted colonic endoscopic submucosal dissection using clip and line: a feasibility study.

Endosc Int Open 2016 Jan 30;4(1):E51-5. Epub 2015 Nov 30.

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.

Background And Study Aims: Colonic endoscopic submucosal dissection (ESD) is a challenging procedure because it is often difficult to maintain good visualization of the submucosal layer. To facilitate colonic ESD, we designed a novel traction method, namely traction-assisted colonic ESD using clip and line (TAC), and investigated its feasibility.

Patients And Methods: We retrospectively analyzed 23 patients with large colonic superficial lesions who had undergone TAC. The main outcome was the procedural success rate of TAC, which we defined as successful, sustained application of clip and line to the lesion until the end of the procedure.

Results: The procedural success rate of TAC was 87 % (20/23). In all three unsuccessful cases, the lesions were in the proximal colon and the procedure times over 100 minutes. The overall mean procedure time was 61 min (95 % confidence interval, 18 - 172 min). We achieved en bloc resections of all lesions. There were no perforations or fatal adverse events.

Conclusions: TAC is feasible and safe for colonic ESD and may improve the ease of performing this procedure.
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http://dx.doi.org/10.1055/s-0041-107779DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4713171PMC
January 2016

Feasibility of cold snare polypectomy in Japan: A pilot study.

World J Gastrointest Endosc 2015 Nov;7(17):1250-6

Yoji Takeuchi, Takeshi Yamashina, Noriko Matsuura, Takashi Ito, Mototsugu Fujii, Kengo Nagai, Fumi Matsui, Tomofumi Akasaka, Noboru Hanaoka, Koji Higashino, Hiroyasu Iishi, Ryu Ishihara, Noriya Uedo, Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka 537-8511, Japan.

Aim: To investigate the feasibility of cold snare polypectomy (CSP) in Japan.

Methods: The outcomes of 234 non-pedunculated polyps smaller than 10 mm in 61 patients who underwent CSP in a Japanese referral center were retrospectively analyzed. The cold snare polypectomies were performed by nine endoscopists with no prior experience in CSP using an electrosurgical snare without electrocautery.

Results: CSPs were completed for 232 of the 234 polyps. Two (0.9%) polyps could not be removed without electrocautery. Immediate postpolypectomy bleeding requiring endoscopic hemostasis occurred in eight lesions (3.4%; 95%CI: 1.1%-5.8%), but all were easily managed. The incidence of immediate bleeding after CSP for small polyps (6-9 mm) was significantly higher than that of diminutive polyps (≤ 5 mm; 15% vs 1%, respectively). Three (5%) patients complained of minor bleeding after the procedure but required no intervention. The incidence of delayed bleeding requiring endoscopic intervention was 0.0% (95%CI: 0.0%-1.7%). In total, 12% of the resected lesions could not be retrieved for pathological examination. Tumor involvement in the lateral margin could not be histologically assessed in 70 (40%) lesions.

Conclusion: CSP is feasible in Japan. However, immediate bleeding, retrieval failure and uncertain assessment of the lateral tumor margin should not be underestimated. Careful endoscopic diagnosis before and evaluation of the tumor residue after CSP are recommended when implementing CSP in Japan.
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http://dx.doi.org/10.4253/wjge.v7.i17.1250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4658605PMC
November 2015