Background
Whether rescue surgery confers a survival benefit in patients undergoing non‐curative endoscopic resection of early gastric cancer remains controversial.
Methods
This was a retrospective ...review of patients who underwent non‐curative endoscopic resection of at least one lesion of differentiated‐type early gastric cancer between 2000 and 2011. Patients with a positive lateral resection margin as the only non‐curative factor were excluded. Outcome was investigated by univariable (Kaplan–Meier) and multivariable (Cox proportional hazards) analysis.
Results
Some 341 patients underwent non‐curative endoscopic resection for at least one lesion of differentiated‐type early gastric cancer. Sixty‐seven patients with a positive lateral resection margin as the only non‐curative factor were excluded, leaving 274 patients for analysis; 194 had rescue surgery and 80 had no additional treatment. The median duration of follow‐up was 60·5 months. Patients who had rescue surgery were younger, had a lower Charlson co‐morbidity index score, smaller tumours and a higher lymphovascular invasion rate than patients with no treatment. Among 194 patients who had rescue surgery, intragastric local residual tumours were found in ten (5·2 per cent) and lymph node metastases in 11 (5·7 per cent). Patients with lymph node metastasis were significantly older than those without metastasis; no other significant differences were found. Univariable analysis showed that patients aged less than 65 years, those with a Charlson co‐morbidity index score below 4 and patients undergoing rescue surgery had significantly longer overall survival. Five‐year overall survival rates in the rescue surgery and no‐treatment groups were 94·3 and 85 per cent respectively. In multivariable analysis, rescue surgery was identified as the only independent predictor of overall survival after non‐curative endoscopic resection of early gastric cancer.
Conclusion
Rescue surgery confers a survival benefit after non‐curative endoscopic resection of early gastric cancer.
Improves survival in fit patients
Background
With the widespread use of endoscopy, small and low‐grade type 3 gastric neuroendocrine tumours (NETs) are increasingly being detected. The clinicopathological features, biological ...behaviour and appropriate treatment strategy for these NETs remain unclear.
Methods
Patients with biopsy‐proven gastric NET and a normal fasting serum gastrin level were identified from a prospectively maintained database. Clinicopathological features and long‐term outcome of local resection for type 3 NETs were reviewed retrospectively and compared according to tumour grade.
Results
Some 32 patients with type 3 gastric NETs were included (25 patients with NET grade G1, 5 with G2 and 2 with G3). Pathological tumour size was 2·0 cm or less in 30 patients. All tumours were well differentiated, even G3 lesions, and all tumours but one were confined to the submucosal layer. G1 NETs were significantly smaller and had a significantly lower lymphovascular invasion rate than G2 and G3 NETs. Twenty‐two patients with a G1 NET without lymphovascular invasion were treated with wedge or endoscopic resection. After a median follow‐up of 59 (range 6–102) months, no patient with a G1 NET of 1·5 cm or smaller developed recurrence and one patient with a G1 NET larger than 1·5 cm had recurrence in a perigastric lymph node. Among seven patients with a G2 or G3 NET, two had lymph node metastasis and one had liver metastases.
Conclusion
Low‐grade type 3 gastric NET has non‐aggressive features and a favourable prognosis. Wedge or endoscopic resection may be a valid option for patients with type 3 gastric G1 NET no larger than 1·5 cm without lymphovascular invasion.
Limited resection suffices in selected patients
Summary
Background
The risk of spontaneous bacterial peritonitis (SBP) associated with proton pump inhibitor (PPI) use has been raised in cirrhotic patients with ascites. However, this is based on ...case–control studies, often with a small series.
Aim
To determine whether PPI use increases the risk of SBP using a large cohort.
Methods
This retrospective cohort study included 1965 cirrhotic patients with ascites diagnosed between January 2005 and December 2009. The SBP incidence rate was compared between the PPI and non‐PPI groups before and after propensity score matching to reduce the effect of selection bias and potential confounders. Multivariate analysis was conducted to confirm the association of PPI use with SBP.
Results
After excluding 411 patients, 1554 were analysed. Among them, 512 patients (32.9%) were included in the PPI group. The annual SBP incidence rate was higher in the PPI group than in the non‐PPI group (10.6% and 5.8%, P = 0.002) before matching. Indications for PPI use and dose of PPI were similar between patients with and without SBP. In the propensity score matched cohort (402 pairs), the SBP incidence rate was also higher in the PPI group than in the non‐PPI group (10.8% vs. 6.0%, P = 0.038). Multivariate analysis revealed that PPI use (Hazard ratio 1.396; 95% confidence interval, 1.057–1.843; P = 0.019) was the independent risk factor for SBP.
Conclusions
Proton pump inhibitor use significantly increases the risk of spontaneous bacterial peritonitis in cirrhotic patients with ascites. Proton pump inhibitor use should be undertaken with greater caution and appropriately in patients with cirrhosis.
Background
Integrated relaxation pressure (IRP) is a key metric for diagnosing esophagogastric junction outflow obstruction (EGJOO). However, its normal value might be different according to the ...manufacturer of high‐resolution manometry (HRM). This study aimed to investigate optimal value of IRP for diagnosing EGJOO in Sandhill HRM and to find clinicomanometric variables to segregate clinically relevant EGJOO.
Methods
We analyzed 262 consecutive subjects who underwent HRM between June 2011 and December 2016 showing elevated median IRP (> 15 mm Hg) but did not satisfy criteria for achalasia. Clinically relevant subjects were defined as follows: (i) subsequent HRM met achalasia criteria during follow‐up (early achalasia); (ii) Eckardt score was decreased at least two points without exceeding a score of 3 after pneumatic dilatation (variant achalasia); and (iii) significant passage disturbance on esophagogram without structural abnormality (possible achalasia).
Key Results
Seven subjects were clinically relevant, including two subjects with early achalasia, four subjects with variant achalasia, and one subject with possible achalasia. All clinically relevant subjects had IRP 20 mm Hg or above. Among subjects (n = 122) with IRP 20 mm Hg or more, clinically relevant group (n = 7) had significantly higher rate of dysphagia (100% vs 24.3%, P < .001) and compartmentalized pressurization (85.7% vs 21.7%, P = .001) compared to clinically non‐relevant group (n = 115).
Conclusions & Inferences
Our results suggest that IRP of 20 mm Hg or higher could segregate clinically relevant subjects showing EGJOO in Sandhill HRM. Additionally, if subjects have both dysphagia and compartmentalized pressurization, careful follow‐up is essential.
Our results suggest that 20 mm Hg is the optimal cut‐off value of integrated relaxation pressure for diagnosing esophagogastric junction outflow obstruction in the Sandhill system. Dysphagia and compartmentalized pressurization on manometry are crucial clinicomanometric factors that can segregate clinically relevant esophagogastric junction outflow obstruction patients.
Abstract Background To achieve en bloc resection for large lesions, endoscopic mucosal resection after circumferential precutting and endoscopic submucosal dissection techniques have been developed. ...Aim To compare endoscopic submucosal dissection with endoscopic mucosal resection after circumferential precutting in terms of the clinical efficacy and safety. Patients and methods 346 consecutive patients underwent their first endoscopic mucosal resection after circumferential precutting (103 patients) or endoscopic submucosal dissection (243 patients) for early gastric cancer and their clinical outcomes were compared. Results For early gastric cancer ≥20 mm endoscopic submucosal dissection group demonstrated significantly higher en bloc resection and en bloc plus R0 resection rate compared with endoscopic mucosal resection after circumferential precutting group. For early gastric cancer with size of 10–19 mm, endoscopic submucosal dissection group also showed significantly higher en bloc resection rate. For early gastric cancer <20 mm, however, en bloc plus R0 resection rate for endoscopic mucosal resection after circumferential precutting group was comparable to that for endoscopic submucosal dissection group. In case of R0 resection of intramucosal differentiated cancer, neither group showed local recurrence during the median 29 and 17 months of follow-up. Two groups did not show significant difference in the bleeding or perforation rates. Conclusion For early gastric cancer <20 mm endoscopic mucosal resection after circumferential precutting may be considered as an alternative choice to endoscopic submucosal dissection. However, for early gastric cancer ≥20 mm endoscopic submucosal dissection should be considered as the first choice for treating early gastric cancer.
Extremely well-differentiated tubular adenocarcinomas (EWDAs) of the stomach are characterized by surface maturation and their mimicking of intestinal metaplasia. Endoscopically, intramucosal EWDAs ...are frequently ill defined with indistinct borders due to the pallor of the neoplastic mucosa and the lack of contrast against the background atrophic and metaplastic mucosa. We evaluated the effectiveness of endoscopic resection for EWDAs after endoscopic submucosal dissection (ESD). Among 872 patients with early gastric cancer, 17 EWDAs were identified (1.9 %). Endoscopically, the flat or depressed type was significantly more common among EWDAs (88.2 %) than among early gastric cancers of other histologies (37.8 %; P < 0.01). The discrepancy between endoscopically estimated tumor size and tumor size as confirmed in pathology reports was significantly greater among EWDAs (18.4 ± 22.0 mm) than among others (5.8 ± 7.5 mm). Involvement of the lateral resection margin was more common (29.4 % vs. 2.5 %; P < 0.05), and complete resection was achieved less often in EWDAs (47.1 % vs. 80.4 %; P = 0.01) compared to the others. EWDAs are associated with higher rates of incomplete resection after ESD, especially along the lateral margins. Pathologists should alert endoscopists when this diagnosis is made, with its associated risks; and endoscopists should pay particular attention to the extent of these tumors during resection.
Summary
This study aims to assess the influence of esophagectomy with gastric transposition on the gastroesophageal reflux (GER) and gastric acidity in patients with esophageal cancer. Data on 53 ...esophageal cancer patients who underwent 24-hour impedance-pH monitoring after esophagectomy were retrospectively analyzed. We used a solid-state esophageal pH probe in which the esophageal pH sensor is placed 1.5 cm distal to the upper esophageal sphincter and the gastric pH sensor is located 15 cm distal to the esophageal pH channel. 24-hour impedance-pH monitoring data and other clinical data including anastomosis site stricture and incidence of pneumonia were collected. We defined pathologic reflux with reference to known normative data. Stricture was defined when an intervention such as bougienage or balloon dilatation was required to relieve dysphagia. The esophageal and gastric mean pH were 5.47 ± 1.51 and 3.33 ± 1.64, respectively. The percent time of acidic pH (<4) was 6.66 ± 12.49% in the esophagus and 70.53 ± 32.19% in the stomach. Esophageal pathologic acid reflux was noticed in 32.1%, 20.8%, and 35.8% during total, upright, and recumbent time, respectively. Esophageal pathologic bolus reflux was noted in 83.0%, 77.4%, and 64.2% during total, upright, and recumbent time, respectively. Gastric acidity increased with time after esophagectomy. Esophageal acid exposure time correlated with intragastric pH. However, esophageal pathologic acid reflux was not associated with anastomosis site stricture or pneumonia. In conclusion, GER frequently occurs after esophagectomy. Thus, strict lifestyle modifications and acid suppression would be necessary in patients following esophagectomy.
We present 19 cases in which argon plasma coagulation (APC) was used as curative initial treatment for 5 low-grade esophageal squamous intraepithelial neoplasias (ESINs), 12 high-grade ESINs, and 2 ...early esophageal squamous cell carcinomas (ESCCs). Complete response was defined as the absence of tumor from any biopsy taken from the ablated lesion. At follow-up endoscopy 2 - 4 months after APC, 94.7 % of patients had achieved complete response in a single treatment session. Only one patient with high-grade ESIN showed local recurrence. This patient underwent additional APC and showed complete response at 12 months after initial APC. At the 12-month follow-up endoscopy, again 94.7 % had a complete response. The exception was one patient with local recurrence, who underwent additional APC. After the 12-month follow-up endoscopy, no patient showed local recurrence during a median follow-up of 22 months. No stricture requiring endoscopic dilation occurred after the procedure. This study suggests that APC is a feasible and effective treatment modality for ESIN and early ESCC.
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•E. coli O157:H7 exposed to the microgravity was examined by RNA-sequencing.•Transcriptional changes showed the clues for the active growth and biofilm formation.•Host cell contact ...secretion was dysregulated in the microgravity condition.•Microgravity also stimulates the pathogenicity via upregulation of toxin genes.
Escherichia coli O157:H7 EDL933 exposed to low-shear modeled microgravity (LSMMG) and normal gravity (NG) was used for a transcriptomic analysis. The modified Gompertz model (R2 = 0.81–0.99) showed an increased growth rate of E. coli O157:H7 under LSMMG. The mechanism of this active growth was associated with highly upregulated genes in nutrient and energy metabolism, including the TCA cycle, glycolysis, and pyruvate metabolism. Green fluorescent protein-labeled E. coli O157:H7 also formed significantly thick biofilms (fluorescent unit: NG, 1,263; LSMMG, 1,533; P = 0.0473) under LSMMG, whereas bacterial mobility decreased slightly (P = 0.0310). The transcriptomic analysis revealed that genes encoding glycogen biosynthesis (glgCAP operon) were upregulated (1.40 to 1.82 of log fold change FC) due to the downregulation of csrA (2.17 of log FC), which is the global regulator of biofilm formation of E. coli. We also identified 52 genes in E. coli O157:H7 EDL933 that were involved in the secretion pathway, 32 of which showed ≥2-fold significant changes in transcription levels after cultivation under LSMMG. Notably, all downregulated genes belonged to the type III and VI secretion systems, indicating that host cell contact secretion was dysregulated in the LSMMG cultures compared to the NG cultures. LSMMG also stimulates the pathogenicity of E. coli O157:H7 via transcriptional upregulation of Shiga toxin 1 (1.36 to 2.81 log FC) and toxin HokB (6.1 log FC). Our results suggest LSMMG affects bacterial growth, biofilm formation, and E. coli O157:H7 pathogenicity at some transcriptional levels, which indicates the importance of understanding biological consequences.
Diabetes Technology Society assembled a panel of clinician experts in diabetology, cardiology, clinical chemistry, nephrology, and primary care to review the current evidence on biomarker screening ...of people with diabetes (PWD) for heart failure (HF), who are, by definition, at risk for HF (Stage A HF). This consensus report reviews features of HF in PWD from the perspectives of 1) epidemiology, 2) classification of stages, 3) pathophysiology, 4) biomarkers for diagnosing, 5) biomarker assays, 6) diagnostic accuracy of biomarkers, 7) benefits of biomarker screening, 8) consensus recommendations for biomarker screening, 9) stratification of Stage B HF, 10) echocardiographic screening, 11) management of Stage A and Stage B HF, and 12) future directions. The Diabetes Technology Society panel recommends 1) biomarker screening with one of two circulating natriuretic peptides (B-type natriuretic peptide or N-terminal prohormone of B-type natriuretic peptide), 2) beginning screening five years following diagnosis of type 1 diabetes (T1D) and at the diagnosis of type 2 diabetes (T2D), 3) beginning routine screening no earlier than at age 30 years for T1D (irrespective of age of diagnosis) and at any age for T2D, 4) screening annually, and 5) testing any time of day. The panel also recommends that an abnormal biomarker test defines asymptomatic preclinical HF (Stage B HF). This diagnosis requires follow-up using transthoracic echocardiography for classification into one of four subcategories of Stage B HF, corresponding to risk of progression to symptomatic clinical HF (Stage C HF). These recommendations will allow identification and management of Stage A and Stage B HF in PWD to prevent progression to Stage C HF or advanced HF (Stage D HF).
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