During the coronavirus disease 2019 pandemic, whether endoscopy generates aerosols needs to be determined.
In patients undergoing upper gastrointestinal endoscopy with an enclosure covering their ...heads, 0.3-10-μm aerosols were measured for 60 seconds before, during, and after endoscopy by an optical counter. Whether aerosols increased in the situation with and without endoscopy was examined.
The analysis included 103 consecutive patients undergoing endoscopy and 90 control patients. Aerosols increased significantly during endoscopy compared with the control group. Body mass index and burping were significant factors related to increased aerosols during endoscopy.
Upper gastrointestinal endoscopy was an aerosol-generating procedure.
Background and aims
The withdrawal of antithrombotic therapy from patients at high risk of thromboembolism is controversial. Previously, treatment with anticoagulants, such as warfarin and ...dabigatran, was recommended for heparin bridge therapy (HBT) during endoscopic submucosal dissection (ESD). However, HBT is associated with a high risk of bleeding during and after ESD. This study aimed to investigate the clinical outcomes of colorectal ESD in patients treated with warfarin and direct oral anticoagulants (DOAC).
Methods
This study included 412 patients with superficial colorectal neoplasms that were resected by ESD between June 2010 and June 2018. The patients were classified into two groups: without antithrombotics (
n
= 286) and with anticoagulants (
n
= 51). The anticoagulants group was further divided into two groups: warfarin (
n
= 26) and DOAC (
n
= 25).
Results
Among all patients, delayed bleeding occurred in 35 (8.5% 35/412) patients. The bleeding rate in the anticoagulants group (11.8% 6/51) was higher than that in the group without antithrombotics (6.6% 19/286), but the difference was not statistically significant (
P
= 0.240). The bleeding rate in the DOAC group (16.0% 4/25) was higher than that in the warfarin group (7.7% 2/26), but the difference was not statistically significant (
P
= 0.419). All delayed bleeding was successfully managed with endoscopic hemostasis. Thromboembolic events were not observed in any patients.
Conclusions
The bleeding rate with anticoagulants was relatively high. However, all bleeding events with anticoagulants were minor and clinically controllable. Colorectal ESD with DOAC and warfarin may be feasible and acceptable.
Background and Aim
Endoscopic ultrasound‐guided biliary drainage (EUS‐BD) can be carried out by two different approaches: choledochoduodenostomy (CDS) and hepaticogastrostomy (HGS). We compared the ...efficacy and safety of these approaches in malignant distal biliary obstruction (MDBO) patients using a prospective, randomized clinical trial.
Methods
Patients with malignant distal biliary obstruction after failed endoscopic retrograde cholangiopancreatography were randomly selected for either CDS or HGS. The procedures were carried out at nine tertiary centers from September 2013 to March 2016. Primary endpoint was technical success rate, and the noninferiority of HGS to CDS was examined with a one‐sided significance level of 5%, where the noninferiority margin was set at 15%. Secondary endpoints were clinical success, adverse events (AE), stent patency, survival time, and overall technical success including alternative EUS‐BD procedures.
Results
Forty‐seven patients (HGS, 24; CDS, 23) were enrolled. Technical success rates were 87.5% and 82.6% in the HGS and CDS groups, respectively, where the lower limit of the 90% confidence interval of the risk difference was −12.2% (P = 0.0278). Clinical success rates were 100% and 94.7% in the HGS and CDS groups, respectively (P = 0.475). Overall AE rate, stent patency, and survival time did not differ between the groups. Overall technical success rates were 100% and 95.7% in the HGS and CDS groups, respectively (P = 0.983).
Conclusions
This study suggests that HGS is not inferior to CDS in terms of technical success. When one procedure is particularly challenging, readily switching to the other could increase technical success.
Colorectal endoscopic submucosal dissection (ESD) is a time-consuming procedure because of the technical difficulty. The newly developed saline-pocket ESD (SP-ESD) provides a clearer view and better ...traction of the submucosal layer compared with the standard ESD with gas insufflation (S-ESD). This study aimed to prospectively compare the efficacy and safety between S-ESD and SP-ESD in patients with superficial colorectal neoplasms (SCNs).
From April 2017 to November 2018, 95 patients with SCNs ≥20 mm in diameter were prospectively and randomly enrolled. Four patients were excluded because of an incomplete ESD procedure. Patients were finally allocated to 2 groups, S-ESD with 45 patients and SP-ESD with 46 patients. The primary outcome was dissection speed. Secondary outcomes were ESD procedure time, en bloc and complete resection rates, perforation rate, and adverse effects.
Median dissection speed was significantly faster in the SP-ESD than the S-ESD group (20.1 mm2/min range, 17.3-28.1 vs 16.3 mm2/min range, 11.4-19.8; P < .001). Median procedure time was significantly shorter in the SP-ESD than the S-ESD group (29.5 minutes range, 22.3-44 vs 41 minutes range, 31-55; P < .001). The en bloc and complete resection rates were 100% in both groups. No perforations occurred among patients. The volume of saline solution used in the SP-ESD group was significantly greater than that in the S-ESD group (200 mL range, 120-250 vs 150 mL range, 100-200; P = .016).
SP-ESD improved dissection speed and procedure time compared with S-ESD. SP-ESD may be an alternative method for resection of SCNs. (Clinical trial registration number: UMIN 000026317.)
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We herein report an extremely rare case of adenocarcinoma of the minor duodenal papilla (MiDP) which was successfully treated by endoscopic mucosal resection (EMR). An asymptomatic 84-year-old man ...underwent upper gastrointestinal endoscopy, which revealed a slightly elevated lesion at the MiDP. The biopsy findings were suggestive of adenocarcinoma. Computed tomography, magnetic resonance images and endoscopic ultrasonography did not reveal pancreatic tumor infiltration nor any apparent distant metastases. Therefore, we treated the lesion using EMR with complete resection. No recurrence or metastasis has been detected at 13 months after EMR. Total resection of the MiDP can thus serve as a relatively safe and simple treatment.
During endoscopic submucosal dissection (ESD), a clear view is essential for precise dissection of the appropriate submucosal layer. Some advantages have been reported for underwater techniques of ...endoscopic resection in comparison with the gas insufflation method. We have developed a new ESD method with the creation of a local water pocket (WP) that provides a clear view in the dissection field. Therefore, we aimed to investigate the feasibility and safety of WP-ESD for superficial gastric neoplasms.
We prospectively recruited 50 patients with gastric neoplasms (early gastric cancer or gastric adenomas) between April 2017 and December 2017. Among them, 48 patients were treated with the WP-ESD technique. The patients undergoing WP-ESD were compared with 48 patients treated with standard ESD (S-ESD) who were selected by propensity score matching. The primary outcome was the ESD procedure time.
Total procedure time was significantly shorter in the WP-ESD group than in the S-ESD group (median interquartile range, 27.5 19-45 minutes vs 41 29.8-69 minutes; P < .001). Similarly, the dissection speed was significantly greater in the WP-ESD group than in the S-ESD group (median interquartile range, 22.5 16.8-35.3 mm2/min vs 17.3 12.7-22.1 mm2/min; P < .001). The rates of complete en bloc resection in the WP-ESD group and the S-ESD group were 97.9% and 95.8%, respectively (P > .99). There were no perforations in either group.
WP-ESD was associated with a shorter procedure time than S-ESD. WP-ESD may provide an alternative method for resection of superficial gastric neoplasms. (Clinical trial registration number: UMIN 000030266.)
Pancreatic neuroendocrine tumors(p NETs) are particularly rare. The various forms of PNETs, such as cystic degeneration, make differentiation from other similar pancreatic lesions difficult. We can ...detect small lesions by endoscopic ultrasound(EUS) and obtain preoperative pathological diagnosis by EUS-guided fine needle aspiration(FNA). We describe, here, an interesting case of p NET in a 42-year-old woman with no family history. Computed tomography and magnetic resonance imaging revealed an 18 mm × 17 mm cystic lesion with a nodule in the pancreatic tail. Two microtumors about 7 mm in diameter in the pancreatic body detected only by EUS, cystic rim and nodules all showed similar enhancement on contrast-harmonic EUS. Preoperative EUS-FNA of the microtumor was performed, diagnosing multiple p NETs. Macroscopic examination of the resected pancreatic body and tail showed that the cystic lesion had morphologically changed to a 13-mm main nodule, and 11 new microtumors(diameter 1-3 mm). Microscopically, all microtumors represented p NETs. From the findings of a broken peripheral rim on the main lesion with fibrosis, rupture of the cystic p NET was suspected. Postoperatively, pituitary adenoma and parathyroid adenoma were detected. The final diagnosis was multiple grade 1 p NETs with multiple endocrine neoplasia type 1. To the best of our knowledge, no case of spontaneous rupture of a cystic p NET has previously been reported in the English literature. Therefore, this case of very rare p NET with various morphological changes is reported.
Pancreatic ductal adenocarcinoma (PDAC) arises from precursor lesions, such as pancreatic intra-epithelial neoplasia (PanIN) and intraductal papillary mucinous neoplasm (IPMN). The prognosis of ...high-grade precancerous lesions, including high-grade PanIN and high-grade IPMN, without invasive carcinoma is good, despite the overall poor prognosis of PDAC. High-grade PanIN, as a lesion preceding invasive PDAC, is therefore a primary target for intervention. However, detection of localized high-grade PanIN is difficult when using standard radiological approaches. Therefore, most studies of high-grade PanIN have been conducted using specimens that harbor invasive PDAC. Recently, imaging characteristics of high-grade PanIN have been revealed. Obstruction of the pancreatic duct due to high-grade PanIN may induce a loss of acinar cells replaced by fibrosis and lobular parenchymal atrophy. These changes and additional inflammation around the branch pancreatic ducts (BPDs) result in main pancreatic duct (MPD) stenosis, dilation, retention cysts (BPD dilation), focal pancreatic parenchymal atrophy, and/or hypoechoic changes around the MPD. These indirect imaging findings have become important clues for localized, high-grade PanIN detection. To obtain pre-operative histopathological confirmation of suspected cases, serial pancreatic-juice aspiration cytologic examination is effective. In this review, we outline current knowledge on imaging characteristics of high-grade PanIN.
High-grade pancreatic intraepithelial neoplasia and invasive pancreatic ductal adenocarcinoma ≤10 mm are targets for early detection of pancreatic cancer. However, their imaging characteristics are ...unknown. We aimed to identify endoscopic ultrasound findings for the detection of these lesions.
Patients diagnosed with high-grade pancreatic intraepithelial neoplasia (n=29), pancreatic ductal adenocarcinoma ≤10 mm (n=11) (who underwent surgical resection), or benign main pancreatic duct stenosis (n=20) between January 2014 and January 2021 were retrospectively included. Six features differentiating these lesions were examined by endoscopic ultrasonography: main pancreatic duct stenosis, upstream main pancreatic duct dilation, hypoechoic areas surrounding the main pancreatic duct irregularities (mottled areas without demarcation or round areas with demarcation), branch duct dilation, prominent lobular segmentation, and atrophy. Interobserver agreement was assessed by two independent observers.
Hypoechoic areas surrounding the main pancreatic duct irregularities were observed more frequently in high-grade pancreatic intraepithelial neoplasia (82.8%) and pancreatic ductal adenocarcinoma ≤10 mm (90.9%) than in benign stenosis (15.0%) (p<0.001). High-grade pancreatic intraepithelial neoplasia exhibited mottled hypoechoic areas more frequently (79.3% vs 18.9%, p<0.001), and round hypoechoic areas less frequently (3.4% vs 72.7%, p<0.001), than pancreatic ductal adenocarcinoma ≤10 mm. The sensitivity and specificity of hypoechoic areas for differentiating high-grade pancreatic intraepithelial neoplasia, pancreatic ductal adenocarcinoma ≤10 mm, and benign stenosis were both 85.0%, with moderate interobserver agreement.
The hypoechoic areas surrounding main pancreatic duct irregularities on endoscopic ultrasound may differentiate between high-grade pancreatic intraepithelial neoplasia, pancreatic ductal adenocarcinoma ≤10 mm, and benign stenosis (Trial Registration: UMIN Clinical Trials Registry (UMIN000044789).
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