Endoscopic submucosal dissection (ESD) is the standard treatment method for esophageal, gastric, and colorectal cancers. However, it has not been standardized for duodenal lesions because of its high complication rates. Recently, minimally invasive and simple methods such as cold snare polypectomy and underwater endoscopic mucosal resection have been utilized more for superficial nonampullary duodenal epithelial tumors (SNADETs). Although the rate of complications associated with duodenal ESD has been gradually decreasing because of technical advancements, performing ESD for all SNADETs is unnecessary. As such, the appropriate treatment plan for SNADETs should be chosen according to the lesion type, patient condition, and endoscopist’s skill.

Prediction of histology by endoscopic examination is important in the clinical management of non-ampullary duodenal epithelial tumors (NADETs), including adenoma and adenocarcinoma. The use of a simple scoring system based on the findings of white-light endoscopy or magnified endoscopy with narrow-band imaging is useful to differentiate between Vienna category 3 (C3) and C4/5 lesions. Less invasive endoscopic resection procedures, such as cold snare polypectomy, are quick to perform and convenient for small (<10 mm) C3 lesions. Neoplasms with higher grade histology, such as C4/5 lesions, should be treated by endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or surgery. Although EMR often requires piecemeal resection, the complication rate is acceptable. Excellent complete resection rates could be achieved by ESD; however, it remains a challenging method considering the high risk of complications. Shielding or closure of the ulcer after ESD is effective at decreasing the risk of delayed bleeding and perforation. Laparoscopic endoscopic cooperative surgery is an ideal treatment with a high rate of en bloc resection and a low rate of complications, although it is limited to high-volume centers. Patients with NADETs could benefit from a multidisciplinary approach to stratify the optimal treatment based on endoscopic diagnoses.

BACKGROUND/AIMS: To compare the diagnostic yield of 20-gauge forward-bevel core biopsy needle (CBN) and 22-gauge needle for endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of solid pancreatic masses. METHODS: The use of 20-gauge CBN was prospectively evaluated for 50 patients who underwent EUS-FNA from June 2016 to December 2016. Data were compared with those obtained by a retrospective study of 50 consecutive patients who underwent EUS-FNA using standard 22-gauge needles between December 2016 and April 2017. At least two punctures were performed for each patient; the sample from the first pass was used for cytology with or without histology and that from the second pass was used for histology. Sample quantity was evaluated using the sample obtained from the second pass. RESULTS: There was no significant difference in the diagnostic accuracy rate between the first and second passes (20-gauge CBN: 96% [48/50]; standard 22-gauge needle: 88% [44/50]). Samples >10× power fields in length were obtained from 90% (43/48) and 60% (30/50) of patients using the 20-gauge CBN and standard 22-gauge needle, respectively (p=0.01). Technical failure occurred for two patients with the 20-gauge CBN. CONCLUSIONS: Diagnostic accuracy of the 20-gauge CBN was comparable to that of the 22-gauge needle. However, two passes with the 20-gauge CBN yielded a correct diagnosis for 100% of patients when technically feasible. Moreover, the 20-gauge CBN yielded core tissue for 90% patients, which was a performance superior to that of the 22-gauge needle.
Biopsy ; Biopsy, Fine-Needle ; Diagnosis ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Humans ; Needles ; Pancreas ; Prospective Studies ; Punctures ; Retrospective Studies ; Ultrasonography

Early detection and treatment decrease the mortality rate associated with gastric cancer (GC). However, the natural history of GC remains unclear. An 85-year-old woman was referred to our hospital for evaluation of a gastric tumor. Esophagogastroduodenoscopy identified a 6 mm, flat-elevated lesion at the lesser curvature of the antrum. A biopsy specimen showed a well-differentiated tubular adenocarcinoma. The depth of the lesion was estimated to be intramucosal. Although the lesion met the indications for endoscopic resection, periodic endoscopic follow-up was performed due to the patient's advanced age and comorbidities. The mucosal GC invaded into the submucosa 3 years later, and finally progressed to advanced cancer 5 years after the initial examination. The patient died of tumor hemorrhage 6.4 years after the initial examination. In this case, mucosal GC progressed to advanced GC, eventually leading to the patient's death from GC. Early and appropriate treatment is required to prevent GC-related death.
Adenocarcinoma ; Aged, 80 and over ; Biopsy ; Comorbidity ; Endoscopy, Digestive System ; Female ; Follow-Up Studies ; Hemorrhage ; Humans ; Mortality ; Natural History* ; Stomach Neoplasms*

BACKGROUND/AIMS: Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) has been used to diagnose gastrointestinal submucosal tumors (SMTs). Although rapid on-site evaluation (ROSE) has been reported to improve the diagnostic accuracy of EUS-FNA for pancreatic lesions, on-site cytopathologists are not routinely available. Given this background, the usefulness of ROSE by endosonographers themselves for pancreatic tumors has also been reported. However, ROSE by endosonographers for diagnosis of SMT has not been reported. The aim of this study was to evaluate the diagnostic accuracy of EUS-FNA with ROSE by endosonographers for SMT, focusing on diagnosis of gastrointestinal stromal tumor (GIST), compared with that of EUS-FNA alone. METHODS: Twenty-two consecutive patients who underwent EUS-FNA with ROSE by endosonographers for SMT followed by surgical resection were identified. Ten historical control subjects who underwent EUS-FNA without ROSE were used for comparison. RESULTS: The overall diagnostic accuracy for SMT was significantly higher in cases with than without ROSE (100% vs. 80%, p=0.03). The number of needle passes by FNA with ROSE by endosonographers tended to be fewer, although accuracy was increased (3.3±1.3 vs. 5.9±3.8, p=0.06). CONCLUSIONS: ROSE by endosonographers during EUS-FNA for SMT is useful for definitive diagnosis, particularly for GIST.
Biopsy, Fine-Needle* ; Diagnosis* ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Gastrointestinal Stromal Tumors* ; Humans ; Needles

BACKGROUND/AIMS: Transpapillary forceps biopsy is an effective diagnostic technique in patients with biliary stricture. This prospective study aimed to determine the usefulness of the wire-grasping method as a new technique for forceps biopsy. METHODS: Consecutive patients with biliary stricture or irregularities of the bile duct wall were randomly allocated to either the direct or wire-grasping method group. In the wire-grasping method, forceps in the duodenum grasps a guide-wire placed into the bile duct beforehand, and then, the forceps are pushed through the papilla without endoscopic sphincterotomy. In the direct method, forceps are directly pushed into the bile duct alongside a guide-wire. The primary endpoint was the success rate of obtaining specimens suitable for adequate pathological examination. RESULTS: In total, 32 patients were enrolled, and 28 (14 in each group) were eligible for analysis. The success rate was significantly higher using the wire-grasping method than the direct method (100% vs 50%, p=0.016). Sensitivity and accuracy for the diagnosis of cancer were comparable in patients with the successful procurement of biopsy specimens between the two methods (91% vs 83% and 93% vs 86%, respectively). CONCLUSIONS: The wire-grasping method is useful for diagnosing patients with biliary stricture or irregularities of the bile duct wall.
Bile Ducts ; Biliary Tract ; Biopsy* ; Constriction, Pathologic* ; Diagnosis ; Duodenum ; Hand Strength ; Humans ; Methods* ; Prospective Studies* ; Sphincterotomy, Endoscopic ; Surgical Instruments*

We performed waiting time prediction using the data collected from prescription pick-up. A regression equation was used to predict waiting time. An explanatory variable was adopted as “a number of retention prescriptions at the time of acceptance”, “the variety of drug to dispense”and “the presence or absence of a particular task of time-consuming work in computing multiple medications into one package”. Using waiting time as an objective variable, three regression equations were formulated. Method ①: A single regression equation using the number of retention prescriptions with only one explanatory variable. Method ②: Multiple regression equation using factors such as number of prescriptions and variety of drugs to be dispensed as explanatory variables. Method ③: Multiple regression equation using number of prescriptions, variety of drugs and the presence or absence of particular tasks involved in the preparation of the prescription. Compared to the prediction of Method ①, the prediction of Method ② resulted in better accuracy. Compared to Method ①, Method ② resulted in better accuracy, and Method ③ resulted in even better accuracy than Method ②, as predicted.

PURPOSE: In cardiac 2-[F-18]fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) examination, interpretation of myocardial viability in the low uptake region (LUR) has been difficult without additional perfusion imaging. We evaluated distribution patterns of FDG at the border zone of the LUR in the cardiac FDG-PET and established a novel parameter for diagnosing myocardial viability and for discriminating the LUR of normal variants. MATERIALS AND METHODS: Cardiac FDG-PET was performed in patients with a myocardial ischemic event (n = 22) and in healthy volunteers (n = 22). Whether the myocardium was not a viable myocardium (not-VM) or an ischemic but viable myocardium (isch-VM) was defined by an echocardiogram under a low dose of dobutamine infusion as the gold standard. FDG images were displayed as gray scaled-bull's eye mappings. FDG-plot profiles for LUR (= true ischemic region in the patients or normal variant region in healthy subjects) were calculated. Maximal values of FDG change at the LUR border zone (a steepness index; S(max) scale/pixel) were compared among not-VM, isch-VM, and normal myocardium. RESULTS: S(max) was significantly higher for n-VM compared to those with isch-VM or normal myocardium (ANOVA). A cut-off value of 0.30 in Smax demonstrated 100% sensitivity and 83% specificity for diagnosing n-VM and isch-VM. S(max) less than 0.23 discriminated LUR in normal myocardium from the LUR in patients with both n-VM and isch-VM with a 94% sensitivity and a 93% specificity. CONCLUSION: S(max) of the LUR in cardiac FDG-PET is a simple and useful parameter to diagnose n-VM and isch-VM, as well as to discriminate thr LUR of normal variants.
Aged ; Aged, 80 and over ; Echocardiography ; Female ; Fluorodeoxyglucose F18/*metabolism ; Humans ; Male ; Middle Aged ; Myocardial Infarction/metabolism/pathology ; Myocardium/*metabolism/*pathology ; Positron-Emission Tomography ; Young Adult

OBJECTIVESThe aim of this study was to investigate the determinants of serum total homocysteine level (tHcy) in patients with type 2 diabetes mellitus (DM) according to sex.

METHODSA total of 1,276 Japanese, diabetics (n = 280) with a control group of non-diabetics (n = 996), were enrolled into the study from 2003 to 2005. This cross-sectional study was conducted for all the subjects, using personal data regarding clinical characteristics and lifestyle. Multiple regression analysis was performed to analyze the association of tHcy with selected factors.

RESULTSIn diabetic subjects, estimated glomerular filtration rate (eGFR) and serum creatinine levels (Cre), even those within the normal range, were strongly associated with tHcy after adjustment in both sexes; the standardized partial regression coefficient of eGFR for tHcy was -0.251, (p = 0.001) in diabetic men and -0.523, (p < 0.001) in diabetic women. Furthermore, the eGFR of the diabetics, except patients with nephropathy, also had significant association with tHcy in both sexes. Fasting plasma glucose levels and serum triglyceride levels were strongly associated with tHcy in diabetic men only. HbA1c was also associated with tHcy in diabetic men only, though not as significantly. Age and presence of hypertension were significantly associated with tHcy in women.

CONCLUSIONSThis study suggests that there are some differences in the factors associated with tHcy between diabetics and non-diabetics, and between the sexes. There is, therefore, circumstantial evidence that elevated tHcy should be evaluated clinically. Because tHcy was strongly associated with eGFR and Cre, even within the normal ranges, tHcy may have important implications regarding the microangiopathy of the kidney and atherosclerosis.

OBJECTIVETo investigate the personal features associated with dropout from regular outpatient care among persons with type 2 diabetes mellitus (DM).

METHODSA total of 160 DM patients were enrolled in the study. As a retrospective analysis, outpatient's clinical characteristics, lifestyle, or social features were gathered from their medical records or interview sheets. All the subjects were divided into two groups by adherence to diabetic care, namely, 'dropout case' (DC), or 'ongoing case' (OC), and were subjected to comparative analysis. We called the patients who did not receive outpatient treatment from the clinic on a regular basis, including treatment from other clinics or dropout of diabetic care, as DC. In contrast, patients who regularly visited the clinic were defined as OC. An unconditional multiple logistic regression analysis was performed to analyze the association of a dherence to diabetic care with several personal features.

RESULTSSixty-eight of 160 subjects (42.5%) were recognized as DC. The remaining 92 subjects (57.5%) were considered as OC. Young age (p=0.045), low plasma glucose (p=0.005) and hemoglobin A1c (HbA1c) levels (p=0.005), nonmedication (p<0.001) and no past history of DM (p=0.007) at the initial visit were the features related to dropout by crude analysis. Even after adjustment for age and gender by multivariate analysis, there remained significant inverse associations of dropout with HbA1c level, medical treatment (oral agents or insulin) and previous DM history. Neither occupation, distance from residence to clinic, smoking habit nor drinking habit was associated with dropout. Dropout mostly occurred after the initial or second visit.

CONCLUSIONSA mild condition of DM may be related to dropout from regular outpatient care. It may be necessary to clearly show the objectives and importance of regular visit to an outpatient clinic for diabetic care, particularly for screened mild DM cases in public health activities.