Digestive Endoscopy最新文献

Endoscopic resection is the treatment of choice for gastric foveolar-type adenomas with a raspberry-like appearance (GFA-R) that are small lesions with a low-grade malignancy potential.^{1, 2} However, an endoscopic treatment strategy for GFA-Rs has not been established, and resection methods vary among endoscopists.^{1, 3, 4} Cold forceps polypectomy (CFP) is a suitable method for resecting small lesions and carries a lower risk compared to endoscopic mucosal resection/endoscopic submucosal dissection (EMR/ESD); however, the en bloc resection rate falls drastically for larger lesions and reaches rates as low as 70% for lesions sized 5 mm.⁵ Therefore, a low-risk en bloc resection method is desirable. Here, we describe a “grasp-and-lift technique” as a novel method for GFA-R en bloc resection using CFP. A 34-year-old man underwent endoscopic resection of a 6 mm GFA-R located at the greater curvature of the middle third of the stomach (Fig. 1a). Using large forceps (Radial Jaw 4 Jumbo, Boston Scientific), we grasped the base of the lesion along with the background mucosa while suctioning air (Fig. 1b,c). The lesion was removed carefully by lifting it toward the contralateral wall (Fig. 1d) and retrieving it along with the endoscope without pulling the lesion through the forceps channel to avoid damage (Fig. 1e). Evaluation of the mucosal defect revealed no residual tumor (Fig. 1f), and the pathological examination confirmed curative resection (Fig. 2). Here, we present the grasp-and-lift technique, a novel method in which a 6 mm GFA-R was successfully resected using CFP. This method can potentially remove lesions with a base smaller than the length of the forceps. Compared to traditional CFP techniques, this technique may offer higher en bloc resection rates. Furthermore, it is less time-consuming, more economical, and has a lower risk than EMR/ESD (Video S1).

Authors declare no conflict of interest for this article.

Approval of the research protocol by an Institutional Reviewer Board: This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Juntendo University School of Medicine (approval number: H19-0050).

Informed Consent: All patients had given their informed consent before treatment for this study.

Registry and the Registration No. of the study/trial: N/A.

Animal Studies: N/A.

Sedation during gastrointestinal (GI) endoscopy plays a crucial role in ensuring both patient comfort and procedural success.¹ The quality of sedation can also affect compliance with surveillance endoscopy, such as colonoscopy for colorectal cancer surveillance and endoscopic ultrasonography (EUS) for high-risk individuals for pancreatic cancer. However, sedation is potentially associated with adverse events, such as hypoxia and hypotension. Since periprocedural monitoring is essential and requires additional costs and resources, the onset time and recovery time of sedatives are also important considerations. Midazolam, one of the most commonly used benzodiazepines, has a relatively long recovery time. Flumazenil, a benzodiazepine antagonist, is often used to shorten the length of stay in the recovery room.

In this issue of Digestive Endoscopy, Ikehara et al.² demonstrated a high sedation success rate of 93.5% with an acceptable safety profile for remimazolam, a new ultra-short-acting benzodiazepine, when used in combination with analgesics for GI endoscopy. The prospective enrollment of 62 cases is a strength of the study, but its limitation lies in the absence of a control group. The study confirmed a short sedation onset of 4.0 min and a recovery time of 2.0 min for remimazolam, which would be beneficial for outpatient endoscopic procedures. Of note, remimazolam worked well in various GI endoscopic procedures, including upper endoscopy, colonoscopy, EUS, endoscopic retrograde cholangiopancreatography, and enteroscopy. However, the number of each type of procedure was small, necessitating further investigation.

Propofol is also one of the most commonly used sedatives for GI endoscopy, with a rapid onset and recovery time. Despite its favorable safety profile under appropriate monitoring, propofol carries potential risks of hypoxia and hypotension. A randomized controlled trial comparing propofol and remimazolam during upper GI endoscopy³ demonstrated that both the rate of hypoxia and the frequency of additional sedative injections were higher in the propofol group. In a recent meta-analysis,⁴ although remimazolam had a slightly lower sedation success rate (risk ratio [RR] 0.991), it was associated with lower rates of hypoxia (RR 0.41) and hypotension (RR 0.43) compared with propofol. Ikehara et al.² reported the rate of hypoxia was 12.9%, but all hypoxia recovered by a temporary increase in oxygen. Furthermore, hypotension was observed only in 1.6%. Those results were in line with previous reports⁴ suggesting the safety of remimazolam. Given the priority of safety in sedation for GI endoscopy, remimazolam offers a certain advantage over propofol. Additionally, nonanesthesiologist-administered propofol sedation requires specialized training, as well as dedicated person

Five-year survival rates for pancreatic cancer and biliary tract cancer are the first and second poorest, respectively, among all cancers in Japan. In clinical practice, computed tomography (CT) and other imaging modalities play a major role in determining treatment options, including surgery. Patients with pancreatic cancer are divided into three groups (i.e., resectable, borderline resectable, and unresectable). The degree of tumor invasion into the great vessels determines resectability. Therefore, diagnosis of perivascular soft-tissue cuffing (PSTC) is important when deciding whether a tumor is resectable.¹

Some pancreatobiliary cancers appear as PSTC on CT and magnetic resonance imaging (MRI). PSTC is thought to be caused by the complexity of lymphatic drainage,² a process called extravascular migratory metastasis (EVMM); however, differential diagnoses of PSTC include benign diseases such as retroperitoneal fibrosis and chronic pancreatitis. Diagnosis of EVMM among PSTCs on CT and MRI is difficult due to nonspecific, often diminutive, overlapping imaging features indicative of inflammation, as well as changes induced by therapy.

Endoscopic ultrasound (EUS) is superior to other modalities for detection of small lesions due to its superior spatial resolution.³ Moreover, preoperative EUS is better than CT for diagnosing vascular invasion by pancreatic cancer. In fact, a meta-analysis of nine studies comparing EUS with CT for assessment of vascular invasion by pancreatic cancer revealed that the diagnostic abilities of EUS and CT were a sensitivity of 69% and 48%, respectively, with an area under the curve (AUC) of 0.94 and 0.86, respectively.⁴ In addition, EUS-guided tissue acquisition (EUS-TA) enables a pathological diagnosis based on samples taken from lesions; this is especially important in cases where the differential diagnosis of PSTC is difficult, or when PSTC is detected by EUS alone. Moreover, accurate diagnosis based on EUS-TA is important for determining treatment strategies and avoiding unnecessary surgery. However, it should be noted that the accuracy of EUS-TA depends on the skill level of the endoscopist (i.e., expert vs. nonexpert).

Maehara et al. reported the sensitivity, specificity, and accuracy of EUS-TA for PSTC as 92.1%, 100%, and 92.5%, respectively, with a technical success rate of 98.1%.⁵ There are only two previous reports of EUS-TA for PSTC.^{6, 7} One of these found that the diagnostic yield of PSTC by EUS-guided fine-needle aspiration was 65%.⁷ Another recent report found that EUS-TA for PSTC had a sensitivity, specificity, and diagnostic accuracy of 81.1%, 100%, and 85.8%, respectively.⁶ Compared with previous reports,^{6, 7} the data presented in that report⁵