No abstract

Background: Endoscopic submucosal dissection (ESD) is becoming widely popular as a less invasive treatment option for superficial esophageal squamous cell carcinoma.However, data on long-term survival after esophageal ESD in patients with severe comorbidities are limited. This study aimed to evaluate long-term survival after ESD in such patients.Methods: Altogether, 584 consecutive patients underwent esophageal ESD at our institution from May 2004 to September 2016. Based on the American Society of Anesthesiologists Physical Status (ASA-PS) classification system, patients were grouped according to severe (ASA-PS ≥3) or non-severe comorbidities (ASA-PS 1/2). The overall survival (OS), disease-specific survival (DSS), and risk factors for mortality were compared between the groups using a propensity score matching analysis.Results: In a matched cohort of 69 pairs, the 5-year OS rate was poorer in ASA-PS 3 patients than in ASA-PS 1/2 patients (63.9% vs. 92.5%, P < 0.01), while the 5-year DSS rate was similar between the groups (100% vs. 100%). The mortality rate was significantly higher in ASA-PS 3 patients than in ASA-PS 1/2 patients (hazard ratio, 3.47; 95% confidence interval 1.79-6.74; P < 0.01). Death due to exacerbation of comorbidities was significantly more frequent in ASA-PS 3 patients than in ASA-PS 1/2 patients (42.4% vs. 8.3%, P < 0.04).Conclusions: Because of the exacerbation of comorbidities, patients with severe comorbidities had poorer long-term outcomes after esophageal ESD than those with nonsevere comorbidities. Further studies will be necessary to evaluate esophageal ESD in patients with severe comorbidities.

A 63-year-old man with a history of surgery for thoracic aortic dissection was transferred to our hospital with obscure gastrointestinal bleeding (OGIB) and bloody stools. Laboratory examination revealed the following results: hemoglobin, 9.9 g/dL; platelets, 94 000/µL; creatinine, 1.29 mg/dL. Video capsule endoscopy following anterograde and retrograde double-balloon enteroscopy (DBE) could not identify the bleeding source. Fresh bloody stools recurred 4 days after the resumption of feeding and the patient required transfusion. Emergency colonoscopy revealed an intramural hematoma in the sigmoid colon, with rupture and bleeding into the surrounding mucosa (• " Fig. 1). Contrast-enhanced computed tomography (CT) revealed a dissection of the abdominal aorta (• " Fig. 2). Laboratory data indicated disseminated intravascular coagulation (DIC): platelets, 96 000/µL; prothrombin time, 13.5 seconds; fibrinogen, 69 mg/dL; fibrin/fibrinogen degradation products, 105 µg/dL; D-dimer, 99 µg/dL; plasmin-α 2 -plasmin inhibitor complex, 11.4 µg/mL; thrombin-antithrombin III complex, 49.5 ng/mL. We diagnosed an intramural hematoma of the colon due to chronic DIC associated with aortic dissection. The patient was not a candidate for surgery for the aortic dissection because of his comorbidities. Continuous intravenous heparin (15 000 units/day) improved the laboratory abnormalities. Follow-up colonoscopy 16 days after the initial treatment showed healing ulceration (• " Fig. 3). The patient was changed to oral warfarin, following which no recurrent bleeding was observed. Bleeding associated with DBE is rare and mostly follows polypectomy or biopsy [1]. Intramural hematoma of the colon is rare but can be the result of blunt trauma typically in the presence of anticoagulant therapy or other hematologic disease [2]. In this case, DBE compressed the mucosa, resulting in an intramural hematoma of the colon, under conditions of chronic DIC, which is a rare finding often associated with aortic aneurysm and dissection [3]. Surgery is the primary treatment to eliminate the cause but heparin has been reported to treat chronic DIC effectively [3]. We recommend careful examination of coagulation studies prior to DBE in patients with OGIB and an aortic aneurysm or dissection. Endoscopy_UCTN_Code_CPL_1AI_2ADCompeting interests: None Cases and Techniques Library (CTL) E105Nagami Yasuaki et al. Intramural hematoma caused by DBE … Endoscopy 2016; 48: E105-E106

No abstract

Endoscopic ultrasonography (EUS) is useful for detecting early-stage pancreatic cancer. Because the detection of small lesions is difficult, it is important to detect indirect findings, namely caliber change, retention cysts, and dilatation of the branch duct, during the procedure. Although two types of EUS endoscopes are frequently used, there is no comparative study on their efficacy for detecting indirect findings. Therefore, we aimed to compare the diagnostic efficacy of these two types for indirect findings. We retrospectively analyzed 316 consecutive patients who had undergone EUS for pancreaticobiliary disease at a single center between January 2017 and December 2018. The main outcome was the detection rate of indirect findings and its comparison between the two echoendoscope types. This outcome was achieved using the inverse probability of treatment weighting (IPTW) analysis. The detection rate of indirect findings was higher for the radial-arrayed endoscope than for the convex-arrayed echoendoscope (9.2% vs. 2.3% (p = 0.02)). The univariate analysis also revealed that the radial-arrayed echoendoscope was significantly superior to the convex-arrayed echoendoscope in terms of the detection of indirect findings (odds ratio, 5.94; 95% confidence interval, 1.68–21.10; p = 0.01) after IPTW. After adjustment for magnetic resonance imaging (MRI) and computed tomography (CT), radial-arrayed echoendoscope remained an independent factor for indirect finding detection (odds ratio, 6.04; 95% confidence interval, 1.74–21.00; p = 0.01). Finally, five patients who had indirect EUS findings were diagnosed with pancreatic cancer. Our results indicate that the radial-arrayed echoendoscope is useful for the detection of indirect findings.