IntroductionVarious endoscopic procedures under fluoroscopic guidance are being rapidly adopted, and radiation exposure is considered to be increasing. However, there is little concern about this issue in gastroenterology practice. This study aims to evaluate the actual radiation exposure dose (RD) during endoscopic retrograde cholangiopancreatography (ERCP) and the factors affecting the RD.MethodsIn this retrospective, single-center cohort study of 1157 consecutive patients who underwent ERCP between October 2012 and February 2017, we analyzed the influences of patient characteristics, procedure time (min), total fluoroscopy time (min), type of processing engine, experience of the endoscopist, and type of disease on the total RD (mGy).ResultsThe median procedure times were 28 min for common bile duct stones (CBDS), 25 min for distal malignant biliary obstruction (MBO), and 30 min for proximal MBO. Similarly, the median fluoroscopy times were 10.3, 8.8, and 13.4 min, and the median RDs were 167, 123, and 242 mGy, respectively. Proximal MBO required significantly longer procedure time and fluoroscopy time and resulted in greater RD than distal MBO (P = 0.0006, <0.0001, <0.0001) and CBDS (P = 0.015, <0.0001, <0.0001). Multiple linear regression showed that distal MBO and a novel processing engine negatively correlate with RD (P = 0.04, <0.0001) and that proximal MBO positively correlates with RD (P = 0.0001).DiscussionProcedure time and fluoroscopy time were significantly longer for proximal MBO than for CBDS and distal MBO. The type of disease and processing engine significantly influenced the RD during ERCP.

Background and study aims  Adenoma detection rate (ADR) is a well-known quality indicator (QI) for colonoscopy. It is, however, difficult to evaluate ADR during practice. The aim of this study was to investigate the number of endoscopically detected polyps as a QI for colonoscopy. Patients and methods  This was a retrospective single-center cohort study of 5,190 consecutive patients who underwent colonoscopy from January 2015 to May 2016. Among these patients, we ultimately enrolled 1,937 patients for initial colonoscopy. We evaluated QIs including bowel preparation, cecum intubation time, withdrawal time, number of endoscopically detected polyps, ADR and advanced neoplasia detection rate (ANDR) Results  The mean number of endoscopically detected polyps, ADR and ANDR were 1.5 ± 2.3 (95 % confidence interval (CI)1.4 – 1.6), 38.6 % (95 % CI 36.5-40.8), and 18.3 % (95 % CI 16.6 – 20.1), respectively. ADR and ANDR increased with the number of endoscopically detected polyps, but the correlation reached a plateau at five or more polyps. We divided the patients into three groups based on the number of polyps (1 to 2, 3 to 4, and 5 or more). Logistic regression analysis adjusted by age and sex revealed that presence of a large number of polyps was a strong predictor of advanced neoplasia (odds ratio: 3.1 [95 % CI 2.2 – 4.3] for 3 to 4 polyps and 7.9 [95 % CI 5.4 – 11.8] for 5 or more polyps when using the presence of 1 or 2 polyps as a reference). Conclusion  The number of endoscopically detected polyps can predict risk of advanced neoplasia and may thus be a new QI for colonoscopy.

A 42-year-old man was diagnosed with cStage IIIb malignant melanoma and underwent resection. After interferon-beta therapy, 18-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) showed multiple lung metastases, and he received nivolumab (2 mg/kg) every 3 weeks, resulting in a total of 17 cycles. After treatment, 18F-FDG PET/CT showed a significant decrease in the size of the metastases, but he had a Grade 4 alanine aminotransferase (ALT) elevation. Liver histology revealed drug-induced liver damage. Therefore, we performed steroid half-pulse therapy followed by oral methylprednisolone, but his ALT level did not completely recover to the normal range even after five months. We herein report a case with specific, sustained liver injury induced by nivolumab as an immune-related adverse events.

ObjectivesThe aim of the present study was to assess the appropriate administration dose of non-steroidal anti-inflammation drugs to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). Importantly, the 100 mg dose of diclofenac recommended in Western countries has not been permitted in Japan.DesignA retrospective study.SettingsA single centre in Japan.ParticipantsThis study enrolled patients who underwent ERCP at the Department of Gastroenterology, Osaka Saiseikai Senri Hospital, from April 2011 through June 2013, and who received either a 25 or a 50 mg dose of rectal diclofenac after ERCP.Primary outcome measureThe occurrence of post-ERCP pancreatitis (PEP). A multivariate regression model was used to assess the effect of the 50 mg dose (the 50 mg group) of rectal diclofenac and to compare it to the occurrence of PEP referring to the 25 mg group.ResultsA total of 155 eligible patients received either 25 mg (84 patients) or 50 mg (71 patients) doses of rectal diclofenac after ERCP to prevent PEP. The proportion of PEP was significantly lower in the 50 mg group than in the 25 mg group (15.5% (11/71) vs 33.3% (28/84), p=0.018). In a multivariate analysis, the occurrence of PEP was significantly lower in the 50 mg group than in the 25 mg group even after adjusting potential confounding factors (adjusted OR=0.27, 95% CI 0.11 to 0.70).ConclusionsFrom this observation, the occurrence of PEP was significantly lower among ERCP patients with the 50 mg dose of rectal diclofenac than among those with the 25 mg dose.

Background and study aims Fluoroscopy-guided gastrointestinal procedures (FGPs) are increasingly common. However, the radiation exposure (RE) to patients undergoing FGPs is still unclear. We examined the actual RE of FGPs. Patients and methods This retrospective, single-center cohort study included consecutive FGPs, including endoscopic retrograde cholangiopancreatography (ERCP), interventional endoscopic ultrasound (EUS), enteral stenting, balloon-assisted enteroscopy, tube placement, endoscopic injection sclerotherapy (EIS), esophageal balloon dilatation and repositioning for sigmoid volvulus, from September 2012 to June 2019. We measured the air kerma (AK, mGy), dose area product (DAP, Gycm2), and fluoroscopy time (FT, min) for each procedure. Results In total, 3831 patients were enrolled. Overall, 2778 ERCPs were performed. The median AK, DAP, and FT were as follows: ERCP: 109 mGy, 13.3 Gycm2 and 10.0 min; self-expandable enteral stenting (SEMS): 62 mGy, 12.4 Gycm2 and 10.4 min; tube placement: 40 mGy, 13.8 Gycm2 and 11.1 min; balloon-assisted enteroscopy: 43 mGy, 22.4 Gycm2 and 18.2 min; EUS cyst drainage (EUS-CD): 96 mGy, 18.3 Gycm2 and 10.4 min; EIS: 36 mGy, 8.1 Gycm2 and 4.4 min; esophageal balloon dilatation: 9 mGy, 2.2 Gycm2 and 1.8 min; and repositioning for sigmoid volvulus: 7 mGy, 4.7 Gycm2 and 1.6 min. Conclusion This large series reporting actual RE doses of various FGPs could serve as a reference for future prospective studies.

Background: A blister-packaged drug might be useful to enhance the eradication of Helicobacter pylori. We investigated the effect of a blister-packaged drug for H. pylori eradication. Methods: We treated 1,758 patients with H. pylori infections and evaluated the successful eradication rate in patients who underwent first-line eradication between January 2013 and May 2018. Treatments included a conventional proton pump inhibitor (PPI) blister-packaged drug containing lansoprazole or rabeprazole with clarithromycin (CAM) and amoxicillin (AC), vonoprazan (VPZ) with CAM and AC in a separate tablet, or a VPZ blister-packaged drug (VONOSAP) containing VPZ with CAM and AC, with all drugs given twice daily for 7 days. Results: Finally, we evaluated 1,263 patients (conventional PPI: n = 644, VPZ: n = 326, and VONOSAP: n = 293). The overall successful eradication rates were 71.9% in the conventional PPI group, 90.2% in the VPZ group, and 92.2% in the VONOSAP group. There was a significantly lower eradication rate in the PPI group than in the VPZ and VO-NOSAP (p < 0.00001, p < 0.0001) groups, but there was no significant difference between the VPZ and VONOSAP groups (p = 0.4006). We enrolled a total of 256 age-and gender-matched patients in the VPZ and VONOSAP groups, and both groups had successful eradication rates of approximately 90% (89.8 vs. 90.4%, respectively, p = 0.7641). After analyzing the subgroup of patients older than 75 years, there was a significant treatment benefit of VONOSAP but not of VPZ in elderly patients (EPs). Conclusion: Triple-drug blisterpackaged drugs including VPZ may improve the first-line eradication of H. pylori in EPs.

INTRODUCTION: The global needs for a reduction in radiation exposure (RE) are increasing. Endoscopic retrograde cholangiopancreatography (ERCP) is a significant fluoroscopic procedure in the gastrointestinal field. However, the actual RE in ERCP and its annual trend are still unclear. Therefore, we examined the yearly trend of RE in ERCP. METHODS: This retrospective, single-center cohort study included consecutive cases of ERCP from September 2012 to June 2019. We measured the air kerma (AK, mGy), dose area product (DAP, Gycm2), and fluoroscopy time (FT, min). We also evaluated the annual trend of the RE before and after the fluoroscopy device update. RESULTS: In total, 2,174 patients receiving ERCP were enrolled. Among these, the mean age was 74.3 years, and 913 patients were women (42.0%). The median/third quartile values of AK (mGy), DAP (Gycm2), and FT (min) were 109/234 mGy, 13.3/25.8 Gycm2, and 18.2/27.7 minutes. The annual AK, DAP, and FT from 2012 to 2019 were 138, 207, 173, 177, 106, 71.0, 45.0, and 33.3 mGy; 23, 21.4, 19, 18.3, 11.9, 9.0, 6.8, and 6.4 Gycm2; and 12.5, 12.1, 9.7, 9.8, 8.2, 10.8, 9.4, and 10.3 minutes, respectively. The corresponding values before and after the update in July 2016 were 177 and 52 mGy (P < 0.0001), 19.2 and 7.6 Gycm2 (P < 0.0001), and 10.2, and 9.9 minutes (P = 0.05), respectively. DISCUSSION: The RE from ERCP tended to decrease every year, especially after fluoroscopy device updates.

BACKGROUND It is unclear whether treatment delay affects the clinical outcomes of chemotherapy in advanced gastric cancer (A-GC). AIM To assess whether treatment delay affects the clinical outcomes of chemotherapy in A-GC. METHODS This single-center retrospective study examined consecutive patients with A-GC between April 2012 and July 2018. In total, 110 patients with stage IV A-GC who underwent chemotherapy were enrolled. We defined the wait time (WT) as the interval between diagnosis and chemotherapy initiation. We evaluated the influence of WT on overall survival (OS). RESULTS The mean OS was 303 d. The median WT was 17 d. We divided the patients into early and elective WT groups, with a 2-wk cutoff point. There were 46 and 64 patients in the early and elective WT groups, respectively. Compared with the elective WT group, the early WT group had significantly lower albumin (Alb) levels and higher neutrophil/lymphocyte ratios and C-reactive protein (CRP) levels but not a lower performance status. The elective WT group underwent more combination chemotherapy than did the early WT group. OS was different between the two groups (230 d vs 340 d, respectively). Multivariate analysis revealed that higher CRP levels, lower Alb levels and monotherapy were significantly related to a poor prognosis. To minimize potential selection bias, patients in the elective WT group were 1:1 propensity score matched with patients in the early WT group; no significant difference in OS was found (303 d vs 311 d, respectively, log-rank P = 0.9832). CONCLUSION A longer WT in patients with A-GC does not appear to be associated with a worse prognosis.