Clean 2D superconductivity in a bulk van der Waals superlattice

Advances in low-dimensional superconductivity are often realized through improvements in material quality. Apart from a small group of organic materials, there is a near absence of clean-limit two-dimensional (2D) superconductors, which presents an impediment to the pursuit of numerous long-standing predictions for exotic superconductivity with fragile pairing symmetries. We developed a bulk superlattice consisting of the transition metal dichalcogenide (TMD) superconductor 2H-niobium disulfide (2H-NbS2) and a commensurate block layer that yields enhanced two-dimensionality, high electronic quality, and clean-limit inorganic 2D superconductivity. The structure of this material may naturally be extended to generate a distinct family of 2D superconductors, topological insulators, and excitonic systems based on TMDs with improved material properties.

Innovative therapeutic endoscopy in the upper gastrointestinal tract: Review of Japan Gastroenterological Endoscopic Society Core Sessions

Workshops on "Innovative Therapeutic Endoscopy" for upper gastrointestinal tract diseases were held four times as the Japan Gastroenterological Endoscopic Society (JGES) Core Sessions at the 93rd to 96th Biannual Meetings of the JGES. A total of 48 research presentations (including two invited lectures) were reported, and various discussions were held on these topics. When the research presentations were categorized according to the therapeutic procedure, endoscopic submucosal dissection (ESD) was the most frequent with 28 presentations (58.3%), followed by laparoscopy endoscopy cooperative surgery (LECS) with six presentations (12.5%). When the research presentations were classified by the target organ of the therapeutic procedures, the duodenum was the most frequent with 26 presentations (54.1%), followed by the stomach with 13 presentations (27.1%). The most important issue was the establishment of a safe and reliable endoscopic resection method for duodenal lesions. Issues related to gastric ESD were establishing an efficient traction method and a method to prevent post-ESD bleeding in high-risk patients. Other important issues were establishment of an efficient traction method and methods of preventing delayed bleeding in high-risk patients who undergo gastric ESD, expansion of indications for minimally invasive treatment using LECS for gastric cancer, the development of endoscopic full-thickness resection (EFTR) for gastric submucosal tumors (SMTs), and improvement of per-oral endoscopic myotomy (POEM) for esophageal achalasia and per-oral endoscopic tumor resection (POET) for esophageal SMTs. Through the JGES Core Sessions, it is expected that the minimally invasive treatments using endoscopes developed in Japan will be further advanced.

DNA barcoding of pear psyllids (Hemiptera: Psylloidea: Psyllidae), a tale of continued misidentifications

Pear psyllids (Hemiptera: Psylloidea: Psyllidae: Cacopsylla spp.) belong to the most serious pests of pear (Pyrus spp.). They damage pear trees by excessive removal of phloem sap, by soiling the fruits with honeydew which, in turn, provides a substrate for sooty mould, and by transmission of Candidatus Phytoplasma spp., the causal agents of the pear decline disease. The morphological similarity, the presence of seasonal dimorphism that affects adult colour, size and wing morphology and uncritical use of species names, led to much confusion in the taxonomy of pear psyllids. As a result, pear psyllids have been frequently misidentified. Many of the entries attributed to Cacopsylla pyricola and other species in the GenBank are misidentifications which led to additional, unnecessary confusion. Here we analysed DNA barcodes of 11 pear psyllid species from eastern Asia, Europe and Iran using four mitochondrial gene fragments (COI 658 bp, COI 403 bp, COI-tRNAleu-COII 580 bp and 16S rDNA 452 bp). The efficiency of identification was notably high and considerable barcoding gaps were observed in all markers. Our results confirm the synonymies of the seasonal forms of Cacopsylla jukyungi ( = C. cinereosignata, winter form) and C. maculatili ( = C. qiuzili, summer form) previously suggested based on morphology. Some previous misidentifications (C. chinensis from China, Japan and Korea = misidentification of C. jukyungi; C. pyricola and C. pyrisuga from East Asia = misidentification of C. jukyungi and C. burckhardti, respectively; C. pyricola from Iran = misidentification of C. bidens, C. pyri and Cacopsylla sp.) are also corrected. There is no evidence for the presence of European pear psyllid species in East Asia.

Automated operative phase identification in peroral endoscopic myotomy

BACKGROUND

Artificial intelligence (AI) and computer vision (CV) have revolutionized image analysis. In surgery, CV applications have focused on surgical phase identification in laparoscopic videos. We proposed to apply CV techniques to identify phases in an endoscopic procedure, peroral endoscopic myotomy (POEM).

METHODS

POEM videos were collected from Massachusetts General and Showa University Koto Toyosu Hospitals. Videos were labeled by surgeons with the following ground truth phases: (1) Submucosal injection, (2) Mucosotomy, (3) Submucosal tunnel, (4) Myotomy, and (5) Mucosotomy closure. The deep-learning CV model-Convolutional Neural Network (CNN) plus Long Short-Term Memory (LSTM)-was trained on 30 videos to create POEMNet. We then used POEMNet to identify operative phases in the remaining 20 videos. The model's performance was compared to surgeon annotated ground truth.

RESULTS

POEMNet's overall phase identification accuracy was 87.6% (95% CI 87.4-87.9%). When evaluated on a per-phase basis, the model performed well, with mean unweighted and prevalence-weighted F1 scores of 0.766 and 0.875, respectively. The model performed best with longer phases, with 70.6% accuracy for phases that had a duration under 5 min and 88.3% accuracy for longer phases.

DISCUSSION

A deep-learning-based approach to CV, previously successful in laparoscopic video phase identification, translates well to endoscopic procedures. With continued refinements, AI could contribute to intra-operative decision-support systems and post-operative risk prediction.

Phase I/II study of adding intraperitoneal paclitaxel in patients with pancreatic cancer and peritoneal metastasis

BACKGROUND

Intraperitoneal chemotherapy using paclitaxel is considered an experimental approach for treating peritoneal carcinomatosis. This study aimed to determine the recommended dose, and to evaluate the clinical efficacy and safety, of the combination of intravenous gemcitabine, intravenous nab-paclitaxel and intraperitoneal paclitaxel in patients with pancreatic cancer and peritoneal metastasis.

METHODS

The frequencies of dose-limiting toxicities were evaluated, and the recommended dose was determined in phase I. The primary endpoint of the phase II analysis was overall survival rate at 1 year. Secondary endpoints were antitumour effects, symptom-relieving effects, safety and overall survival.

RESULTS

The recommended doses of intravenous gemcitabine, intravenous nab-paclitaxel and intraperitoneal paclitaxel were 800, 75 and 20 mg/m² respectively. Among 46 patients enrolled in phase II, the median time to treatment failure was 6·0 (range 0-22·6) months. The response and disease control rates were 21 of 43 and 41 of 43 respectively. Ascites disappeared in 12 of 30 patients, and cytology became negative in 18 of 46. The median survival time was 14·5 months, and the 1-year overall survival rate was 61 per cent. Conversion surgery was performed in eight of 46 patients, and those who underwent resection survived significantly longer than those who were not treated surgically (median survival not reached versus 12·4 months). Grade 3-4 haematological toxicities developed in 35 of 46 patients, whereas non-haematological adverse events occurred in seven patients.

CONCLUSION

Adding intraperitoneal paclitaxel had clinical efficacy with acceptable tolerability.

Clinical Questions and Answers on Gastrointestinal Endoscopy during the Novel Coronavirus Disease 2019 pandemic

Some situations may require endoscopy during the COVID-19 (Coronavirus Disease 2019) pandemic. Here, we describe the necessary precautions in the form of clinical questions and answers (Q&A) regarding the safe deployment of gastrointestinal endoscopy in such situations while protecting endoscopy staff and patients from infection. Non-urgent endoscopy should be postponed. The risk of infection in patients should be evaluated in advance by questionnaire and body temperature. The health of staff must be checked every day. Decisions to employ endoscopy should be based on the institutional conditions and aims of endoscopy. All endoscopic staff need to wear appropriate personal protective equipment (PPE). The endoscope and other devices should be cleaned and disinfected after procedures in accordance with the relevant guidelines. Optimal management of the endoscopy unit is required. Endoscopy for infected patients or those with suspected infection demands exceptional caution. When a patient who undergoes endoscopy is later found to have COVID-19, the members of staff involved are considered exposed to the virus and must not work for at least 14 days if their PPE is considered insufficient. When PPE resources are limited, some equipment may be used continuously throughout a shift as long as it is not contaminated. Details of the aforementioned protective measures are described.

Gastrointestinal endoscopy in the era of the acute pandemic of coronavirus disease 2019: Recommendations by Japan Gastroenterological Endoscopy Society (Issued on April 9th, 2020)

All gastrointestinal endoscopic procedures have a high risk of aerosol contamination of the coronavirus disease 2019 (COVID-19) to endoscopists, nurses, and healthcare assistants. Given the current pandemic situation of COVID-19, the Japan Gastroenterological Endoscopy Society issued the recommendation for gastrointestinal (GI) endoscopy based on the status of COVID-19 as of April 9, 2020, in Japan: (i) indications for GI endoscopy in the pandemic of COVID-19; (ii) practical protective equipment for medical personnel depending on the risk for COVID-19; (iii) preprocedural management, such as pharyngeal local anesthesia using lidocaine spray which has a potential to generate the aerosols; (iv) ideal settings of the endoscopy room including the numbers of the staff and the patients; (v) postprocedural management, such as undressing and follow-up of the patients, as well as the involved staff, were documented to fit the practical scenarios in GI endoscopy, with the available data in Japan and the world. We believe that certain measures will prevent further spread of COVID-19.

Practice of endoscopy during COVID-19 pandemic: position statements of the Asian Pacific Society for Digestive Endoscopy (APSDE-COVID statements)

Coronavirus-19 (COVID-19) caused by SARS-CoV-2 has become a global pandemic. Risk of transmission may occur during endoscopy and the goal is to prevent infection among healthcare professionals while providing essential services to patients. Asia was the first continent to have a COVID-19 outbreak, and this position statement of the Asian Pacific Society for Digestive Endoscopy shares our successful experience in maintaining safe and high-quality endoscopy practice at a time when resources are limited. Sixteen experts from key societies of digestive endoscopy in Asia were invited to develop position statements, including patient triage and risk assessment before endoscopy, resource prioritisation and allocation, regular monitoring of personal protective equipment, infection control measures, protective device training and implementation of a strategy for stepwise resumption of endoscopy services after control of the COVID-19 outbreak.

Peroral endoscopic myotomy for achalasia: a prospective multicenter study in Japan

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) is an available treatment modalities for achalasia. The reported efficacy of POEM in the only prospective multicenter study was 82%; however, a retrospective multicenter study in Japan reported a higher efficacy rate of 95%. The aim of this study was to prospectively verify treatment outcomes after POEM at multiple facilities in Japan.

METHODS

This was a prospective single-arm trial of POEM for achalasia at 8 facilities in Japan between April 2016 and March 2018 to evaluate its safety and efficacy. Patients were re-evaluated at 3 months and up to 1 year after POEM.

RESULTS

Among the 233 patients with achalasia who underwent POEM, procedure-related adverse events occurred in 24 patients (10.3%), none of whom required surgical intervention. In the 207 patients satisfying the inclusion criteria, the efficacy rate of POEM, defined by an Eckardt score ≤3 at 1 year, was 97.4% (95% CI, 95.3%-99.7%). The Eckardt score decreased significantly from 6.6 ± 2.0 preoperatively to 1.1 ± 1.1, 1 year after POEM. Postoperative reflux esophagitis, severe reflux esophagitis, and symptomatic GERD were reported in 54.2%, 5.6%, and 14.7%, respectively, and proton pump inhibitors were administered in 21.1%.

CONCLUSIONS

Our prospective multicenter study in Japan showed greater efficacy of POEM for achalasia compared with the results of a previous prospective multicenter study. POEM is safe and highly effective for at least 1 year. (Clinical trial registration number: UMIN 000021550.).

Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer

The Japan Gastroenterological Endoscopy Society has developed endoscopic submucosal dissection/endoscopic mucosal resection guidelines. These guidelines present recommendations in response to 18 clinical questions concerning the preoperative diagnosis, indications, resection methods, curability assessment, and surveillance of patients undergoing endoscopic resection for esophageal cancers based on a systematic review of the scientific literature.

Endocytoscopy: technology and clinical application in upper gastrointestinal tract

Over the past few years, the innovative field of magnifying endoscopy has been expanding with various cutting-edge technologies, one of which is endocytoscopy, to facilitate improvement in the detection and diagnosis of gastrointestinal lesions. Endocytoscopy is a novel ultra-high magnification endoscopic technique enabling high-quality in-vivo assessment of lesions found in the gastrointestinal tract with the use of intraprocedural stains. The main scope of this review article is to offer a closer look at the latest endocytoscopic technology and its clinical application in the upper gastrointestinal tract, especially in the esophagus and stomach, as well as to introduce readers to our simplified and up-to-date endocytoscopic classification, specifically developed for the esophagus and stomach, for the in-vivo assessment and diagnosis of esophageal and gastric lesions. Despite the good accuracy of endocytoscopy in the diagnosis of esophageal and gastric lesions in recent studies, some challenges still remain (e.g., staining method and standardized endocytoscopic classification). Through continuous evaluation and improvement of methods and skills, these challenges may be overcome thus establishing current techniques and classification, paving the way for further advances in the field of endocytoscopy and magnifying endoscopy. In all, endocytoscopy seems to aid in the in-vivo diagnosis of gastrointestinal tract lesions and may, in the future, revolutionize the field of in-vivo endoscopic diagnosis of gastrointestinal cancer, representing another step towards the so-called optical biopsy.

Endocytoscopy for the differential diagnosis of colorectal low-grade adenoma: a novel possibility for the "resect and discard" strategy

BACKGROUND AND AIMS

Endocytoscopy, a next-generation endoscopic system, facilitates observation at a maximum magnification of ×520. To our knowledge, no study has reported high-precision diagnosis of colorectal low-grade adenoma, endoscopically. We aimed to reveal which endocytoscopic findings may be used as indicators of low-grade adenoma and to assess whether a "resect and discard" strategy using endocytoscopy is feasible.

METHODS

Lesions diagnosable with endocytoscopy were examined retrospectively between May 2005 and July 2017. A normal pit-like structure in endocytoscopic images was considered a normal pit (NP) sign and used as an indicator of low-grade adenoma. The primary outcome was the diagnostic accuracy of the NP sign for low-grade adenoma. We evaluated agreement rates between endocytoscopic and pathologic diagnosis for surveillance colonoscopy interval recommendation (SCIR) and performed a validation study to verify the agreement rates.

RESULTS

For 748 lesions in 573 cases diagnosed as colorectal adenoma using endocytoscopy, the results were as follows: sensitivity of the NP sign for low-grade adenoma, 85.0%; specificity, 90.7%; positive predictive value, 96.6%; negative predictive value, 66.1%; accuracy, 86.4%; and positive likelihood ratio, 9.2 (P < .001). The agreement rate between endocytoscopic and pathologic diagnosis for SCIR was 94.4% (95% confidence interval [CI], 92.2%-96.1%; P < .001) under United States guidelines and 96.3% (95% CI, 94.5%-97.7%; P < .001) under European Union guidelines. All inter- and intraobserver agreement rates for expert and nonexpert endoscopists had κ values ≥0.8 except one nonexpert pair.

CONCLUSIONS

Endocytoscopy is an effective modality in determining the differential diagnosis of colorectal low-grade adenoma. (University Hospital Medical Information Network Clinical Trials database registration number: UMIN000018623.).

Clinical outcomes of per-oral endoscopic tumor resection for submucosal tumors in the esophagus and gastric cardia

OBJECTIVES

The clinical success of per-oral endoscopic myotomy (POEM) has led to the development of a new field of 'submucosal endoscopy'. This study aimed to evaluate the safety, efficacy, and limitations of per-oral endoscopic tumor resection (POET) in the management of submucosal tumors (SMTs) in the esophagus and the gastric cardia.

METHODS

POET was performed in 47 patients from January 2011 to December 2017. The indication for POET was SMTs ≤ 30 mm in minor axis diameter. Patient and tumor characteristics (age, gender, tumor location, size, and histology), operative and clinical results of POET (procedure time and completion rate, en bloc resection rate, length of hospitalization, adverse events and tumor recurrence) were analyzed retrospectively.

RESULTS

POET was successfully completed in 43 patients (91.5%) without any major adverse events (Clavien-Dindo IIIb-IV). Four patients required conversion to an open surgical procedure due to suboptimal visualization during POET. Four patients underwent piecemeal resection of their SMTs including GISTs. Median follow-up was 44 months (10-96 months), during that time, there were no incidences of tumor recurrence. Tumors that had a minor axis diameter > 30 mm or a tumor mass index (TMI) [major axis diameter (mm) × minor axis diameter (mm)] >1000 had a high likelihood of being converted to surgical resection.

CONCLUSIONS

POET is a safe and effective treatment for SMTs. However, in patients where the minor axis diameter is > 30 mm or the TMI > 1000, surgical excision should be considered. Furthermore, application of POET for SMTs with malignant potential should be carefully considered to ensure optimal oncologic outcomes.

Anti-reflux mucosal ablation (ARMA) as a new treatment for gastroesophageal reflux refractory to proton pump inhibitors: a pilot study

Background  The incidence of proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) has been increasing. While surgical intervention with Laparoscopic Nissen Fundoplication remains the gold standard, less invasive anti-reflux interventions are desired. We have developed a minimally invasive anti-reflux mucosal ablation (ARMA) treatment. Herein, we report its technical details and describe its feasibility, safety, and efficacy in PPI-refractory GERD. Methods  We conducted a prospective single-center single-arm interventional trial evaluating the outcome of ARMA in 12 patients with PPI-refractory GERD. GERD-Health Related Quality of Life Questionnaire (GERD-HRQL) evaluation, Frequency Scale for the Symptoms of GERD (FSSG) assessment, and impedance-pH monitoring were performed at baseline and at 2 months post-ARMA. Results  A total of 12 patients underwent ARMA with a median follow-up duration of 9 months (range: 6 - 14 months). Median GERD-HRQL score significantly improved from 30.5 to 12 ( P  = 0.002); median FSSG score significantly improved from 25 to 10.5 ( P  = 0.002), and median DeMeester score decreased from 33.5 to 2.8 ( P  = 0.049) at 2 months follow-up. No immediate complications were observed. Conclusion  Our pilot study has shown that ARMA, a new endoscopic treatment for PPI-refractory GERD, is simple, safe, and improves GERD-related symptoms and objective acid reflux parameters.

Identification of human herpes virus 1 encoded microRNAs in biopsy samples of lower esophageal sphincter muscle during peroral endoscopic myotomy for esophageal achalasia

Esophageal achalasia is a rare chronic debilitating disorder characterized by incomplete lower esophageal sphincter (LES) relaxation and abnormal peristalsis as a result of myenteric plexus degeneration. Although complex interactions among immunity, viruses and inheritance have been proposed, its causes remain unknown. MicroRNAs (miRs) play crucial roles in the regulation of gene expression during pathophysiological processes. Certain viruses such as herpes simplex virus (HSV) encode miRs derived from their own genomes. To determine the underlying relationship of miRNAs to achalasia, we analyzed the expression profile of miRNAs using biopsy samples obtained from LES muscle during peroral endoscopic myotomy. Peroral LES muscle biopsy sampling was uneventfully carried out in our case series of achalasia. Control biopsy tissues were also obtained from LES muscle of patients without symptoms relating to abnormal esophageal motility whose esophagogastric junction was surgically excised. RNA was extracted from biopsy specimens and analyzed using a microarray. Differentially expressed miRNAs in achalasia patients compared to controls were identified and analyzed using reverse transcription quantitative polymerase chain reaction. HSV-1-derived hsv1-miR-H1 and -H18 was significantly overexpressed in achalasia cohorts compared to controls. Correlations between the expression levels of viral miR and the patients' clinical characteristics including achalasia morphological type, dilatation grading, and disease duration were not identified. Further studies with a larger sample size are needed to replicate the current heuristic identification of neurotropic viral miRs and unravel their functional significance in order to provide new insight linking neurodegenerative etiology in achalasia.

Statement for gastroesophageal reflux disease after peroral endoscopic myotomy from an international multicenter experience

It has been 10 years since peroral endoscopic myotomy (POEM) was reported for the first time, and POEM has currently become the standard treatment for achalasia and related disorders globally because it is less invasive and has a higher curative effect than conventional therapeutic methods. However, there are limited studies comparing the long-term outcomes of POEM with those of conventional therapeutic methods, particularly in the occurrence of gastroesophageal reflux disease (GERD) after therapy. With this background, we held a consensus meeting to discuss the pathophysiology and management of GERD after POEM based on published papers and experiences of each expert and to discuss the prevention of GERD and dealing with anti-acid drug refractory GERD. This meeting was held on April 27, 2018 in Tokyo to establish statements and finalize the recommendations using the modified Delphi method. This manuscript presents eight statements regarding GERD after POEM.

Gastroesophageal reflux disease after peroral endoscopic myotomy: lest we forget what we already know

After the performance of the first peroral endoscopic myotomy (POEM) in 2008, POEM has now spread worldwide and has arguably become a first-line treatment option for achalasia. Recently, there is increasing debate regarding post-POEM gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD). The reported incidences of GERD vary widely, owing to the variability in the definitions used. The literature regarding GERD and achalasia patients with a focus on 24-hour pH testing, esophageal acid exposure, and fermentation and the definitions of GERD used in the POEM literature are examined. 24-hour pH testing in achalasia patients may be abnormal due to fermentation both pre- and post-treatment. It is vital that POEM operators ensure that fermentation is recognized during 24-hour pH testing and excluded in the analysis of acid exposure time (AET) used in the diagnosis of GERD. In untreated achalasia, 24-hour pH testing may suggest abnormal AET in over a third of patients. However, most abnormal AETs in untreated achalasia patients are due to fermentation rather than GER. In treated achalasia, up to half of the patients with abnormal AET may be attributable to fermentation. To have a candid discussion and appropriately address the questions surrounding post-POEM GERD, consistent definitions need to be applied. We suggest the recent definition of GERD from the Lyon Consensus to be utilized when diagnosing GERD in post-POEM patients. Further studies are required in establishing ideal parameters for 24-hour pH testing in achalasia patients.

A novel endoscopic assessment of the gastroesophageal junction for the prediction of gastroesophageal reflux disease: a pilot study

Background and aim  Hiatal hernia and lower esophageal sphincter (LES) dysfunction play major roles in gastroesophageal reflux disease (GERD) pathogenesis. We developed a novel endoscopic assessment to evaluate the gastroesophageal junction (GEJ). This study aims to evaluate the feasibility of this method for the diagnostic prediction of GERD. Methods  A retrospective analysis of patients with GERD symptoms who underwent gastroscopy and esophageal pH-impedance monitoring was conducted. The novel assessment evaluated the following in retroflex view: 1) Cardiac Opening (CO): diameter of the opening of the cardia, 2) Sliding Hernia (SH): length from the diaphragmatic crus to the squamocolumnar junction, 3) Scope Holding Time% (SHT%): the percentage of time that the Scope Holding Sign (SHS) was observed out of 30 seconds. The SHS is defined as the lower esophagus holding the endoscope under excessive insufflation. The results of this assessment and that of pH-impedance monitoring were compared. Results  In total, 61 patients (mean age ± SD, 54.1 ± 16.4 years, 32 males) were enrolled. CO and SH were significantly correlated with acid exposure time (AET) (ρ = 0.36, P  = 0.005, and ρ = 0.36, P  = 0.004). The optimal cutoff of CO for AET > 6 % was 3 cm (Sensitivity = 72.4 %, Specificity = 46.9 %, AUC = 0.64) and that of SH was 2 cm (Sensitivity = 55.2 %, Specificity = 75.0 %, AUC = 0.70). When the population was stratified according to this cutoff, patients with CO > 3 cm and those with SH > 2 cm presented higher AET (15.1 vs 4.1 %, P  = 0.037, and 23.0 vs 3.6 %, P  = 0.026). Optimal cutoff of SHT% for the number of all reflux episodes > 80 was 75 % (Sensitivity = 81.8 %, Specificity = 54.6%, AUC = 0.67). Patients with SHT% < 75 % presented a higher number of all reflux episodes (88 vs 65, P  = 0.014). Sensitivity, specificity, and accuracy of SHT% < 75 % for all reflux episodes > 80 were 81.8 % (95 %CI: 67.7 - 91.8), 54.5% (95 %CI: 40.4 - 64.5), and 68.2 % (95 %CI: 54.0 - 78.1). Conclusion  This novel endoscopic assessment of GEJ significantly predicted the presence of GERD and merits further testing in future studies.

Analysis of serum by Raman spectroscopy finds changes in blood metabolites of cancer patients in 45 seconds

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Background: Cancer is an important disease that accounts for many of the causes of death worldwide, and early diagnosis is important for improving treatment results. In medical care, blood test is a simple and excellent test method, but there is still no cancer blood diagnosis method with high accuracy that can be performed in general hospitals. We are trying to detect cancer patients by analyzing serum using Raman spectroscopy. Methods: Among the outpatients who underwent upper gastrointestinal endoscopy or colonoscopy, 236 subjects who agreed to participate in the study were included. Raman scattering spectra were measured by irradiating a 1064 nm wavelength laser for 15 seconds with serum collected from the subject before endoscopic examination. The average value measured a total of three times was taken as the measured value, and the three measured values were averaged to obtain the value of each examinee. In the obtained Raman scattering spectra, the scattering spectral intensities of the wavelength originating in the specific molecules were analyzed. Results: We were able to obtain clear Raman scattering spectra of all serum samples. When comparing the Raman scattering spectral intensities of the wavelength originating in specific molecules, a large number of serum measurement values were gathered at the center, and the measurement values of the cancer patients' serum were over low or high. By setting the appropriate cutoff line, cancer patients (gastric cancer or colon cancer) and non-cancerous persons could be relatively clearly distinguished (sensitivity, 100%; Specificity, 75%). Conclusions: Our micro Raman system is able to acquire Raman scattering spectra of serum samples. Furthermore, it has been suggested that cancer diagnosis using serum could be possible by comparing the scattering spectral intensities caused by specific molecules. Clinical trial information: UMIN000034306.

P3587Tip detection method using the new short-tip IVUS with pull-back system which facilitates the 3D wiring technique in percutaneous coronary intervention for chronic total occlusion

Background

The strategy of intravascular ultrasound (IVUS)-guided wiring for CTO PCI, that is, leading the second guidewire into the true lumen under observing by IVUS from subintimal space, is the last resort. We developed the angiography-based 3D wiring method. During establishment of the angiography-based 3D wiring method, we deduced that observation of the guidewire tip as well as the shaft named “The tip detection method” simplifies and facilitates 3D wiring under IVUS-guided wiring. Therefore, we produced New CTO IVUS which is the upgraded version of Navifocus WR IVUS by adding the pull-back transducer system. This pull-back system enables us to detect the tip as well as the shaft of the second guidewire in real time (tip detection method), which facilitates the 3D wiring technique under IVUS-guided wiring.

Objective

We evaluated the efficacy of the tip detection method during 3D wiring for CTO PCI with New CTO IVUS.

Method

We created a target pinpoint penetration model and performed the procedures using an experimental heartbeat model. The target (a tube with a lumen 0.6 mm in diameter) was placed in the distal part of a CTO 20 mm in length made of 2.5% agar. After the second guidewire (Conquest-12g) was advanced into the CTO lesion to within 5mm of the target using the angiography-based wiring, IVUS-guided wiring was performed by using Navifocus WR or New CTO IVUS each five times.

Result

The frequency of the puncture time was reduced using the new CTO IVUS compared to the Navifocus WR (1.7±0.8 vs. 28.8±23.2, p=0.17). The procedure time was significantly shorter using the new CTO IVUS compared to the Navifocus WR (103±61 vs. 459±373 seconds, p=0.04).

Conclusion

The tip detection method during 3D wiring with the new short tip IVUS with the pull-back system enables us to easily perform 3D wiring and will change the CTO PCI strategy.

Combination of laparoscopic and endoscopic approaches for neoplasia with non-exposure technique (CLEAN-NET) for gastric submucosal tumors: updated advantages and limitations

Laparoscopic and endoscopic cooperative surgery (LECS) for gastric submucosal tumors (SMTs) has been developed under the concept of resecting gastric tumors with both complete curability and preserving organ functions. Precise resection is obtained by classical LECS, however, concerns regarding intraoperative bacterial infection and dissemination of the tumor cells into the abdominal cavity by LECS with exposure technique still remain. To prevent these concerns, several LECS-related procedures with non-exposure techniques, such as combination of laparoscopic and endoscopic approaches for neoplasia with non-exposure technique (CLEAN-NET) and non-exposed endoscopic wall-inversion surgery (NEWS), have been reported to be safe and feasible. Classical LECS, CLEAN-NET, and NEWS have the same concept, however, each has its own different characteristic procedures; exposure or non-exposure technique, inversion of the tumor into or outer the lumen, retrieval of tumor per oral or through the abdominal cavity, and dominance in the role of the endoscopist or the laparoscopic surgeon. Familiarization with these procedure details is important to understand their indications, advantages and limitations, resulting in providing a tailored minimally invasive surgery for patients. The main scope of this review article is to introduce readers to the clinical application, procedure, and results of CLEAN-NET, both from previous literatures and from our experience, as well as to offer a closer look at its advantages and limitations while comparing with other LECS procedures from the viewpoint of introducing CLEAN-NET first.

P5668A decision-support tool framework to predict adverse outcome in patients with atrial fibrillation: J-Rhythm registry substudy

Background

Atrial fibrillation (AF) is associated with increased mortality and morbidity. Modelling the risk of thrombosis, major bleeding and total mortality are often limited by the inadequate number of independent predictors.

Purpose

We compared the predictive accuracy of the decision-support tool framework and conventional risk score in AF patients.

Methods

We used data of AF patients enrolled into the nationwide AF registry. A random forest model was implemented to predict each outcome, and its predictive power was tested by a 5-fold cross-validation.

Results

We analyzed 7,937 patients with AF (age 70±10 years, female 31%). The type of AF was paroxysmal (37%), persistent (14%), and permanent (49%). The number of antithrombotic treatments were follows: warfarin only (n=5461), antiplatelet only (n=581), both warfarin and antiplatelet (n=1471) and no antithrombotic agents (424). The mean CHA2DS2-VASc score was 2.8±1.6 and HAS-BLED score was 2.7±1.2, respectively. We selected 20 from 50 clinical parameters and compared by the area-under-curve with the CHA2DS2-VASc score for thromboses and the HAS-BLED score for major bleeding. During the 2-year follow-up, 126 patients (1.6%) had thromboses, 140 (1.8%) had major bleeding, and 195 (2.5%) died. A random forest model had a higher value of the area-under-curve for predicting thromboses compared with the CHA2DS2-VASc (0.66 vs. 0.61, P<0.05), and had a significantly higher area-under-curve for major bleeding compared with the HAS-BLED (0.67 vs. 0.61, P<0.05). The area-under-curve for the all-cause mortality was 0.77.

Conclusions

A random forest model has a higher accuracy than conventional risk scheme in predicting thromboses and major bleeding, in addition to total mortality.

P980Post-procedural plasma brain natriuretic peptide level early after catheter ablation predicts the future clinical outcome in patients with persistent atrial fibrillation and reduced ejection fraction

Background

Successful restoration of sinus rhythm (SR) by catheter ablation (CA) for persistent atrial fibrillation (AF) improves cardiac function, resulting in decrease of plasma brain natriuretic peptide (BNP) level. The exact significance and prognostic implications of this change have yet to be determined.

Purpose

To examine the impact of pre- and post-procedural BNP level on the clinical outcome after CA in patients with persistent AF and reduced left ventricular ejection fraction (LVEF).

Methods

Out of 242 patients with LVEF <50% who underwent first-time CA for persistent AF between March 2012 and September 2018 at our institute, we enrolled 137 patients (61±10 years, 83% male) whose plasma BNP level was available both at baseline and early after CA (during 1–3 month). We evaluated the impact of the BNP levels on future AF recurrence 3 months after CA as the primary endpoint. Additional secondary endpoints included heart failure (HF) hospitalization and cardiovascular death.

Results

All patients successfully restored SR at the end of CA. Within 3 months of a blanking period (BP), improvement of LVEF (from 39±10% to 65±12%, p<0.001) and reduction of BNP levels (from 178 [107–332] pg/ml to 42.3 [21.1–78.6] pg/ml, p<0.001) were observed. During the median follow-up of 21 months after BP, the incidence of AF recurrence, HF hospitalization, and cardiovascular death was 37% (n=50), 3% (n=4), and 1% (n=1), respectively. Cox proportional hazard regression analysis after adjustment for age and gender revealed that post-procedural BNP level was a significant predictor of the AF recurrence (hazard ratio [HR] per 100-pg/ml increase, 1.13; 95% confidence interval [CI], 1.02–1.25; p=0.023), but pre-procedural BNP level was not (1.02; 0.95–1.09; p=0.56). Receiver operating curve analysis determined the post-procedural BNP level of 55.5 pg/ml as the best cut-off value for predicting the AF recurrence, with area under the curve of 0.620 (95% CI, 0.534–0.702; p=0.018). The incidence of AF recurrence was significantly higher in patients with post-procedural BNP level >55.5 pg/ml (n=50) than the others (50% vs. 29%; HR, 3.99; 95% CI, 2.07–7.68; p<0.001). No patients with post-procedural BNP level ≤55.5 pg/ml experienced HF hospitalization and cardiovascular death (8% vs. 0% and 2% vs. 0%, p=0.006 and p=0.17, respectively)

Conclusions

Not pre-procedural but post-procedural BNP level early after CA predicted the future clinical outcome in patients with persistent AF and reduced LVEF. Decreased but still elevated BNP level after restoration of SR would identify the residual risk for developing unfavorable outcome.

Diagnostic performance of the endoscopic pressure study integrated system (EPSIS): a novel diagnostic tool for gastroesophageal reflux disease

BACKGROUND

The endoscopic pressure study integrated system (EPSIS) is a prototypic system for monitoring intragastric pressure (IGP) fluctuations that result from opening of the cardia during gastric distension. The performance of EPSIS for the diagnosis of gastroesophageal reflux disease (GERD) was evaluated.

METHODS

A retrospective analysis was conducted of data prospectively collected over a 2-year period from 59 patients who underwent gastroscopy, EPSIS, and 24-hour pH monitoring. Using a dedicated electronic device and a through-the-scope catheter, maximum IGP (IGP_max) and IGP waveform pattern (uphill/flat) were recorded.

RESULTS

The optimal IGP_max cutoff was 18.7 mmHg. IGP_max < 18.7 mmHg (sensitivity 74.2 %, 95 % confidence interval [CI] 56.8 - 86.3; specificity 57.1 %, 95 %CI 39.1 - 73.5) and flat pattern (sensitivity 71.0 %, 95 %CI 53.4 - 83.9; specificity 82.1 %, 95 %CI 64.4 - 92.1) were associated with GERD. "Double" EPSIS positivity (IGP_max < 18.7 mmHg and flat pattern) provided maximum specificity (85.7 %, 95 %CI 68.5 - 94.3), whereas "any" EPSIS positivity (IGP_max < 18.7 mmHg or flat pattern) provided maximum sensitivity (80.6 %, 95 %CI 63.7 - 90.8). Maximum specificity and sensitivity for nonerosive reflux disease (NERD) was > 70 %. In multivariate analysis, "double" EPSIS positivity was the strongest predictor of GERD (odds ratio [OR] 16.05, 95 %CI 3.23 - 79.7) and NERD (OR 14.7, 95 %CI 2.37 - 90.8).

CONCLUSION

EPSIS emerges as a reliable adjunct to routine gastroscopy for GERD diagnosis, and might prove helpful for the stratification and management of patients with reflux disorders.

Utilizing fourth-generation endocytoscopy and the 'enlarged nuclear sign' for in vivo diagnosis of early gastric cancer

Background and study aims  Fourth-generation endocytoscopy is an ultra-high magnification endoscopic technique designed to provide excellent quality in vivo histologic assessment of gastrointestinal lesions. This study aims to evaluate the diagnostic accuracy of endocytoscopy in early gastric cancer diagnosis. Patients and methods  A single-center, retrospective analysis of prospectively collected data from all gastric endocytoscopic examinations was conducted. Two expert endoscopists, blinded to white-light and narrow-band imaging findings as well as histopathologic diagnosis, independently reviewed and diagnosed all endocytoscopic images. A newly recognized "enlarged nuclear sign" was detected, and its implication in early gastric cancer diagnosis was evaluated. The diagnostic performance of fourth-generation endocytoscopy was assessed while using the gold standard histopathology as a reference. Results  Forty-three patients (mean age±SD, 72.6 ± 12.1 years; 31 males) were enrolled. Based on histopathology, 23 had well-differentiated adenocarcinomas, four adenomas, and 16 non-neoplastic lesions. The sensitivity, specificity, and accuracy of fourth-generation endocytoscopy for gastric cancer diagnosis were 87.0 % (95 % CI: 67.9 - 95.5), 80.0 % (95 % CI: 58.4 - 91.9), and 83.7 % (95 % CI: 70.0 - 91.9) by endoscopist A; and 91.3 % (95 % CI: 73.2 - 97.6), 75.0 % (95 % CI: 53.1 - 88.8), and 83.7 % (95 % CI: 70.0 - 91.9) by endoscopist B. The inter-observer agreement, Kappa statistic = 0.71 (95 % CI: 0.50 - 0.93), was good. The sensitivity, specificity, and accuracy of the enlarged nuclear sign for early gastric cancer diagnosis were 87.0 % (95 % CI: 67.9 - 95.5), 95.0 % (95 % CI: 76.4 - 99.1), and 90.7 % (95 % CI: 78.4 - 96.3) by endoscopist A; and 82.6 % (95 % CI: 62.9 - 93.0), 85.0 % (95 % CI: 64.0 - 94.8), and 83.7 % (95 % CI: 70.0 - 91.9) by endoscopist B. The inter-observer agreement, Kappa statistic = 0.68 (95 % CI: 0.51 - 0.89) was good. Conclusion: Fourth-generation endocytoscopy appears to aid in the diagnosis of early gastric cancer, particularly well-differentiated adenocarcinomas, due to its good diagnostic accuracy and identification of the "enlarged nuclear sign," and deserves further evaluation in future studies.

Scoring System to Predict pt2 in Gallbladder Cancer Based on Carcinoembryonic Antigen and Tumor Diameter

BACKGROUND AND AIMS

T2 gallbladder cancer requires lymph node dissection for curative resection, whereas simple cholecystectomy is adequate to treat T1 gallbladder cancer. Hence, this study aimed to develop an accurate scoring system to preoperatively predict pT2 in gallbladder cancer.

MATERIAL AND METHODS

We retrospectively assessed data from 57 patients with suspected gallbladder cancer who underwent curative resection between September 2003 and May 2017. Six with apparent invasion of adjacent organs on preoperative images were excluded. We evaluated preoperative computed tomography, magnetic resonance and endoscopic ultrasonographic images, blood biochemistry, and the maximum standard uptake value in fluorodeoxyglucose-positron emission tomography images. We analyzed whether correlations between preoperative findings and the depth of tumor invasion could predict pT2.

RESULTS

The pathological diagnosis was gallbladder cancer in 30 (58.8%) patients, of whom 21 (69.9%) had pT2 or worse. Multivariate analyses selected carcinoembryonic antigen and tumor diameter as independent predictors of pT2 or worse (odds ratios = 1.741 and 1.098, respectively; 95% confidence intervals = 1.004-3.020 and 1.008-1.197, respectively). A regression formula was created using carcinoembryonic antigen and tumor diameter to calculate pT2 predictive scores. The area under the receiver operating characteristics curve of the pT2 predictive score was 0.873.

CONCLUSION

We created a scoring system to predict pT2 in gallbladder cancer using carcinoembryonic antigen and tumor diameter. The present findings suggested that carcinoembryonic antigen is important for the preoperative evaluation of gallbladder cancer.

Evaluation of the effect of a heat-killed lactic acid bacterium, Enterococcus faecalis 2001, on oral candidiasis

The effect of a preparation of heat-killed Gram-positive lactic acid bacteria Enterococcus faecalis 2001 (EF-2001) on oral candidiasis was evaluated by two studies. An in vitro study was performed to assess the inhibitory effect on mycelial growth of Candida strains isolated from a patient with oral candidiasis, and a clinical study was done in patients with oral candidiasis. In the in vitro study, EF-2001 inhibited mycelial growth of IT-1, a Candida strain isolated from a patient with oral candidiasis, at concentrations ≥2.34×109 cells/ml. An open clinical study was performed in 13 patients with oral candidiasis. The subjects took a powder containing 7.5×1011 heat-killed EF-2001 once a day before bedtime for seven consecutive days. In 11 of the 12 patients available for analysis (92%), the oral Candida load (cfu/swab) showed a significant decrease (P=0.01079, d=-0.437). There was a 55% decrease of Candida albicans and a 93.8% decrease of Candida glabrata. The following symptoms showed significant improvement: tinnitus (P=0.048, d=-0.462), cold feeling (P=0.048, d=-0.463), and depression (P=0.019, d=-0.34). In addition, 4 out of 26 oral symptoms tended to improve. These results suggest that EF-2001 significantly decreased the oral Candida load in patients with oral candidiasis by inhibiting mycelial growth and that EF-2001 is an effective treatment for oral candidiasis.

Distribution of lymph node metastases in esophageal carcinoma [TIGER study]: study protocol of a multinational observational study

BACKGROUND

An important parameter for survival in patients with esophageal carcinoma is lymph node status. The distribution of lymph node metastases depends on tumor characteristics such as tumor location, histology, invasion depth, and on neoadjuvant treatment. The exact distribution is unknown. Neoadjuvant treatment and surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy has not been reached. The aim of this study is to determine the distribution of lymph node metastases in patients with resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed. This can be the foundation for a uniform worldwide staging system and establishment of the optimal surgical strategy for esophageal cancer patients.

METHODS

The TIGER study is an international observational cohort study with 50 participating centers. Patients with a resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed in participating centers will be included. All lymph node stations will be excised and separately individually analyzed by pathological examination. The aim is to include 5000 patients. The primary endpoint is the distribution of lymph node metastases in esophageal and esophago-gastric junction carcinoma specimens following transthoracic esophagectomy with at least 2-field lymphadenectomy in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and (disease free) survival.

DISCUSSION

The TIGER study will provide a roadmap of the location of lymph node metastases in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and survival. Patient-tailored treatment can be developed based on these results, such as the optimal radiation field and extent of lymphadenectomy based on the primary tumor characteristics.

TRIAL REGISTRATION

NCT03222895 , date of registration: July 19th, 2017.

Multicenter collaborative retrospective evaluation of peroral endoscopic myotomy for esophageal achalasia: analysis of data from more than 1300 patients at eight facilities in Japan

BACKGROUND

Peroral endoscopic myotomy (POEM) is a novel, minimally invasive treatment for esophageal achalasia. We retrospectively examined and evaluated the results following POEM to verify the technique's efficacy and safety.

METHODS

We retrospectively analyzed data for patients who underwent POEM at eight Japanese facilities between September 2008 and October 2015. Pre- and postoperative assessments 3 months and 1 year after POEM included patient interviews, endoscopy, and manometry.

RESULTS

A total of 1346 patients underwent POEM during the study period. Achalasia was the straight type in 1105 patients (82%) and the sigmoid type in 241 patients (18%). The average patient age was 47.2 years (range 3-95 years); 617 patients (46%) were men and 729 (54%) were women. Previous treatment included balloon dilatation in 381 patients (28%) and Heller-Dor operation in 43 patients (3%). The average operation time was 99.6 min. The mean length of the myotomy in the esophageal body was 10.8 cm, and the myotomy extended into the stomach a mean of 2.8 cm. The response rate (Eckardt score ≤ 3) was 95.1% 3 months postoperatively and 94.7% 1 year postoperatively. We noted 50 adverse events (3.7%) of Clavien-Dindo classification grade ≤ IIIa, and all resolved with conservative treatment. There were no Clavien-Dindo classification grade ≥ IIIb adverse events. After POEM, erosive esophagitis according to the Los Angeles classification was absent in 37% of the patients, grade A in 33%, B in 24%, C in 6%, and D in 0.2%. Symptomatic gastroesophageal reflux disease after POEM was confirmed in 14.8% of the patients; both erosive esophagitis and symptomatic gastroesophageal reflux disease responded to treatment with a proton-pump inhibitor.

CONCLUSION

Our results confirmed the safety and efficacy of POEM in a large patient series and support POEM as the first-line and standard treatment for esophageal achalasia.

Persistent chest pain in young male patient: Jackhammer esophagus treated with peroral endoscopic myotomy

Initial esophagogastroduodenoscopy (EGD) shows segmental contractions right above the gastro‐esophageal junction, which may be related to the symptoms. A clip was applied during a previously performed manometry. There was no evidence of stricture. High‐resolution manometry before peroral endoscopic myotomy shows a hypercontractile esophagus expressed as distal contractile integral > 8000 mmHg cm s two times out of 10.

Anterior versus posterior myotomy during poem for the treatment of achalasia: systematic review and meta-analysis of randomized clinical trials

BACKGROUND AND AIMS

The optimal orientation of the myotomy during peroral endoscopic myotomy (POEM) is unknown. This meta-analysis aims to compare anterior and posterior myotomy regarding clinical success and safety.

METHODS

PubMed, Embase, Cochrane Library, WOK, and clinicaltrials.gov were searched to identify randomized clinical trials (RCTs) comparing anterior and posterior myotomy during POEM for the treatment of achalasia. The primary outcome was clinical success. Secondary outcomes included postprocedural gastroesophageal reflux disease (GERD), adverse events (AEs), manometric findings, and procedure-related parameters. Random-effects models were used for the primary analysis.

RESULTS

Four RCTs enrolling 488 patients were included. Overall clinical success 3-12 months after POEM was 97% (95% confidence interval [CI] 93-100%) and did not differ between anterior and posterior myotomy (Relative risk [RR] 0.98, 95%CI: 0.96-1.01; I2: 0%). Incidence of GERD after POEM based on 24-hour pH monitoring (RR 0.98, 95%CI: 0.75-1.28), endoscopy (RR 1.04, 95%CI: 0.78-1.38), and symptoms (RR 0.89, 95%CI: 0.55-1.42) was similar. Posterior myotomy was associated with fewer AEs (RR 0.63, 95%CI: 0.42-0.94), lower risk of mucosotomy (RR 0.42, 95%CI: 0.27-0.66) and shorter incision closure time (mean difference: -2.28 minutes, 95%CI: -3.46 to -1.10). Anterior myotomy was associated with a shorter length of hospitalization (mean difference: 0.31 days, 95%CI: 0.05-0.57), although the clinical relevance of this finding is negligible. No significant differences were found regarding manometric outcomes, total operation and myotomy time.

CONCLUSIONS

Anterior and posterior myotomy are equally effective for the treatment of achalasia, without significant differences in postprocedural GERD. Posterior POEM was associated with fewer AEs and a shorter incision closure time.

Periodontitis Is Associated with Chronic Obstructive Pulmonary Disease

Although they are known to share pathophysiological processes, the relationship between periodontitis and chronic obstructive pulmonary disease (COPD) is not fully understood. The aim of the present study was to test the hypothesis that periodontitis is associated with a greater risk of development of COPD, when smoking is taken into account. The analysis in a 5-y follow-up population-based cohort study was based on 900 community-dwelling Japanese adults (age: 68.8 ± 6.3 [mean ± SD], 46.0% male) without COPD aged 60 or older with at least 1 tooth. Participants were classified into 3 categories according to baseline periodontitis severity (no/mild, moderate, and severe). COPD was spirometrically determined by a fixed ratio of <0.7 for forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) and by FEV1/FVC below the lower limit of normal. Poisson regression was used to calculate the relative risk (RR) of developing COPD according to the severity of periodontitis. The population attributable fraction (PAF) was also calculated. During follow-up, 22 (2.4%) subjects developed COPD. Compared with no/mild periodontitis subjects, a significantly increased risk of COPD occurred among severe periodontitis subjects (RR = 3.55; 95% confidence interval [CI], 1.18 to 10.67), but no significant differences were observed between the no/mild and moderate categories (RR = 1.48; 95% CI, 0.56 to 3.90). After adjustment for potential confounders, including smoking intensity, the relationship between severe periodontitis and risk of COPD remained significant (RR = 3.51; 95% CI, 1.15 to 10.74). Likewise, there was a positive association of periodontitis severity with risk of COPD ( P for trend = 0.043). The PAF for COPD due to periodontitis was 22.6%. These data highlight the potential importance of periodontitis as a risk factor for COPD.

Bioactive TiNbSn alloy prepared by anodization in sulfuric acid electrolytes

The bioactivity of anodized near-β TiNbSn alloy with low Young's modulus prepared in sulfuric acid electrolytes was examined to explore the osseointegration mechanism with a focus on the role of anodic oxide. Hydroxyapatite (HA) precipitated on the surface of anodic oxide following immersion in Hank's solution, and precipitation accelerated with increase in the sulfuric acid concentration of the electrolyte. HA is formed on the surface of as-anodized oxide without subsequent annealing or hot water (HW) treatment. This outcome differs from that of a previous study using anodized TiNbSn alloy prepared in acetic acid electrolytes requiring for subsequent HW treatment. It was found that the oxide anodized in sulfuric acid electrolyte contains a large amount of internal pores and is highly crystallized thick TiO₂, whereas the same prepared in the acetic acid electrolyte is low crystalline thin TiO₂ containing a small amount of pores. The present anodized TiNbSn alloy is preferred for maintaining the low Young's modulus of the alloy and eliminating the subsequent treatment to increase the Young's modulus. A model to rationalize the bioactivity of the present anodic oxide is proposed based on the series of studies. It is concluded that the sulfuric acid electrolyte is favorable for both HA formation and low Young's modulus, and the bioactivity is attributed to the anodic TiO₂ that facilitates incorporation of bone ingredients.

Peroral endoscopic myotomy (POEM) for complex achalasia and the POEM difficulty score

BACKGROUND

Peroral endoscopic myotomy (POEM) for achalasia is technically challenging to carry out in patients with type III, multiple prior treatments, prior myotomy, and sigmoid type. Herein, we present a series of consecutive patients with complex achalasia and introduce the POEM difficulty score (PDS).

AIM

To demonstrate the application and discuss the utility of PDS and present the feasibility, safety, and efficacy of POEM in complex achalasia patients.

METHODS

Forty consecutive POEM were carried out with 28 meeting the criteria for complex achalasia. Primary outcome was clinical success (Eckardt score ≤3) at a minimum of 3 months follow-up. Secondary outcomes included adverse events, procedural velocity and PDS.

RESULTS

Twenty-eight complex and 12 non-complex POEM procedures were carried out with 100% and 92% clinical success, respectively, without any major adverse events with a median follow up of 15 months (complex) and 8 months (non-complex). Mean velocities for non-complex, type III, prior myotomy, ≥4 procedures and sigmoid type were as follows: 4.4 ± 1.6, 4.8 ± 1.5, 5.9 ± 2.2, 6.9 ± 2.2 and 8.2 ± 3.2 min/cm, respectively. Median PDS for non-complex, type III, prior myotomy, ≥4 treatments and sigmoid type were 1 (0-3), 2 (0-4), 2.5 (1-6), 3 (2-6) and 3.5 (1-6), respectively. PDS was shown to correlate well with procedural velocity with a correlation coefficient of 0.772 (Spearman's P < 0.001).

CONCLUSIONS

PDS identifies the factors that contribute to challenging POEM procedures and correlates well with procedural velocity. The order of increasing difficulty of POEM in complex achalasia appears to be type III, prior myotomy, ≥4 treatments and sigmoid type.

Raman spectroscopic evaluation of human serum using metal plate and 785- and 1064-nm excitation lasers

In this study, we utilized a stainless steel (SUS304) plate for measuring the Raman scattering spectra of body fluid samples. Using this stainless steel plate, we recorded the Raman scattering spectra of 99.5% ethanol and human serum samples by performing irradiation with 785- and 1064-nm lasers. Raman scattering spectra with intensities equal to or greater than those reported previously were obtained. In addition, the Raman scattering spectra acquired using the 1064-nm laser were less influenced by autofluorescence than those obtained via use of the shorter-wavelength laser. Moreover, the shapes of the spectra did not show any dependence on integration time, and denaturation of the samples was minimal. Our method, based on 1064-nm laser and the stainless steel plate, provides performance equal to or better than the methods reported thus far for the measurement of Raman scattering spectra from liquid samples. This method can be employed to rapidly evaluate the components of serum in liquid form without using surface-enhanced Raman scattering.

Abstract OT2-02-01: A confirmation study of omitting axillary dissection in patients with breast cancer and positive sentinel nodes

Background

The omission of axillary dissection for positive sentinel-node breast cancer is considered the standard treatment for patients who undergo breast conserving surgery and radiation therapy, according to the results of ACOSOG-Z0011 and AMAROS trials. On the other hand, some surgeons still think that the surgical stress of axillary dissection is minimal, and dissection is permitted. Furthermore, Z0011 contains several problems, such as insufficient number of entry cases and lack of radiation field unity. Thus, we planned a prospective trial to confirm the safety of omitting axillary dissection in patients with breast cancer and positive sentinel nodes.

Trial design

This is a single arm, confirmation study of three medical centers. Prior to surgery, informed consent is obtained, and patients are registered primarily. After surgery, patients with 1 to 2 positive sentinel nodes, for whom axillary dissection was omitted, are finally included in this trial at final registration.

Eligibility criteria

Patients with histologically-diagnosed breast cancer, Tis–2, N0 based on a core needle biopsy, will be included in this trial. Eligible patients must be between 20 and 80 years of age, with a performance status of 0–2 and adequate organ function. They must not have undergone any prior operation, radiation therapy, chemotherapy, endocrine therapy, or immunotherapy.

Specific aims

The primary endpoint is 5-year (y) axillary recurrence rate. Secondary endpoints are 5-y overall survival, 5-y recurrence-free survival, 5-y local recurrence-free survival, the rate of upper-limb lymphedema, quality of life, and comparison of axillary recurrence rates between patients with two or more dissected nodes and those with only one positive node.

Statistical methods

The expected rate of axillary recurrence is 2.0%, and non-inferiority is defined as an axillary recurrence lesser than or equal to 5% in the axillary radiotherapy group. The sample size was calculated with a study power of 80% and type I error of 10% (two-sided). The required number of patients is estimated to be 189.

Present and target accrual

Patient accrual from the three medical centers was initiated in July 2016. We plan to enroll a total of 189 patients at final registration in this trial.

Citation Format: Jibiki N, Hirano A, Ochi T, Sakamoto A, Horiuchi K, Noguchi E, Omi Y, Ogura K, Inoue H, Kamio T, Naritaka Y, Fujibayashi M, Hiroshima K, Nagashima Y, Sakai S, Karasawa K, Okamoto T. A confirmation study of omitting axillary dissection in patients with breast cancer and positive sentinel nodes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-02-01.

Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure

BACKGROUND

Peroral endoscopic myotomy (POEM) has become the minimally invasive endoscopic treatment for achalasia; however, gastroesophageal reflux (GER) post-POEM has been reported. A pilot study was conducted in which an endoscopic fundoplication was added to the standard POEM (POEM + F) procedure to overcome this issue. We report the technical details of POEM + F and short-term safety results.

METHODS

POEM + F was performed in 21 patients. After completing myotomy, the endoscope was advanced from the submucosal tunnel into the peritoneal cavity. A partial mechanical barrier was created by retracting the anterior gastric wall at the esophagogastric junction with the use of endoclips and an endoloop.

RESULTS

POEM + F was technically feasible in all cases and created a visually recognizable fundoplication. The clinical course after POEM + F was uneventful. No immediate or delayed complications occurred.

CONCLUSION

POEM + F may help mitigate the post-POEM incidence of GER and serve as a minimally invasive endoscopic alternative to a laparoscopic Heller-Dor procedure. This is the largest case series of peroral natural orifice transluminal endoscopic surgery without laparoscopic assistance in the human foregut.