Comparable Efficacy of a 1-L PEG and Ascorbic Acid Solution Administered with Bisacodyl versus a 2-L PEG and Ascorbic Acid Solution for Colonoscopy Preparation: A Prospective, Randomized and Investigator-Blinded Trial

BACKGROUND

Two liters of polyethylene glycol (PEG) solution administered with ascorbic acid (Asc) can provide efficacy similar to that of a 4-L PEG solution for colonoscopy preparation. In addition, oral bisacodyl (Bis) has been shown to reduce the volume of PEG needed for a bowel preparation with comparable efficacy. This study aimed to compare the efficacy, tolerability and safety of a 2-L PEG solution mixed with Asc versus the combination of Bis, Asc and a 1-L PEG solution.

METHODS

This was a prospective, randomized, multi-centre, single-blind, non-inferiority trial. Participants who were scheduled for colonoscopy were included and randomized to receive either 2-L PEG and Asc (2L PEG/Asc group) or 1-L PEG, Asc and 20 mg Bis (1L PEG/Asc + Bis group). The quality of bowel preparation was assessed using the Boston Bowel Preparation Scale. Data regarding tolerance, compliance and adverse events were also gathered.

RESULTS

A total of 187 participants were analyzed; 96 were allocated to the 2L PEG/Asc group and 91 to the 1L PEG/Asc + Bis group. Bowel preparation was adequate in 87.5% (84/96) of patients in the 2L PEG/Asc group and 94.5% of the 1L PEG/Asc + Bis group (86/91, p = 0.10). There was no significant difference between the two groups with respect to compliance, tolerability or safety. The patients allocated to the 1L PEG/Asc + Bis group expressed more willingness to repeat the procedure than patients in the 2L PEG/Asc group (p = 0.01).

CONCLUSIONS

Bowel preparation with Bis and a 1-L PEG/Asc solution is as effective, well-tolerated, and safe as a 2-L PEG/Asc solution.

TRIAL REGISTRATION

ClinicalTrials.gov NCT 01745835; Clinical Research Information Service (CRiS) KCT0000708.

Bowel preparation for colonoscopy: state of the art

PURPOSE OF REVIEW

Bowel preparation for colonoscopy is a key quality indicator that impacts on all aspects of the procedure, such as patient comfort, diagnostic yield, and adverse events. Although most laxative regimens currently employed have been compared in a multitude of settings, the optimal preparation regimen still remains an open question.

RECENT FINDINGS

Recent studies have focused on developing new regimens by modifying dosage, timing of administration or by combining laxatives with synergic mechanisms of action with the purpose of increasing patient tolerability while maximizing bowel cleansing. Several low-volume preparations and combinations of laxatives and adjunctive medication have shown promise in delivering both adequate preparation of the colon and good patient tolerability. Also, we have gained a better understanding of the influence of patient-related factors such as health literacy and education on the quality of bowel preparation.

SUMMARY

Although several novel regimens have been tested in recent trials, it remains unclear which, if any, of these bowel preparations can replace the standard bowel cleansing regimens in clinical practice. Also, further data are required on how to improve bowel cleansing by choosing the appropriate regimen for the individual patient.

Prospective evaluation of CT esophagram findings after peroral endoscopic myotomy

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) is a procedure with potential for serious adverse events. Postprocedure imaging is routinely done, yet there is no consensus on the optimal imaging protocol. We describe a novel and simple CT esophagram protocol for evaluation after POEM and for reporting the full spectrum of radiographic findings and subsequent interventions.

METHODS

This was a single-center prospective study of consecutive patients treated with POEM evaluated with CT esophagram.

RESULTS

Eighty-four consecutive patients who had POEM performed underwent CT esophagrams. The most common findings were pneumomediastinum (85.7%), pneumoperitoneum (66.7%), subcutaneous emphysema (52.4%), and pleural effusion (46.4%). Other findings included retroperitoneal air (38.1%), pneumothorax (19%), atelectasis (14.3%), intramural air in the esophagus and/or stomach (13.1%), pericardial effusion (2.4%), and pneumopericardium (2.4%). Five patients required intervention based on CT findings. In 1 patient, a leak was detected on CT esophagram before any clinical manifestation, facilitating prompt intervention and avoiding potential serious outcomes. Four patients were diagnosed with pneumonia and were treated with antibiotics. There was frequent postprocedural atelectasis, which prompted the introduction of routine incentive spirometry in all postoperative POEM cases.

CONCLUSIONS

CT esophagram is a simple and accessible imaging test for routine postoperative POEM evaluation. Numerous and dramatic postprocedure radiographic findings may be expected and demonstrated with this imaging modality. Although most of these findings may not require intervention, some are of potential significance, and early identification may help modify postprocedure management. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01832779.).

Endoscopic Closure for Full-Thickness Gastrointestinal Defects: Available Applications and Emerging Innovations

Full-thickness gastrointestinal defects such as perforation, anastomotic leak, and fistula are severe conditions caused by various types of pathologies. They are more likely to require intensive care and a long hospital stay and have high rates of morbidity and mortality. After intentional full-thickness opening of hollow organs for natural orifice transluminal endoscopic surgery, safe and secure closure is urgently required. The currently available advanced endoscopic closing techniques have a major role in the treatment of full-thickness gastrointestinal defects. Appropriate usage of these techniques requires taking into account their advantages and limitations during practical application. We reviewed the available endoscopic modalities, including endoscopic clips, stents, vacuum-assisted closure, gap filling, and suturing devices, discussed their advantages and limitations when treating full-thickness gastrointestinal defects, and explored emerging innovations, including a novel endoluminal surgical platform for versatile suturing and a cell-laden scaffold for effective gap filling. Although these emerging technologies still require further pre-clinical and clinical trials to assess their feasibility and efficacy, the available modalities may be replaced and refined by these new techniques in the near future.

Spices for Prevention and Treatment of Cancers

Spices have been widely used as food flavorings and folk medicines for thousands of years. Numerous studies have documented the antioxidant, anti-inflammatory and immunomodulatory effects of spices, which might be related to prevention and treatment of several cancers, including lung, liver, breast, stomach, colorectum, cervix, and prostate cancers. Several spices are potential sources for prevention and treatment of cancers, such as Curcuma longa (tumeric), Nigella sativa (black cumin), Zingiber officinale (ginger), Allium sativum (garlic), Crocus sativus (saffron), Piper nigrum (black pepper) and Capsicum annum (chili pepper), which contained several important bioactive compounds, such as curcumin, thymoquinone, piperine and capsaicin. The main mechanisms of action include inducing apoptosis, inhibiting proliferation, migration and invasion of tumors, and sensitizing tumors to radiotherapy and chemotherapy. This review summarized recent studies on some spices for prevention and treatment of cancers, and special attention was paid to bioactive components and mechanisms of action.

Korean Red Ginseng water extract arrests growth of xenografted lymphoma cells

Background

Although numerous studies of the anticancer activities of Korean Red Ginseng (KRG) have been performed, the therapeutic effect of KRG on leukemia has not been fully elucidated. In this study, we investigated the antileukemia activities of KRG and its cellular and molecular mechanisms.

Methods

An established leukemia tumor model induced by xenografted T cell lymphoma (RMA cells) was used to test the therapeutic activity of KRG water extract (KRG-WE). Direct cytotoxic activity of KRG-WE was confirmed by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. The immunomodulatory activities of KRG-WE were verified by immunohistochemistry, nitric oxide production assay. The inhibitory effect of KRG-WE on cell survival signaling was also examined.

Results

Orally administered KRG-WE reduced the sizes of tumor masses. Levels of apoptosis regulatory enzymes and cleaved forms of caspases-3 and -8 were increased by this extract. In addition, expression of matrix metalloproteinase-9, a metastasis regulatory enzyme, was decreased by KRG-WE treatment. The proportion of CD11c+ cells was remarkably increased in the KRG-treated group compared to the control group. However, KRG-WE did not show significant direct cytotoxicity against RMA cells.

Conclusion

Our results strongly suggest that the KRG might have antileukemia activity through CD11c+ cell-mediated antitumor immunity.

Constipation, fiber intake and non-compliance contribute to inadequate colonoscopy bowel preparation: a prospective cohort study

OBJECTIVE

Adequate bowel preparation is important for colonoscopy. Currently available evidence on the determinants of poor bowel preparation is largely derived from studies in Western countries. We aimed to identify the risk factors for inadequate bowel preparation for colonoscopy in the Chinese population.

METHODS

In this single-center study, patients admitted to the Outpatient Department between March 2013 and December 2015 and had indications for colonoscopy were prospectively enrolled. Questionnaires were administered to the patients. Their characteristics and procedure-related parameters such as procedure time were recorded. Bowel preparation was assessed using Boston bowel preparation scale score.

RESULTS

A total of 409 patients with a mean age of 48.8 ± 12.9 years were enrolled in the study, 60.9% of whom were men. On univariate analysis, poor educational level (P = 0.020), chronic constipation (P = 0.001), taking no physical exercise after medication (P < 0.001), a high-fiber diet during the 24-h period immediately preceding the colonoscopy (P < 0.001), incomplete intake of medication (P < 0.001), the passage of yellow or dark stools before colonoscopy (P < 0.001), waiting time (P = 0.001) and stool frequency after medication (P = 0.048) were significantly associated with inadequate bowel preparation. On multivariate analysis, chronic constipation [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.31-3.23, P = 0.002], incomplete intake of the medication (OR 2.77, 95% CI 1.47-5.21, P = 0.002) and a high-fiber diet within 24 h before colonoscopy (OR 2.15, 95% CI 1.40-3.28, P < 0.001) were independent risk factors for inadequate bowel preparation.

CONCLUSIONS

Chronic constipation, poor compliance with treatment and high-fiber diet were predictors of poor bowel preparation. Patients with these risk factors require more effective strategies for bowel preparation.

Neuroendocrine carcinoma of the esophagus: clinical characteristics and prognostic evaluation of 49 cases with surgical resection

BACKGROUND

The clinicopathological features and optimum treatment of esophageal neuroendocrine carcinoma (NEC) are hardly known due to its rarity. Therefore, we conducted a retrospective study to analyze the clinical characteristics and prognosis of patients with surgically resected esophageal NEC.

METHODS

We collected clinicopathological data on consecutive limited disease stage esophageal NEC patients who underwent esophagectomy with regional lymphadenectomy in West China Hospital from January 2007 to December 2013.

RESULTS

A total of forty-nine patients were analyzed retrospectively. The mean age of the patients was 58.4±8.2 years with male predominance. Fifty-five percent of the esophageal NEC were located in the middle thoracic esophagus. Histologically, 28 (57.1%) patients were found to be small cell NECs. Fifty-one percent of the patients were found to have lymph node metastasis. According to the 2009 American Joint Committee on Cancer (AJCC) staging system for esophageal squamous cell carcinoma, 9 patients were at stage I, 21 patients stage II, and 19 patients stage III. Twenty-six patients (53.1%) received adjuvant therapy. After a median follow-up of 44.8 months [95% confidence interval (CI), 35.2-50.4 months], the median survival time of the patients was 22.4 months (95% CI, 14.0-30.8 months). The 1-year and 3-year survival rates for the whole cohort patients were 74.9% and 35.3%, respectively. In univariate analysis, TNM staging, lymph node metastasis and adjutant therapy significantly influenced survival time. In multivariate analysis, TNM staging was the only independent prognostic factor.

CONCLUSIONS

Esophageal NEC has a poor prognosis. The 2009 AJCC TNM staging system for esophageal squamous cell carcinoma may also fit for esophageal NEC. Surgery combined with adjuvant therapy may be a good option for treating limited disease stage esophageal NEC. Further prospective studies defining the optimum therapeutic regimen for esophageal NEC are needed.

Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years

BACKGROUND

The recently developed technique for peroral endoscopic myotomy (POEM) has been shown to be effective in several short-term studies. Longer term outcome data are largely non-existent.

OBJECTIVE

To systematically report clinical outcome with a minimum post-POEM follow-up of 2 years.

DESIGN

All patients treated consecutively by POEM for achalasia at three centres were retrospectively analysed, with a minimum follow-up of 2 years. The main outcome was the rate of POEM failures (Eckardt score >3) related to follow-up time.

RESULTS

Of 85 patients treated, five (5.9%) cases were excluded due to protocol violation or loss to follow-up; the remaining 80 patients (mean age 44.9 years, 54% men) were followed clinically for 29 months (range 24-41). Initial clinical response was observed in 77 cases (96.3%). Clinical recurrences (later failures) were seen in a further 14 cases (17.7%), accounting for a total failure rate of 21.5%. In a multivariate analysis, age and endoscopic reflux signs were independent predictors of treatment success. Of the 17 failures, eight were among the first 10 cases treated in the participating centres. Reflux-associated sequelae included one case of a severe reflux-associated stricture requiring dilatation, and two patients with minor transient Eckardt score elevations curable by proton pump inhibitor (PPI) treatment. Endoscopic signs of reflux oesophagitis, mostly Los Angeles grade A/B, were seen in 37.5% (37/72) at the 2-year control.

CONCLUSIONS

In this multicentre retrospective analysis, a high initial success rate of POEM is followed by a mid-term recurrence rate of 18%. Reflux oesophagitis, albeit mild, is frequent and should probably be treated by regular low-dose PPI therapy.

TRIAL REGISTRATION NUMBER

NCT 01405417 (UKE study).

Clinicopathological Profile of Pure Neuroendocrine Neoplasms of the Esophagus: A South Indian Center Experience

Purpose. Neuroendocrine neoplasms (NENs) of the esophagus are very uncommon with only a few studies published worldwide. Studies on clinical profile, management, and outcomes are very uncommon. Methods. We report the largest single institution retrospective review of 43 patients of pure esophageal NENs out of our registry of gastrointestinal neuroendocrine tumors treated between 2005 and 2014. Data on the incidence, tumor location, clinical symptoms, stage at presentation, grading, treatment protocol, and treatment outcomes was collected and analyzed. Results. Among 1293 cases of esophageal cancers, pure esophageal NENs were diagnosed in 43 cases. The mean patient age was 55.8 years. The male : female ratio was 1.5 : 1. 81.4% of the tumors were located in the lower third of the esophagus and gastroesophageal junction. Neuroendocrine carcinomas (NEC; G3) accounted for the vast majority of NENs (83.7%). 53.5% patients were Stage IV and 32.5% were Stage III at presentation. The combined median survival of stages II and III patients was 18.25 months, with treatment. The median survival of treated patients with metastatic disease was 6.5 months. Conclusion. Esophageal NENs most commonly were neuroendocrine carcinomas, presented in metastatic stage and were associated with poor prognosis. Grade 2 (G2) tumors had better outcomes than NEC (G3). In nonmetastatic disease, presence of lymph node metastasis and unresectable disease had poorer outcomes.

Endoscopic resection versus surgery for early gastric cancer and precancerous lesions: a meta-analysis

Aim

To compare the efficacy and safety of endoscopic resection (ER) and surgery for the treatment of early gastric cancer and precancerous lesions.

Methods

Databases, such as PubMed, EMBASE, Cochrane Library, and Science Citation Index, from 2000 to 2016, were searched for eligible articles. In this meta-analysis, the main outcome measurements were local recurrence, complications, metachronous lesions, hospital stay, and 5-year overall survival.

Results

Nine trials were identified and a total of 2748 patients were included. The rate of complication was higher in the surgery group compared with the ER group (OR 0.41; 95 % CI 0.30–0.55). The rates of local recurrence and metachronous lesions were lower in the surgery group (OR 0.03; 95 % CI 0.00–0.06; OR 8.76; 95 % CI 4.17–18.41). The hospital stay was shorter in the ER group (mean difference −6.96; 95 % CI −7.94 to −5.99). The 5-year overall survival rate did not significantly differ between the two groups (OR 1.23; 95 % CI 1.03–1.47).

Conclusions

We provided evidence that, ER was comparable to surgery in terms of the 5-year overall survival. In addition, ER had a lower rate of complications and shorter hospital stay, but a higher rate of local recurrence and metachronous lesions for the treatment of early gastric cancer and precancerous lesions.

Role of Endoscopic Ultrasonography in Guiding Treatment Plans for Upper Gastrointestinal Subepithelial Tumors

Gastrointestinal (GI) subepithelial tumors (SETs) are usually observed incidentally by endoscopy and have diverse prognoses, varying from benign to potentially malignant. When a GI SET is suspected, endoscopic ultrasonography (EUS) is the most accurate diagnostic method to differentiate it from extraluminal compression. To determine the nature of GI SETs, EUS is also the most accurate diagnostic method, and reveals the precise sonographic nature of the lesion. There are some SETs with typical EUS findings of GI SETs, but most hypoechoic lesions are difficult to diagnose based on EUS images alone. EUS is also helpful to determine GI wall involvement in SETs and optimal treatment methods. For the diagnosis of GI SETs, obtaining a proper specimen is essential. EUS-guided cytology or biopsy methods such as fine-needle aspiration, Tru-Cut biopsy, and the newly introduced fine-needle biopsy (FNB) provide good results. To increase the diagnostic yield for GI SETs, cytology with immunocytochemical staining is used for cytological interpretation, resulting in good diagnostic yields. Recently, EUS-FNB using cheese slicer technology has been introduced, and has been reported to provide good diagnostic results for GI SETs.

Recent developments and innovations in gastric cancer

Gastric cancer has an important place in the worldwide incidence of cancer and cancer-related deaths. It can metastasize to the lymph nodes in the early stages, and lymph node metastasis is an important prognostic factor. Surgery is a very important part of gastric cancer treatment. A D2 lymphadenectomy is the standard surgical treatment for cT1N+ and T2-T4 cancers, which are potentially curable. Recently, the TNM classification system was reorganized, and the margins for gastrectomy and lymphadenectomy were revised. Endoscopic, laparoscopic and robotic treatments of gastric cancer have progressed rapidly with development of surgical instruments and techniques, especially in Eastern countries. Different endoscopic resection techniques have been identified, and these can be divided into two main categories: endoscopic mucosal resection and endoscopic submucosal dissection. Minimally invasive surgery has been reported to be safe and effective for early gastric cancer, and it can be successfully applied to advanced gastric cancer with increasing experience. Cytoreductive surgery and hyperthermıc intraperıtoneal chemotherapy were developed as a combined treatment modality from the results of experimental and clinical studies. Also, hyperthermia increases the antitumor activity and penetration of chemotherapeutics. Trastuzumab which is a monoclonal antibody interacts with human epidermal growth factor (HER) 2 and is related to gastric carcinoma. The anti-tumor mechanism of trastuzumab is not clearly known, but mechanisms such as interruption of the HER2-mediated cell signaling pathways and cell cycle progression have been reported previously. H. pylori is involved in 90% of all gastric malignancies and Japanese guidelines strongly recommend that all H. pylori infections should be eradicated regardless of the associated disease. In this review, we present innovations discussed in recent studies.

Achalasia: current treatment options

Achalasia is a rare esophageal motility disorder, characterized by impaired swallow-induced, lower esophageal sphincter (LES) relaxation and defective esophageal peristalsis. Unfortunately, there are no etiological therapies for achalasia. Patients present with dysphagia, chest pain and regurgitation of undigested food, often leading to weight loss. The currently available treatments have the common aim of relieving symptoms by decreasing the pressure of the LES. This can be achieved with some medications, by inhibiting the cholinergic innervation (botulinum toxin), by stretching (endoscopic dilation) or cutting (surgery) the LES. Recently, other therapeutic options, including per-oral endoscopic myotomy have been developed and are gaining international consensus. The authors report on the benefits and weaknesses of the different therapies and provide an updated approach to the management of achalasia.

Peroral Endoscopic Myotomy for Esophageal Achalasia: Outcomes of the First 100 Patients With Short-term Follow-up

OBJECTIVE

Aim of this study is to report the mid-term outcomes of a large series of patients treated with peroral endoscopic myotomy (POEM) in a single European center.

BACKGROUND

POEM is a recently developed treatment of achalasia, which combines the efficacy of surgical myotomy, with the benefits of an endoscopic procedure. Previous studies, including few patients with a short-term follow-up, showed excellent results on dysphagia relief.

METHODS

The first 100 adult patients treated in a single tertiary referral center were retrospectively identified and included in this study (41 men, mean age 48.4 years). Patients were treated according to a standard technique. Follow-up data, including clinical evaluation, and results of esophagogastroduodenoscopy (EGD), manometry, and pH monitoring were collected and analyzed.

RESULTS

POEM was completed in 94% of patients. Mean operative time was 83 minutes (49-140  minutes). No complications occurred. Patients were fed after a median of 2 days (1-4 days). A mean follow-up of 11 months (3-24 months) was available for 92 patients. Clinical success was documented in 94.5% of patients. Twenty-four-hour pH monitoring documented Gastro-Esophageal Reflux Disease (GERD) in 53.4% of patients. However, only a minority of patients had heartburn (24.3%) or esophagitis (27.4%), and these patients were successfully treated with proton-pump inhibitors.

CONCLUSIONS

Our results confirm the efficacy of POEM in a large series of patients, with a mean follow-up of 11 months. Should our results be confirmed by long-term follow-up studies, POEM may become one of the first-line therapies of achalasia in the next future.

Endoscopic resection of early gastric cancer: current status and new approaches

Endoscopic resection (ER) of early gastric cancer (EGC) has been an optimal treatment for selected patients. As endoscopic submucosal dissection (ESD) has been widely used for treatment of EGC, concerns have been asked to achieve curative resection for EGC while guaranteeing precise prediction of lymph node metastasis (LNM). Moreover, a new microscopic imaging for precise endoscopic diagnosis of EGC is introduced. This review covers the current status and new approaches of ER of EGC.

Optimizing bowel preparation for colonoscopy: a guide to enhance quality of visualization

Colonoscopy is an important screening and therapeutic modality for colorectal cancer. Unlike other screening tests, colonoscopy is dependent on pre-procedure bowel preparation. If the bowel preparation is poor, significant pathology may be missed. Many factors are known to improve bowel preparation. This review will highlight those factors that may optimize the bowel preparation, including choice of bowel preparation, grading or scoring of the bowel preparation, special factors that influence preparation, and diet prior to colonoscopy that affects bowel preparation. The aim of the review is to offer suggestions and guide endoscopists on how to optimize the bowel preparation for the patients undergoing colonoscopy.

Polyethylene glycol plus ascorbic acid is as effective as sodium picosulfate with magnesium citrate for bowel preparation: A randomized trial

OBJECTIVE

This study was aimed to evaluate the efficacy and safety of two low-volume agents, polyethylene glycol (PEG)-3350 plus ascorbic acid (PEG + Asc) and sodium picosulfate with magnesium citrate (SPMC), for bowel preparation.

METHODS

We performed a prospective, endoscopist-blinded, single-center, randomized controlled trial comparing PEG + Asc with SPMC to evaluate the bowel cleansing efficacy of the two regimens using the modified Ottawa bowel preparation scale (OBPS) and the Aronchick scale. Patients' taste and overall tolerance were assessed with a questionnaire.

RESULTS

In total, 200 patients were randomized to receive either PEG + Asc (n = 98) or SPMC (n = 102). Both treatments were similarly efficacious in bowel cleansing, based on the modified OBSP (PEG + Asc 4.01 ± 2.29 vs SPMC 3.86 ± 2.47, P = 0.62) and Aronchick scale (PEG + Asc 1.96 ± 0.70 vs SPMC 1.89 ± 0.70, P = 0.42). Patient-reported taste and tolerance of each regimen, as reported by the questionnaire, were significantly greater in the PEG + Asc group than in the SPMC group (P = 0.01). In terms of adverse events, dizziness was more frequently observed in the PEG + Asc group (P = 0.03), whereas nausea was more common in the SPMC group (P = 0.02).

CONCLUSIONS

PEG + Asc and SPMC show similar efficacy for bowel preparation. However, patient's overall tolerance is higher in the PEG + Asc group.

Curcumin directly inhibits the transport activity of GLUT1

Curcumin, a major ingredient in turmeric, has a long history of medicinal applications in a wide array of maladies including treatment for diabetes and cancer. Seemingly counterintuitive to the documented hypoglycemic effects of curcumin, however, a recent report indicates that curcumin directly inhibits glucose uptake in adipocytes. The major glucose transporter in adipocytes is GLUT4. Therefore, this study investigates the effects of curcumin in cell lines where the major transporter is GLUT1. We report that curcumin has an immediate inhibitory effect on basal glucose uptake in L929 fibroblast cells with a maximum inhibition of 80% achieved at 75 μM curcumin. Curcumin also blocks activation of glucose uptake by azide, glucose deprivation, hydroxylamine, or phenylarsine oxide. Inhibition does not increase with exposure time and the inhibitory effects reverse within an hour. Inhibition does not appear to involve a reaction between curcumin and the thiol side chain of a cysteine residue since neither prior treatment of cells with iodoacetamide nor curcumin with cysteine alters curcumin's inhibitory effects. Curcumin is a mixed inhibitor reducing the Vmax of 2DG transport by about half with little effect on the Km. The inhibitory effects of curcumin are not additive to the effects of cytochalasin B and 75 μM curcumin actually reduces specific cytochalasin B binding by 80%. Taken together, the data suggest that curcumin binds directly to GLUT1 at a site that overlaps with the cytochalasin B binding site and thereby inhibits glucose transport. A direct inhibition of GLUT proteins in intestinal epithelial cells would likely reduce absorption of dietary glucose and contribute to a hypoglycemic effect of curcumin. Also, inhibition of GLUT1 activity might compromise cancer cells that overexpress GLUT1 and be another possible mechanism for the documented anticancer effects of curcumin.

Jackhammer esophagus treated by a peroral endoscopic myotomy

A 49-year-old woman visited our hospital with dysphagia and chest pain. In another hospital, she was diagnosed as reflux esophagitis. Although she had taken proton pump inhibitor and prokinetics drugs for a long time, she was not relieved of any symptoms. On the basis of high resolution manometry and endoscopic ultrasonography findings, Jackhammer esophagus was diagnosed. In this patient, peroral endoscopic myotomy (POEM) was performed for long myotomy of thickened circular muscle. During the procedure, there were no significant complications and she was discharged uneventfully. Symptoms were completely improved during three months after POEM. Here, we report on a case of Jackhammer esophagus treated by POEM.

Double-Scope Peroral Endoscopic Myotomy (POEM) for Esophageal Achalasia: The First Trial of a New Double-Scope POEM

With the accumulation of clinical trials demonstrating its efficacy and safety, peroral endoscopic myotomy (POEM) has emerged as a less invasive treatment option for esophageal achalasia compared with laparoscopic Heller myotomy. However, the difficulty in determining the exact extent of myotomy, a critical factor associated with the success and safety of the procedure, remains a limitation. Although the various endoscopic landmarks and ancillary techniques have been applied, none of these has been proven sufficient. As a solution for this limitation, the double-scope POEM technique with a second endoscope to assure the exact length of the submucosal tunnel has been applied since 2014. Before double-scope POEM was introduced, the second endoscope was applied only to confirm the accuracy of the procedure. In the present study, we performed double-scope POEM in the treatment of esophageal achalasia through a novel procedure of simultaneous application of the second endoscope to assist in the conventional POEM procedure.

Combination could be another tool for bowel preparation?

Optimal bowel preparation increases the cecal intubation rate and detection of neoplastic lesions while decreasing the procedural time and procedural-related complications. Although high-volume polyethylene glycol (PEG) solution is the most frequently used preparation for bowel cleansing, patients are often unwilling to take PEG solution due to its large volume, poor palatability, and high incidence of adverse events, such as abdominal bloating and nausea. Other purgatives include osmotic agents (e.g., sodium phosphate, magnesium citrate, and sodium sulfate), stimulant agents (e.g., senna, bisacodyl, and sodium picosulfate), and prokinetic agents (e.g., cisapride, mosapride, and itopride). A combination of PEG with an osmotic, stimulant, or prokinetic agent could effectively reduce the PEG solution volume and increase patients’ adherence. Some such solutions have been found in several published studies to not be inferior to PEG alone in terms of bowel cleansing quality. Although combination methods showed similar efficacy and safety, the value of these studies is limited by shortcomings in study design. New effective and well-tolerated combination preparations are required, in addition to rigorous new validated studies.

Diagnostic potential of endoscopic ultrasonography-elastography for gastric submucosal tumors: A pilot study

BACKGROUND AND AIM

Qualitative diagnosis for gastric submucosal tumors (SMT) is not easy. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in combination with EUS-elastography (EUS-EG) is reported useful for qualitatively diagnosing pancreatic tissues. We prospectively studied whether EUS-EG could be useful in qualitative diagnosis of gastric SMT.

METHODS

We prospectively registered 25 consecutive patients with gastric SMT diagnosed by esophagogastroduodenoscopy and carried out qualitative evaluations using EUS-EG (May 2013 to March 2015) followed by histopathological diagnosis using EUS-FNA or endoscopic mucosal cutting biopsy. Elastic scores of gastric SMT were compared to the cytological diagnosis.

RESULTS

Of 25 patients, 22 had a confirmed cytological diagnosis. Regarding the Giovannini elastic score, of three patients with aberrant pancreas, one was score 1 and two were score 2; of eight patients with leiomyoma, seven were score 2 and one was score 3. Both of two patients with schwannoma were score 4. Of nine patients with gastrointestinal stromal tumor, six were score 4 and three were score 5. Gastrointestinal stromal tumor (GIST) is harder than other types of gastric SMT, and our study's findings suggested the usefulness of EUS-EG, which can also assess tumor hardness of gastric SMT.

CONCLUSION

EUS-EG might be helpful for the differential diagnosis of gastric SMT, especially to differentiate GIST from other SMT.

Comparison of O-Type HybridKnife to Conventional Knife in Endoscopic Submucosal Dissection for Gastric Mucosal Lesions

Endoscopic submucosal dissection (ESD) has been accepted as a minimal invasive alternative to surgery for localized superficial gastrointestinal neoplasms recently. However, the procedure remains to be technically challenging and time consuming. A new dissecting knife with partially insulated tip has been recently developed with built-in injection capability. The purpose of this study was to investigate whether the efficiency of ESD procedure could be improved with this new device. A total of 78 patients, who underwent ESD with gastric mucosal lesions including flat type polyps, adenoma or early gastric cancer, were randomly assigned to either ESD with O-type HybridKnife or conventional ESD knives without waterjet. Procedure time and related factors of ESD were analyzed. ESD procedure time was 43.0 (interquartile range, IQR 27.0-60.0) minutes in HybridKnife group compared to 60.5 (IQR 44.0-86.3) minutes in the control group (P = 0.001). There was no difference in the clinical outcome and the adverse event rate. The former demonstrated more favorable results in lesions ≤4 cm of specimen size (P ≤ 0.0001) and when located in the distal stomach (P = 0.001), also in lesions with fibrosis (P = 0.008). Multivariate regression analysis showed that O-type Knife (P ≤ 0.0001), specimen size (P ≤ 0.0001), and fibrosis (P ≤ 0.0001) were independent predictors of procedure time. The O-type HybridKnife yielded faster procedure time compared to the conventional knives in gastric ESD with a similar safety profile.

Surgery or Peroral Esophageal Myotomy for Achalasia: A Systematic Review and Meta-Analysis

To date very few studies with small sample size have compared peroral esophageal myotomy (POEM) with the current surgical standard of care, laparoscopic Heller myotomy (LHM), in terms of efficacy and safety, and no recommendations have been proposed.To investigate the efficacy and safety of POEM compared with LHM, for the treatment of achalasia.The databases of Pubmed, Medline, Cochrane, and Ovid were systematically searched between January 1, 2005 and January 31, 2015, with the medical subject headings (MeSH) and keywords "achalasia," "POEM," "per oral endoscopic myotomy," and "peroral endoscopic myotomy," "laparoscopic Heller myotomy" (LHM), "Heller myotomy."All types of study designs including adult patients with diagnosis of achalasia were selected. Studies that did not report the comparison between endoscopic and surgical treatment, experimental studies in animal models, single case reports, technical reports, reviews, abstracts, and editorials were excluded.The total number of included patients was 486 (196 in POEM group and 290 in LHM group).There were no differences between POEM and LHM in reduction in Eckardt score (MD = -0.659, 95% CI: -1.70 to 0.38, P = 0.217), operative time (MD = -0.354, 95% CI: -1.12 to 0.41, P = 0.36), postoperative pain scores (MD = -1.86, 95% CI: -5.17 to 1.44, P = 0.268), analgesic requirements (MD = -0.74, 95% CI: -2.65 to 1.16, P = 0.445), and complications (OR = 1.11, 95% CI: 0.5-2.44, P = 0.796). Length of hospital stay was significantly lower for POEM (MD = -0.629, 95% CI: -1.256 to -0.002, P = 0.049). There was a trend toward significant reduction in symptomatic gastroesophageal reflux rate in favors of LHM compared to POEM group (OR = 1.81, 95% CI: 1.11-2.95, P = 0.017).All included studied were not randomized. Furthermore all selected studies did not report the results of follow-up longer than 1 year and most of them included patients who were both treatment naive and underwent previous endoscopic or surgical interventions for achalasia.POEM represents a safe and efficacy procedure comparable to the safety profile of LHM for achalasia at a short-term follow-up. Long-term clinical trials are urgently needed.

Therapy and follow-up of upper gastrointestinal subepithelial lesions

AIM: To explore the nature, growth, and malignant transformation of upper gastrointestinal submucosal lesions (SMLs), and evaluate the clinical efficacy, necessity and safety of surgery or endoscopic therapy for SMLs.

METHODS: We retrospectively collected 1915 cases of upper gastrointestinal submucous lesions, which were evaluated by endoscopic ultrasonography from January 2014 to December 2014 at our department. This diagnostic modality provided features about lesion location (esophagus and stomach), size, echo performance, layer of origin, etc. Different therapeutic methods were chosen according to the size, origin, and location of SMLs as well as patient's preferences. Clinical treatments included follow-up, endoscopic therapy (endoscopic snare resection, endoscopic resection, endoscopic submucosal resection, endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE), submucosal tunneling endoscopic resection, etc.), and surgery (open surgery, laparoscopy, and thoracoscopy). Endoscopic or surgical treatment of SMLs was performed when lesion size was significantly increased or suspected to have malignant transformation. Successful cases, size of the mass and layer of origin (mucosa layer, muscularis mucosa layer, submucosa layer, and serosal layer), complications (bleeding, perforation) and conversion surgery or not were recorded.

RESULTS: In 1135 cases followed by EUS, median age was 50.7 years ± 10.3 years (range, 19-78 years), and male/female ratio was 1.16. There were 687 esophageal SMLs and 448 gastric SMLs followed by regular endoscopy (range, 3-60 mo). Esophageal cases at initial measurement had a mean size of 0.82 cm ± 0.24 cm, and gastric cases had an initial mean size of 1.31 cm ± 0.44 cm. Of the followed cases of esophagus SMLs, 18 showed an obviously increased size (>2 cm), including 5 significantly increased cases (>3 cm) over a period of 6 mo and 13 moderately increased cases (>2 cm and <3 cm) during 12 mo. Surgical resection was performed in 5 lesions ≥3 cm in size, which were diagnosed as benign lesions in 3 (one leiomyoma and two cysts) and malignant lesions in 2 (1 leiomyosarcoma and 1 malignant granular cell tumor). Of the followed cases of gastric SMLs, 16 had an obviously increased size (>2 cm), including 10 significantly increased cases (>3 cm). Traditional surgery and endoscopic therapy were performed in 10 lesions ≥3 cm in size, which were diagnosed as gastrointestinal stromal tumors (GISTs) in 8 and leiomyomas in 2. A total of 780 cases underwent endoscopic or surgical therapy. Of 112 cases (19 esophageal cases and 93 gastric cases) treated by surgery, 2 (GIST and leiomyosarcoma) developed delayed bleeding, and the success rate of surgical treatment was 98.2%. Of 668 cases who underwent endoscopic therapy, 6 (4 in ESE group and 2 in ESD group) ended up with perforation and 4 of them (4 in ESE group) were converted to surgery; 2 (both in ESE group) developed intraoperative bleeding, which was managed by endoscopic spraying of drugs, electric coagulation and clips to achieve hemostasis; 2 cases in ESE group had failed dissection and then followed by EUS. The success rate of endoscopic therapy was 98.5%. Of 431 esophageal SMLs, there were 371 (86.08%) leiomyomas, 21 (4.87%) GISTs, and 13 (3.02%) cysts. Of 349 gastric SMLs, there were 168 (48.13%) GISTs, 87 (24.92%) leiomyomas, and 60 (17.91%) cases of ectopic pancreas.

CONCLUSION: No matter where the lesion is located, the esophagus or stomach, lesion size significantly increased over a period of 6 mo after initial measurement. However, few further change were observed in size, shape and EUS finding such as echo pattern or regularity of the outer margin over a period of 6-60 mo. Leiomyoma is the most common gastrointestinal SML in the esophagus, while GISTs are common in the stomach. Leiomyoma lesions rarely showed significant change as shown by endoscopic examination. Excessive medical therapy involves known issues associated with cost-effectiveness, patient compliance and risk of complications, and conservative treatment with regular clinical follow-up is recommended.

Greater curvature myotomy is a safe and effective modified technique in per-oral endoscopic myotomy (with videos)

BACKGROUND

Per-oral endoscopic myotomy (POEM) for achalasia with esophagocardiomyotomy in the lesser curvature (LC myotomy) is now established and accepted widely. However, in some cases LC myotomy is precluded by previous procedures, such as Heller myotomy, or by other anatomic considerations that obscure the normal dissection planes. It may also be difficult to identify the esophagogastric junction (EGJ), which can result in an incomplete gastric myotomy and poor rates of symptom relief. On the other hand, the angle of His is always located in the greater curvature of the stomach and serves as a consistent, definite landmark of the gastric side.

OBJECTIVE

To evaluate esophagocardiomyotomy in the greater curvature (GC myotomy) as an alternative POEM technique in cases where a prior LC myotomy or supervening anatomic constraints make identification of the EGJ technically challenging.

DESIGN

Prospective.

SETTING

Single-center study.

PATIENTS

Twenty-one achalasia patients who received POEM with GC myotomy.

INTERVENTIONS

POEM.

MAIN OUTCOME MEASUREMENTS

Efficacy and safety of GC myotomy measured in terms of reduction in lower esophageal sphincter (LES) pressures, improvement in Eckardt scores, and development of intraoperative or postoperative adverse events.

RESULTS

Identification of the EGJ was achieved in all cases, resulting in a mean gastric myotomy length of 2.6±1.1 cm. Mean LES pressure and Eckardt symptom scores decreased significantly (21.2±7.3 vs 10.5±2.7 mm Hg, 5 [2-8] vs 1 [0-5], respectively) (P<.01). Endoscopic evidence of gastroesophageal reflux was identified in 52% of patients (11/21) postmyotomy; however, only 9.5% (2/11) were symptomatic, and these patients were successfully controlled with proton pump inhibitors. No severe adverse events were encountered.

LIMITATIONS

Single center.

CONCLUSIONS

GC myotomy is a promising, safe modification of the POEM technique and may be especially useful in cases of redo POEM, POEM post-Heller myotomy, or when the EGJ is difficult to recognize because of supervening anatomic constraints.

Assessing Upper Esophageal Sphincter Function in Clinical Practice: a Primer

The upper esophageal sphincter constitutes an important anatomic and functional landmark in the physiology of pharyngeal swallowing. A variety of clinical circumstances may call for a dedicated evaluation of this mechanism, from the etiologic evaluation of indeterminate symptoms to the generation of complex locoregional therapeutic strategies. Multiple diagnostic tools exist for the assessment of pharyngeal swallowing generally and of upper esophageal sphincter function specifically, some well established and others not yet settled into routine practice. This report reviews five specific modalities for use in making this assessment, outlining the strengths, weaknesses, and logistical considerations of each with respect to its potential use in clinical settings. In many cases, these studies will provide complementary information regarding pharyngeal function, suggesting the relative advantage of a multimodal evaluation.

Long-Term Outcome of Endoscopic Resection vs. Surgery for Early Gastric Cancer: A Non-inferiority-Matched Cohort Study

OBJECTIVES

Few studies have compared the long-term outcomes of endoscopic resection and surgery. The aim of this study was to compare the long-term outcomes of endoscopic resection with those of surgery for early gastric cancer (EGC).

METHODS

We reviewed prospectively collected data of patients who had undergone endoscopic resection (1,290 patients) or surgery (1,273 patients) for EGC. To reduce the effect of selection bias, we performed a propensity score-matching analysis between the two groups. The primary outcome was overall survival (OS). The secondary outcomes were disease-specific survival, disease-free survival (DFS), recurrence-free survival (RFS), occurrence of metachronous gastric cancer, treatment-related complications, length of hospital stay, and 30-day outcomes. The study was designed as a non-inferiority study and tested in an intention-to-treat analysis.

RESULTS

In a propensity-matched analysis of 611 pairs, the 10-year OS proportion was 96.7% in the endoscopic resection group and 94.9% in the surgery group (P=0.120) (risk difference -1.8%, 95% confidence interval (CI) -4.04-0.44, Pnon-inferiority=0.014), which met the non-inferiority criterion. In contrast, the 10-year RFS proportion was 93.5% in the endoscopic resection group and 98.2% in the surgery group (P<0.001) (risk difference 4.7%, 95% CI 2.50-6.97, Pnon-inferiority=0.820), which did not meet the non-inferiority criterion, mainly because of metachronous recurrence in the endoscopic resection group. The rate of early complications was higher in the endoscopic resection group than in the surgery group (9.0 vs. 6.6%, P=0.024), whereas the rate of late complications was higher in the surgery group than in the endoscopic resection group (0.5 vs. 2.9%, P<0.001). In the multiple Cox regression analysis, patient's age, the comorbidity index, the performance index, sex, tumor morphology, and depth of invasion were predictors of OS in patients with EGC.

CONCLUSIONS

Endoscopic resection might not be inferior to surgery with respect to OS in patients with EGC lesions that meet the absolute or expanded criteria. However, DFS, RFS, and metachronous RFS might be lower after endoscopic resection than after surgery.

Systematic review and meta-analysis: sodium picosulfate/magnesium citrate vs. polyethylene glycol for colonoscopy preparation

BACKGROUND AND AIMS

Previous studies comparing sodium picosulfate/magnesium citrate (SPMC) with polyethylene glycol (PEG) drew inconsistent conclusions. We conducted a meta-analysis to compare the performance of the two agents for colonoscopy preparation.

METHODS

A search of randomized controlled trials (RCTs) up to July 2015 was acquired, using MEDLINE, EMBASE, the Cochrane Library, and Google Scholar. We calculated the pooled estimates of bowel cleanliness, polyp/adenoma detection rate (PDR/ADR), completion of preparation, willingness to repeat identical bowel preparation, and adverse events by using relative risk (RR) with random-effects models. A non-inferiority analysis was performed, comparing SPMC to PEG for bowel cleaning efficacy.

RESULTS

A total of 25 RCTs were qualified for analysis. There was no statistically significant difference between the two agents in bowel cleanliness, but the effect direction showed a trend in favor of PEG (RR 0.93; 95 % CI 0.86-1.01, P = 0.07). The non-inferiority analysis demonstrated the non-inferiority of SPMC by retaining at least 90 % of the effect of PEG. Similarly, there was no significant difference between the two agents in PDR (RR 0.94; 95 % CI 0.82-1.08, P = 0.37) and ADR (RR 0.88; 95 % CI 0.74-1.05, P = 0.16). However, a higher proportion of patients were likely to complete SPMC preparation (RR 1.08; 95 % CI 1.04-1.13, P < 0.001) and were willing to repeat SPMC preparation (RR 1.44; 95 % CI 1.25-1.67, P < 0.001). The total number of adverse events was significantly lower in the SPMC group (RR 0.78; 95 % CI 0.66-0.93, P = 0.004).

CONCLUSIONS

SPMC, with better tolerability and less frequent adverse events, demonstrated non-inferior bowel cleaning efficacy than that of the PEG. Large-scale, well-organized, head-to-head studies are warranted.

Gastroesophageal reflux disease after peroral endoscopic myotomy: Analysis of clinical, procedural and functional factors, associated with gastroesophageal reflux disease and esophagitis

BACKGROUND AND AIM

Peroral endoscopic myotomy (POEM) does not include any antireflux procedure, resulting in a certain risk of iatrogenic gastroesophageal reflux disease (GERD). The aim of the present study was to evaluate the incidence of iatrogenic GERD after POEM and identify preoperative, perioperative and postoperative factors associated with GERD.

METHODS

All patients treated at a single center who had a complete GERD evaluation after POEM were included in the study. Demographics, preoperative and follow-up data, results of functional studies and procedural data were collected and analyzed.

RESULTS

A total of 103 patients (mean age 46.6 years, 47 males) were included. Postoperative altered esophageal acid exposure was attested in 52 patients (50.5%). A total of 19 patients (18.4%) had heartburn and 21 had esophagitis (20.4%). Overall, a clinically relevant GERD (altered esophageal acid exposure, associated with heartburn and/or esophagitis) was diagnosed in 30 patients (29.1%). Correlation between the severity of esophageal acid exposure with heartburn and esophagitis after POEM was found. Patients with heartburn had a lower postoperative 4-second integrated relaxation pressure compared to patients without symptoms (7.6 ± 3.8 mmHg vs 10.01 ± 4.4 mmHg, p<0.05). No correlations were identified with patient sex, age, postoperative body mass index, esophageal shape (sigmoid vs non sigmoid), lower esophageal sphincter pressure, length of myotomy, previous therapies and type of achalasia at high-resolution manometry.

CONCLUSIONS

Preoperative, perioperative or postoperative factors minimally correlated with GERD after POEM. Clinically relevant GERD was identified in less than one-third of patients, but all patients were well controlled with medical therapy.

Oropharyngeal dysphagia: manifestations and diagnosis

Swallowing disorders (dysphagia) have been recognized by the WHO as a medical disability associated with increased morbidity, mortality and costs of care. With increasing survival rates and ageing of the population, swallowing disorders and their role in causing pulmonary and nutritional pathologies are becoming exceedingly important. Over the past two decades, the study of oropharyngeal dysphagia has been approached from various disciplines with considerable progress in understanding its pathophysiology. This Review describes the most frequent manifestations of oropharyngeal dysphagia and the clinical as well as instrumental techniques that are available to diagnose patients with dysphagia. However, the clinical value of these diagnostic tests and their sensitivity to predict outcomes is limited. Despite considerable clinical research efforts, conventional diagnostic methods for oropharyngeal dysphagia have limited proven accuracy in predicting aspiration and respiratory disease. We contend that incorporation of measurable objective assessments into clinical diagnosis is needed and might be key in developing novel therapeutic strategies.

Peroral Endoscopic Myotomy for Treating Achalasia and Esophageal Motility Disorders

Peroral endoscopic myotomy (POEM) is the application of esophageal myotomy to the concept of natural orifice transluminal surgery (NOTES) by utilizing a submucosal tunneling method. Since the first case of POEM was performed for treating achalasia in Japan in 2008, this procedure is being more widely used by many skillful endosopists all over the world. Currently, POEM is a spotlighted, emerging treatment option for achalasia, and the indications for POEM are expanding to include long-standing, sigmoid shaped esophagus in achalasia, even previously failed endoscopic treatment or surgical myotomy, and other spastic esophageal motility disorders. Accumulating data about POEM demonstrate excellent short-term outcomes with minimal risk of major adverse events, and some existing long-term data show the efficacy of POEM to be long lasting. In this review article, we review the technical details and clinical outcomes of POEM, and discuss some considerations of POEM in special situations.

Management of treatment-naïve limited-stage small cell esophagus carcinoma

Objectives:

To identify the problems and principles of treatment decisions in treatment-naïve limited-stage small cell esophagus carcinoma (LD-SCEC).

Methods:

Clinical data from 39 patients with LD-SCEC treated in the Chinese People’s Liberation Army General Hospital, Beijing, China between 2000 and 2013 were retrospectively collected with regard to pathologic characteristics, overall survival (OS), and relevant prognostic factors.

Results:

The median OS was 21.1 months (95% confidence interval [CI]: 12.4-29.7 months). The one-year OS was 76%, 3-year was 25%, and the 5-year OS was 8%. Depth of invasion, lymph metastasis status, and chemotherapy were independent prognostic factors. Of the 39 cases, only 38.4% (15 cases) were diagnosed as SCEC by the biopsy specimen. Eight of the 15 patients (group A) received chemotherapy and/or radiotherapy, while the remaining 7 patients (group B) and the other 24 patients (group C) received surgery as initial treatment. The one-year survival of group A was 87%, of group B was 69%, and of group C was 74% (p=0.037). The accuracy of the biopsy diagnosis influenced the treatment decisions and prognosis.

Conclusion:

Small cell esophagus carcinoma is a systemic disease, with depth of invasion, lymph metastasis status, and chemotherapy as independent prognostic factors. Systemic therapy based on chemotherapy is recommended. The top priority is to improve the accuracy of diagnosis before deciding on the initial treatment option.

[Unpleasant Journey from Helicobacter pylori-associated Gastritis to Gastric Cancer: Cancer Prevention by Taking a Detour]

As a commensal or a pathogen, Helicobacter pylori can change the balance of a complex interaction that exists among gastric epithelial cells, microbes, and their environment. Therefore, unraveling this complex relationship of these mixtures can be expected to help prevent cancer as well as troublesome unmet medical needs of H. pylori infection. Though gastric carcinogenesis is a multi-step process, precancerous lesion can be reversible in the early phase of mucosal damage before reaching the stage of no return. However, biomarkers to predict rejuvenation of precancerous atrophic gastritis have not been identified yet and gastric cancer prevention is still regarded as an impregnable fortress. However, when we take the journey from H. pylori-associated gastritis to gastric cancer, it provides us with the clue for prevention since there are two main preventive strategies: eradication and anti-inflammation. The evidence supporting the former strategy is now ongoing in Japan through a nation-wide effort to eradicate H. pylori in patients with chronic gastritis, but suboptimal apprehension to increasing H. pylori resistance to antibiotics and patient non-compliance still exists. The latter strategy has been continued in the author'sresearch center under siTRP (short-term intervention to revert premalignant lesion) strategy. By focusing on the role of inflammation in the development of H. pylori-associated gastric carcinogenesis, this review is intended to explain the connection between inflammation and gastric cancer. Strategies on H. pylori eradication, removal of inflammation, and reverting preneoplastic lesion will also be introduced. In the end, we expect to be able to prevent gastric cancer by take a detour from the unpleasant journey, i.e. from H. pylori-associated gastritis to gastric cancer.

Comparison of endoscopic resection and gastrectomy for the treatment of early gastric cancer: a meta-analysis

BACKGROUND

Endoscopic resection methods, including endoscopic mucosal resection and endoscopic submucosal dissection, have become standard treatment modalities for patients with early gastric cancer (EGC) and absolute indications, with en bloc resection being more frequent with the latter. Endoscopic resection, however, has been associated with higher recurrence and metachronous cancer rates than gastrectomy. This meta-analysis compared the efficacy and safety of endoscopic resection and gastrectomy for EGC.

METHODS

PubMed, EMBASE and Web of Science were electronically searched for relevant studies comparing endoscopic resection and gastrectomy for EGC from 1976 through March 2015. The primary endpoints were en bloc resection and histologically complete resection rates. The secondary endpoints were duration of hospital stay and rates of complications, recurrence, metachronous cancer and overall survival.

RESULTS

This meta-analysis enrolled 10 studies with 2070 patients: 993 patients who underwent endoscopic resection and 1077 who underwent gastrectomy. Endoscopic resection was associated with shorter hospital stay (standardized mean difference -2.02; 95 % confidence interval [CI] -2.64 to -1.39) and lower complication rate (relative risk [RR] 0.41; 95 % CI 0.22-0.76) than gastrectomy. However, endoscopic resection was associated with lower rates of en bloc resection (odds ratio [OR] 0.05; 95 % CI 0.02-0.16) and histologically complete resection (OR 0.04; 95 % CI 0.01-0.11) and higher rates of recurrence (RR 5.23; 95 % CI 2.43-11.27) and metachronous cancer (RR 5.22; 95 % CI 2.40-11.34) than gastrectomy. Overall survival rate (OR 1.18; 95 % CI 0.76-1.82) was similar.

CONCLUSIONS

Endoscopic resection is minimally invasive and as effective as surgery, suggesting that the former be considered standard treatment for EGC. It should be recommended as standard treatment for EGC with indications. Additional randomized controlled trials from more countries are required.

Endoscopic submucosal dissection for treatment of early esophageal cancer and precancerous lesions

Esophageal cancer is the eighth most common form of cancer worldwide. Advances in endoscopic therapy have resulted in dramatic changes in the way early esophageal cancer and precancerous lesions are managed. Endoscopic submucosal dissection (ESD) is a newly developed resection technique that is able to achieve a high R0 resection rate and a low local recurrence rate. Techniques of ESD have become established as standard methods of endoscopic resection. This review addresses some of the recent developments in the field of ESD for early esophageal cancer and precancerous lesions.

Prospective cohort study comparing transient EUS guided elastography to EUS-FNA for the diagnosis of solid pancreatic mass lesions

BACKGROUND

Semiquantitative EUS-elastography has been introduced to distinguish between malignant and benign pancreatic lesions. This study investigated whether semiquantitative EUS-guided transient real time elastography increases the diagnostic accuracy for solid pancreatic lesions compared to EUS-FNA.

PATIENTS AND METHODS

This single centre prospective cohort study included all patients with solitary pancreatic lesions on EUS during one year. Patients underwent EUS-FNA and semiquantitative EUS-elastography during the same session. EUS and elastography results were compared with final diagnosis which was made on the basis of tissue samples and long-term outcome.

RESULTS

91 patients were recruited of which 68 had pancreatic malignancy, 17 showed benign disease and 6 had cystic lesions and were excluded from further analysis. Strain ratios from malignant lesions were significantly higher (24.00; 8.01-43.94 95% CI vs 44.00; 32.42-55.00 95% CI) and ROC analysis indicated optimal cut-off of 24.82 with resulting sensitivity, specificity and accuracy of 77%, 65% and 73% respectively. B-mode EUS and EUS-FNA had an accuracy for the correct diagnosis of malignant lesions of 87% and 85%. When lowering the cut-off strain ratio for elastography to 10 the sensitivity rose to 96% with specificity of 43% and accuracy of 84%, resulting in the least accurate EUS-based method. This was confirmed by pairwise comparison.

CONCLUSION

Semiquantitative EUS-elastography does not add substantial value to the EUS-based assessment of solid pancreatic lesions when compared to B-mode imaging.

A systematic review and meta-analysis on outcomes after Rx or R1 endoscopic resection of superficial gastric cancer

OBJECTIVE

Endoscopic resection is a standard treatment for gastric superficial lesions. A positive or a nonevaluable margin is considered a noncurative criterion. We aimed to systematically review recurrence, residual disease, lymph node metastasis (LNM) and cancer-related death following Rx/R1 resection of gastric lesions in the absence of other noncurative criteria.

MATERIALS AND METHODS

MEDLINE systematic review and meta-analysis by July 2014.

RESULTS

Data were extracted from 31 manuscripts. Definitions and results differed significantly. However, nonevaluable (HMx) and positive horizontal margins (HM1) were associated with 10% [95% confidence interval (CI) 5-15%] and 36% (95% CI 24-48%) rates of recurrence/residual disease, respectively, with an odds ratio of 2.85 (95% CI 1.6-5.8, P<0.01) for HM1 compared with HMx. Nonevaluable (VMx) or positive (VM1) vertical margin was associated with a 43% (95% CI 17-68%) rate of recurrence/residual. VMx/VM1 was associated with a higher risk of recurrence/residual compared with HMx/HM1 (odds ratio 3.76, 95% CI 1.71-6.82, P<0.01). The most common strategy after HMx/HM1 was endoscopic surveillance and retreatment, whereas surgery was recommended after VMx/VM1. No cases of LNM or cancer-related death were noticeable if neither submucosal invasion more than 500 µm nor lymphovascular infiltration was also reported.

CONCLUSION

Rx/R1 resection in the absence of other noncurative criteria does not appear to be a significant risk factor for LNM or cancer-related death. The risk of recurrence/residual disease is higher after HM1 than HMx and higher after VMx/VM1 than HMx/HM1. However, considerable heterogeneity was found in studies. Standard definitions should be created and applied in future studies.

Single-day sodium picosulfate and magnesium citrate versus split-dose polyethylene glycol for bowel cleansing prior to colonoscopy: A prospective randomized endoscopist-blinded trial

BACKGROUND AND AIM

The intake of polyethylene glycol (PEG) prior colonoscopy is frequently associated with nausea and abdominal discomfort. The aim of this study was to investigate whether sodium picosulfate and magnesium citrate (PMC) is superior to a polyethylene glycol (PEG) preparation in regard to patient acceptance. Furthermore, it investigates possible differences in efficiency and patient safety.

METHODS

In a randomised, prospective, and endoscopist-blinded study patients were 1:1 randomized to either use PMC or 4-L PEG in order to prepare for colonoscopy. Cleansing regimes consisted of a split-dose administration in the PEG arm and standard administration in the PMC arm. Primary end point was proportion of patients evaluating the bowel preparation procedure as "very distressing," defined as ≥ 8 points on a 10-point numeric rating scale (NRS). Secondary end points were quality of bowel preparation and electrolyte parameters.

RESULTS

PMC bowel-cleansing procedure was better tolerated compared with PEG (PMC(NRS<8)  = 89.9% vs PEG(NRS<8)  = 79.2%, P = 0.037). Mean declines in serum sodium (ΔSodium(PEG)  = -0.76 ± 3.07 vs ΔSodium(PMC)  = -3.38 ± 3.56 mmol/L; P < 0.001), chloride (ΔChloride(PEG)  = -1.00 ± 3.22 vs ΔChloride(PMC)  = -3.49 ± 3.51 mmol/L; P < 0.001), and osmolality (ΔOsmolality(PEG)  = -4.23 ± 6.82 vs ΔOsmolality(PMC)  = -8.83 ± 7.43 mosmol/kg; P < 0.001) were higher in the PMC arm than in the PEG arm. Hyponatremia after bowel preparation occurred more often in PMC (21.2%) than in PEG (4.0%) (P < 0.001). Successful preparation was achieved more frequently in the PEG arm (42.9% vs 82.2%; P < 0.001).

CONCLUSION

Standard picosulfate/magnesium citrate is better accepted than a split-dose PEG regimen. From the perspective of successful preparation and patients' safety, PEG is superior to PMC.

Large-Cell Neuroendocrine Carcinoma of the Esophagus: A Case from Saudi Arabia

Neuroendocrine carcinomas of the esophagus are very rare, and the majority are high grade (poorly differentiated). They occur most frequently in males in their sixth and seventh decades of life. There have been no concrete data published on clinical features or on prognosis. We report a case of large-cell neuroendocrine carcinoma of the esophagus in a 66-year-old Saudi female with progressive dysphagia and weight loss. Upper endoscopy revealed an esophageal ulcerated mass.

A jackhammer in the gullet: high amplitude oesophageal contractions as a cause of atypical chest pain

Chest pain is a common cause for referral to emergency departments. A proportion of these patients have non-cardiac chest pains with normal investigations. Such patients should be considered for oesophageal studies as these may reveal an underlying dysmotility disorder. We report the case of a 51-year-old man who presented with chest pain and underwent oesophageal studies. He was diagnosed with acid reflux and high amplitude oesophageal contractions, otherwise known as a jackhammer oesophagus. Treatment was successful with omeprazole and glyceryl trinitrate relieving his symptoms.

A randomized trial to compare the efficacy and tolerability of sodium picosulfate-magnesium citrate solution vs. 4 L polyethylene glycol solution as a bowel preparation for colonoscopy

PURPOSE

The purpose of this study is to compare the efficacy and acceptability of an evening-before regimens of sodium picosulfate/magnesium citrate (SPMC) and polyethylene glycol (PEG) as bowel cleansers and to explore the results of a same-day regimen of SPMC.

METHODS

Multicenter, randomized, observer-blinded, parallel study carried out in subjects who were 18-80 years old and were undergoing diagnostic colonoscopy for the first time. The primary outcome was treatment success, which was a composite outcome defined by (1) the evaluation of the overall preparation quality as "excellent" or "good" by two blinded independent evaluators with the Fleet(®) Grading Scale for Bowel Cleansing and (2) a subject's acceptability rating of "easy to take" or "tolerable." The primary outcome was analyzed using a logistic regression with site, gender, and age group (age ≥65 years and <65 years) as factors.

RESULTS

Four hundred ninety subjects were included in the efficacy evaluation. Although treatment success was significantly higher in subjects assigned to the evening-before regimen of SPMC vs. subjects assigned to the evening-before PEG, when evaluating the two individual components for treatment success, there were significant differences in the ease of completion but not in the quality of preparation. The same-day SPMC regimen was superior to both the evening-before regimen of SPMC and PEG in terms of the quality of preparation, especially regarding the proximal colon.

CONCLUSIONS

An evening-before regimen of SPMC is superior to an evening-before regimen of PEG in terms of subject's acceptability. The same-day SPMC regimen provides better cleansing levels in the proximal colon.

Management of non-acute gastrointestinal defects using the over-the-scope clips (OTSCs): a retrospective single-institution experience

INTRODUCTION

Advanced endoscopic techniques provide novel therapies for complications historically treated with surgical interventions. Over-the-scope clips (OTSCs) have recently been shown to be effective at endoscopic closure of gastrointestinal (GI) defects. We hypothesize that by following classic surgical principles of fistula management, a high rate of long-term success can be achieved with endoscopic closure of non-acute GI tract defects.

METHODS

A retrospective review of a single-institution prospectively maintained database (2012-2015) of all patients referred for the management of GI leaks or fistulae who underwent attempted closure with the OTSC system (Ovesco, Germany) was performed. Acute perforations were excluded. The primary endpoint was long-term success defined by the absence of radiographic or clinical evidence of leak or fistula during follow-up. Patients were stratified by success or failure of OTSC closure and compared with Fisher's exact and Mann-Whitney U tests.

RESULTS

We identified 22 patients with 28 defects (22 fistulae and 6 leaks). Most patients were female (59 %) with a mean age of 54 years (±14), median BMI of 29, and prior bariatric procedure (55 %). Comorbidities included smoking history (68 %) and diabetes (23 %). The majority of defects were solitary (64 %), involved the upper GI tract (82 %), and had been present for >30 days (50 %). Multiple therapeutic interventions were necessary in 46 % of defects. There were no adverse outcomes related to OTSC placement or misfiring. Endoscopic adjuncts were used in 61 % of cases. Overall success rate was 82 % (100 % for leaks and 76 % for fistulae) at a median follow-up of 4.7 months (IQR 2.1-8.4 months). Predictors of success and failure could not be distinguished due to limited sample size.

CONCLUSIONS

Over-the-scope clips can be safely and effectively used in patients presenting with GI leaks and fistulae. Further research is required to characterize the determinants of long-term success and risk factors for failure.

A delayed onset of bowel activity after the start of conventional polyethylene glycol predicts inadequate colon cleansing before colonoscopy: A prospective observational study

BACKGROUND

Evaluation of factors correlating with the quality of bowel preparation (QBP) is critical to ensure high-quality colonoscopy.

OBJECTIVES

We sought to determine whether the time interval between the start of conventional polyethylene glycol (PEG) ingestion and the onset of bowel activity is predictive of QBP.

METHODS

Consecutive adult outpatients attending colonoscopy were prospectively assessed. Data including demographics, medical history, time of starting/completion of PEG and time when bowel activity started were recorded. The QBP was assessed according to the Ottawa bowel preparation score (OBPS); inadequate QBP was OBPS ≥7.

RESULTS

A total of 171 patients (92 males, mean age: 60.5 years) complying with preparation instructions were included. The median OBPS was 5 (range: 1-13) and 57 (33.3%) had inadequate QBP. The median interval between the initiation of PEG and the onset of bowel activity was 60 min (range: 9-300 min). Patients (n = 52, 30.4%) with a delayed (>90 min) onset of bowel activity had poorer QBP (p = 0.0001). In multivariate analysis, male gender (OR: 2.38, p = 0.03), the interval between the end of preparation and the start of colonoscopy (OR: 1.94, p = 0.02) and time to onset of bowel activity >90 min (OR: 3.38, p = 0.004) were predictive of inadequate QBP.

CONCLUSION

The time interval between the initiation of PEG ingestion and the onset of bowel activity is predictive of the QBP. Our data support "on demand" intensification of bowel preparation in patients with a delayed onset of purgative response to PEG.