Tomohiro Kadota

Objectives: Postendoscopic submucosal dissection (ESD) bleeding remains a critical concern in patients receiving antithrombotic therapy, yet the risk after esophageal ESD is poorly characterized. This multicenter retrospective study evaluated the incidence of post‐ESD bleeding and thromboembolism in patients undergoing esophageal ESD while receiving antiplatelet therapy. Methods: We analyzed 570 patients with esophageal squamous cell carcinoma treated with ESD while on antiplatelet therapy between 2017 and 2022 at 21 institutions in Japan. Patients were categorized into guideline‐based discontinuation or continuation, excluding guideline‐deviating discontinuation. The primary endpoint was the rate of post‐ESD bleeding among thienopyridine users (monotherapy or dual antiplatelet therapy; DAPT) managed with guideline‐based discontinuation. Secondary endpoints included bleeding rates according to antiplatelet regimen and thromboembolism incidence. Results: A total of 154, 41, and 375 patients received thienopyridine monotherapy, DAPT, and aspirin monotherapy, respectively. Antiplatelet therapy was continued perioperatively in 32.5%, 31.7%, and 73.1% of these groups. Post‐ESD bleeding rates were 2.3% (3/132) and 3.2% (2/63) for guideline‐based discontinuation and continuation of thienopyridine users, respectively. Bleeding rates for discontinuation vs. continuation were 0% (0/101) vs. 0.7% (2/274) for aspirin monotherapy, 1.9% (2/104) vs. 4.0% (2/50) for thienopyridine monotherapy, and 3.6% (1/28) vs. 0% (0/13) for DAPT. Thromboembolism occurred in two patients, both receiving aspirin monotherapy. Conclusions: A substantial number of patients underwent esophageal ESD while continuing antiplatelet therapy. These descriptive findings suggest a need for further evaluation of continued therapy in larger studies.

Objectives: Endoscopic local triamcinolone injection is a standard therapy for esophageal stricture (ES) prevention after extensive endoscopic submucosal dissection (ESD); however, oral prednisolone administration is a promising alternative. This trial aimed to investigate the superiority of oral prednisolone administration to local triamcinolone injection for ES prevention after extensive ESD. Methods: This phase 3, open‐label, multicenter, randomized controlled trial enrolled patients with extensive superficial esophageal squamous cell carcinoma. The primary endpoint was stricture‐free survival (SFS). Secondary endpoints were the number of endoscopic balloon dilations (EBDs) for 12 weeks after ESD, dysphagia score ≤ 1 at 12 weeks after ESD, and adverse events (AEs). Results: A total of 281 patients from 45 institutions were enrolled. The 12‐week SFS rates were 88.5% (95% confidence interval [CI]: 81.6–92.9) and 94.8% (95% CI: 89.4–97.5) in the triamcinolone and prednisolone arms, respectively (hazard ratio 0.672, 90% CI [0.361–1.250], p = 0.14). Thirty‐eight and 26 EBDs were performed for 14 and 10 patients, respectively, in the triamcinolone and prednisolone arms within 12 weeks after ESD. In the triamcinolone and prednisolone arms, 73.8% (95% CI: 65.7–80.8) and 80.7% (95% CI: 73.2–86.9) of patients, respectively, had dysphagia scores ≤ 1 at 12 weeks after ESD ( p = 0.20). Grade 3/4 AEs occurred in 12 (8.7%) and 9 patients (6.7%) in the triamcinolone and prednisolone arms, respectively. Conclusions: While oral prednisolone administration and local triamcinolone injection demonstrated comparable outcomes, oral prednisolone did not demonstrate superiority for ES prevention after extensive esophageal ESD.

Objectives: Endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) has enabled en bloc resection of large lesions; however, post‐ESD esophageal stricture remains an unresolved issue. Particularly, the standard steroid triamcinolone injection (LTI) therapy alone is insufficient for ≥ 7/8 circumferential mucosal defects (non‐circumferential) after ESD. Thus, we aimed to compare the efficacy of LTI with a combination therapy of LTI and oral prednisolone administration (OPA). Methods: Between January 2010 and December 2020, we enrolled patients with post‐ESD mucosal defects involving seven‐eighths or more of the circumference of the esophagus but not circumferential, who had received LTI or a combination therapy of LTI and OPA as prophylactic treatment. Esophageal stricture was defined as a case where an ordinary‐sized endoscope could not pass through the post‐ESD site, thus requiring endoscopic balloon dilation (EBD) repeatedly until relief of the stricture was achieved. We retrospectively compared LTI and a combination of LTI and OPA in terms of stricture‐free survival, stricture rate, and refractory stricture (requiring ≥ 6 EBD procedures) rate. Results: Overall, 42 and 26 patients in the LTI and combination group were enrolled. The stricture and refractory stricture rates were 42.9% and 16.7% in the LTI group and 26.9% and 15.4% in the combination group, respectively. The SFS rates at 12 weeks were 64.3% and 76.9% in the LTI group and the combination group, respectively. Conclusions: This study suggested that the combination therapy of LTI and OPA for ≥ 7/8 circumferential mucosal defects (non‐circumferential) post‐ESD may be useful for preventing strictures.

Photodynamic therapy (PDT) is a salvage endoscopic treatment option for local failure after chemoradiotherapy for esophageal squamous cell carcinoma (ESCC). PDT is usually performed using ordinary-sized conventional endoscopes (CEs); however, some patients with local failure have esophageal stenosis caused by chemoradiotherapy or endoscopic resection. In such cases, an ultra-thin endoscope (UTE) is sometimes used, but the efficacy and safety of PDT performed with UTEs (UTE-PDT) remain unclear. In this study, we compared the treatment outcomes of UTE-PDT with those of PDT using CEs (CE-PDT). This retrospective study analyzed patients who underwent talaporfin sodium-based PDT for histologically confirmed local ESCC failure between October 2015 and June 2022. Short-term outcomes, including the local complete response (L-CR) rate and adverse events, were compared between UTE-PDT and CE-PDT. In total, eight patients underwent UTE-PDT and 81 underwent CE-PDT. L-CR rates were 50.0% and 59.3% for the UTE-PDT and CE-PDT groups, respectively. The L-CR rates for lesions ≤ 20 mm were 50.0% (4/8) and 63.4% (45/71) in the UTE-PDT and CE-PDT groups, and for cT1 lesions, they were 57.1% (4/7) and 63.2% (43/68), respectively. Adverse events included esophageal pain (12.5% and 39.5%) and esophageal stenosis (12.5% and 4.9%) in the UTE-PDT and CE-PDT groups, respectively; however, all were grade ≤ 2. UTE-PDT for local failure after chemoradiotherapy for ESCC showed short-term outcomes that did not differ substantially from those of CE-PDT and may represent a potential therapeutic option for patients with no alternative treatment options.

Objectives: To investigate whether considering the B2 vessel area (B2VA) size and macroscopic type improves diagnostic performance. Methods: In total, 136 esophageal squamous cell carcinoma (ESCCs) with B2 but not B3 vessels were prospectively enrolled. Tumor invasion depth was assessed using the standard Japan Esophageal Society (JES) classification and a “B2VA‐based” method that incorporates B2VA size and macroscopic type. Lesions with B2VA ≤ 4 mm (B2‐narrow) were classified as cEP/LPM; B2VA ≥ 10 mm (B2‐wide) or type 0–I or 0–III within the B2VA were classified as cSM2–3; intermediate lesions were classified as cMM/SM1. All lesions underwent endoscopic resection or esophagectomy with histopathological confirmation. The primary endpoint was diagnostic accuracy, and positive likelihood ratios (+LRs) were calculated for each endoscopic feature. Results: Among the 136 ESCCs, 27.2% were pEP/LPM, 49.3% were pMM/SM1, and 23.5% were pSM2–3. The overall diagnostic accuracy was 49.3% for the standard JES evaluation and 50.0% for the B2VA‐based evaluation ( p = 1.00). B2VA size correlated with pathological depth, with median values of 3, 5, and 10 mm for pEP/LPM, pMM/SM1, and pSM2–3, respectively. B2‐narrow predicted pEP/LPM (+LR 2.26), whereas B2‐wide predicted pSM2–3 (+LR 3.45), and type 0–I within the B2VA predicted pSM2–3 (+LR 4.47). Combination of B2‐wide and 0–I demonstrated the highest predictive value for pSM2–3 (+LR 9.75). Conclusions: B2VA‐based evaluation incorporating B2VA size and macroscopic type did not improve the diagnostic accuracy compared with that of the standard JES evaluation for predicting invasion depth in ESCC with B2 vessels. Trial Registration: Registry and registration number: UMIN000051145

Background: In this study, we investigated the diagnostic performance of magnifying endoscopy (ME) with third-generation narrow-band imaging (3G-NBI) for early gastric cancer (EGC), primarily in patients with Helicobacter pylori eradication. Methods: This was a post hoc analysis of a multicenter, randomized trial comparing 3G-NBI, texture and color enhancement imaging, and white-light imaging in gastric neoplasm (GN) detection. For all detected lesions, the endoscopic diagnosis of ME using 3G-NBI was compared with the pathological diagnosis. The primary analyses focused on the sensitivity and specificity of ME with 3G-NBI for EGC or non-EGC. The diagnostic performance was analyzed according to confidence level, macroscopic type, lesion size, and H. pylori infection status. Results: This study included 901 patients; 228 suspected GN lesions in 187 patients were analyzed. The lesions were diagnosed with EGC in 62 (27 with high confidence) and non-EGC in 166 (91 with high confidence) patients using ME with 3G-NBI and pathologically diagnosed as EGC in 61 and non-EGC in 167 patients. The overall diagnostic performance was sensitivity and specificity of 70.5% and 88.6%, respectively. The diagnostic performance of each category was as follows: (1) confidence level (high/low); sensitivity 78.1%/62.1%, specificity 97.7%/79.0%; (2) macroscopic type (elevated/flat or depressed); sensitivity 84.6%/66.7%, specificity 96.7%/86.9%; (3) lesion diameter (< 10 mm/ ≥ 10 mm); sensitivity 65.7%/76.9%, specificity 88.6%/88.9%; (4) H. pylori infection status (uninfected/previously infected/currently infected); sensitivity 50.0%/71.0%/86.7%, specificity 91.3%/88.2%/88.9%. Conclusions: The diagnostic performance of ME with 3G-NBI for EGC was acceptable, primarily in patients with H. pylori eradication. Trial Registration: This trial was registered in jRCT (Identifier jRCT1032210213).

Objectives: Endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinomas (ESCCs) localized on the distal side of strictures requires dilation to pass a conventional endoscope. While an ultra‐slim endoscope can pass without dilation, ESD using it remains clinically challenging. Despite its small outer diameter of only 7.9 mm, the EG‐840TP features a 3.2‐mm working channel, an auxiliary water channel, and 160° downward angulation capability. We evaluated the efficacy and safety of ESD using the EG‐840TP for ESCCs localized on the distal side of strictures. Methods: This retrospective study included patients who underwent ESD for ESCCs localized on the distal side of strictures that a conventional endoscope (diameter ≥8.9 mm) could not pass at our institute from December 2015 to November 2024. Patients were categorized into novel thin endoscope (the EG‐840TP) and conventional endoscope (treated after stricture dilation) groups. Patients with strictures narrower than 6 mm were excluded. Results: Of 28 patients (36 lesions), 13 patients (19 lesions) underwent ESD using the novel thin endoscope, whereas 15 patients (17 lesions) underwent ESD using the conventional endoscope. The treatment speed was significantly faster in the novel thin endoscope group (4.91 mm ² /min vs. 1.63 mm ² /min, p = 0.03). No serious adverse events were observed in either group. Conclusions: ESD using the EG‐840TP demonstrated superior efficacy for superficial ESCCs located on the distal side of strictures, offering an alternative to dilation‐based approaches.

Background and aims Endoscopic submucosal dissection (ESD) is a minimally-invasive curative treatment for early gastric cancer (EGC). Recently, JCOG1009/1010, a multicenter, prospective, single-arm, confirmatory trial, showed that of ESD for undifferentiated early gastric cancer (UD-EGC) ≤ 2 cm without ulceration are comparable with those of gastrectomy, resulting in the expansion of the indications of ESD for UD-EGC. Herein, we explored the factors associated with technical difficulty in ESD in patients with UD-EGC using data from JCOG1009/1010. Methods The inclusion criteria for JCOG1009/1010 were histologically proven undifferentiated-type adenocarcinoma, cT1aN0M0, absence of ulceration, and tumor size of < 2 cm. The technically difficult cases were defined as those with an ESD procedure time of > 120 min, intraoperative perforation, or incomplete en bloc resection. We compared difficult and non-difficult ESD cases and performed multivariable analysis. Results Of 346 patients enrolled in JCOG1009/1010, 332 were analyzed. Technical difficulties were experienced in 70 (21%) patients: procedure > 120 min (55 patients, intraoperative perforation (18 patients), and incomplete en bloc resection (four patients). Upper location (versus [vs.] lower, odds ratio [OR]: 4.20, 95% confidence interval [CI]: 1.52–11.64, p = 0.006), post-eradication of Helicobacter pylori infection (vs. presence, OR: 0.40, 95% CI: 0.17–0.98, p = 0.045), and absence of atrophy in the background mucosa around the lesion (vs. presence, OR: 2.56, 95% CI: 1.22–5.41, p = 0.013) were independent factors significantly associated with technical difficulty in ESD. Conclusion Upper location, H. pylori infection, and absence of atrophy in the background mucosa around the lesion were associated with technical difficulty in ESD for UD-EGC. Graphical abstract