Kazuya Akahoshi

Objective: Gastrointestinal stromal tumors (GISTs) are often reported to coexist with other malignancies, mainly on the basis of postoperative pathological studies for GISTs or other malignancies. This preliminary study aimed to examine the preoperative clinical prevalence of synchronous malignancies and patient and tumoral features in patients with gastric GISTs preoperatively diagnosed using endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Materials and Methods: 184 patients with gastric GIST diagnosed using preoperative EUS-FNA and postoperative histopathology were analyzed in this retrospective single-center observational study. Staging and assessment for synchronous malignancies was performed using preoperative esophagogastroduodenoscopy (EGD), total colonoscopy (TCS), and computed tomography (CT) of the chest, abdomen, and pelvis. Results: Ten gastric GIST patients had a single synchronous malignancy and two patients harbored two. Two of the 184 patients who underwent EGD exhibited synchronous upper gastrointestinal (GI) malignancy on EGD (1.1%): gastric intramucosal adenocarcinoma in one and superficial esophageal squamous cell carcinoma in the other. Five of the 150 patients who underwent TCS exhibited synchronous lower GI malignancy (3.3%): colorectal adenocarcinoma in three and submucosal carcinoid tumor in two. Extra-GI malignancy was found in a variety of organs in seven of 172 patients who underwent CT (4.1%). Patients with a synchronous malignancy were significantly older than those without (p = 0.02). Conclusion: Preoperative synchronous malignancy is relatively common in patients diagnosed with gastric GIST using EUS-FNA. Preoperative EGD, TCS, and CT of the chest to pelvis are desirable in these patients to assess for synchronous malignancies, as it may affect the treatment plan.

Background/Aims: The efficacy and safety of endoscopic submucosal dissection using a clutch cutter (ESD-CC) for subepithelial lesions within the esophagogastric submucosa (SELEGSM) has not been investigated. This study aimed to assess the efficacy and safety of ESD-CC for the treatment of SELEGSM.Methods: This prospective study included 15 consecutive patients with 18 SELEGSMs diagnosed by endoscopic ultrasonography. The primary outcomes were short-term outcomes including en bloc resection rate, R0 resection rate, procedure time, and complication rate. The secondary outcome was final histological diagnosis.Results: Among the participants, 18 lesions were identified: 12 in the stomach (nine patients) and six in the esophagus (six patients). The en bloc resection rate was 94.4% (17/18). The R0 resection rate was 88.9% (16/18). The median operating time was 39 min, and no instances of perforation or bleeding were observed. The final diagnoses of SELEGSM included six neuroendocrine tumors (33.3%), six granular cell tumors (33.3%), two ectopic pancreases (11.1%), one inflammatory fibroid polyp (5.6%), one leiomyoma (5.6%), one lipoma (5.6%), and one leiomyosarcoma (5.6%).Conclusions: ESD-CC appears to be a technically efficient and safe approach for SELEGSM resection, suggesting its potential as a valuable treatment option.

Introduction/Purpose: For gastric subepithelial lesions (GSELs) showing a hypoechoic mass (HM) on endoscopic ultrasonography (EUS) imaging, the utility of EUS‐guided tissue acquisition using conventional fine‐needle aspiration needles (EUS‐TA‐CFNAN) and the frequency of histological types remain unclear. This study aimed to examine this issue.Methods: This prospective observational study enrolled 291 consecutive patients who underwent EUS‐TA‐CFNAN for GSELs showing an HM (GSELHM) on EUS imaging. Immunohistochemical analysis was performed for all EUS‐TA‐CFNAN and surgically resected specimens. The main outcome measures were the technical results of EUS‐TA‐CFNAN and the frequency of histological types in GSELHM.Results: The endoscopic ultrasound‐guided tissue acquisition using conventional fine‐needle aspiration needle diagnosis rate for GSELHM was 80.1% (95% confidence interval [CI]: 75.0–84.5, 233/291). It was significantly lower for antrum (P = 0.004) and lesions smaller than 2 cm (P = 0.003). There were no adverse events. The immunohistochemical diagnoses of EUS‐TA‐CFNAN included 149 cases of gastrointestinal stromal tumour (GIST) (51.2%), 48 cases of leiomyoma (16.5%), 11 cases of schwannoma (3.8%), 8 cases of the ectopic pancreas (2.7%), 5 cases of subepithelial lesion like cancer (1.7%), 12 cases of other lesions (4.1%), and 58 cases of undiagnosable lesions (19.9%). The frequency of malignant or potentially malignant tumour in GSELHM was 55.0% (95% CI: 49.1–60.8, 160/291). Surgery was performed in 149 patients according to the conclusive EUS‐TA‐CFNAN results, in which the diagnostic accuracy of EUS‐TA‐CFNAN was 97.3% (95% CI: 94.7–99.9, 145/149).Conclusion: The use of EUS‐TA‐CFNAN for GSELHMs is safe and accurate. Gastric subepithelial lesions showing a hypoechoic mass have a reasonably high possibility of containing malignant or potentially malignant tumours, including GISTs.

Background/Aims: For duodenal subepithelial lesions showing a hypoechoic mass on endoscopic ultrasound imaging, the utility of endoscopic ultrasound-guided fine-needle aspiration and the frequency of histological types have not been the focus of previous literature. This study aimed to clarify this. Materials and Methods: This prospective observational study enrolled 22 consecutive patients who underwent endoscopic ultrasoundguided fine-needle aspiration for duodenal subepithelial lesions with hypoechoic mass on endoscopic ultrasound. Immunohistochemical analysis was performed for all endoscopic ultrasound-guided fine-needle aspiration and surgically resected specimens. The main outcome measures were the technical results of endoscopic ultrasound-guided fine-needle aspiration and the frequency of histological types of duodenal subepithelial lesions with hypoechoic mass. Results: Thirteen fine-needle aspiration specimens were obtained from the duodenal bulb and eight from the descending duodenal region. The puncture was not performed because of intervening vessels in one patient. The diagnostic rate was 81% (95% confidence interval: 58.1-94.6, 17/21 patients). In 12 patients receiving surgical resection (excluding one cancellation of endoscopic ultrasoundguided fine-needle aspiration), the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration was 75% (95% confidence interval: 42.8-94.5, 9/12 patients). No complications were observed. The histopathological diagnoses included 11 cases of gastrointestinal stromal tumor (50%), 2 cases of leiomyoma (9%), 2 cases of metastatic cancer (9%), 2 cases of benign inconclusive, and 1 case each of carcinoid, malignant lymphoma, leiomyosarcoma, gauzeoma, and aberrant pancreas (4.5% each). The frequency of malignant tumors in the duodenal subepithelial lesions with hypoechoic mass group was 73% (16/22 patients). Conclusions: Endoscopic ultrasound-guided fine-needle aspiration for duodenal subepithelial lesions with hypoechoic mass was safe and accurate. As duodenal subepithelial lesion with hypoechoic mass has a reasonably high possibility of containing malignant tumors, it is desirable to perform endoscopic ultrasound-guided fine-needle aspiration. Cite this article as: Akahoshi K, Akahoshi K, Shiratsuchi Y, et al. Endoscopic ultrasonography-guided fine-needle aspiration for duodenal subepithelial lesions showing a hypoechoic mass on endoscopic ultrasound imaging. Turk J Gastroenterol. 2023;34(11):1156-1162.

Background and objectives: There is inadequate data on the clinical outcomes of proton pump inhibitors in patients with post-endoscopic submucosal dissection (ESD) gastric ulcers (PESDGU). The clinical course of PESDGU is affected by various ESD methods, including the types of devices and endoscopists’ skills. No previous reports have compared the clinical outcomes of different proton pump inhibitors for PESDGU healing in patients who underwent the same ESD method using the same device by the same well-trained endoscopist. This study aims to compare the clinical outcome of esomeprazole vs. rabeprazole in PESDGU using the same ESD method and by the same endoscopist. Methods: Sixty patients with gastric tumors participated in this randomized clinical trial. Patients who underwent ESD using the Clutch Cutter (ESDCC) method by the same endoscopist were prospectively randomly assigned to esomeprazole 20 mg (EM) or rabeprazole 20 mg (RM) monotherapy groups. All patients received 20 mg omeprazole intravenously daily for the first 2 days post-ESDCC, followed by oral administration of EM or RM for 8 weeks. All patients remained hospitalized for 7 days postoperation to monitor any ESD-related complications. Esophagogastroduodenoscopy was performed 8 weeks post-ESD to evaluate the healing status of each artificial ulcer. Results: Of the 60 patients in this study, 30 each were assigned to the EM and RM groups. Eight patients from both groups did not complete the regimen and were excluded. Exactly 52 patients completed the study, with 27 and 25 in the EM and RM groups, respectively. There were no significant differences in the demographic characteristics of the two groups. There were no post-ESD perforations in either group. Post-ESD bleeding occurred in one patient in the RM group 5 days post-ESD. Scarring rates at the endpoint 8 weeks after ESD in the EM and RM groups were 96% and 76%, respectively. There were no significant differences between the two groups in the scarring stage (S1 or S2) at 8 weeks post-ESD. Conclusion: EM and RM have equivalent therapeutic effects on PESDGUs.

Endoscopic submucosal dissection (ESD) is a globally accepted minimally invasive therapy for early-stage gastrointestinal tract tumors. Although numerous electrosurgical knives have been developed for ESD, technical difficulties and high complication rates (bleeding and perforation) have limited their use worldwide. The grasping-type scissors forceps [clutch cutter (CC)] is the first forceps-type resection device developed with reference to hemostatic forceps. The aim was to allow easy and safe ESD throughout the gastro intestinal tract, as a biopsy technique, using one device. The CC can grasp the target tissue accurately and pull it away from the underlying muscle layer prior to energizing the tissue, for safe and effective incision and hemostasis during ESD. Reported clinical studies showed that ESD using the CC (ESD-CC) is a safe (perforation rate: 0%-3.6%; delayed bleeding rate: 0%-4.2%), technically efficient (en-bloc resection rate: 88.9%-100%), and single-device method for dissecting early-stage gastrointestinal tract tumors. The ESD-CC technique is simple and easy to learn because it can be completed simply by repeating the grasp, pull, and coagulate and/or incise actions using an electrosurgical current. The reported self-completion rate by non-experts was significantly better with the CC than with conventional knives (61.7% vs 24.5%, respectively; P < 0.001). Furthermore, the CC is used for other endoscopic therapies, such as endoscopic polypectomy for large pedunculated polyps, endoscopic myotomy for Zenker’s diverticulum, endoscopic treatment of buried bumper syndrome, and endoscopic necrosectomy for wall-off pancreatic necrosis. The initial reports using CC for these therapies have shown favorable results. In this review, we describe the structural features of the CC, how to use the instrument, efficacies of ESD-CC, and other unique endoscopic therapies using the CC.

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Endoscopists are at high risk of allowing transmission of coronavirus disease 2019 (COVID-19) during gastrointestinal endoscopy (GIE) procedures under pandemic conditions. The main avenues of droplet-containing aerosol generated during GIE are the mouth, anus, and endoscopic forceps channel. Although the usefulness of personal protective equipment for preventing COVID-19 dissemination has been well reported, measures to address infected aerosol escaping during endoscopic forceps use have been neglected. Pathogen-contaminated aerosol from the endoscopic forceps channel, leading into the gastrointestinal lumen, has been confirmed and is a highly problematic source of infection. We developed a technique that entails covering the forceps entry/exit hole with a vinyl bag, thereby preventing contamination of the endoscopy room by the infected aerosol that escapes from this hole. The technique can be used in daily clinical endoscopic practice. Furthermore, this shielding technique is useful for all patients who undergo GIE, regardless of the purpose of the procedure such as for making a diagnosis, administering therapy, or in an urgent situation. In this letter, we introduce our novel, easily performed, inexpensive method of infection prevention by disallowing infected aerosol to escape from a COVID-19-infected patient into the air during a procedure that requires the use of endoscopic forceps.

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Opinion statement: With the widespread use of esophagogastroduodenoscopy in recent years, the detection rate of superficial non-ampullary duodenal epithelial tumors (SNADETs) is increasing. Most SNADETs are early-stage adenocarcinoma or benign conditions, including adenoma. Therefore, endoscopic resection is desirable from the perspective of quality of life. However, endoscopic resection for SNADETs has not yet been established. Endoscopic submucosal dissection (ESD) is the most promising method for the treatment of SNADETs, because ESD provides a high rate of en bloc resection and a low rate of recurrence regardless of the tumor size. However, the difficulty of the procedure and a high rate of severe adverse events including perforation and bleeding have become major problems. Various preventive countermeasures for adverse events, such as use of specific devices, endoscope stabilization methods, and endoscopic closure of the post-ESD ulcer using clips, are reported to reduce the risk of the adverse events of ESD for SNADETs. This article reviews and highlights the current state of ESD for SNADETs and new challenges towards safe and effective ESD.