Determining factors for dexmedetomidine sedation in endoscopic submucosal dissection for early-stage gastric cancer.

Background and Aim: Although no specific sedation recommendations exist in early-stage gastric cancer (ESGC) for endoscopic submucosal dissection (ESD), dexmedetomidine (DEX) is useful along with benzodiazepines and analgesics. Furthermore, DEX is used for endoscopic treatment requiring lengthy sedation. However, it is unclear which patients should be administered DEX. We examined the factors that determine when DEX should be added for sedation during ESD for ESGC. Methods: Of 316 patients undergoing ESD for ESGC at our hospital between January 2017 and December 2020, we examined 310 receiving intravenous anesthesia. Preoperative patient factors and treatment outcomes were retrospectively examined according to the sedation method. Results: Among patients with ESGC undergoing ESD at our hospital, DEX was more frequently used alongside sedation in men, those undergoing gastrectomy, those with a lesion diameter ≥20 mm, and those with preoperative ulcers. In the standard group, patients whose treatment duration exceeded 120 min typically had a lesion diameter ≥20 mm, preoperative ulcers, lesions located outside the L region, and were treated by junior physicians. Conclusion: It is important to evaluate specific preoperative factors (lesion diameter ≥20 mm, preoperative ulcers, lesion located outside the L region, and having a junior physician as the treating physician) in patients undergoing ESD for ESGC to determine whether the combined use of DEX in sedation is necessary.

Using a novel hemostatic peptide solution to prevent bleeding after endoscopic submucosal dissection of a gastric tumor.

BACKGROUND: Endoscopic mucosal dissection has become the standard treatment for early gastric cancer. However, post-endoscopic submucosal dissection (ESD) ulcer occurs in 4.4% of patients. This study hypothesized whether applying PuraStat, a novel hemostatic peptide solution, prevents post-ESD bleeding. AIM: To investigate the preventive potential of PuraStat, a hemostatic formulation, against bleeding in post-ESD gastric ulcers. METHODS: Between May 2022 and March 2023, 101 patients (Group P) underwent ESD for gastric diseases at our hospital and received PuraStat (2 mL) for post-ESD ulcers. We retrospectively compared this group with a control group (Group C) comprising 297 patients who underwent ESD for gastric diseases at our hospital between April 2017 and March 2021. P values < 0.05 on two-sided tests indicated significance. RESULTS: Post-ESD bleeding occurred in 6 (5.9%) (95%CI: 2.8-12.4) and 20 (6.7%) (95%CI: 4.4-10.2) patients in Groups P and C, respectively, with no significant between-group difference. The relative risk was 1.01 (95%CI: 0.95-1.07). The lesser curvature or anterior wall was the bleeding site in all 6 patients who experienced postoperative bleeding in Group P. In multivariate analysis, the odds ratios for resection diameter ≥ 50 mm and oral anticoagulant use were 6.63 (95%CI: 2.52-14.47; P = 0.0001) and 4.04 (1.26-0.69; P = 0.0164), respectively. The adjusted odds ratio of post-ESD bleeding and PuraStat was 1.28 (95%CI: 0.28-2.15). CONCLUSION: PuraStat application is not associated with post-ESD bleeding. However, the study suggests that gravitational forces may affect the effectiveness of applied PuraStat.

Factors that affect the development of acute hemorrhagic rectal ulcer syndrome and rebleeding.

Objectives: Acute hemorrhagic rectal ulcer syndrome (AHRUS) causes massive bleeding and often recurrent rebleeding from rectal ulcers that form immediately above the dentate line. This study aimed to determine the clinical background and risk factors contributing to rebleeding in patients with AHRUS and the most appropriate method of hemostasis treatment. Methods: This retrospective study included 93 patients diagnosed with AHRUS at Showa University Fujigaoka Hospital, Japan, between April 2009 and November 2018. Information on clinical background factors, endoscopic findings, and hemostasis was obtained from medical records. The relationship with episodes of rebleeding was analyzed by multivariate logistic regression analysis. Results: The median age was 79 years, and 84 patients (90%) had a performance status of grade 2 or higher. The patients had multiple background factors, with a median number of 5 per patient. The background factors could be classified into two major factors: those related to arteriosclerosis and those related to delayed wound healing.In the multivariate analysis, significantly more rebleeding occurred in patients with active bleeding during the initial endoscopy (odds ratio 4.88, 95% confidence interval 1.80-14.46, p = 0.003); significantly less rebleeding occurred in patients for whom hemostasis was first performed by clipping (odds ratio 0.30, 95% confidence interval 0.09-0.88, p = 0.035). Conclusions: In bedridden older individuals with poor general health, multiple combinations of arteriosclerosis-related factors and protracted wound healing factors can induce AHRUS. We strongly recommend performing hemostasis via the clipping method on suspected bleeding points, including active bleeding sites, in AHRUS.

Multiple myeloma with esophageal involvement: A rare case.

A 77-year-old man presented with a spinal cord tumor at the cervical 7/thoracic 1 level and pain and weakness in the right hand. Blood tests revealed anemia, renal dysfunction, and hyperproteinemia. Immunoelectrophoresis revealed the M-protein component of immunoglobulin G gamma globulin. Bone marrow aspirate contained an increased number of atypical plasma cells. He was diagnosed with symptomatic myeloma and treated with radiation therapy, chemotherapy, and extradural tumor resection. Upper gastrointestinal endoscopy, performed because of anemia progression, revealed a 5-mm submucosal tumor-like elevated lesion in the upper thoracic esophagus. On white light observation, the lesion appeared whitish with a central redness. Our patient was diagnosed with extramedullary multiple myeloma. Extramedullary lesions are rare in the gastrointestinal tract. To our knowledge, this case is the first of multiple myeloma with esophageal involvement.

Successful conservative treatment of emphysematous gastritis.

Emphysematous gastritis is an extremely rare disease with an unfavorable prognosis. To date, very few studies have been conducted regarding the intragastric recovery process based on endoscopic findings. We herein report a case of emphysematous gastritis that improved with long-term (five months) conservative treatment in which we were able to observe the intragastric recovery process endoscopically. In cases in which emphysematous gastritis is suspected, it is important to provide prompt diagnostic imaging (including CT) and early appropriate treatment in order to improve the prognosis.