In Japan, endoscopic submucosal dissection (ESD) is the standard treatment for superficial esophageal squamous cell carcinoma (ESCC). Although clinical guidelines outline indications, additional treatment, and stricture prevention, real-world practice patterns remain insufficiently characterized. The present nationwide survey aimed to clarify the current endoscopic management of ESCC in Japan. A web-based, 20-item multiple-choice questionnaire was distributed to endoscopists performing upper gastrointestinal endoscopy at least weekly. Invitations were disseminated through the mailing lists of the Japan Esophageal Society and the individual mailing lists of core study members. The survey assessed diagnostic strategies, endoscopic treatment selection, indications for additional therapy after ESD, and approaches to stricture prevention. Altogether, 303 endoscopists who had performed endoscopic treatment for ESCC within the preceding year were enrolled. Most respondents reported using ESD exclusively. For clinical muscularis mucosa (MM) or shallow submucosa (SM1) lesions, treatment selection depended on circumferential extent, with ESD performed on 95.0

Robotic surgery is increasingly adopted for rectal cancer management, including selected patients with locally advanced disease. We evaluated perioperative safety and medium- to long-term outcomes after robot-assisted rectal cancer surgery with multivisceral resection for cT4 rectal cancer in a single high-volume center. We retrospectively reviewed 45 consecutive patients with locally advanced rectal cancer who underwent robot-assisted surgery with multivisceral resection between April 2021 and June 2025. Demographic and clinical variables, surgical and postoperative outcomes, and pathological findings were extracted from medical records. Recurrence-free survival (RFS), overall survival, and local recurrence were assessed. The study included 45 patients (19 females) with a median age of 72 years. Postoperative complications of Clavien–Dindo grade III or higher occurred in 4 patients (8.8

INTRODUCTION:Factor XIII deficiency (FXIIID) is a rare coagulation disorder that can cause severe or delayed bleeding and impair wound healing despite normal routine coagulation test results. Congenital FXIIID is caused by homozygous germline pathogenic variants of F13A or F13B. Herein, we report the successful treatment of a patient with FXIIID who underwent surgery for juvenile polyposis syndrome (JPS)-associated early gastric cancer. CASE PRESENTATION:A 44-year-old woman was admitted to the hospital with anemia secondary to menorrhagia. Gastrointestinal examination revealed polyposis throughout the stomach and type 0-Is early gastric cancer, which was consistent with the histological diagnosis of the biopsy specimens. Investigation into her family history revealed that her mother and maternal aunt had gastric polyposis. Preoperative laboratory tests were almost normal, except for low levels of hemoglobin (6.0 g/dL) and Factor XIII (FXIII) activity (31%). Robot-assisted total gastrectomy with D1-level lymph node dissection, followed by Roux-en-Y reconstruction, was successfully performed, with an operative time of 347 min and estimated blood loss of 26 mL. To prevent surgery-related bleeding, preoperative and postoperative administration of FXIII concentrate (30 IU/kg) was planned. The postoperative course was uneventful, and the patient was discharged on POD 9. Genetic testing identified a germline pathogenic frameshift variant in SMAD4 (c.96delT [p.Ser32fs*13]), which was consistent with the phenotype of JPS, and a heterozygous missense variant of uncertain significance in F13A1 (c.308A>T [p.Glu103Val]). Nine months postoperatively, FXIII activity was re-evaluated and remained low at 59%, although it was higher than the preoperative level. CONCLUSIONS:Recognition of FXIIID and appropriate perioperative management may help prevent unexpected bleeding and enable safe gastrectomy in patients with FXIIID.

Although prompt treatment is desirable for malignancies, surgical delays are sometimes unavoidable. Previous studies show conflicting results on the effect of diagnosis-to-surgery delay in esophageal cancer, mainly focusing on advanced stages treated preoperatively. Early stage disease, particularly cT1bN0, often involves longer waiting times, but the acceptable delay remains unclear. We conducted this study to evaluate the impact of surgical waiting time on postoperative survival in patients with clinical T1bN0M0 esophageal squamous cell carcinoma (ESCC) undergoing upfront esophagectomy. This multicenter retrospective study included 160 patients with cT1bN0M0 ESCC undergoing subtotal esophagectomy with lymphadenectomy at seven Japanese institutions between 2008 and 2021. Receiver operating characteristic (ROC) analysis identified the optimal waiting time cutoff predicting recurrence. Survival outcomes were compared between short and long waiting groups using the Kaplan–Meier method and Cox regression analyses. ROC analysis identified 66.5 days as the optimal cutoff value. The long waiting group (≥ 67 days) showed significantly worse 3-year recurrence-free survival (87.9

Abstract Topic Esophageal Cancer: New Diagnostic Modalities (Including PET, PET-CT, New Tracers) Background Background Ultra-high magnification endoscopic observation using endocytoscopy (EC) enables cellular-level visualization and allows in vivo assessment comparable to histopathological diagnosis. We previously proposed a three-tier classification system based on surface cellular morphology and reported that Type 3 lesions can be diagnosed histologically as malignant using EC images alone. Methods Patients and Methods Type classification Type 1 (non-cancerous) is defined as low nuclear density, a small nuclear-to-cytoplasmic (N/C) ratio, and absence of nuclear atypia. Type 2 (borderline lesion) shows increased nuclear density and nuclear size variation but is insufficient for a definitive diagnosis of malignancy. Type 3 (malignant) is characterized by nuclear enlargement, high nuclear density, and marked nuclear atypia. Between November 2011 and June 2025, 843 EC examinations with corresponding histopathological evaluation were performed. We retrospectively evaluated the diagnostic accuracy of the Type classification based on observations of 359 cases and 325 esophageal cancer lesions. Results Results EC observation was performed in 288 cases of squamous cell carcinoma (SCC) involving 323 lesions and in 36 cases of non-SCC esophageal cancer. Among the 331 adequately visualized cases, 314 (94.6%) were classified as Type 3 and 10 (3.0%) as Type 2, indicating that cancer cells were identifiable in the vast majority of lesions. Of the 79 patients who underwent endoscopic treatment, 17 (21.5%) were diagnosed as malignant based solely on EC findings, and biopsy was omitted. Among these, four had previously been diagnosed as borderline lesions by biopsy at referring institutions or at our hospital but were definitively diagnosed as esophageal carcinoma by EC. The biopsy-omitted lesions consisted of nine type 0-IIb and eight type 0-IIc lesions, with a median tumor diameter of 15 mm (range, 2–55 mm). Histological examination of resected specimens after endoscopic submucosal dissection (ESD) confirmed squamous cell carcinoma in all cases. Conclusion Conclusion EC observation of the esophagus enables definitive in vivo histopathological diagnosis of esophageal cancer and is particularly useful for small lesions that remain borderline on biopsy.

Aim:Spigelman stage IV duodenal polyposis (SP-stage IV DP) is associated with high duodenal cancer risk in patients with familial adenomatous polyposis (FAP). This study evaluated the surgical and oncological outcomes of pancreas-sparing total duodenectomy (PSTD) as a surgical prophylaxis for severe duodenal polyposis in FAP. Methods:Medical records were reviewed to evaluate factors concerning short- and long-term clinical and oncological outcomes in consecutive patients with FAP who underwent PSTD for SP-stage IV DP. Results:There were twenty-seven patients (median age: 48 years) from 26 families, of whom 12 were female. Clavien-Dindo grade IIIa/IIIb complications included delayed gastric emptying (n = 14) and pancreatic fistula (n = 10); no mortalities were observed. Histopathological examinations revealed no malignant neoplasms deeper than T1a in the duodenum and ampulla. Follow-up (median 6.4 years) revealed anastomotic stricture of the reconstructed neo-common channel (n = 5), anastomotic ulcer of the gastrojejunostomy site (n = 5), acute pancreatitis (n = 4), and acute cholangitis (n = 2), all of which were successfully treated endoscopically or conservatively. Malignant neoplasms after PSTD included gastric cancer (n = 3), remnant ano-rectal cancer (n = 3), ileal cancer (n = 1), ileal pouch cancer (n = 1), and endometrial cancer (n = 1). The cumulative 10-year survival rate following PSTD was 87.4%. Conclusions:PSTD for the prophylactic management of SP-stage IV DP was associated with notable but manageable postoperative morbidity. Long-term surveillance remains essential for the development of extraduodenal malignancies to confirm the oncological efficacy of this type of surgery.

Intramedullary spinal cord metastasis (ISCM) is a rare condition. ISCM from esophageal cancer is extremely uncommon. We report a rare case of lumbar ISCM from esophageal cancer in a woman in her 70 s, initially diagnosed with clinical stage IVA (cT4bN1M0) esophageal cancer. She underwent definitive radiotherapy (60 Gy in 30 fractions) with concurrent chemotherapy of 5-fluorouracil and cisplatin (FP), followed by two additional cycles of FP chemotherapy. A complete response was maintained for 1 year and 7 months post-radiotherapy by endoscopy. However, the patient began to experience mild bladder and rectal dysfunction and back pain. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) revealed high FDG uptake in the spinal cord cavity at the L1 level and contrast-enhanced spinal magnetic resonance imaging (MRI) showed an intramedullary tumor corresponding to the areas of FDG accumulation. Based on the appearance of new lesions and elevated tumor markers, the lesion was diagnosed as ISCM from esophageal cancer rather than a primary spinal cord tumor, and palliative radiotherapy (20 Gy in 5 fractions) was promptly administered. Two months after radiotherapy, the patient’s neurologic symptoms improved, and she continued treatment with immune chemotherapy. To our knowledge, this is the first reported case of immune checkpoint inhibitors after the diagnosis of ISCM from esophageal cancer. Although rare, ISCM should be considered in cancer patients presenting with new neurological symptoms, and timely multidisciplinary intervention is essential for optimal management.

Intraoperative nerve monitoring (IONM) during esophageal cancer surgery can help to identify and preserve the recurrent laryngeal nerve (RLN). To devise a useful parameter for prediction of left vocal cord palsy (VCP), we measured the electromyographic (EMG) amplitude of the left RLN and vagus nerve (VN) using intermittent IONM. We studied 35 consecutive patients who underwent esophagectomy with lymph node dissection around the left RLN. After lymph node dissection, the left RLN and left VN were stimulated, and the EMG amplitude was measured using IONM. The VN/RLN ratio (V/R ratio) was calculated, and the presence of left VCP, diagnosed by laryngoscopy on the first postoperative day, was compared among the patients. Ten of the 35 patients (28.6

BACKGROUND/AIM:Hypoxia-inducible factor 1α (HIF-1α) plays a significant role in angiogenesis; however, few studies have examined its expression in superficial esophageal carcinoma. This study examined the timing at which the hypoxia-induced angiogenesis switch is turned on by investigating the expression of HIF-1α and its downstream target, erythropoietin (Epo), in superficial esophageal carcinoma. MATERIALS AND METHODS:We used 53 lesions of superficial esophageal carcinoma and conducted immunohistochemistry for HIF-1α and Epo. Cases were divided into three groups: T1a-EP/LPM group (22 lesions), T1a-MM/T1b-SM1 group (15 lesions), and T1b-SM2,3 group (16 lesions). HIF-1α and Epo expression levels were compared across groups using H scores. Additionally, in 24 cases with intraepithelial spread, expression was compared between intraepithelial and invasive components. RESULTS:Both HIF-1α and Epo were most strongly expressed in T1a-EP/LPM, with significantly reduced expression observed in tumors that invaded the muscularis mucosae or deeper layers. A strong positive correlation was found between HIF-1α and Epo expression scores. HIF-1α and Epo values were significantly higher in the intraepithelial area than in the invaded area. CONCLUSION:In esophageal carcinoma, HIF-1α and Epo were strongly expressed at the earliest stages of carcinogenesis. As the carcinoma progressed beyond the muscularis mucosae, the expression of these markers significantly declined, suggesting a resolution of hypoxia likely associated with active angiogenesis.

Aim:Severe duodenal polyposis associated with familial adenomatous polyposis considerably increases the risk of duodenal cancer. Pancreas-sparing total duodenectomy is an alternative surgical approach for managing severe duodenal polyposis. This study evaluated the postoperative nutritional outcomes following pancreas-sparing total duodenectomy in patients with severe duodenal polyposis associated with familial adenomatous polyposis. Methods:This retrospective analysis compared 28 patients who underwent pancreas-sparing total duodenectomy for Spigelman stage IV duodenal polyposis with 29 patients who underwent pancreatoduodenectomy for low-malignancy duodenal neoplasms. Patient demographics, postoperative complications, and nutritional parameters were analyzed at 3, 6, 9, and 12 months postoperatively. Results:Compared with patients in the pancreatoduodenectomy group, those in the pancreas-sparing total duodenectomy group were younger and had a higher incidence of previous abdominal surgeries (p < 0.01). Postoperatively, the pancreas-sparing total duodenectomy group showed significantly better preservation of total protein, albumin, and total cholesterol levels, body mass index, body weight, and psoas major muscle area compared to the pancreatoduodenectomy group (p < 0.05). Additionally, glucose tolerance was better maintained in the pancreas-sparing total duodenectomy group than in the pancreatoduodenectomy group (p < 0.01), with no patients requiring the initiation of insulin therapy or experiencing the exacerbation of diabetes. Conclusions:Pancreas-sparing total duodenectomy effectively preserves the postoperative nutritional status in patients with duodenal polyposis associated with familial adenomatous polyposis. This surgical option maintains postoperative nutritional integrity and improves long-term outcomes.

Between January 2020 and November 2024, we retrospectively analyzed the results of mismatch repair protein immunohistochemistry(MMR-IHC)/microsatellite instability(MSI)test, RAS, and BRAF genetic tests in 48 consecutive patients under 50 years of age who underwent primary tumor resection of colorectal cancer. Of these, 35 patients underwent MMR-IHC/ MSI testing, revealing 32 proficient MMR(pMMR)/non-MSI-high and 3 deficient MMR(dMMR)/MSI-high, 2 of whom were diagnosed as having Lynch syndrome. RAS/BRAF testing was performed in 28 patients, identifying 6 with KRAS variants, while no BRAFV600E or KRASG12C were found. The frequencies of dMMR and Lynch syndrome in patients under 50 years old was comparable to our previous report in which testing was conducted as part of research. Our results suggest that in patients under 50 years old(, 1)the utility of BRAF testing as an adjunctive diagnostic tool for Lynch syndrome is limited, and (2)BRAFV600E or KRASG12C was not detected;however, a larger accumulation of cases is necessary.

This review outlines the process of the development of the endocytoscope (EC) with reference to previously reported studies including our own. The EC is an ultra-high-magnification endoscope capable of imaging at the cellular level. The esophagus is the most suitable site for EC observation because it is amenable to vital staining. The diagnosis of esophageal lesions using EC is based on nuclear density and nuclear abnormality, allowing biopsy histology to be omitted. The observation of nuclear abnormality requires a magnification of ×600 or higher using digital technology. Several staining methods have been proposed, but single staining with toluidine blue or methylene blue is most suitable because the contrast at the border of a cancerous area can be easily identified. A three-tier classification of esophageal lesions visualized by EC is proposed: Type 1 (non-cancerous), Type 2 (endocytoscopic borderline), and Type 3 (cancerous). Since characteristic EC images reflecting pathology can be obtained from non-cancerous esophageal lesions, a modified form of classification with four additional characteristic non-cancerous EC features has also been proposed. Recently, deep-learning AI for analysis of esophageal EC images has revealed that its diagnostic accuracy is comparable to that of expert pathologists.

Endocytoscopy (EC) facilitates real-time histological diagnosis of esophageal lesions in vivo. We developed a deep-learning artificial intelligence (AI) system for analysis of EC images and compared its diagnostic ability with that of an expert pathologist and nonexpert endoscopists. Our new AI was based on a vision transformer model (DeiT) and trained using 7983 EC images of the esophagus (2368 malignant and 5615 nonmalignant). The AI evaluated 114 randomly arranged EC pictures (33 ESCC and 81 nonmalignant lesions) from 38 consecutive cases. An expert pathologist and two nonexpert endoscopists also analyzed the same image set according to the modified type classification (adding four EC features of nonmalignant lesions to our previous classification). The area under the curve calculated from the receiver-operating characteristic curve for the AI analysis was 0.92. In per-image analysis, the overall accuracy of the AI, pathologist, and two endoscopists was 91.2%, 91.2%, 85.9%, and 83.3%, respectively. The kappa value between the pathologist and the AI, and between the two endoscopists and the AI showed moderate concordance; that between the pathologist and the two endoscopists showed poor concordance. In per-patient analysis, the overall accuracy of the AI, pathologist, and two endoscopists was 94.7%, 92.1%, 86.8%, and 89.5%, respectively. The modified type classification aided high overall diagnostic accuracy by the pathologist and nonexpert endoscopists. The diagnostic ability of the AI was equal or superior to that of the experienced pathologist. AI is expected to support endoscopists in diagnosing esophageal lesions based on EC images.

Background: Laparoscopic proximal gastrectomy (LPG) is an attractive option for the treatment of early gastric cancer in the upper third of the stomach. No optimal method of reconstruction after LPG has been established because of problems associated with postoperative reflux. Gastric tube reconstruction, a type of esophagogastrostomy, is a simple procedure, but it is associated with a high frequency of reflux esophagitis (RE). We investigated the relationship between RE and gastric emptying, along with nutritional parameters. Subjects and Methods: We compared gastric emptying in patients who had undergone curative LPG with gastric tube reconstruction for gastric cancer with that of patients after total gastrectomy (TG), distal gastrectomy (DG) and of healthy volunteers and patients after DG. The LPG group was divided into an RE LPG-RE (+) group and a non-reflux esophagitis (non-RE) an LPG-RE (−) group, and we compared gastric emptying and indices of nutrition, such as body weight and laboratory findings, between those among LPG-RE (+), LPG-RE (−), and TG groups. Results: The time lag between ingestion and peak 13CO2 expiration (T lag) in the healthy volunteer group was significantly shorter in the LPG group longer than those in the healthy volunteer LPG group and TG group. The T lag was significantly shorter in the RE LPG-RE (+) group than in the non-RE LPG-RE (−) group. The percentage change in body weight percentage in the non-RE LPG-RE (−) group was significantly larger than that in the RE LPG-RE (+) group at 12 months after surgery. Both the serum albumin and hemoglobin levels in the non-RE LPG-RE (−) tended to be preserved compared with those in the RE LPG-RE (+) group and TG group. Conclusions: Gastric emptying was accelerated after LPG, and was associated with RE. Our data suggest that RE could be associated with body weight loss after LPG.

Digestive EndoscopyVolume 33, Issue 5 p. 870-871 Letters, Techniques and Images Mucosal duodenal cancer originating from a Peutz–Jeghers polyp: Endocytoscopic features Youichi Kumagai, Corresponding Author Youichi Kumagai kuma7srg1@gmail.com orcid.org/0000-0001-9895-8820 Departments of, Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, JapanSearch for more papers by this authorMorihiro Higashi, Morihiro Higashi Department of, Pathology, Saitama Medical Center, Saitama Medical University, Saitama, JapanSearch for more papers by this authorHideyuki Ishida, Hideyuki Ishida Departments of, Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, JapanSearch for more papers by this author Youichi Kumagai, Corresponding Author Youichi Kumagai kuma7srg1@gmail.com orcid.org/0000-0001-9895-8820 Departments of, Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, JapanSearch for more papers by this authorMorihiro Higashi, Morihiro Higashi Department of, Pathology, Saitama Medical Center, Saitama Medical University, Saitama, JapanSearch for more papers by this authorHideyuki Ishida, Hideyuki Ishida Departments of, Digestive Tract and General Surgery, Saitama Medical Center, Saitama Medical University, Saitama, JapanSearch for more papers by this author First published: 09 March 2021 https://doi.org/10.1111/den.13967Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume33, Issue5July 2021Pages 870-871 RelatedInformation

Background Gastric tube reconstruction is a form of esophagogastrostomy performed after laparoscopic proximal gastrectomy (LPG). It is a simple and safe technique, but it may cause reflux esophagitis (RE) and impair postsurgical QOL. For several years, we have developed the gastric tube reconstruction and performed it on more than 100 patients. This study aimed to determine whether gastric tube reconstruction can be a feasible choice after LPG in regard to surgical safety and postoperative nutritional status. Methods The subjects consisted of 171 patients who underwent LPG (n = 102) or laparoscopic total gastrectomy (LTG) (n = 69). We compared the two groups in terms of surgical outcomes, incidence rate of RE, and nutritional status including postoperative weight loss and hemoglobin levels. Results There were no significant differences with regard to the surgical duration and blood loss between the two groups. The incidence of RE was not significantly higher with LPG than with LTG (16.7% vs. 10.1%, respectively; P = 0.07). Later than 2 years and 6 months after surgery, the body weight percentage of preoperative body weight in the LPG group was significantly higher than that in the LTG group. Hemoglobin and ferritin levels in the LPG group were significantly higher than those in the LTG group, later than one after surgery. The overall survival rates were similar between the two groups (5-year survival rates: 97.1% vs. 94.2% in the LPG and LTG groups, respectively; P = 0.69). Conclusions Gastric tube reconstruction after LPG is simple and had better outcomes than LTG in terms of postoperative nutritional status.

Objective We determined the anastomotic site during gastric tube reconstruction in esophagectomy according to the "90-to 60-s rule" using indocyanine green (ICG) fluorescence angiography. We evaluated its safety and efficacy in a prospective multicenter setting. Methods We enrolled 129 patients who underwent subtotal esophagectomy for esophageal cancer. ICG fluorescence angiography was performed after making a wide gastric tube, and the time from the initial enhancement of the right gastroepiploic artery to the tip of the gastric tube was used as a parameter. Esophago-gastro anastomosis was made at the area that was enhanced within 90 s (preferably within 60 s). The enhancement time and the incidence of anastomotic leakage were compared. Results In all cases, anastomosis was made at the site enhanced within 90 s. Anastomotic leakage was found in only 4 (3.1%) of 129 cases; specifically, it was detected in 3 (2.4%) of 126 cases whose anastomotic site was enhanced within 60 s and in 1 (33.3%) of 3 cases where the enhancement time exceeded 60 s (p = 0.09). Conclusions Determining the anastomotic site using the 90-to 60-s rule with ICG imaging in gastric tube reconstruction helps reduce the rate of anastomotic leakage.

Our previous study of duodenal adenoma using an endocytoscopy system (ECS) demonstrated that disappearance of goblet cells and spindle-shaped nuclei with loss of polarity were characteristic features. In addition, round duct openings and finger-like projections were observed in tubular adenoma and villous adenoma, respectively. Here, we retrospectively investigated six cases of histologically proven sporadic non-ampullary mucosal duodenal cancer (NAMDC) using ECS. Immunohistochemistry for CD10, MUC2, MUC5AC, and MUC6 was employed to determine the mucin phenotype in addition to conventional HE histology. Immunohistochemistry revealed one case involving the duodenal bulb that was considered to be the mixed type. The other five cases, located in the second or third portion, were considered to be the intestinal type. Vital staining of the mixed-type case was considered insufficient for ECS observation because of surface mucus. However, all five cases of intestinal-type duodenal cancer demonstrated a villous structure, disappearance of goblet cells and enlarged nuclei with loss of polarity. Tubular structures were admixed in four of those cases. Four cases demonstrated oval-shaped nuclei, and one case had spindle-shaped nuclei. Cases showing spindle-shaped nuclei in most of the lesion were diagnosed histologically as cancer in adenoma where the adenomatous component of the tumor was dominant. Oval-shaped nuclei and nuclear enlargement are the characteristic features of NAMDC revealed by ECS and are included among the histological criteria used for diagnosis. ECS offers the potential to perform real-time histological diagnosis of NAMDC in vivo.