Ulcer Scar Research Articles

Prevalence and risk factors for lymph node metastasis after noncurative endoscopic resection for early gastric cancer: a systematic review and meta-analysis.

Additional surgery for all patients with noncurative resection after endoscopic resection (ER) for early gastric cancer (EGC) may be excessive due to the relatively low rate of lymph node metastasis (LNM) in such patients. However, the prevalence and risk factors for LNM after noncurative ER have not been consistent across studies. We performed a systematic review of electronic databases through August 10, 2018 to identify cohort studies with patients who underwent additional surgery after noncurative ER for EGC. The prevalence of LNM in such patients was extracted for all studies. Odds ratios (ORs) were combined using random-effects meta-analyses to assess the risk of LNM, when possible. We identified 24 studies comprising 3877 patients with 311 having LNM (pooled prevalence, 8.1%). The risk of LNM was significantly increased in lymphatic invasion (OR [95% confidence interval] = 4.22 [2.88-6.19]), lymphovascular invasion (LVI) (4.17 [2.90-5.99]), vascular invasion (2.38 [1.65-3.44]), positive vertical margin (2.16 [1.59-2.93]), submucosal invasion depth of ≥ 500μm (2.14 [1.48-3.09]), and tumor size > 30mm (1.77 [1.31-2.40]). In contrast, there was no significant association between undifferentiated-type or ulceration (scar) and LNM. When studies were restricted to those that evaluated the adjusted OR, the risk of vascular invasion for LNM did not reach statistical significance. Several pathological factors, most notably lymphatic invasion and LVI, were associated with LNM in patients with noncurative resection after ER for EGC. Lymphatic and vascular invasion should be assessed separately instead of LVI (PROSPERO CRD42018109996).

Antibacterial Activity Assay From Sintrong Leaf Crassocephalum crepidiodies Against Staphylococcus aureus Bacteria

Sintrong (Crassocephalum crepidioides) is Asteraceae's family plant. In Medan in addition used as a vegetable, sintrong leaves also be used as traditional medicine; among them to cope with stomach disorders, headache, and ulcer scars. The purpose of this research was spesification about characteristic, determination of chemical compounds group and antibacterial activity of ethanol extract, n-heksana fraction, ethylacetate fraction and water fraction of sintrong leaves against Staphylococcus aureus. The sample used was sintrong (Crassocephalum crepidioides) taken from Mupakat Jadi Village, Sub-District Bukit, districts Bener Meriah. This research purposive stages, namely materials plant, identification, preparation and characterization simplisia, determination the class of chemical compounds of simplex, preparation extract and antibacterial activity tested. Test of antibacterial activity by agar diffusion method used paper disc. Parameters measured were inhibition zone of Staphylococcus aureus. Antibacterial activity test results shows are effectivity, with a concentration of 2,5 mg/ml provides inhibition area diameter (9,5 mm) against Staphylococcus aureus bacteria, a concentration of 5 mg/ml provides inhibition area diameter (10,7 mm) to Staphylococcus aureus, a concentration of 7,5 mg/ml provides inhibition area diameter (10,9 mm) to Staphylococcus aureus, and a concentration 10 mg/ml provides inhibition area diameter (11,5 mm) to Staphylococcus aureus.

Numerous lymph node metastases in early gastric cancer without preoperatively enlarged lymph nodes: a case report

BackgroundAccording to the 2018 Japanese gastric cancer treatment guidelines (ver. 5), a reduced extent of lymphadenectomy (D1 or D1+) is indicated for cT1 N0 tumors that do not meet the criteria for endoscopic resection. However, early gastric cancer with multiple lymph node metastases is not unknown, and cases have been reported. We report a case of a patient with early gastric cancer and numerous nodal metastases who underwent laparoscopic proximal gastrectomy based on a preoperative diagnosis of T1 N0.Case presentationA 69-year-old woman underwent emergent endoscopic hemostasis for massive hematemesis of the stomach, and endoscopic examination showed ulceration with a visible vessel. Pathological biopsy examination of the ulcer identified poorly differentiated adenocarcinoma with signet ring cells. The patient was diagnosed with early gastric cancer that was not indicated for endoscopic resection because of the ulceration and histological type. Endoscopic ultrasound showed that the third layer was poorly demarcated at the ulcer scar, indicating invasion to the submucosal layer. Computed tomography did not reveal enlarged lymph nodes or distant metastasis. The preoperative diagnosis was early gastric cancer of the fundus without nodal metastasis, and laparoscopic proximal gastrectomy with D1+ lymphadenectomy was performed. The initial postoperative pathological diagnosis was intramucosal carcinoma without lymphovascular invasion; however, the presence of 26 lymph node metastases was revealed unexpectedly. Additional pathological examination of more resected specimens transected every 2–3 mm revealed that only one lesion contained a small number of cancer cells in the lymphatic duct below the muscularis mucosa.ConclusionsWe report a case of early gastric cancer with 26 nodal metastases in which lymph node involvement was not identified prior to surgery. These findings indicate that the extent of lymphadenectomy and the surgical procedure should be carefully decided even in cT1 N0 early gastric cancer when several risk factors for lymph node metastasis are present.

Reduction in the procedure time of hybrid endoscopic submucosal dissection for early gastric neoplasms: a multi-center retrospective propensity score-matched analysis

Background:Endoscopic submucosal dissection (ESD) for early gastric neoplasms is still a technically difficult and time-consuming procedure. Hybrid ESD (H-ESD) involves circumferential incision with partial submucosal dissection combined with subsequent mucosal resection by snaring, wherein the newly developed device allows us to perform H-ESD using a single device. This study aimed to determine the clinical outcomes of H-ESD compared with conventional ESD (C-ESD) for early gastric neoplasms.Methods:In this multi-center, retrospective study, using propensity score-matched analysis, we reviewed the charts of patients with early gastric neoplasms smaller than 20 mm treated with H-ESD or C-ESD at three hospitals between January 2017 and October 2018. The primary outcome was the procedure time, and the secondary outcomes were other factors, including the en bloc resection rate, complete resection rate, curative resection rate, and rate of adverse events.Results:Among 215 patients, 29 underwent H-ESD and 186 underwent C-ESD; 29 pairs were created by propensity score matching. In the H-ESD group, 82.8% of lesions met the absolute indication [mucosal lesions limited to 20-mm diameter, dominated by differentiated adenocarcinoma without ulcer (scar)] for endoscopic resection (ER). As a result, the procedure time of H-ESD was significantly shorter than that of C-ESD [20 (interquartile range, 12–27) min versus 40 (30–50) min; p < 0.001]. There was no significant difference in the secondary outcomes between the two groups.Conclusion:H-ESD contributed to reduced procedure time. Therefore, H-ESD could be an alternative endoscopic treatment for gastric neoplasms when the lesion fulfils the absolute indication for ER.

Correlation between the macroscopic severity of Crohn’s disease in resected intestine and bowel wall thickness evaluated by water-immersion ultrasonography

Objectives: Transabdominal ultrasonography is a common and accurate tool for managing Crohn’s disease (CD); however, the significance of the resulting data is poorly understood. This study was performed to determine the association between bowel wall thickness evaluated by water-immersion ultrasonography and macroscopic severity, namely, refractory inflammation and subsequent fibrosis in CD surgical specimens.Materials and methods: We retrospectively evaluated 100 segments of colon and small intestine from 27 patients with CD. The resected specimens were placed in saline postoperatively, and bowel wall thickness was measured by water-immersion ultrasonography and compared with macroscopic findings. Correlations between bowel wall thickness and macroscopic findings were assessed using analysis of variance and receiver operating characteristic curves.Results: According to the progression of macroscopic severity, the mean bowel wall thickness was increased as follows: macroscopically intact: 4.1 mm, longitudinal ulcer scars: 5.4 mm, longitudinal open ulcers: 6.0 mm, large ulcers: 6.4 mm, cobblestone-like lesions: 7.1 mm, and fibrotic strictures: 7.4 mm. For all lesions except longitudinal ulcer scars, the bowel wall thickness was significantly thicker than that of macroscopically-intact areas (p < .001). According to receiver operating characteristic curves, bowel wall thickness >4.5 mm was associated with CD lesions, and thickness >5.5 mm was associated with more severe lesions.Conclusions: The bowel wall thickness of CD lesions was evaluated by water-immersion ultrasonography correlated with macroscopic disease severity.

Silicone elastomer gel impregnated with 20(S)-protopanaxadiol-loaded nanostructured lipid carriers for ordered diabetic ulcer recovery.

Inefficient diabetic ulcer healing and scar formation remain a challenge worldwide, owing to a series of disordered and dynamic biological events that occur during the process of healing. A functional wound dressing that is capable of promoting ordered diabetic wound recovery is eagerly anticipated. In this study, we designed a silicone elastomer with embedded 20(S)-protopanaxadiol-loaded nanostructured lipid carriers (PPD-NS) to achieve ordered recovery in scarless diabetic ulcer healing. The nanostructured lipid carriers were prepared through an emulsion evaporation-solidification method and then incorporated into a network of silicone elastomer to form a unique nanostructured lipid carrier-enriched gel formulation. Interestingly, the PPD-NS showed excellent in vitro anti-inflammatory and proangiogenic activity. Moreover, in diabetic mice with full-thickness skin excision wound, treatment with PPD-NS significantly promoted in vivo scarless wound healing through suppressing inflammatory infiltration in the inflammatory phase, promoting angiogenesis during the proliferation phase, and regulating collagen deposition in the remodeling phase. Hence, this study demonstrates that the developed PPD-NS could facilitate ordered diabetic wound recovery via multifunctional improvement during different wound-healing phases. This novel approach could be promising for scarless diabetic wound healing.

A case of transpapillary removal of choledocholithiasis using a forward-viewing scope by the rendezvous method via the PTGBD route

A 75-year-old woman was referred to our department to be investigated for liver damage. Abdominal computed tomography findings revealed choledocholithiasis with an 11-mm stone. We attempted endoscopic lithotomy using a duodenoscope. However, it was impossible to pass the duodenoscope beyond a gastric deformity with duodenal ulcer scar. The intrahepatic biliary duct was not dilatated, so we performed percutaneous transhepatic gallbladder drainage (PTGBD). Although we attempted percutaneous removal of the stone via the PTGBD route, this was difficult due to the steep angle of the cystic duct junction. We finally succeeded in removing the stone by the rendezvous method via the PTGBD route, as a forward-viewing scope could reach the papilla of Vater. The rendezvous method via the PTGBD route was an effective option for a patient with choledocholithiasis.

Hydroa vacciniforme-like lymphoma

Hydroa vacciniforme-like lymphoma is a rare cutaneous T-cell lymphoma occurring in children associated with Epstein–Barr virus (EBV) infection. We reported a 15-year-old Chinese boy who presented with a 3-month history of recurrent special clinical manifestations including vesicles, erythematous papules, ulcer, crusting, and smallpox-like scar on his head, face, neck, limbs, and ankles. EBV-DNA level was positive. Immunohistochemistry showed CD2(+++), CD3(+++), CD4(+), CD5(++), CD7(+), CD8(±), CD56(+), ki67 (30%+), Gr-B(+++). The patient showed a significant improvement in clinical symptoms after being treated with interferon alpha and prednisone.

Clutch Cutter knife efficacy in endoscopic submucosal dissection for early gastric neoplasms.

AIMTo compare the outcomes of endoscopic submucosal dissection (ESD) for gastric neoplasms using Clutch Cutter (ESD-C) or other knives (ESD-O).METHODSThis was a single-center retrospective study. Gastric neoplasms treated by ESD between April 2016 and October 2017 at Kitakyushu Municipal Medical Center were reviewed. Multivariate analyses and propensity score matching were used to reduce biases. Covariates included factors that might affect outcomes of ESD, including age, sex, underlying disease, anti-thrombotic drugs use, tumor location, tumor position, tumor size, tumor depth, tumor morphology, tumor histology, ulcer (scar), and operator skill. The treatment outcomes were compared among two groups. The primary outcome was ESD procedure time. Secondary outcomes were en bloc, complete, and curative resection rates, and adverse events rates including perforation and delayed bleeding.RESULTSA total of 155 patients were included in this study; 44 pairs were created by propensity score matching. Background characteristics were quite similar among two groups after matching. Procedure time was significantly shorter for ESD-C (median; 49 min) than for ESD-O (median; 88.5 min) (P < 0.01). However, there was no significant difference in treatment outcomes between ESD-C and ESD-O including en bloc resection rate (100% in both groups), complete resection rate (100% in both groups), curative resection rate (86.4% vs 88.6%, P = 0.730), delayed bleeding (2.3% vs 6.8%, P = 0.62) and perforation (0% in both groups).CONCLUSIONESD-C achieved shorter procedure time without an increase in complication risk. Therefore, ESD-C could become an effective ESD option for gastric neoplasms.

Positive Antinucleolar Antibodies on Direct Immunofluorescence of Lesional Skin of a Patient With Limited Systemic Sclerosis

To the Editor: Limited systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis of the skin and internal organs. Circulant anticentromere antibody is usually positive.1 Antinucleolar antibodies are positive less frequently (15%–40%),2 having prognostic significance on the overall course of the patients. We present a case of limited SSc with negative serologic test for extractable nuclear antigens in which direct immunofluorescence revealed positive antinuclear antibodies (ANA) with nucleolar pattern. A 54-year-old man was referred to the dermatology department because of a 5-year history of multiple asymptomatic telangiectasias on the face and neckline. Clinical examination revealed the presence of sclerodactyly and multiple scars of ulcers in the fingertips that appeared when the patient worked in a frigorific chamber. Capillaroscopy showed predominance of areas of angiogenesis and some small avascular areas. The patient complained about mild interphalangeal arthralgias without inflammatory changes. Unspecific gastrointestinal symptoms and dyspnea were also present. High-resolution chest computed tomography showed mild pulmonary fibrosis predominantly in peripheral areas and bases of the lungs. Echocardiography confirmed the clinical suspicion of pulmonary hypertension, and bosentan therapy was initiated. Circulant ANA resulted positive at 1:1280 dilution. The determinations of extractable nuclear antigens, antibodies against parietal cells, against smooth muscle, and against double-stranded DNA were all negative. A skin biopsy of the neckline area with telangiectasia revealed lymphocytic perifolliculitis, with no other alterations. Direct immunofluorescence study (DIF) performed on lesional skin showed the presence of IgG ANA with a nucleolar pattern (Fig. 1).FIGURE 1.: Direct immunofluorescence on a skin biopsy from an area with telangiectasia in the patient's neckline. IgG resulted positive with a nucleolar pattern (×100).Circulating autoantibodies are found in as many as 95% of patients with SSc and carry greater weight in the newly proposed ACR/EULAR classification system. Centromere (CEN) proteins (P), topoisomerase I, and RNA polymerase III autoantibodies closely reflect patterns of organ involvement and disease progression.3 Circulating anti-Th/To type antinucleolar antibodies are detectable mainly by immunoprecipitation, which is not performed routinely in most clinical laboratories. Its positivity is related to limited skin involvement and frequent fibrosis of internal organs (interstitial lung disease, pericarditis, and renal involvement). Frequency of negative circulating antibodies with positive DIF findings is largely unknown because the last is not routinely performed. In the study by Kulthanan et al,4 a subgroup of patients with SSc presented positive DIF findings in 77% of the cases with the dermoepidermal junction and epidermal nuclei as the most common site, and of these patients, 45% presented negative serum ANA. Shibeshi et al5 reported a DIF positivity rate of 25,7% in 63 patients with SSc, with only one case with no circulating autoantibodies at all, and another with positive serum ANA but no characteristic antibodies of SSc. Antinucleolar pattern has been rarely reported in DIF of patients with SSc. Only 6 cases were found in the literature, all of them with high ANA titles. As these cases date from the 1980s, only circulating anti-ribonucleoprotein was performed, resulting positive in one of the patients.6,7 Our patient had ANA in peripheral blood, but more specific antibodies were not detected (antinucleolar, Scl70, or anticentromere). However, a skin biopsy with DIF was allowed to demonstrate the fixation of antibodies with a nucleolar pattern. Nucleolar pattern ANA in DIF of a skin biopsy is an unusual finding. We believe this technique can help to confirm clinical diagnosis and assess prognosis on individual patients.

Probe-Based Confocal Endomicroscopy May Improve the Diagnosis of Clinical Complete Response After Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Neoplasia

Introduction: Neoadjuvant chemoradiotherapy (nCRxt) followed by surgery represents the optimal approach for medium and distal advanced rectal tumors; however patients with clinical complete response (cCR) may be followed closely without surgery (watch and wait policy). Magnetic resonance imaging (MRI) and endoscopy have low sensitivity for the diagnosis of cCR. Probe-based confocal endomicroscopy (pCLE) represents a real time in vivo method allowing acquisition of optical biopsies with 1000 times magnification, evaluating both cellular and vascular patterns. Aim: to evaluate the contribution of pCLE in the diagnosis of cCR after nCRxt for advanced rectal cancer. Methods: We evaluated 40 patients with locally medium and distal advanced rectal neoplasia (T3 - T4, or N+) between October 2016 and February 2018 who underwent nCRxt (5-fluoroucacil, 5040 cGy), and who were submitted to pCLE. Cell irregularity, atypical glands, vascular enlargement and tortuosity were considered pCLE patterns of malignancy. pCLE was performed pre and post nCRxt, and guided tissue biopsies subsequently. Images of pCLE post nCRxt were recorded and blinded compared to the histology of the surgical specimens. Results: Twenty-one patients had tumor lesions located at medium rectum and 19 patients at distal rectum. Twenty-three (57.5%) patients were men. Mean age was: 63.15 years, varying from 36 to 82 years. Thirty-three had only partial nresponse, all of them confirmed by pCLE. Seven patients (17.5%) had good endoscopic response, and presented only a small ulcer (n=3) or residual scar (n=4). In this subgroup of patients, pCLE post nCRxt correctly diagnosed all but one (6/7 patients). Two negative pCLE patients were confirmed by surgical pathology. Three positive pCLE patients presented pathological residual disease in the surgical specimen. pCLE misdiagnosed one patient who was considered positive, however the surgical pathological result showed only mucin areas without neoplastic cells. One negative pCLE patient has been followed up for one year without any evidence of recurrence at endoscopy and MRI. pTNM stages of the subgroup were: 2 ypT0 ypN0, 1 ypT0 ypN1, 1 ypT1 ypN0, and 2 ypT2ypN0. Conclusion: 1. pCLE could be useful for improving the diagnosis of cCR, and may alter the patient management; 2. pCLE procedure might be valuable for identifying the patients with advanced rectal cancer who will benefit from watch and wait policy, avoiding surgical treatment and consequently achieving better quality of life.

Propensity score-matching analysis to compare clinical outcomes of endoscopic submucosal dissection for early gastric cancer in the postoperative and non-operative stomachs

BackgroundEndoscopic submucosal dissection (ESD) of the postoperative stomach (ESD-P) for early gastric cancer (EGC) is considered a technically difficult procedure. However, it is difficult to compare the outcomes of ESD-P and ESD of the non-operative stomach (ESD-N) because their baseline characteristics are different. Therefore, we aimed to compare the technical outcomes of ESD-P with those of ESD-N using a propensity score-matching analysis to compensate for the differences.MethodsThe chart records of 1046 patients with EGC who were treated with ESD between January 2004 and July 2016 at Kitakyushu Municipal Medical Center in Japan were reviewed in this retrospective study. Multivariate analyses and propensity score-matching were performed for age, sex, lesion location, lesion size, tumor invasion, tumor size, ulcer (scar), and operator skill. The primary outcome was procedure time. Secondary outcomes were percentages of en bloc, complete, and curative resections, and percentages of adverse events, which were evaluated between the two groups.ResultsForty-one patients were in the ESD-P group and 1005 patients were in the ESD-N group. Propensity score-matching created 41 matched pairs. According to the adjusted comparisons, ESD-P required a significantly longer procedure time (85 min vs 51 min, p < 0.001). Other treatment outcomes showed an en bloc resection rate of 100% for both groups (p = 1) and complete resection rates of 95.1 and 97.6% (p = 1), curative resection rates of 90.2 and 90.2% (p = 1), perforation during ESD rates of 2.4 and 0% (p = 1), and postprocedure bleeding rates of 2.4 and 2.4% (p = 1) for the ESD-P and ESD-N groups, respectively. For the ESD-P group, lesions on the suture line or anastomotic site were significantly associated with longer procedure times (p = 0.038).ConclusionsESD-P was a more time-consuming procedure than ESD-N. However, ESD-P and ESD-N achieved high rates of curative resection with a low rate of adverse events for the treatment of EGC. ESD could be selected as the treatment for EGC even in the postoperative stomach provided that careful attention is given to lesions on the suture line or anastomotic site.

Role of mucoprotective agents in endoscopic submucosal dissection-derived ulcers: A systematic review.

Currently, it is still unclear whether adding a mucoprotective agent to a proton pump inhibitor (PPI) results in better outcomes compared with using a PPI alone in patients with post-gastric endoscopic submucosal dissection (ESD) ulcers. This study aimed to examine the efficacy of PPI alone versus combination treatment in healing of post-gastric ESD ulcers, as well as on delayed bleeding and amount of blood transfused. A systematic search of MEDLINE, EMBASE, Cochrane, and ISI Web of knowledge databases, up until May 2017, for randomized trials comparing PPI alone versus PPI plus a mucoprotective drug in achieving ulcer healing in patients undergoing gastric ESD was performed. The primary outcome is scarring stage on endoscopic assessment at 4 or 8weeks after gastric ESD. From an initial 3071 citations, eight articles (n=953 lesions from 934 patients) were analyzed. Patients receiving combination treatment achieved a scarring stage significantly more often than those on a PPIs alone at 4 or 8weeks after ESD, (risk ratio=1.36, 95% CI; 1.06-1.75). No study reported amount of blood transfused. There were no significant between treatment-group differences in terms of delayed bleeding (risk ratio=0.58, 95% CI; 0.17-1.99). Neither location of ulcer nor Helicobacter pylori infection was related to ulcer scarring stage. The limited evidences suggested combination treatment may be more effective in accelerating the process of ulcer healing in patients undergoing gastric ESD than the use of PPI alone, but does not appear to alter delayed bleeding risk.

Systemic inflammatory response to shoulder ulcers and lack of preventive effect of postpartum pain medication with ketoprofen in sows

Shoulder lesions are common in lactating sows and can affect their welfare. We assessed the systemic inflammatory response to shoulder ulcers and monitored the preventive effect of postpartum administration with non-steroidal anti-inflammatory medication (ketoprofen) on their prevalence. In a double-blind placebo-controlled field trial, 144 YxL hybrid sows farrowing in crates with a cast-iron floor received either ketoprofen (3 mg/kg) or placebo as an intramuscular injection on days 0-1 after parturition. During the lactation period (weeks 1–4) all sows were assessed weekly for the presence of shoulder ulcers (0 = no ulcer, 1 = unilateral ulcer, 2 = bilateral ulcers; in all cases at least epithelial damage). From a subset of 37 sows, haptoglobin (Hp), albumin (ALB) and cortisol (COR) were measured from blood samples taken 10 to 12 days after farrowing. Results were analyzed according to a linear regression model for associations between Hp, ALB, COR and shoulder ulcers. A random ordered logistic model was used to assess risk factors (body condition score (BCS), back and shoulder fat, decrease in BCS or fat layer thickness during lactation, parity, number of live born and stillborn piglets, piglets weaned, shoulder ulcer scar) and the effect of ketoprofen treatment. Total prevalence of shoulder ulcers at lactation weeks 1–4 was 26.4%, 33.3%, 38.2% and 38.9%, respectively. Prevalences of unilateral shoulder ulcers at lactation weeks 1–4 were 16.7%, 19.4%, 20.8% and 18.8%, and prevalences of bilateral shoulder ulcers were 9.7%, 13.9%, 17.4%, and 20.1%. There was a decrease in albumin and an increase in Hp levels in sows with bilateral shoulder ulcers compared with sows without shoulder ulcers (P < 0.001) or unilateral shoulder ulcers (P = 0.014 for ALB, P = 0.021 for Hp). Changes in COR levels were not statistically significant but sows with bilateral shoulder ulcers tended to have lower cortisol levels than sows without ulcers (P = 0.061) and sows with unilateral shoulder ulcers (P = 0.089). Ketoprofen failed to protect against shoulder ulcers, but instead the treated sows had an increased number of shoulder lesions at the second and third lactation week (P = 0.023 and P = 0.049). Previous shoulder ulcer was a predisposing factor for shoulder ulcers at all lactation weeks (P < 0.001). Higher body condition score (BCS) and a thicker back and shoulder fat layer protected against shoulder ulcers. The results indicate that bilateral shoulder ulcers trigger a systemic response and should therefore be regarded as a significant finding in clinical evaluation. Postpartum administration of ketoprofen was ineffective in shoulder ulcer prevention.

Epidemiological and pathological study of cutaneous leishmaniasis in hilla and Diwanya/Iraq

Cutaneous leishmaniasis is an endemic diease in the middle and south of Iraq. distribution of infection was studied in two governorates (diwanya and hilla), total number of patients attended to the dermatology center in three months (December 2016, January, February 2017) in diwanyia was 1940, 132 were cutaneous leihmaniasis (10.7%) while in hilla 1757 patients were attended to the dermatology center at the asme months, cutaneous leihmaniasis cases were 42 (2.4%). total number of cutaneous leishmaniasis was 208, 132 for diwanya 76% while for hilla was 42, 24%.infected males were higer than females in both cities 74.3%,25.7% respectibely. Age variations reveal all infected cases were in all ages but high percent were in age of ten years old and below 35.6%. no cases were recorded during summer months and the peak of this sisease was in January 28.5%, February 30.9%. pathological lesions were classified grossly as follows, papule (redness and swelling ) pustule (redness with crusts sometimes with pus)ulcer (it was no crusts with shallow ulceration irregular margin)scar formation. Hematological study revealed increase in number of erythrocytes and variation in size (poikilocytosis). Treatment were mostly, systemic injection with topical treatment, several types of ointment.

Laparoscopic and endoscopic cooperative surgery for intra-mucosal gastric carcinoma adjacent to the ulcer scars

BackgroundLaparoscopic and endoscopic cooperative surgery (LECS) was performed for the local resection of gastrointestinal stromal tumors (GIST). LECS enables less resection of the lesion area and preserves function. Furthermore, LECS can be safely performed and independent of tumor location. However, LECS is not usually used for cases involving gastric carcinoma because it may seed tumor cells into the peritoneal cavity when the gastric wall is perforated. Here, we report seven cases of LECS for intra-mucosal gastric carcinoma, which were difficult to carry out by endoscopic submucosal dissection (ESD) because of ulcer scars.MethodsWe performed LECS (classical LECS and inverted LECS) in seven cases of intra-mucosal gastric carcinoma. All cases had ulcer scars beside the tumor. LECS was chosen because ESD was thought to be difficult because of the ulcer scars. We only selected cases in which the patients did not prefer gastrectomy and endoscopic examination was indicative of intra-mucosal gastric carcinoma.ResultsIn all cases, LECS was performed without severe complications including postoperative stenosis. Histopathology findings proved that the tumors were intra-mucosal carcinoma and had been resected completely. Furthermore, there were ulcer scars (Ul IIIs-IVs) beside the tumor. Currently, dissemination and recurrence have not been apparent.ConclusionsLECS for intra-mucosal gastric carcinoma is an efficient procedure, but strict observation is necessary because of the possibility of peritoneal dissemination. Results suggest that LECS is likely to be effective for cases involving intra-mucosal gastric carcinoma that are difficult to treat by ESD due to ulcer scars.

Risk factors and peculiarities of clinical course of ulcer disease in employees of antibiotic industry.

A total of 62 patients engaged in antibiotic production (main group) and 59 control subjects were examined. Risk factors of ulcer disease in these patients could be dust inhalation, contact with solvents, shift work, and smoking. Patients of the main group had a more severe disease and higher frequency of complications, larger amounts of Helicobacter pylori in the gastric mucosa, its more pronounced morphological changes, slower disappearance of clinical symptoms of exacerbation, and longer period of ulcer scarring. Also, they underwent more severe disorders of humoral immunity than control subjects which might account for the unfavourable clinical picture of their condition.

Efficacy and safety of Helicobacter pylori eradication therapy immediately after endoscopic submucosal dissection.

In the treatment of patients after endoscopic submucosal dissection (ESD), there is no consensus on the optimum time to start Helicobacter pylori eradication therapy or on whether eradication therapy improves ulcer healing rate after ESD. The aim of this study was to examine the effect of immediate eradication of H.pylori on ulcer healing after ESD in patients with early gastric neoplasms. A total of 330 patients who underwent ESD for early gastric neoplasms were enrolled. Patients were assigned to either H.pylori eradication group (Group A: H.pylori eradication+proton pump inhibitor 7weeks) or non-eradication group (Group B: proton pump inhibitor 8weeks). The primary end point was gastric ulcer healing rate (Group A vs Group B) determined on week 8 after ESD. Patients in Group A failed to meet non-inferiority criteria for ulcer scarring rate after ESD compared with that in Group B (83.0% vs 86.5%, P for non-inferiority=0.0599, 95% confidence interval: -11.7% to 4.7%). There were, however, neither large differences between the two groups in the ulcer scarring rate nor the safety profile. This study failed to demonstrate the non-inferiority of immediate H.pylori eradication therapy after ESD to the non-eradication therapy in the healing rate of ESD-caused ulcers. However, because the failure is likely to attribute to small number of patients enrolled, immediate eradication therapy may be a treatment option for patients after ESD without adverse effects on eradication therapy in comparison with the standard therapy.

Vonoprazan is Superior to Rabeprazole for Healing Endoscopic Submucosal Dissection: Induced Ulcers

Background and Aims: Endoscopic submucosal dissection (ESD) is a well-established minimally invasive treatment for early gastric cancer. To heal ESD-induced ulcers, we commonly prescribe proton pump inhibitors (PPIs). Vonoprazan is our new choice, which is reported to have a stronger and longer acid inhibitory effect than existing PPIs. Here, we aimed to evaluate the efficacy of vonoprazan for healing ESD-induced ulcers compared with rabeprazole. Methods: We reviewed 190 patients who underwent ESD before and after we switched the acid secretion inhibitor from rabeprazole to vonoprazan. We evaluated scarring and reduction rates at 4 weeks after ESD. Results: Scarring rates were not different between vonoprazan and rabeprazole (31.7 vs. 18.9%; p = 0.07). However, for ulcers ≤35 mm, vonoprazan was superior to rabeprazole (42.2 vs. 19.2%; p < 0.05). Reduction rates were superior for vonoprazan compared with rabeprazole (93.0 vs. 90.4%; p < 0.05). In multivariate analysis, vonoprazan was superior to rabeprazole for ulcer scarring (OR 2.21; p < 0.05), and ulcer location in the lower-third of the stomach had higher risk of incomplete scarring (OR 0.37; p < 0.05). Conclusion: Vonoprazan was superior to rabeprazole for healing ESD-induced ulcers.

Usefulness of the S-O clip for gastric endoscopic submucosal dissection (with video).

Endoscopic submucosal dissection (ESD) is technically one of the most complicated endoscopic procedures. Traction methods have been reported to be effective for ESD. A recent study revealed that the S-O clip allowed faster and safer colonic ESD. We assessed the efficacy and safety of gastric ESD with the S-O clip for gastric epithelial neoplasm. We performed a retrospective cohort study of patients treated for gastric ESD using the S-O clip between September and November 2016 (SO group, n=48). The subjects were matched with patients treated with conventional gastric ESD from September 2015 to August 2016 (control group, n=258) at Sendai Kousei Hospital, a tertiary endoscopic center. The primary outcome was procedure time. Multivariate logistic regression and propensity score matching analyses were performed to reduce the effects of selection bias for potential confounding factors differences like age, sex, lesion location, lesion position, presence of ulcer scarring, resected specimen size, and operator experiences. Forty-eight pairs were created after propensity score matching. The mean procedure time (including the S-O clip attachment time) was significantly shorter in the SO group (47.2±24.6 vs. 69.2±67.1min, p=0.035). The mean clip attachment time was 4.4 (range 2-15) min. There were no significant differences in other treatment outcomes (en-bloc resection rate: 100 vs. 100%, p=1.000; perforation rate: 0 vs. 2.1%, p=0.315; delayed bleeding rate: 2.1 vs. 4.3%, p=0.558). The S-O clip improved the speed of gastric ESD by approximately 25%, without increasing adverse events.