[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: After endoscopic resection (ER) for superficial pharyngeal cancer (SPC), additional treatments such as radical surgical resection or radiation therapy may be needed in cases of possible incomplete resection. However, the benefit of prophylactic additional treatment is unclear. OBJECTIVE: To evaluate the feasibility of a "resect and watch" strategy with ER for SPC. DESIGN: Retrospective, single-center cohort study. SETTING: Tertiary cancer center. PATIENTS: A total of 32 patients with 47 SPCs were eligible. INTERVENTION: A "resect and watch" strategy of initial ER and observation until development of secondary diseases, including local recurrence, neck lymph node metastasis (LNM), and metachronous pharyngeal cancer. MAIN OUTCOME MEASUREMENTS: Complications, tumor recurrence, development of metachronous pharyngeal cancer, overall survival, and cause-specific survival. RESULTS: There were no severe complications related to ER. Median length of follow-up was 43 months (range, 7-76 months). Cumulative development of secondary diseases at 5 years was 44% (95% CI, 24.5%-63.8%). Local recurrence (N = 4) and neck LNM (N = 5) were successfully treated by local resection (2 partial surgical resections and 2 additional ERs) and neck dissection, respectively. Metachronous pharyngeal cancers (N = 6) were completely removed by ER. The overall survival and cause-specific survival rates at 5 years were 84.4% (95% CI, 70.0%-98.8%) and 100%, respectively. No patient needed radical surgery as an additional therapy. Thus, the larynx and its function were preserved in all patients. LIMITATIONS: Retrospective nature, single-center setting, relatively small sample size. CONCLUSIONS: A "resect and watch" strategy with ER for SPC is feasible and rational.
Full-text · Article · Mar 2013 · Gastrointestinal endoscopy
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The behavior of early gastric cancer (EGC) with mixed-type histology (differentiated and undifferentiated) is incompletely understood. This study aimed to clarify the clinicopathological features of EGC with mixed-type histology in relation to lymph node (LN) metastasis. METHODS: Clinicopathological data from 410 patients who underwent surgical resection for intramucosal EGC were reviewed. Lesions were classified into four types according to the proportion of differentiated and undifferentiated components at histopathology: pure differentiated (PD) type, mixed predominantly differentiated (MD) type, mixed predominantly undifferentiated (MU) type, and pure undifferentiated (PU) type. We examined the clinicopathological differences between PD and MD, and between PU and MU, and the rate of LN metastasis according to tumor size and ulceration. RESULTS: Moderately differentiated adenocarcinoma was the primary component in MD relative to PD (90.7 vs. 46.1 %). Signet ring cell carcinoma was the main component in PU relative to MU (81.5 vs. 33.3 %). LN metastasis was more common in MU than PU (19.0 vs. 6.0 %). For intramucosal tumors larger than 20 mm without lymphovascular invasion and without ulceration, the rate of LN metastasis was 0 % for MD and 24 % for MU. For intramucosal lesions less than 30 mm with ulceration but without lymphovascular invasion, the rate of LN metastasis was 0 % for MD and 20 % for MU. CONCLUSIONS: Histologically mixed-type EGC with a predominantly undifferentiated component should be managed as an undifferentiated-type tumor. Further investigation is required to determine whether mixed-type EGC with a predominantly differentiated component could be managed the same way as a differentiated-type EGC.
[Show abstract][Hide abstract] ABSTRACT: A Phase II clinical trial has been initiated to evaluate the efficacy and safety of endoscopic submucosal dissection for intramucosal (cT1a) gastric cancer of undifferentiated type. Patients with cT1a gastric cancer with undifferentiated-type adenocarcinoma are eligible for the study. The tumor size should be 2 cm or less without ulceration. The study will enroll a total of 325 patients from 51 institutions over a 4-year period. The primary endpoint is proportion of 5-year overall survival (% 5-year overall survival) in patients with undifferentiated dominant type. The secondary endpoints are overall survival, relapse-free survival, distant metastasis-free survival, % 5-year overall survival without either recurrence or gastrectomy, % en-bloc resection with endoscopic submucosal dissection, % pathological curative resection with endoscopic submucosal dissection, % 5-year overall survival in patients with differentiated dominant type, % 5-year overall survival in patients with pathologically curative resection with endoscopic submucosal dissection and adverse events. This trial was registered at the UMIN Clinical Trials Registry as UMIN000004995.
Full-text · Article · Nov 2012 · Japanese Journal of Clinical Oncology
[Show abstract][Hide abstract] ABSTRACT: Autoimmune pancreatitis (AIP) sometimes mimics pancreatic cancer, and is rarely resected under this misdiagnosis. However, there is no report in the literature regarding a case of AIP, which was misdiagnosed as an inoperative stage of pancreatic cancer and which received systemic chemotherapy with or without radiation. We report a 59-year-old man with a mass-forming lesion at the pancreatic head involving the common hepatic artery and portal vein, initially diagnosed as locally advanced pancreatic cancer and treated with chemoradiation therapy. After a month of continuous infusion of low dose 5-fluorouracil with concurrent local radiation (50.4 Gy), the pancreatic lesion diminished in size. However, the pancreatic body gradually enlarged and a capsule-like limb appeared in the following year. Serological markers and endoscopic retrograde cholangiopancreatography were compatible with those of AIP. No neoplastic tissue was identified on the fine needle aspiration biopsy of the pancreas. The pancreatic lesion responded well to steroid therapy and the patient remained in remission for one year after the withdrawal of steroids. Similar to pancreatic cancer, this current case of AIP responded to chemoradiation. Both serological and histological examinations were essential for images equivocal for either locally advanced pancreatic cancer or AIP.
Full-text · Article · Sep 2011 · Journal of gastrointestinal and liver diseases: JGLD
[Show abstract][Hide abstract] ABSTRACT: To evaluate the effectiveness of short-course radiotherapy (RT) with 30 Gy in 10 fractions for bleeding from advanced gastric cancer.
We reviewed the data for all patients with gastric cancer requiring blood transfusions due to gastric bleeding who were treated with RT at the Shizuoka Cancer Center Hospital between September 2002 and March 2007. Patients with curative-intent chemoradiotherapy or previous irradiation were excluded. RT was planned to deliver a total of 30 Gy at 3 Gy per fraction. We defined RT as effective if the patients did not require blood transfusions for 1 or more months after RT.
Twenty-two out of 30 patients (73%) responded to RT, and rebleeding occurred in 11 (50%) of 22 patients responding to RT. The median actuarial time to rebleeding was 3.3 months. Twelve patients received concurrent chemoradiotherapy and had a significantly lower rebleeding rate than patients undergoing RT alone (P = 0.001). Among patients receiving CRT, 1 with grade 3 non-hematological toxicity and 5 with grade 3-4 hematological toxicity were observed. No Grade 3 or higher adverse events were observed in patients treated with RT alone.
RT with 30 Gy in 10 fractions is an adequate treatment for bleeding from advanced gastric cancer, especially in patients with poor prognosis.
No preview · Article · Mar 2010 · Journal of Cancer Research and Clinical Oncology
[Show abstract][Hide abstract] ABSTRACT: Although use of gastrointestinal endoscopy for response evaluation in patients with esophageal cancer undergoing chemoradiotherapy or radiotherapy (CRT/RT) treatment is widely accepted, optimal timing for evaluation has not been sufficiently investigated. Here, we investigated optimal timing of primary site response evaluation in esophageal cancer patients treated with CRT/RT.
This study examined esophageal cancer patients who underwent CRT/RT between September 2002 and December 2004. Time to complete response (CR) at the primary site was assessed in patients designated as CR at the primary site, while progression-free survival at the primary site (PFSp) was assessed in patients designated as incomplete response at the primary site.
Eighty-three patients were enrolled in this study. Median total RT dose was 60 Gy (range, 50-60 Gy), and median RT duration was 53 days (range, 35-74 days). Mean time to CR at the primary site was 97 days (range, 52-201 days). In four patients, although initial examination of biopsy specimens found evidence of viable cancer cells within 75 days of treatment initiation, subsequent examination found no such evidence, and the patients were thus designated as CR. Median PFSp was 149 days (range, 67-399 days), and PFSp rate at 90 days was 97%. Median interval between the previous examination and initial primary progressive disease was 37 days.
Recommended time of first response evaluation for esophageal cancer following initiation of CRT/RT was found to be between 75 and 90 days. Subsequent evaluation should be carried out approximately one month following non-CR/non-progressive disease declassification.
No preview · Article · Oct 2009 · Digestive Endoscopy
[Show abstract][Hide abstract] ABSTRACT: Metallic stent migration is a well-known complication which cannot always be managed by removal or repositioning, especially in case of uncovered stent. We report a patient who developed obstructive jaundice due to migration of an expandable metallic stent (EMS) inserted in the lower bile duct. Trimming of the EMS using argon plasma was performed, with the power setting of 60 W and 2.0 l/min of argon flow. The distal part of the EMS was removed and mechanical cleaning using balloon catheter was performed for remnant EMS. Without additional stent insertion, jaundice was relieved in a few days. No complication was recognized during the procedure and no recurrence of jaundice in the rest of his life.
Full-text · Article · Jul 2009 · Case Reports in Gastroenterology
[Show abstract][Hide abstract] ABSTRACT: A Phase II trial was started in Japan to evaluate the efficacy and safety of endoscopic submucosal dissection for macroscopic
mucosal (cT1a) gastric cancer beyond the present indication described in the Gastric Cancer Treatment Guidelines by the Japan
Gastric Cancer Association. Patients with cT1a gastric cancer, which is histologically proven differentiated (intestinal)
type adenocarcinoma, are eligible. In this study, the tumor is >2 cm for ulceration (UL)-negative cases or ≤3 cm for UL-positive
cases. A total of 330 patients are enrolled from 26 institutions over 2 years. The primary endpoint is the 5-year overall
survival (OS). The secondary endpoints are OS in the UL-negative subset and the UL-positive subset, recurrence-free survival
(RFS), 5-year RFS with preserved stomach, proportion of en bloc resection, proportion of pathological curative resection and adverse events.
Preview · Article · Jul 2009 · Japanese Journal of Clinical Oncology
[Show abstract][Hide abstract] ABSTRACT: Background: Pancreatitis is the most common and serious complication to occur after endoscopic retrograde cholangiopancreatography (ERCP). It is often associated with additional diagnostic modalities and/or treatment of obstructive jaundice. The aim of this study was to determine the risk of post-ERCP pancreatitis associated with pancreaticobiliary examination and endoscopic biliary drainage (EBD).Methods: A total of 740 consecutive ERCP procedures performed in 477 patients were analysed for the occurrence of pancreatitis. These included 470 EBD procedures and 167 procedures to further evaluate the pancreaticobiliary tract using brush cytology and/or biopsy, intraductal ultrasound and/or peroral cholangioscopy or peroral pancreatoscopy. The occurrence of post-ERCP pancreatitis was analysed retrospectively.Results: The overall incidence of post-ERCP pancreatitis was 3.9% (29 of 740 procedures). The risk factors for post-ERCP pancreatitis were: being female (6.5%; odds ratio [OR] 2.5, P= 0.02); first EBD procedure without endoscopic sphincterotomy (ES) (6.9%; OR 3.0, P= 0.003), and performing additional diagnostic procedures on the pancreatobiliary duct (9.6%; OR 4.6, P < 0.0001). Pancreatitis after subsequent draining procedures was rare (0.4%; OR for first-time drainage 16.6, P= 0.0003). Furthermore, pancreatitis was not recognized in 59 patients who underwent ES. Seven patients with post-EBD pancreatitis were treated with additional ES.Conclusions: Invasive diagnostic examinations of the pancreaticobiliary duct and first-time perampullary biliary drainage without ES were high-risk factors for post-ERCP pancreatitis. Endoscopic sphincterotomy may be of use to prevent post-EBD pancreatitis.
[Show abstract][Hide abstract] ABSTRACT: Introduction
Carcinoid of papilla of the Vater is a rare entity. Detailed prognostic factors of this tumor have not yet been elucidated, and treatment choices include local resection and pancreatoduodenectomy with excision of lymph nodes.
A 59-year-old woman, who was diagnosed with liver dysfunction and underwent a cholecystectomy, was referred to our institution with a suspected ampullary tumor. Computed tomography showed 1 cm of enhancement at the duodenal ampulla, but no visible lymph adenopathy. In the duodenoscopic view, her papilla was slightly enlarged without orifice, so that forceps biopsy was performed from the common ampullary channel after needle-knife incision. Tissue obtained by biopsy revealed a possible carcinoid tumor, with 1.1% of Ki-67 labeling index. Pancreatoduodenectomy was performed, and the resected specimen showed a carcinoid tumor of the ampulla, 1.2 cm in diameter, with metastases to regional lymph nodes and a 4% Ki-67 labeling index. It is suggested that despite the small size and low proliferation index, an ampullary carcinoid may not be cured by local resection. Clinicians must pay careful attention to the choice of treatment and monitoring after the resection.
No preview · Article · Mar 2009 · Journal of Gastrointestinal Cancer
[Show abstract][Hide abstract] ABSTRACT: In Japan, chemotherapeutic agents that have been approved for the treatment of esophageal cancer include cisplatin, nedaplatin, 5-fluorouracil, vindesine, and docetaxel. We retrospectively investigated the efficacy and toxicity of a combination of nedaplatin plus vindesine, or docetaxel alone, for patients with unresectable or recurrent squamous cell carcinoma of the esophagus refractory to prior chemotherapy with 5-fluorouracil plus platinum.
Nedaplatin was administered at 90 mg/m(2) intravenously on day 1, and vindesine was administered at 3 mg/m(2) intravenously on days 1 and 8 every 28 days. Docetaxel 60 mg/m(2) or 70 mg/m(2) was administered intravenously every 21 days. We analyzed the response rate, overall survival time, progression-free survival time, and toxicity in 24 patients treated with nedaplatin plus vindesine and 28 patients treated with docetaxel.
In patients treated with nedaplatin plus vindesine, the response rate of the 13 patients with measurable lesions was 8% (1/13), the median progression-free survival time was 1.8 months, and the median survival time was 5.5 months. In patients treated with docetaxel, the response rate of the 17 patients with measurable lesions was 18% (3/17), the median progression-free survival time was 2.1 months, and the median survival time was 5.1 months. The most frequent toxicity was neutropenia (grade 4; 13% in the group with nedaplatin plus vindesine and 50% in the docetaxel group), and febrile neutropenia (grade 3; 4% and 18%, respectively).
The efficacy of the two regimens for unresectable or recurrent squamous cell carcinoma of the esophagus refractory to chemotherapy with 5-fluorouracil plus platinum was unsatisfactory. New, more effective therapies are needed.
No preview · Article · May 2008 · International Journal of Clinical Oncology
[Show abstract][Hide abstract] ABSTRACT: Although endoscopic submucosal dissection (ESD) of early gastric cancer using an insulation-tipped diathermic (IT) knife enables the removal of large and ulcerative lesions en bloc, expert endoscopic skill is required. We developed an improved IT knife (IT-2) and compared its efficacy and safety with that of the original IT knife (IT-OM).
We performed ESD of 602 gastric cancers. Of these, 314 previously untreated single lesions of initial onset were analyzed. Operating time, rate of en-bloc resection, and incidence of complications were compared in the IT-2 group (161 patients) and IT-OM group (153 patients). Lesions were further analyzed as to whether they met the Japanese Gastric Cancer Association indications for ESD or extended indications.
Mean resection time was significantly shorter in the IT-2 than in the IT-OM group (48 vs 63 min). There were fewer surgeries lasting longer than 2 h in the IT-2 group than in the IT-OM group (3% vs 12%). En-bloc and margin-free resection rates in the IT-OM and IT-2 groups were 95% and 99%, respectively. Perforations occurred in 3.9% of patients in the IT-OM group and in 5% of patients in the IT-2 group (difference not significant [NS]). The incidence of postoperative hemorrhage was 7.8% in the IT-OM group and 8.7% in the IT-2 group (NS). In both groups, complications were treated endoscopically, and emergency surgery was unnecessary.
Resectability and complication rates were similar in the two groups. However, operating time was shorter with IT-2, irrespective of the indications for the performance of ESD. This study suggests benefits of the IT-2 over the IT-OM.
[Show abstract][Hide abstract] ABSTRACT: Endoscopic mucosal resection (EMR) of early gastric cancer (EGC) without any risk of lymph node metastasis was developed in Japan in the 1980s, and it has been one of the standard treatments of EGC for nearly 20 years. Recently, several EMR techniques developed in Japan have been accepted and done in Western countries. These EMR techniques are safe and efficacious but unsuitable for large lesions. Because we could not remove a large lesion in 1 fragment, which was very important for the precise diagnosis of tumor depth, local recurrence increased in large-lesion cases. An innovative procedure using newly developed endoscopic knives, called endoscopic submucosal dissection (ESD), was developed in the late 1990s, which made it possible to remove a large lesion en bloc. Theoretically, ESD has no limitation with respect to tumor size; therefore, it is expected to replace the surgical treatment in some situations. Although ESD has spread throughout Japan within a short period, there remain several disadvantages, such as a higher incidence of complications and a requirement of higher endoscopic skills compared to those of conventional EMR methods. The endoscopic indications, procedures, complications and treatment outcomes of the ESD of EGC are described in this review.
[Show abstract][Hide abstract] ABSTRACT: Short-term infusion of 5-fluorouracil with leucovorin in combination with irinotecan or oxaliplatin has been considered as standard treatment for metastatic colorectal cancer. However, until infusion of 5-fluorouracil regimens and oxaliplatin was approved for the treatment of metastatic colorectal cancer in Japan early in 2005, combination of irinotecan with bolus 5-fluorouracil/leucovorin had been the standard treatment. This retrospective study evaluates the efficacy and safety of a modified irinotecan with bolus 5-fluorouracil/leucovorin regimen in Japanese colorectal cancer patients.
Forty-six patients untreated with chemotherapy for metastatic colorectal cancer received a modified form of the irinotecan with bolus 5-fluorouracil/leucovorin regimen, consisting of intravenous irinotecan (100 mg/m2) and l-leucovorin (10 mg/m2), and then 5-fluorouracil 500 mg/m2 as an intravenous bolus infusion, weekly for 4 weeks, repeated every 6 weeks until progression or unacceptable toxicity.
The overall response rate was 48% (95% confidence interval, 34-62%), and 48% of patients had stable disease. Median progression-free survival was 8.3 months and overall survival was 20.3 months. The incidence of grade 3 or 4 toxicity was as follows: neutropenia, 50%; diarrhea, 4%; fatigue, 13%; nausea, 7%; and vomiting, 7%. Neither treatment-related nor all-cause mortality occurred within 60 days of chemotherapy initiation. Despite the limited availability of oxaliplatin, 29 patients received an oxaliplatin-based regimen after progression.
A modified irinotecan plus bolus 5-fluorouracil/l-leucovorin regimen was an active and well-tolerated regimen in Japanese patients with advanced colorectal cancer, showing a different toxicity profile from Western patients.
Full-text · Article · Oct 2007 · Japanese Journal of Clinical Oncology
[Show abstract][Hide abstract] ABSTRACT: Endoscopic mucosal resection (EMR) is now commonly indicated for esophageal squamous cell carcinoma (ESCC) within the lamina propria mucosa. However, EMR for ESCC that has invaded the muscularis mucosa is controversial because the risk of lymph node metastasis is not negligible. We conducted a multicenter retrospective cohort study to investigate the incidence of lymph node metastasis and survival after EMR for ESCC invading the muscularis mucosa.
A total of 104 patients with 111 lesions invading the muscularis mucosa, were retrospectively studied at eight institutes. No patients exhibited evidence of metastasis of lymph nodes or distant organs prior to EMR. Overall and cause-specific survival rates were calculated from the date of EMR to the date of death or the most recent follow-up visit. Survival curves were plotted according to the Kaplan-Meier method.
In total, 86 patients (82.7%) who did not receive further treatment such as chemotherapy, irradiation therapy, chemoradiotherapy, or esophagectomy after EMR were followed up. Only two patients (1.9%) developed lymph node metastasis after EMR. With a median follow-up period of 43 months (range, 8-134 months), overall and cause-specific survival rates at 5 years after EMR were 79.5% and 95.0%, respectively.
EMR for ESCC that invades the muscularis mucosa has curative potential as a minimally invasive treatment option.
[Show abstract][Hide abstract] ABSTRACT: Recently, outpatient chemotherapy centers have become popular in Japan. To clarify the actual conditions of outpatient clinics, we surveyed entire clinical courses of chemotherapy in patients with unresectable or recurrent gastric cancer.
From the medical records of 64 patients with unresectable or recurrent gastric cancer with no prior chemotherapy, we obtained data on overall survival, non-hospitalized survival, the number of and reasons for attendance at the outpatient clinic and hospitalization, and medical conditions at discharge.
The median follow-up time was 520 days, the median survival time was 353 days, and the median non-hospitalized survival time was 282 days. Patients attended the outpatient clinic 1917 times in total; 145 (8%) of these were unplanned visits for accidental disease, disease progression, or toxicity. Patients were hospitalized 291 times in total: 110 (38%) of hospitalizations were unplanned or emergencies because of disease progression or toxicity. Patients were discharged 290 times in total; in 56 of these discharges (19%) unresolved medical problems remained, such as toxicity, total parenteral nutrition, or symptoms related to cancer. Three patients (5%) died from treatment-related leucopenia and thrombocytopenia.
Patients with unresectable and recurrent gastric cancer were treated at outpatient clinics for periods up to 80% longer than the entire clinical course of chemotherapy. However, there were some unplanned or emergency hospitalizations and some patients still experienced medical problems at discharge. The role of the outpatient clinic is very important to chemotherapy for patients with unresectable or recurrent gastric cancer.
Full-text · Article · Mar 2007 · Japanese Journal of Clinical Oncology
[Show abstract][Hide abstract] ABSTRACT: A patient was diagnosed with a small cell carcinoma of the esophagus (T4N1M1b by the International Union Against Cancer [UICC] classification) in October 2002, and initially received two courses of concurrent chemotherapy with 5-fluorouracil (5-FU; 400 mg/m(2) by continuous infusion; days 1-5 and 8-12) and cisplatin (40 mg/m(2) by drip infusion; days 1 and 8) and radiation therapy (2 Gy/day, days 1-5, 8-12, and 15-19; total, 30 Gy per course) with the second course given after a 2-week interval. Two courses of chemotherapy with 5-FU (800 mg/m(2); days 1-5) and cisplatin (80 mg/m(2); day 1) given after this was completed. Although a complete response had been confirmed, recurrence with multiple liver and lymph node metastases was detected 3 months after the cessation of the second course of chemotherapy. Although the patient received second-line chemotherapy with irinotecan (150 mg/m(2); every 2 weeks) from June 2003, the disease progressed. Brain metastases developed during third-line chemotherapy with gemcitabine (1000 mg/m(2) weekly by drip infusion). The symptoms were attenuated after whole-brain radiation (30 Gy), and fourth-line chemotherapy using paclitaxel (80 mg/m(2); weekly) was initiated from November 2003. A computed tomography scan 1 month after the first course of paclitaxel showed remarkable regression of the liver metastases. The treatment strategy used for treating small cell carcinomas of the lung may be applicable for these carcinomas of the esophagus.
No preview · Article · Jan 2006 · International Journal of Clinical Oncology
[Show abstract][Hide abstract] ABSTRACT: Background: Endoscopic mucosal resection (EMR) is widely accepted as a minimally invasive treatment for early gastric cancer (EGC) in Japan. However, the criteria for EMR must be strictly adhered to otherwise patients will miss the chance for additional therapy. We assess the important factor in expanding the indication of EMR.
Methods: We investigated 1101 EGCs that had been resected by EMR at the National Cancer Center Hospital (NCCH), Tokyo, Japan, according to the indication recommended by Japanese Gastric Cancer Association (JGCA) and the expanded indication proposed by NCCH. Curability and local recurrence of the EMRs were assessed related to the applied indication and the number of resected specimens.
Results: The recurrence rate of non-evaluable resection was higher than that of evaluable resection (P < 0.0001). Eighty-three lesions among 772 lesions in the JGCA group were non-evaluable. Thirty-seven leisons among 329 lesions in the NCCH group were non-evaluable. There was no difference in the rate of non-evaluable resection between JGCA and NCCH groups (P = 0.8329). However, the rate of curative resection was lower in the NCCH group than in the JGCA group (P = 0.0009). In piecemeal resection, there was no difference in the rate of non-evaluable resection between JGCA and NCCH groups (P = 0.0527). In one-piece resection, the rate of non-evaluable resection was lower in the NCCH group than the JGCA group (P = 0.0137).
Conclusion: Based on our series of cases, we propose one-piece resection as a gold standard for EMR because it enables accurate histological evaluation, even in the EMR, according to the expanded indication.
No preview · Article · Mar 2003 · Digestive Endoscopy