Sedation in gastroenterological endoscopy has become an important medical option in routine clinical care. Here, the Japan Gastroenterological Endoscopy Society and the Japanese Society of Anesthesiologists together provide the revised “Guidelines for sedation in gastroenterological endoscopy” as a second edition to address on‐site clinical questions and issues raised for safe examination and treatment using sedated endoscopy. Twenty clinical questions were determined and the strength of recommendation and evidence quality (strength) were expressed according to the “MINDS Manual for Guideline Development 2017.” We were able to release up‐to‐date statements related to clinical questions and current issues relevant to sedation in gastroenterological endoscopy (henceforth, “endoscopy”). There are few reports from Japan in this field (e.g., meta‐analyses), and many aspects have been based only on a specialist consensus. In the current scenario, benzodiazepine drugs primarily used for sedation during gastroenterological endoscopy are not approved by national health insurance in Japan, and investigations regarding expense‐related disadvantages have not been conducted. Furthermore, including the perspective of beneficiaries (i.e., patients and citizens) during the creation of clinical guidelines should be considered. These guidelines are standardized based on up‐to‐date evidence quality (strength) and supports on‐site clinical decision‐making by patients and medical staff. Therefore, these guidelines need to be flexible with regard to the wishes, age, complications, and social conditions of the patient, as well as the conditions of the facility and discretion of the physician.

Background and study aims: As more early gastric cancer (EGC) patients are being treated with endoscopic submucosal dissection (ESD), it is important to understand the outcomes of patients who develop metachronous gastric cancer (MGC). The aim of this study was to evaluate the long-term surveillance and treatment outcomes of MGC after curative gastric ESD. Patients and methods: The study included 1526 consecutive patients who underwent curative ESD resection of EGC. They were generally followed by annual or biannual esophagogastroduodenoscopy. The risk factors and treatment outcomes for MGC were assessed along with the 5-year, 7-year, and 10-year cumulative incidence functions of MGC and disease-specific survival (DSS). Results: During a median follow-up period of 82.2 months, 238 patients developed MGC post-ESD resection of EGC. The 5-year, 7-year, and 10-year cumulative incidence functions of MGC were 9.5 %, 13.1 % and 22.7 %, respectively. Male sex and multiple initial EGCs were independent risk factors for MGC in the Cox proportional hazard model. Of the 238 patients with MGC, 215 were treated with endoscopic resection, of which 183 achieved curative resection, although one patient later died of his initial EGC. A further 14 patients were treated surgically, three had metastatic disease and received palliative chemotherapy, and the remaining six were observed without any intervention. A total of seven patients died of MGC, five at least 5 years after their index ESD. The 5-year, 7-year, and 10-year DSSs were 99.2 %, 98.6 %, and 92.5 %, respectively. Conclusions: The incidence of MGC increases with time after curative gastric ESD, therefore surveillance endoscopy should be continued indefinitely.

Seiichiro Abe, Shih Yea Sylvia Wu, Mai Ego, Hiroyuki Takamaru, Masau Sekiguchi, Masayoshi Yamada, Satoru Nonaka, Taku Sakamoto, Haruhisa Suzuki, Shigetaka Yoshinaga, Takahisa Matsuda, Ichiro Oda, and Yutaka Saito. Gut and Liver 1999;0:. https://doi.org/10.5009/gnl19266

This review article summarizes knowledge about metachronous gastric cancer (MGC) occurring after curative endoscopic resection (ER) of early gastric cancer (EGC), treatment outcomes of patients who developed MGC, and efficacy of Helicobacter pylori eradication to prevent MGC. The incidence of MGC following curative ER increases over time and is higher than in patients undergoing gastrectomy. Increasing age and multifocal EGC are independent risk factors for developing MGC. An MGC following curative ER is usually a small (<20 mm) and differentiated intramucosal cancer. Most MGC lesions are found at an early stage on semiannual or annual surveillance endoscopy and are successfully treated by further ER, with excellent long-term outcomes. Eradication of H. pylori may reduce the risk of MGC following ER of EGC, but further prospective studies with long-term outcomes are required. Surveillance endoscopy following gastric ER should be continued indefinitely, due to the risk of MGC even after successful H. pylori eradication. Risk stratification and tailored endoscopic surveillance schedules need to be developed.