Is colorectal endoscopic submucosal dissection safe and effective for 15-19-mm tumors?

PURPOSE: The outcomes of colorectal endoscopic submucosal dissection (ESD) in 15-19-mm tumors are unclear. This study compared the effectiveness and safety of colorectal ESD for 15-19-mm tumors and tumors exceeding that size. METHODS: From August 2018 to December 2020, 213 cases of colorectal tumors removed by colorectal ESD at a tertiary hospital were enrolled in this study. The cases were divided into two groups according to the pathologically measured size of the resected lesion: an intermediate group (15-19 mm, n = 62) and a large group (≥ 20 mm, n = 151). The en bloc resection rate, complete resection rate, and complications were investigated retrospectively. RESULTS: The en bloc resection rate was significantly higher in the intermediate than large group (100% vs. 94%, p = 0.049), and the mean total procedure time was shorter in the intermediate than large group (29.2 [Formula: see text] 12.6 vs. 48.4 [Formula: see text] 28.8 min, p < 0.001). However, the mean procedure speed was significantly lower in the intermediate than large group (0.25 [Formula: see text] 0.10 vs. 0.28 [Formula: see text] 0.11 cm2/min, p = 0.031). The complete resection rate, post-procedural bleeding, and perforation rate were not significantly different between the two groups. In multivariate analyses, the total procedure time and mean procedure speed were significantly associated with lesion size. CONCLUSION: Colorectal ESD of 15-19-mm lesions is effective, and has a shorter procedure time and higher en bloc resection rate than the same procedure for larger lesions.

Risk of Metachronous Colorectal Advanced Neoplasia and Cancer in Patients With 3-4 Nonadvanced Adenomas at Index Colonoscopy: A Systematic Review and Meta-Analysis.

INTRODUCTION: This systematic review and meta-analysis evaluated the available evidence on the risk of metachronous advanced neoplasia (AN) and colorectal cancer (CRC) in patients with 3-4 nonadvanced adenomas (NAAs). METHODS: We searched MEDLINE, EMBASE, and Cochrane Library databases up to January 2021 for studies evaluating metachronous AN and CRC risk by comparing 3 groups (1-2 vs 3-4 vs ≥5 NAAs) at index colonoscopy. The estimates for risk of metachronous AN and CRC were evaluated using random-effects models. RESULTS: Fifteen studies (n = 36,375) were included. The risk of metachronous AN was significantly higher in the 3-4 NAAs group than in the 1-2 NAAs group (relative risk [RR] 1.264, 95% confidence interval [CI] 1.053-1.518, P = 0.012; I2 = 0%); there was no difference between the ≥ 5 NAAs and 3-4 NAAs groups (RR 1.962, 95% CI 0.972-3.958, P = 0.060; I2 = 68%). The risks of metachronous CRC between the 1-2 NAAs and 3-4 NAAs groups (RR 2.663, 95% CI 0.391-18.128, P = 0.317; I2 = 0%) or the 3-4 NAAs and ≥ 5 NAAs groups (RR 1.148, 95% CI 0.142-9.290, P = 0.897; I2 = 0%) were not significantly different. DISCUSSION: Although the risk of metachronous AN was greater in the 3-4 NAAs group than in the 1-2 NAAs group, the risk of metachronous AN and CRC between the 3-4 NAAs and ≥ 5 NAAs groups was not different. This suggests that further studies on metachronous AN and CRC risk in the 3-4 NAAs group are warranted to confirm a firm ≥5-year interval surveillance colonoscopy.

1 L- versus 2 L-polyethylene glycol with ascorbic acid for bowel preparation in elderly patients: a randomized multicenter study.

BACKGROUND: 1 L-polyethylene glycol (PEG)/ascorbic acid (Asc) was developed to reduce the required oral preparation volume through increasing osmotic load through containing a greater quantity of ascorbate components. We aimed to compare the efficacy, tolerability, and safety of a split-dosing regimen of 1 L-PEG/Asc versus 2 L-PEG/Asc in elderly patients undergoing scheduled colonoscopy. METHODS: This was a prospective, non-inferiority, randomized, investigator-blinded multicenter study conducted in Korea between July 2019 and December 2020. Patients aged between 65 and 85 years were randomized at a ratio of 1:1 to either the 1 L-PEG/Asc or 2 L-PEG/Asc group. The efficacy of the bowel preparation was evaluated using the Harefield Cleansing Scale (HCS) and the Boston Bowel Preparation Scale (BBPS). RESULTS: A total of 202 patients were analyzed. Successful overall bowel preparation was similar between the 1 L-PEG/Asc and 2 L-PEG/Asc groups based on HCS (95.1% vs. 93.1%, P = 0.528) and BBPS (93.1% vs. 90.0%, P = 0.422). The perfect overall bowel preparation rate in the 1 L-PEG/Asc group was higher than that in the 2 L-PEG/Asc group (HCS, 40.2% vs. 25.0%, P = 0.021; BBPS, 80.4% vs. 68.0%, P = 0.044). There were more high-quality bowel preparations for the right colon in the 1 L-PEG/Asc group (HCS, 46.1% vs. 30.0%, P = 0.019; BBPS, 83.3% vs. 70.0%, P = 0.025). The adenoma detection rate (47.1% vs. 49.0%, P = 0.782), rate of adverse events (25.5% vs. 23.0%, P = 0.680), shifts in laboratory results, and tolerability were comparable between the groups. CONCLUSION: 1 L-PEG/Asc was as effective, safe, and tolerable as 2 L-PEG/Asc in elderly patients with comorbidities.

Does precutting prior to endoscopic piecemeal resection of large colorectal neoplasias reduce local recurrence? A KASID multicenter study.

BACKGROUND: It would be expected that local recurrence could be reduced by performing precutting (with sufficient margins) prior to endoscopic piecemeal mucosal resection (EPMR). We explored the clinical outcomes and local recurrence after precutting EPMR of large colorectal neoplasias. METHODS: Between January 2005 and December 2015, in total, 223 patients with colorectal neoplasias ≥ 2 cm in diameter removed via EPMR in four tertiary hospitals were enrolled. The patients were divided into a precut EPMR group (n = 62) and a non-precut EPMR group (n = 161). We retrospectively evaluated clinical outcomes and factors associated with local recurrence. RESULTS: The mean total procedure time was significantly shorter in the non-precut EPMR group than in the precut EPMR group. However, the number of pieces, and the complete resection and recurrence rates, did not differ significantly [for the latter, precut 8.1% vs. non-precut 9.9%, P = 0.668]. The complete resection rate, number of pieces, and use of argon plasma coagulation (APC) were significantly associated with the local recurrence rate on univariate analysis. In the Cox's proportional hazards model, prophylactic APC [hazard ratio 0.307, 95% confidence interval (CI) 0.114-0.823; P = 0.019] and complete resection rate (odds ratio 0.083, 95% CI 0.011-0.655; P = 0.018) were significantly associated with the local recurrence rate. CONCLUSION: Precutting prior to EPMR did not significantly reduce the local recurrence rate or the number of resected pieces. Histologically complete resection, reducing the number of pieces, and prophylactic APC seem to be important in terms of reducing local recurrence.

Usefulness of narrow-band imaging for the detection of remnant sessile-serrated adenoma (SSA) tissue after endoscopic resection: the KASID multicenter study.

BACKGROUND: A sessile-serrated adenoma (SSA) has a high risk for incomplete resection. Little is known regarding how to immediately detect remnant SSA tissue after endoscopic resection. We investigated the usefulness of narrow-band imaging (NBI) to detect remnant SSA tissue after endoscopic mucosal resection (EMR). METHODS: We performed a prospective randomized study on 138 patients who had suspicious SSA on colonoscopy at five centers. After EMR on the suspected SSA determined on the endoscopic morphology, all lesions were randomized into two inspection methods, NBI and white light endoscopy (WLE), to detect remnant tissue on the resected margin. If remnant tissue was detected, an additional resection was performed. Finally, we obtained quadrant biopsies on the resection margin to evaluate the incomplete resection. The proportion of incomplete resection was calculated by combining the detection of remnant tissue and the positivity of SSA cells on the final quadrant biopsies. The primary outcome was the proportion of remnant tissue detection, and the secondary outcome was the proportion of incomplete resection of SSA. RESULTS: In all, 145 lesions from 138 patients were removed. The diagnostic rate of SSA was 87.6% (127/145). After randomization, NBI inspection was performed on 69 lesions, and WLE inspection was performed on 76 lesions. The histologic diagnostic rate of SSA was 89.9% (62/69) in the NBI group and 85.5% (65/76) in the WLE group (p > 0.05). There were no significant differences in the detection of remnant tissue (12.9% (8/62) vs. 15.4% (10/65), p > 0.05), the proportion of SSA in remnant tissue (11.3% (7/62) vs. 12.3% (8/65), p > 0.05), or the proportion of incomplete resection (6.5 (4/62) vs. 10.8 (7/65), p > 0.05) between the NBI and WLE inspection groups, respectively. CONCLUSION: NBI was not superior to WLE for detecting remnant SSA tissue after EMR and could not decrease the proportion of incomplete resection of SSA.

Cap-Assisted Chromoendoscopy Using a Mounted Cap Versus Standard Colonoscopy for Adenoma Detection.

OBJECTIVES: Some neoplastic lesions remain undetected on colonoscopy. To date, no studies have investigated whether combining cap-assisted colonoscopy with chromoendoscopy increases the adenoma detection rate (ADR). This study aimed to compare cap-assisted chromoendoscopy (CAP/CHROMO) with standard colonoscopy (SC) with respect to their efficacy in detecting adenomas. METHODS: This prospective, multicenter, randomized controlled trial included asymptomatic subjects aged 45-75 years who underwent colonoscopy for the first time at 14 university hospitals. Subjects were randomized to either the CAP/CHROMO group (with 0.09% indigo carmine spraying using a cap-mounted catheter at the tip of the colonoscope) or the SC group. All polyps were resected, but only histologically confirmed neoplastic lesions were considered for analysis. The primary outcome was ADR, defined as the proportion of subjects with at least 1 adenoma. RESULTS: A total of 1,905 subjects were randomized to the CAP/CHROMO (n = 948) or SC (n = 957) group at 14 centers. Subjects' demographic characteristics were similar between both groups. The CAP/CHROMO group had significantly higher ADR than the SC group (54.4% vs 44.9%, P < 0.001). Significantly, more subjects with at least 1 proximal colon adenoma were identified by CAP/CHROMO (38.6%) than by SC (31.2%) (P = 0.001). The proximal serrated polyp detection rate by CAP/CHROMO was significantly higher in the female subgroup vs SC. However, advanced ADR was not different between the CAP/CHROMO and SC groups (9.3% vs 7.6%, P = 0.180). DISCUSSION: CAP/CHROMO markedly improved the ADR and enhanced the detection of proximal adenoma. CAP/CHROMO is feasible for routine application and will allow for a more effective surveillance program.

Impact of Endoscopists' Personality Traits on Adenoma and Polyp Detection Rates in Colonoscopy: A KASID Multicenter Study.

BACKGROUND: The personality traits of endoscopists have been suggested to affect the adenoma detection rate (ADR). We thus evaluated the relationship between endoscopists' personality traits and the ADR during colonoscopy using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). METHODS: In total, 1230 patients (asymptomatic and aged 50-80 years) who underwent screening or surveillance (≥ 5 years) colonoscopy were recruited from 13 university hospitals by 20 endoscopists between September 2015 and December 2017. We retrospectively measured the ADR, polyp detection rate (PDR), and number of adenomas per colonoscopy (APC). All 20 endoscopists completed all 567 true/false MMPI-2 items. RESULTS: The overall mean colonoscopy withdrawal time, PDR, ADR, and APC were 7.3 ± 2.8 min, 55%, 45.3%, and 0.97 ± 1.58, respectively. No significant difference was observed in the MMPI-2 clinical scales (e.g., hypochondriasis and psychasthenia), content scales (e.g., obsessiveness and type A character), or supplementary scales (e.g., dominance and social responsibility) between the high ADR group (ADR ≥45%, n = 10) and the low ADR group (ADR < 45%, n = 10). In multivariate logistic regression analysis, the ADR was associated significantly with patient age and sex. The ADR was related significantly to endoscopists' colonoscopy experience and the per-minute increase in the colonoscopy withdrawal time (OR 1.21, 95% CI 1.06-1.38, p = 0.005). In a logistic regression analysis adjusted for patient factors, the ADR was associated significantly with ego strength (OR 1.04, 95% CI 1.00-1.09, p = 0.044), as measured by the MMPI-2. CONCLUSIONS: With the exception of ego strength, the endoscopists' personality traits were not associated with adenoma or polyp detection.

Relationship between the endoscopic withdrawal time and adenoma/polyp detection rate in individual colonic segments: a KASID multicenter study.

BACKGROUND AND AIMS: Appropriate colonoscopy withdrawal times for individual colonic segments are not well known. The relationship between withdrawal time and adenoma detection rate (ADR)/polyp detection rate (PDR) in individual colonic segments was examined in this study. METHODS: This was a prospective observational study involving 724 patients who underwent colonoscopy screening or surveillance colonoscopy from October 2015 to February 2017 at 10 university hospitals. RESULTS: In the right side of the colon, the ADR (33.2% vs 13.7%, P < .001), PDR, serrated polyp detection rate, and number of adenomas per colonoscopy (APC) were significantly higher when the colonoscopy withdrawal time was ≥2 minutes compared with <2 minutes. When the withdrawal time was ≥4 minutes in the proximal colon and ≥3 minutes in the left segment of the colon, the ADR, PDR, and APC were significantly higher compared with withdrawal times of <4 minutes and <3 minutes, respectively. Multivariate analyses showed that the ADR was significantly associated with withdrawal times of ≥2 minutes in the right side of the colon (odds ratio [OR], 2.98; 95% confidence interval [CI], 1.72-5.15; P < .001), ≥4 minutes in the proximal colon (OR, 4.48; 95% CI, 3.15-6.36; P < .001), and ≥3 minutes in the left segment of the colon (OR, 2.92; 95% CI, 1.74-4.91; P < .001). CONCLUSIONS: The PDR and ADR appeared to be significantly increased when the withdrawal time was ≥2 minutes in the right-sided colon segment, ≥4 minutes in the proximal colon, and ≥3 minutes in the left-sided colon segment compared with shorter withdrawal times.

Randomized, back-to-back trial of a new generation NBI with a high-definition white light (HQ290) for detecting colorectal polyps.

Background: The benefits of narrow band imaging (NBI) for improving the detection rate of colorectal polyps remain unclear. New generation NBI using the 290 system (290-NBI) provides an at least two-fold brighter image than that of the previous version. We aimed to compare polyp miss rates between 290-NBI colonoscopy and high-definition white light endoscopy (HDWL). Methods: In total, 117 patients were randomized to undergo either 290-NBI or HDWL from June 2015 to February 2017. In the HDWL group, we performed HDWL as an initial inspection, followed by a second inspection with NBI. In the 290-NBI group, NBI was performed as the initial inspection, followed by a second inspection with HDWL. We compared polyp and adenoma detection rates and polyp miss rates (PMR) between the two groups and analyzed the factors associated with the PMR. Results: In total, 127 polyps were detected in the 117 patients. No differences in adenoma or polyp detection rates were observed between the two groups. The PMR for 290-NBI was 20.6% and that for HDWL was 33.9% (p = .068). However, the non-adenomatous PMR for 290-NBI was significantly lower than that of HDWL (11.5% vs. 52.2%, p = .002). Furthermore, the miss rates of polyps on the left side of the colon, flat-type polyps, and non-adenomatous polyps were significantly lower in the 290-NBI than HDWL. Conclusions: New generation NBI may reduce PMR, especially of flat-type and non-adenomatous polyps and those on the left side of the colon. (UMIN000025505).

Cost-effectiveness of a tailored Helicobacter pylori eradication strategy based on the presence of a 23S ribosomal RNA point mutation that causes clarithromycin resistance in Korean patients.

BACKGROUND AND AIM: The Helicobacter pylori eradication rate using conventional triple therapy has decreased due to clarithromycin (CAM) resistance in H. pylori. Recently, dual priming oligonucleotide (DPO)-based multiplex polymerase chain reaction (PCR) can be used to detect H. pylori and point mutations in the 23S ribosomal RNA gene causing CAM resistance. This study aimed to evaluate the success rate and cost-effectiveness of tailored H. pylori eradication using DPO-PCR. METHODS: The H. pylori-positive patients diagnosed by a rapid urease test or DPO-PCR were enrolled from a single academic hospital. The patients with positive rapid urease test results received a CAM-based triple regimen. In the tailored therapy group that underwent DPO-PCR testing, patients with A2142G and/or A2143G point mutations were treated with a bismuth-containing quadruple regimen. The cost-effectiveness of H. pylori eradication success was evaluated according to the average cost per patient and the incremental cost-effectiveness ratio. RESULTS: A total of 243 patients were allocated to the triple therapy group and 124 patients to the tailored therapy group. The first-line eradication rate of H. pylori was significantly higher in the tailored therapy group than in the conventional triple therapy group (92.7% vs 76.5%, P < 0.001). The average costs per patient for tailored therapy were $307.37 and $299.59 for first-line and second-line treatments, respectively. Compared with triple therapy, the incremental cost-effectiveness ratios of tailored therapy were $3.96 and -$3.81 per patient for first-line and second-line treatments, respectively. CONCLUSION: In Korea, tailored H. pylori eradication using DPO-PCR may be more cost-effective than conventional triple therapy.

Optimal Timing of Simethicone Addition for Bowel Preparation Using Polyethylene Glycol Plus Ascorbic Acid.

BACKGROUND: Colonic bubbles obscure the colonic mucosa during colonoscopy following bowel preparation with polyethylene glycol plus ascorbic acid (PEG-Asc). Simethicone is used to enhance visualization during colonoscopy. We aimed to determine the optimal timing of simethicone addition to improve bowel preparation using PEG-Asc. METHODS: This prospective, randomized study enrolled patients undergoing elective colonoscopy from April 2017 to January 2018. They were randomly assigned to one of the following three groups: PEG-Asc only (control) or simethicone addition in the morning on the day of colonoscopy (PEG-S1) or in the evening of the day prior to colonoscopy (PEG-S2). The primary outcome was the quality of colon cleansing, and the secondary outcomes were the adenoma detection rate (ADR), polyp detection rate (PDR), and diminutive (≤ 5 mm) ADR. RESULTS: In total, 240 patients were randomly allocated to the three groups; six patients were withdrawn. Of the 234 patients evaluated, 78, 79, and 77 were allocated to the control, PEG-S1, and PEG-S2 groups, respectively. The bubble scores of all colonic segments were lowest in the PEG-S2 group. There was no significant difference in ADR or PDR among the three groups. However, the diminutive ADR was significantly higher in the PEG-S2 group compared to the other two groups (control 5.1% vs. PEG-S1 8.9% vs. PEG-S2 20.8%; P = 0.009). CONCLUSION: Addition of simethicone to PEG-Asc at the optimal time prevents the formation of air bubbles and so improves the quality of bowel preparation, especially enhancing diminutive ADR.

Risk of metachronous neoplasia on surveillance colonoscopy in young patients with colorectal neoplasia.

BACKGROUND AND AIMS: Few prior reports exist that address the appropriate colonoscopy surveillance interval for individuals <50 years old. We compared the risk of metachronous neoplasia between younger (20-49 years) and older (50-54 years) cohorts. METHODS: This multicenter retrospective cohort study compared the incidence of metachronous neoplasia in younger and older cohorts according to baseline risk stratification. Subjects were eligible if they underwent their first colonoscopy between June 2006 and May 2010 and had at least 1 or more surveillance colonoscopy up to June 2015. RESULTS: Among a total of 10,477 subjects who underwent baseline colonoscopy, 9722 were eligible after excluding 755 subjects. Of those 9722 subjects, 43% underwent surveillance colonoscopy. In the baseline high-risk adenoma group (n = 840), the 3-year risk of metachronous advanced neoplasia was 10.7% in the younger patients on screening colonoscopy and 8.9% in the older patients (P > .1). In the baseline low-risk adenoma group (n = 1869), the 5-year risk of metachronous advanced neoplasia was 4.9% in the younger patients on screening colonoscopy and 5.1% in the older patients (P > .1). Similarly, in the baseline no neoplasia group (n = 7013), the 5-year risk of metachronous advanced neoplasia was 4.1% in the younger patients on screening colonoscopy and 5.6% in the older patients (P > .1). CONCLUSIONS: Considering the similar risk of metachronous advanced neoplasia in younger and older individuals, we suggest a 3-year surveillance interval for high-risk adenoma and a 5-year surveillance interval for low-risk adenoma in young individuals without a strong family history.

Impact of patient audiovisual re-education via a smartphone on the quality of bowel preparation before colonoscopy: a single-blinded randomized study.

BACKGROUND AND AIMS: Education on preparation is essential for successful colonoscopy. This study aimed to evaluate the impact of audiovisual (AV) re-education via a smartphone on bowel preparation quality before colonoscopy. METHODS: A prospective, endoscopist-blinded, randomized, controlled study was performed. Patients who underwent colonoscopy with 3 purgatives, including 4 L of polyethylene glycol (4-L PEG), 2 L of PEG with ascorbic acid (2-L PEG/Asc), and sodium picosulfate with magnesium citrate (SPMC), were enrolled and randomized into the AV re-education via smartphone group (AV group, n = 160) and a control group (n = 160). The primary outcome was the quality of the bowel preparation according to the Boston Bowel Preparation Scale (BBPS). The secondary outcomes included instruction adherence using adherence score (AS) and patient satisfaction with education using a visual analog scale (VAS). RESULTS: A total of 283 patients (AV group, n = 139; control group, n = 144) were analyzed per protocol. The mean BBPS (7.53 vs 6.29, P < .001) and the proportion with adequate preparation were higher in the AV group. The mean BBPS of the AV group was significantly higher than that of the control group for the 2-L PEG/Asc and SPMC preparations, but not for the 4-L PEG preparation. The mean AS and the mean VAS score were all significantly higher in the AV group. Among the 3 purgatives, the mean AS was lowest in the 4-L PEG group (P = .041). CONCLUSIONS: AV re-education via smartphone was easy and convenient, and enhanced preparation quality, patient adherence to instructions, and patient satisfaction.

An Adjusted Level of Adenoma Detection Rate is Necessary for Adults Below 50 Years Old.

BACKGROUND: Although adenoma prevalence is lower in younger people compared with screening-aged adults 50 years old and above, there is no adjustment recommendation for the target adenoma detection rate (ADR) in young people. Herein, we estimated a different target ADR for adults below 50 years old based on screening colonoscopy findings. MATERIALS AND METHODS: Asymptomatic, average-risk adults below 50 years old who underwent screening colonoscopy were enrolled at 12 endoscopy centers in Korea between February 2006 and March 2012. Screening colonoscopies were stratified into low or high ADR groups with ADR levels of 20% and 25%, respectively. RESULTS: The ADRs from 12 endoscopy centers ranged from 12.1% to 43.8% (median ADR, 24.1%) based on 5272 young adults receiving screening colonoscopies. Using 20% as an ADR level, the risks for metachronous adenoma and advanced adenoma were significantly higher in the low ADR group than the high ADR group (35.4% vs. 25.7%, P<0.001; 8.3% vs. 3.7%, P=0.001, respectively). However, using ADR level of 25%, the risk for metachronous neoplasia was similar in the high and low ADR groups in young adults according to screening colonoscopy. In subgroup analysis, similar findings were found in males, but not in females. CONCLUSIONS: Optimal target ADR may be different between younger and older populations, and the adoption of a 20% target ADR could be used as a performance indicator for young populations.

Correction to: Factors Predictive of Complete Excision of Large Colorectal Neoplasia Using Hybrid Endoscopic Submucosal Dissection: A KASID Multicenter Study.

The original version of the article unfortunately contained errors in author affiliation. Affiliation of third and ninth author was incorrectly assigned.

Factors Predictive of Complete Excision of Large Colorectal Neoplasia Using Hybrid Endoscopic Submucosal Dissection: A KASID Multicenter Study.

BACKGROUND: Endoscopic submucosal dissection (ESD) with snaring (hybrid ESD) bridges the gap between ESD and endoscopic mucosal resection. We evaluated factors predictive of en bloc and complete resection of large colorectal neoplasms using hybrid ESD. METHODS: This was a prospective clinical study of 78 patients who underwent hybrid ESD for excision of colorectal neoplasms (≥ 2 cm) between May 2015 and September 2016 at six university hospitals. We evaluated lesion and patient characteristics, endoscopist experience level (< 50 or ≥ 50 cases with colorectal ESD), and technical factors such as concurrent fibrosis, completion of a circumferential incision, degree of submucosal dissection (< 50 or ≥ 50%), and visualization during snaring (< 50 or ≥ 50%). RESULTS: Multivariate analyses showed that the en bloc resection rate was significantly related to the degree of visualization during snaring (odds ratio (OR) 7.811, 95% confidence interval [CI] 1.722-35.426; p = 0.008) and the presence of fibrosis (OR 0.258, 95% CI 0.68-0.993; p = 0.049). The complete resection rate was significantly related to the colorectal ESD endoscopist skill level (OR 5.626, 95% CI 1.485-21.313; p = 0.011) and gross lesion type (OR 0.145, 95% CI 0.022-0.936; p = 0.042). When all three technical factors, i.e., completion of circumferential incision, ≥ 50% submucosal dissection, and ≥ 50% visualization during snaring, were satisfied performing hybrid ESD, the en bloc resection rate (87.5%) was similar to that of ESD. CONCLUSIONS: Visualization during snaring, presence of fibrosis, gross lesion type, and endoscopist colorectal ESD experience level affect en bloc or complete resection of large colorectal neoplasia using hybrid ESD.

Factors for improving the diagnostic efficiency of the rapid urease test from the gastric corpus.

OBJECTIVE: This study aimed to evaluate the optimal biopsy site for Helicobacter pylori detection by comparing the results of rapid urease test (RUT) between the gastric corpus and the antrum. METHODS: A biopsy specimen from each subject was obtained from the corpus and from the antrum. For each subject, the two specimens were separately immersed in two different RUT kits. Positive reaction times were measured at 20 minutes and 1, 3, and 24 hours. If either of the two RUT kits showed a positive reaction, H. pylori infection was confirmed. RESULTS: A total of 310 H. pylori-infected subjects were eligible for study inclusion. Compared with the antrum, positive RUT reaction times in the corpus were shorter when the degree of gastric atrophy was moderate or severe (p = .001 and p < .001, respectively). A multivariate analysis revealed that the factors resulting in a faster positive RUT reaction in the corpus were age ≥50 years (odds ratio [OR] = 1.84; 95% confidence interval [CI] = 1.10-3.08; p = .021) and severe gastric atrophy (OR = 2.41; 95% CI = 1.13-5.13; p = .023). Also, severe gastric atrophy was an independent factor associated with positive RUT reaction only in the corpus (OR = 5.12; 95% CI = 1.55-16.88; p = .007). CONCLUSIONS: In subjects aged ≥50 years or with severe gastric atrophy, biopsy of the corpus mucosa optimized the efficiency of H. pylori detection through a faster positive RUT reaction.

Risks of colorectal advanced neoplasia in young adults versus those of screening colonoscopy in patients aged 50 to 54 years.

BACKGROUND AND AIM: The role of screening or diagnostic colonoscopy to detect advanced neoplasia in young cohorts of age < 50 is unclear. This study compared the risk of colorectal neoplasia in a young age cohort against that in 50-54s screening cohort. METHODS: A multi-center retrospective study was conducted at 14 university hospitals to compare the detection rates of neoplasia and advanced neoplasia in screening or diagnostic colonoscopy in the young cohort of < 50s against those in screening colonoscopy in the 50-54s cohort. RESULTS: Among 10 477 eligible subjects, 9765 subjects were enrolled after excluding 712 subjects. Advanced neoplasia detection rates in the young screening cohort was significantly lower than that in the 50-54s screening cohort (5.9% vs 9.3%, P < 0.001). Compared with 50-54s screening cohort, the risk of advanced neoplasia was significantly reduced by 23%, 53%, and 54% in the 45-49s, 40-44s, and 20-39s screening cohorts, respectively. The detection rates of advanced neoplasia in the young diagnostic cohort was 5.0%, which was much lower than 11.8% in 50-54s screening cohort (P < 0.001). Compared with the 50-54s screening cohort, the risk of advanced neoplasia was significantly reduced by 50%, 66%, and 71% in the 45-49s, 40-44s, and 20-39s diagnostic cohorts, respectively. CONCLUSIONS: Colonoscopy to detect advanced neoplasia in young adults aged < 50 years should be reconsidered as their risk of advanced neoplasia on screening or diagnostic colonoscopy was much lower than those of 50-54s screening cohort; however, colonoscopy screening may be justified for high-risk 45-49s cohorts.

Endoscopic Resection of Cecal Polyps Involving the Appendiceal Orifice: A KASID Multicenter Study.

BACKGROUND: Endoscopic resection of polyps located at the appendiceal orifice (AO) is challenging, and the feasibility and outcomes of endoscopic resection for cecal polyps involving AO are unconfirmed. AIMS: We evaluated the feasibility and outcomes of endoscopic resection for cecal polyps involving AO. METHODS: In this retrospective, multicenter study involving nine tertiary referral centers, we evaluated 131 patients who underwent endoscopic resection for cecal polyps involving AO. RESULTS: The median size of polyps resected was 10 mm (range 3-60 mm). Endoscopic mucosal resection, endoscopic piecemeal mucosal resection, and endoscopic submucosal dissection were performed in 75 (57.3%), 31 (23.7%), and 5 (3.8%) patients, respectively. The en bloc resection rate was 68.7%. Endoscopic complete resection was achieved in 123 lesions (93.9%). Intraprocedural and delayed bleeding occurred in 14 (10.7%) and three patients (2.3%), respectively, and perforation occurred in two patients (1.5%). Seven patients (5.3%) underwent additional surgery because of treatment failure or recurrence. Polyps of ≥20 mm in size showed significantly higher rates of perforation and additional surgery (p < 0.05), and a lower rate of en bloc resection (p < 0.005). Patients with polyps involving ≥75% of AO circumference exhibited a significantly lower rate of en bloc resection (p < 0.001), and significantly higher rates of surgery and recurrence (p < 0.05). Recurrence during follow-up occurred in 12 patients (15.6%); polyps involving ≥75% of AO circumference were an independent risk factor for recurrence. CONCLUSION: Endoscopic resection of cecal polyps involving AO is safe and effective in select patients.

Avulsion is superior to argon plasma coagulation for treatment of visible residual neoplasia during EMR of colorectal polyps (with videos).

BACKGROUND AND AIMS: EMR is used widely for treatment of nonpedunculated colorectal adenomas ≥ 2 cm. Recurrence at the resection site occurs in 10% to 30% of cases. METHODS: Records of consecutive patients referred for endoscopic resection over a 4-year period were reviewed retrospectively. In the first part of the study period, our routine practice was to use argon plasma coagulation (APC) to treat all visible residual neoplasia after exhaustive attempts at snare resection during EMR. In the second part of the study period, we changed our practice to use avulsion to treat all visible residual neoplasia after exhaustive attempts at snare resection during EMR. We analyzed the effect of this change in practice on recurrence rates after EMR. RESULTS: Two hundred twenty-three resected lesions were analyzed. Fifty-nine (26%) were treated with en-bloc EMR, 55 (25%) by piecemeal EMR with complete snare removal of all visible neoplasia, 63 (28%) by piecemeal EMR with APC of visible residual neoplasia, and 46 (21%) by piecemeal EMR with avulsion of visible residual neoplasia. There was no significant difference in adverse event rates among the 4 groups. The recurrence rates on follow-up colonoscopy were 4.2%, 3.0%, 59.3%, and 10.3%, respectively. The recurrence rate for patients treated with avulsion was significantly lower than for those treated with APC (odds ratio, .079; P < .001). Multivariate analysis demonstrated that use of avulsion instead of APC was a significant predictor of no recurrence. CONCLUSIONS: After exhaustive attempts at snare resection during EMR, avulsion is superior to APC for treatment of residual visible neoplasia. Compared with APC, avulsion significantly decreases the recurrence rate without significantly increasing the risk of the procedure.