Risk Factors of Delayed Bleeding After Cold Snare Polypectomy for Colorectal Polyps: A Multicenter Study.

BACKGROUND: Delayed bleeding (DB) rarely occurs after cold snare polypectomy (CSP) for colorectal polyps, but no large-scale studies have investigated this. The present study evaluated the rate, characteristics, and risk factors of DB of CSP. METHODS: We conducted a multicenter retrospective study at 10 Japanese institutions. A total of 18,007 patients underwent CSP for colorectal polyps ≤ 10 mm in size from March 2015 to September 2019, and cases of DB (DB group) were analyzed for the rate, antithrombotic drugs, polyp size, morphology, location, and risk factors. As a control, 269 non-bleeding cases (non-DB group) with 606 polyps who underwent CSP at the same 10 facilities in the 2-week study period were extracted. RESULTS: We analyzed 26 DB cases with 28 lesions, and the total DB rate was 0.14% (26/18,007). The DB group had significantly higher rates of using antiplatelets (42.3% vs. 13.0%, p < 0.001) and anticoagulants (19.2% vs. 2.6%, p = 0.002), and significantly higher rates of polyp size ≥ 5 mm (67.9% vs. 45.2%, p = 0.015), rectal lesion (25.0% vs. 6.6%, p = 0.003), and polypoid lesion (89.3% vs. 55.3%, p < 0.001) than the non-DB group. A multivariate analysis (odds ratio; 95% confidence interval) for patient characteristics showed antiplatelet use (4.521; 1.817-11.249, p = 0.001) and anticoagulant use (7.866; 20.63-29.988, p = 0.003) as independent risk factors for DB. Polyp size ≥ 5 mm (3.251; 1.417-7.463, p = 0.005), rectal lesion (3.674; 1.426-9.465, p = 0.007), and polypoid lesion (7.087; 20.81-24.132, p = 0.002) were also risk factors for lesion characteristics. CONCLUSIONS: The rate of DB was 0.14% and antithrombotic drug use, polyp size, location, and morphology were related to it.

Recurrence rate and lesions characteristics after cold snare polypectomy of high-grade dysplasia and T1 lesions: A multicenter analysis.

BACKGROUND AND AIM: High-grade dysplasia (HGD) and T1 lesions are accidentally resected by cold snare polypectomy (CSP) and the characteristics, and follow-up of them has not been reported. In this study, we analyzed the histopathological findings and recurrence of them. METHODS: This was a multicenter retrospective-cohort study. We collected HGD and T1 lesions of ≤ 10 mm resected by CSP among 15 520 patients receiving CSP from 2014 to 2019 at nine related institutions, and we extracted only cases receiving definite follow-up colonoscopy after CSP of HGD and T1 lesions. We analyzed these tumor's characteristics and therapeutic results such as R0 resection and local recurrence and risk factors of recurrence. RESULTS: We collected 103 patients (0.63%) and extracted 80 lesions in 74 patients receiving follow-up colonoscopy for CSP scar. Mean age was 68.4 ± 12.0, and male rate was 68.9% (51/80). The mean tumor size (mm) was 6.6 ± 2.5, and the rate of polypoid morphology and rectum location was 77.5% and 25.0%. The rate of magnified observation was 53.8%. The rates of en bloc resection and R0 resection were 92.5% and 37.5%. The local recurrence rate was 6.3% (5/80, median follow-up period: 24.0 months). The recurrence developed within 3 months after CSP for four out of five recurrent cases. Comparing five recurrent lesions to 75 non-recurrent lesions, a positive horizontal margin was a significant risk factor (60.0% vs 10.7%, P < 0.001). CONCLUSIONS: High-grade dysplasia and T1 resected by CSP were analyzed, and the local recurrence rate of them was substantially high.

Risk of lymph node metastasis after endoscopic treatment for rectal NETs 10 mm or less.

PURPOSE: For rectal neuroendocrine tumors (NETs) ≤ 10 mm, endoscopic resection is a standard treatment. However, there is no consensus whether additional surgery should be performed for patients at risk of lymph node metastasis (LNM) after endoscopic resection. The purpose of this study was to analyze the results of endoscopic resection and additional surgery of rectal NETs, thereby clarify the characteristics of cases with LNM. METHODS: This study was a multicenter retrospective cohort study conducted at 12 Japanese institutions. A total of 132 NETs ≤ 10 mm were analyzed regarding various therapeutic results. A comparative analysis was performed by dividing the cases into two groups that underwent additional surgery or not. Furthermore, the relationship between tumor size and LNM was examined. RESULTS: The endoscopic treatments were 12 endoscopic mucosal resections (EMR), 58 endoscopic submucosal resections with ligation (ESMR-L), 29 precutting EMRs, and 33 endoscopic submucosal dissections (ESD). The R0 resection rates of EMR were 41.7%, and compared to this rate, other three treatments were 86.2% (p < 0.001), 86.2% (p = 0.005), and 97.0% (p < 0.001), respectively. There were 41 non-curative cases (31.1%), and 13 had undergone additional surgery. Then, LNM was observed in 4 of the 13 patients, with an overall rate of LNM of 3.0% (4/132). The rate of positive lymphatic invasion and the rate of LNM by tumor size ≤ 6 mm and 7-10 mm were 9.7 vs. 15.4% (p = 0.375) and 0 vs. 10.3% (p = 0.007). CONCLUSIONS: A multicenter study revealed the priority of each endoscopic resection and the low rate of LNM for rectal NETs ≤ 6 mm.

Garcin Syndrome Due to Meningeal Carcinomatosis from Gastric Cancer.

A 58-year-old woman presented to our hospital with complaints of dysphagia. Esophagogastroduodenoscopy showed an esophagogastric junction tumor with multiple duodenal intramural metastases, and computed tomography showed peritoneal metastasis. In the middle of her fourth cycle of chemotherapy, she displayed symptoms of a left-sided multi-cranial nerve palsy. She was diagnosed with Garcin syndrome caused by meningeal carcinomatosis from gastric cancer based on the results of gadolinium-enhanced brain magnetic resonance imaging and cytology of the cerebrospinal fluid. It is important not to overlook meningeal irritation symptoms or paralysis of cranial nerves and to consider the possibility of Garcin syndrome caused by meningeal carcinomatosis.

The efficacy and safety of colonoscopy in nonagenarians: A multicenter study.

INTRODUCTION: The number of colonoscopy (CS) for the elderly is increasing. There are only a few reports focusing on CS among the very elderly aged ≥ 90-y. We aimed to analyze the efficacy of CS and of colorectal cancer (CRC) for patients aged ≥ 90-y. METHODS: We retrospectively analyzed consecutive patients aged ≥ 90-y receiving CS at eight institutions from October 2016 to September 2017. Bowel preparation, complications, and endoscopic diagnosis were analyzed. The non-elderly group aged between 50-y and 64-y and elderly group aged between 65-y and 79-y were compared to very-elderly group aged ≥ 90-y. Through propensity score matching of sex and CS indications (symptomatic or asymptomatic), the number of CRC and the treatment in each group were analyzed. RESULTS: We analyzed 125 patients receiving 154 colonoscopies (0.9%) in the very-elderly group from among 16,968 cases. Among 92 cases who received bowel-cleansing solution, good preparations were achieved in 94.5%. The rate of CS-related complications was 1.3% (2/154). The rate of CRC in the very-elderly group was 27.2% (34/125), higher than the non-elderly group (7.2%, 9/125, p < 0.01) and elderly group (8.8%, 11/125, p < 0.01). Therapeutic interventions for CRC in the very-elderly group were performed in 73.5% (24/34) patients. The mean survival of 12 patients with CRC resection was 788 days. CONCLUSIONS: CS could be performed safely for the very elderly aged ≥ 90-y with careful considerations. CRC was confirmed to be more frequent in this group with over 70% of patients receiving appropriate therapeutic intervention.

The Efficacy and Safety of Elobixibat for the Elderly with Chronic Constipation: A Multicenter Retrospective Cohort Study.

MATERIALS AND METHODS: This was a multicenter retrospective cohort study. The subjects were patients aged ≥20 years treated for chronic constipation from May 2018 to November 2019 at 12 related institutions. Patients were divided into ≤74 years and ≥75 years old. Elobixibat at 10 mg/day was prescribed for two weeks. We then analyzed the discontinuation due to ineffectiveness, change of spontaneous bowel movements (SBM), stool consistency, the time until the first SBM, adverse events, and effect-related factors. RESULTS: There were 140 cases (61 males) evaluated, with an average age of 72.1 ± 13.6 years (≤74 years: 71 cases; ≥75 years: 69 cases). The discontinuation rate was 7.9%. The SBM (times/week) increased from 2.86 to 6.08 (p < 0.001). The overall SBM improvement rate was 74.0% (≤74 years: 78.2% vs. ≥75 years: 68.9%, p = 0.31; male: 75.0% vs. female: 73.3%, p = 0.78). The overall improvement rate of stool consistency was 59.6% (≤74 years: 62.9%, ≥75 years: 56.1%, p = 0.42). The time until the first SBM (hours) for those ≤74 years and ≥75 years was 17.2 ± 14.3 and 11.2 ± 8.4 (p = 0.04). Adverse event rates for those ≤74 years and ≥75 years were 28.2% and 10.1% (p < 0.01). There were no significant effect-related factors for gender, age, and use of laxatives. CONCLUSIONS: Short-period elobixibat is shown to be effective also for the elderly and male.

Multicenter Study of the Hemorrhage Risk after Endoscopic Mucosal Resection Associated with Direct Oral Anticoagulants.

BACKGROUNDS AND AIMS: Recently, direct oral anticoagulants (DOACs) have become widely used for preventing thromboembolism. However, postoperative hemorrhage (POH) is a major complication associated with endoscopic mucosal resection (EMR) for colorectal lesions. In this multicenter study, we analyzed the incidence of POH after EMR associated with DOACs and explored the associated risk factors. MATERIALS AND METHODS: This study was a multicenter retrospective cohort study conducted at 8 Japanese institutions. A total of 2062 cases that underwent EMR for colorectal lesions at these 8 institutions from October 2016 to September 2017 were analyzed. The cases were divided into 4 groups: the DOAC group (63 cases), warfarin group (34 cases), antiplatelet group (185 cases), and no antithrombotics group (1780 cases). In all lesions of the DOAC and warfarin groups, endoscopic clipping was performed after EMR. The rate of POH in the DOAC group, patients' clinical characteristics, the risk factors of POH, and the rate of thromboembolism due to stopping DOACs were compared with other groups. RESULTS: The rates of POH were 7.9%∗ (5/63), 2.9% (1/34), 3.2% (6/185), and 0.6%∗∗ (11/1780) in the DOAC, warfarin, antiplatelet, and no antithrombotics groups, respectively (∗ vs. ∗∗, p < 0.001). Regarding risk factors, the tumor size with POH (mm) was significantly bigger than that without POH (16.2 ± 8.3 vs. 7.2 ± 4.9, p < 0.001). There were no significant differences in the rates of POH based on the type of DOAC. In addition, no thromboembolisms occurred due to stopping of DOAC treatment. CONCLUSIONS: Patients receiving DOACs had significantly higher rates of POH after EMR than those without antithrombotics.

Multicenter feasibility study of bowel preparation with castor oil for colon capsule endoscopy.

BACKGROUND AND AIM: Extensive use of laxatives and incomplete excretion rates are problematic for colon capsule endoscopy (CCE). The aim of the present study was to determine the effectiveness of castor oil as a booster. METHODS: At four Japanese hospitals, 319 examinees undergoing CCE were enrolled retrospectively. Before and after the introduction of castor oil, other preparation reagents were unchanged. RESULTS: Of 319 examinees who underwent CCE, 152 and 167 examinees took regimens with castor oil (between November 2013 and June 2016) and without castor oil (between October 2015 and September 2017), respectively. Capsule excretion rates within its battery life in the groups with and without castor oil were 97% and 81%, respectively (P < 0.0001). Multivariate analysis showed that ages younger than 65 years (adjusted odds ratio [OR], 3.00; P = 0.0048), male gender (adjusted OR, 3.20; P = 0.0051), and use of castor oil (adjusted OR, 6.29; P = 0.0003) were predictors of capsule excretion within its battery life. Small bowel transit time was shorter and total volume of lavage and fluid intake was lower with castor oil than without (P = 0.0154 and 0.0013, respectively). Overall adequate cleansing level ratios with and without castor oil were 74% and 83%, respectively (P = 0.0713). Per-examinee sensitivity for polyps ≥6 mm with and without castor oil was 83% and 85%, respectively, with specificities of 80% and 78%, respectively. CONCLUSION: Bowel preparation with castor oil was effective for improving capsule excretion rate and reducing liquid loading.

Percutaneous transhepatic sclerotherapy with embolization of the drainage vein for a gastric varix.

We experienced a case with a gastric varix that did not have a catheterizable main drainage vein and had multiple afferent veins. For this case we successfully performed percutaneous transhepatic sclerotherapy using the following procedure. After the drainage vein was embolized by metallic coils and n-butyl cyanoacrylate from a microcatheter that was advanced through the gastric varix, 5% ethanolamine oleate-iopamidol was infused into the gastric varix from one main afferent vein under balloon occlusion.

Simple pathological examination technique for detection of cancer located at the surgical margin of the stomach.

BACKGROUND: The technique for examining surgical resection margins described in the Japanese Classification of Gastric Carcinoma is based on the examination of continuous infiltration by the primary tumor, and discontinuous lesions such as multiple cancers are not examined. However, examining lesions-particularly cancers-at the resection margins is important for the prevention of cancers in the remaining stomach that result from cancer remnants (remnant gastric cancer). METHODS: The clinical usefulness of a simple pathological examination technique for detecting cancer located at the surgical margin of the stomach was studied. A specimen 5-8 mm wide was resected from the surgical cut margin along the entire circumference of the stomach. When the pathological margin was positive for cancer, the surgical margin was also examined, and cases that were positive for cancer were regarded as marginally positive. RESULTS: Of the 1,498 patients with early gastric cancer who were examined using this method, 17 (1.1 %) were marginally positive for multiple cancers, and 8 of these 17 patients (57 %) had microcancers <5 mm in diameter. CONCLUSION: This method is simple and useful for detecting cancer involving the surgical margin, which occurs at a rate of 1.1 %, making it possible to prevent remnant gastric cancer by reoperation.

Novel findings of capsule endoscopy and double-balloon enteroscopy in a case of eosinophilic gastroenteritis.

Eosinophilic gastroenteritis is a rare disease with unknown cause. It is characterized by marked eosinophilic infiltration in the gastrointestinal tract. There are few reports that include detailed endoscopic findings of eosinophilic gastroenteritis in the small intestine. A 48-year-old man complaining of abdominal pain was admitted to our hospital. A complete blood count showed eosinophilia, and ascites showed eosinophilia. Abdominal computed tomography indicated dilation, wall thickening of the small intestine, and ascites. Capsule endoscopy revealed stenosis, dilation, edematous mucosa, and aperistalsis in the upper jejunum, together with circumferential ulcerated lesions and ulcer scars in the ileum. Double-balloon enteroscopy revealed a 10-cm segmental mucosal edema and stenosis in the ileum. In one segment, there were several circumferential ulcerated lesions. These lesions included both small round ulcers and large ulcers with redness and mucosal edema. Histological examination revealed infiltration of eosinophils into biopsy specimens of the ileum. The patient was diagnosed with eosinophilic gastroenteritis. The patient recovered after rehydration therapy. After 9 months, capsule endoscopy revealed no ulcers or edema. In this report, we describe the findings of capsule endoscopy and double-balloon enteroscopy in a case of eosinophilic gastroenteritis.

Development of thrombus in a systemic vein after balloon-occluded retrograde transvenous obliteration of gastric varices.

OBJECTIVE: To retrospectively evaluate the frequency and risk factors for developing thrombus in a systemic vein such as the infrarenal inferior vena cava or the iliac vein, in which a balloon-occluded retrograde transvenous obliteration (B-RTO) catheter was indwelled. MATERIALS AND METHODS: Forty-nine patients who underwent B-RTO for gastric varices were included in this study. The B-RTO procedure was performed from the right femoral vein, and the B-RTO catheter was retained overnight in all patients. Pre- and post-procedural CT scans were retrospectively compared in order to evaluate the development of thrombus in the systemic vein in which the catheter was indwelled. Additionally, several variables were analyzed to assess risk factors for thrombus in a systemic vein. RESULTS: In all 49 patients (100%), B-RTO was technically successful, and in 46 patients (94%), complete thrombosis of the gastric varices was achieved. In 6 patients (12%), thrombus developed in the infrarenal inferior vena cava or the right common-external iliac vein. All thrombi lay longitudinally on the right side of the inferior vena cava or the right iliac vein. One of the aforementioned 6 patients required anticoagulation therapy. No symptoms suggestive of pulmonary embolism were observed. Prothrombin time-international normalized ratio and the addition of 5% ethanolamine oleate iopamidol, on the second day, were related to the development of thrombus. CONCLUSION: Development of a thrombus in a systemic vein such as the inferior vena cava or iliac vein, caused by indwelling of the B-RTO catheter, is relatively frequent. Physicians should be aware of the possibility of pulmonary embolism due to iliocaval thrombosis.

Balloon-occluded retrograde transvenous obliteration of gastric varix via the pericardiacophrenic vein.

We encountered a case of gastric varix without a gastrorenal shunt that drained through the left pericardiacophrenic vein, which entered the left brachiocephalic vein. For this case we successfully performed balloon occluded retrograde transvenous obliteration, in which sclerotic agents were infused via the left pericardiacophrenic vein approached from the left subclavian vein.

Successful endoscopic hemostasis for ruptured duodenal varices after balloon-occluded retrograde transvenous obliteration.

A 75-year-old man with general malaise and appetite loss was transferred to our hospital for assessment and treatment of liver failure. Laboratory findings on admission showed anemia, and gastroduodenoscopy (GDS) revealed linear esophageal varices and tensive duodenal varices (DV) in the second portion of the duodenum. Systemic examinations did not reveal any significant lesion capable of explaining his anemia, except for DV. Balloon-occluded retrograde transvenous obliteration was carried out to prevent DV bleeding. Good pooling of sclerosant was observed using two balloon catheters. However, contrast-enhanced computed tomography after the procedure revealed no thrombosis in DV, and the patient complained of tarry stools before additional therapy. Emergent GDS revealed ruptured DV with fresh blood and erosions on the surface. Emergent endoscopic obliteration using the tissue adhesive N-butyl-2-cyanoacrylate was carried out and complete hemostasis was achieved. Although no rebleeding episodes were observed after emergent obliteration, the patient died of sepsis following spontaneous bacterial peritonitis 53 days after admission. Autopsy revealed that DV dropped out, and the deep vein was replaced by granulation tissue. No signs of thrombi were detected, except varices. This autopsy case revealed the difficulty in DV management.