Adverse Events Associated with Routine Colonoscopy in Patients with End-Stage Renal Disease.

BACKGROUND AND AIM: Although colonoscopy has been widely performed in patients with end-stage renal disease (ESRD), studies on the safety of routine colonoscopy, including bowel preparation and sedation, in these patients are limited. This study aimed to investigate the safety of colonoscopy in patients with ESRD who underwent peritoneal dialysis (PD) or hemodialysis (HD). METHODS: We retrospectively reviewed 538 patients with ESRD who underwent colonoscopy between 2010 and 2020. We compared the incidence of adverse events (AEs) between the ESRD group and a propensity score-matched control group of healthy adults. Cardiovascular/pulmonary and procedure-related AEs were analyzed. We also compared the rates of AEs between patients who underwent PD or HD. RESULTS: The overall rate of AEs was 5.7% in patients with ESRD, which was significantly higher than that in healthy adults (0.6%, P < 0.001). All AEs were cardiovascular/pulmonary in nature, but no perforation or bleeding occurred. Most AEs were not severe and resolved with medical treatment. The incidence of AEs was higher in the HD group than in the PD group, but the difference was not significant (6.1% vs. 3.5%, respectively, P = 0.451). In the HD group, patients with AEs were significantly older than those without AEs (P = 0.009). CONCLUSIONS: The rate of colonoscopy-related AEs in patients with ESRD on dialysis was higher than that in healthy adults, but most AEs were not severe. Routine colonoscopy may be safely performed in patients with ESRD regardless of the method of dialysis, but more carefully in older patients on HD.

Macrophage inhibitory cytokine-1 promotes angiogenesis by eliciting the GFRAL-mediated endothelial cell signaling.

Macrophage inhibitory cytokine-1 (MIC-1) is a cytokine with pleotropic actions and its expression is markedly increased by inflammation and cardiac injury and in cancers. In particular, MIC-1 production after cardiac ischemia injury is associated with enhanced cardiac angiogenesis as well as myocardial protection. However, it remains uncertain whether MIC-1 itself has proangiogenic activity. In this study, we tried to determine the precise role of MIC-1 in physiological and pathological angiogenesis. Human microvessel endothelial cells responded to MIC-1 with enhanced angiogenic behaviors. Employing various angiogenesis assays, MIC-1 was found to promote vessel formation and development with a potency similar to that of vascular endothelial growth factor (VEGF). MIC-1 transgenic (Tg) mice also displayed enhanced neovascularization in both developing embryos and neonatal mouse retinas, compared with wild-type mice. Furthermore, endothelial cells (ECs) isolated from MIC-1 Tg mouse lung exhibited higher angiogenic potential than ECs from wild-type lung. MIC-1-induced angiogenesis was also observed in the recovery or healing processes of injuries such as hindlimb ischemia and skin wounds in mice. However, unlike VEGF, MIC-1 induced neither endothelial inflammation nor increased vascular permeability. In ECs, the MIC-1 signal exerted proangiogenic actions via the MEK/extracellular signal-regulated kinase- and phosphatidylinositol 3-kinase/Akt-dependent pathways. Notably, these MIC-1 signaling events in ECs were abrogated by small interfering RNA-mediated knockdown of GFRAL, suggesting that GFRAL is an EC receptor for MIC-1. In summary, we here show a novel role of MIC-1 as a potent EC activator, which promotes both normal and injury-related angiogenesis.

The metastasis suppressor CD82/KAI1 represses the TGF-ß 1 and Wnt signalings inducing epithelial-to-mesenchymal transition linked to invasiveness of prostate cancer cells.

BACKGROUND: The epithelial-to-mesenchymal transition (EMT) is closely associated with cancer invasion and metastasis. Since the transforming growth factor ß (TGF-ß) and Wnt signals induce EMT in various epithelial cell types, we examined whether and how the CD82/KAI1 metastasis suppressor affects the TGF-ß and Wnt signal-dependent EMT in human prostate cancer cells. METHODS: The invasiveness of cancer cells was evaluated by examining their ability to pass through the basement membrane matrigel. The subcellular localizations of Smad4 and ß-catenin proteins were respectively examined by confocal microscopy following immunofluorescence antibody staining and immunoblotting analysis following subcellular fractionation. The transcriptional activities of the TGF-ß1 -responsive TRE and Wnt-responsive Tcf/Lef promoters were determined by a luciferase reporter assay following transfection of the recombinant reporter vector into the cell. RESULTS: TGF-ß1 and Wnt3a treatments of human prostate cancer cells without CD82 expression resulted in not only increased invasiveness but also EMT involving the development of motile structures, downregulation of E-cadherin, and upregulation of the mesenchymal proteins. However, in the cells with high levels of CD82, the TGF-ß1 and Wnt3a stimulations neither elevated invasiveness nor induced EMT. Furthermore, the TGF-ß1 signaling events occurring in the CD82-deficient cells, such as phosphorylation of Smad2, nuclear translocation of Smad4, and transactivation of the TRE promoter, did not take place in the high CD82-expressing cells. Further, high CD82 expression interfered with the Wnt signal-dependent alterations in the phosphorylation pattern of glycogen synthase kinase 3ß (GSK-3ß) in prostate cancer cells, which allowed GSK-3ß to continue phosphorylating ß-catenin, thereby attenuating the Wnt signaling effects on the nuclear translocation of ß-catenin and subsequent transactivation of the Tcf/Lef promoter. CONCLUSIONS: The results of the present study suggest that CD82/KAI1 functions in suppressing TGF-ß1 - and Wnt-induced EMT in prostate cancer cells by inhibiting the TGF-ß1 /Smad and Wnt/ß-catenin pathways. Therefore, loss or decrease of CD82 expression is likely to render prostate cancer cells prone to respond to the TGF-ß1 and Wnt signals with EMT, resulting in the development of a motile and invasive mesenchymal phenotype related to the initiation of the metastatic cascade.

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).

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.

Promoter CpG-Site Methylation of the KAI1 Metastasis Suppressor Gene Contributes to Its Epigenetic Repression in Prostate Cancer.

BACKGROUND: Repression of the KAI1 metastasis suppressor gene is closely associated with malignancy and poor prognosis in many human cancer types including prostate cancer. Since gene repression in human cancers frequently results from epigenetic alterations by DNA methylation and histone modifications, we examined whether the KAI1 gene becomes silenced through these epigenetic mechanisms in prostate cancer. METHODS: KAI1 mRNA and protein levels were determined by RT-PCR and immunoblotting analyses, respectively. Methylation status of the KAI1 promoter DNA in prostate cancer cell lines and tissues was evaluated by methylation-specific PCR analysis of bisulfite-modified genomic DNAs. Methylated CpG sites in the KAI1 promoter were identified by sequencing the PCR clones of the bisulfite-modified KAI1 promoter DNA. KAI1 protein levels in human prostate cancer tissue samples were examined by immunofluorescence staining of the tissues with an anti-KAI1 antibody. RESULTS: Among the three human prostate cancer cell lines examined, PC3 and DU145 cells exhibited markedly decreased levels of KAI1 mRNA and protein as compared to LNCaP cells, even though the exogenous KAI1 promoter not being methylated was normally functional in all these cell lines. Treatment of the low KAI1-expressing cell lines with a demethylating agent, 5'-aza-2'-deoxycytidine, significantly elevated KAI1 expression levels, implicating the involvement of DNA methylation in KAI1 downregulation. Methylation of CpG islands within the KAI1 promoter region was observed in the low KAI1-expressing cells, but not in the high KAI1-expressing cells. Also, methyl CpG-binding proteins such as MBD2 and MeCP2 were complexed to the KAI1 promoter in the low KAI1-expressing cells. Bisulfite sequencing analysis identified the intensively methylated CpG residues in the KAI1 promoter clones derived from prostate cancer cells and tissues with no or low KAI1 expression. As in prostate cancer cell lines, prostate cancer tissues from patients also displayed a negative association between KAI1 expression levels and methylation status of the KAI1 promoter. CONCLUSIONS: The present data suggest that the KAI1 gene might be repressed by epigenetic alterations through the promoter CpG-site methylation during prostate cancer progression. This epigenetic mechanism could provide a clue for understanding how the KAI1 gene was silenced in metastatic prostate cancers. Prostate 77: 350-360, 2017. © 2016 Wiley Periodicals, Inc.

Effects of administration of a proton pump inhibitor before endoscopic submucosal dissection for differentiated early gastric cancer with ulcer.

BACKGROUND: In ulcerative early gastric cancer, improvement and exacerbation of ulceration repeat as a malignant cycle. Moreover, early gastric cancer combined with ulcer is associated with a low curative resection rate and high risk of adverse events. The aim of this study was to investigate the ulcer healing rate and clinical outcomes with the administration of a proton pump inhibitor before endoscopic submucosal dissection for differentiated early gastric cancer with ulcer. METHODS: A total of 136 patients with differentiated early gastric cancer with ulcer who met the expanded indications for endoscopic submucosal dissection were reviewed between June 2005 and June 2014. Eighty-one patients were given PPI before endoscopic submucosal dissection and 55 patients were not given PPI. RESULTS: The complete ulcer healing rate was significantly different between the two groups (59.3 % vs. 23.6 %, P < 0.001). The procedure time was 38.1 ± 35.7 and 50.8 ± 50.2 min (P = 0.047). However, no significant differences were detected in the en bloc resection rate, complete resection rate, and adverse events including bleeding and perforation. Multivariate analysis showed that administration of PPI (OR = 10.83, P < 0.001) and mucosal invasion (OR = 24.43, P < 0.001) were independent factors that predicted complete healing of ulceration. The calculated accuracy for whether complete healing of the ulcer after PPI administration can differentiate mucosal from submucosal invasion was 75.3 %. CONCLUSIONS: Administration of PPI before ESD in differentiated EGC meeting the expanded criteria is effective to heal the ulcer lesion and reduce the mean procedure time. Complete healing of the ulcer after PPI administration suggests mucosal cancer.

A prospective randomized comparative study of cold forceps polypectomy by using narrow-band imaging endoscopy versus cold snare polypectomy in patients with diminutive colorectal polyps.

BACKGROUND AND AIMS: A previous study reported that cold snare polypectomy (CSP) was superior to cold forceps polypectomy (CFP) for the removal of diminutive colorectal polyps (DCPs) (≤5 mm) when the techniques were assessed for completeness of resection. However, completeness is expected to be greater with CFP when strict investigation of the remnant polyp is performed. The aim of this study was to assess the efficacy of CFP with narrow-band imaging (NBI) evaluation of polypectomy sites for removal of DCPs, compared with CSP. METHODS: This was a randomized, controlled, noninferiority trial at a tertiary-care referral hospital. Of the 380 patients screened, 146 patients with 231 DCPs were enrolled. CFP was used to resect DCPs until no remnant polyp was visible by NBI endoscopy. The primary noninferiority endpoint was histologic eradication of polyps, with a noninferiority margin of -10%. RESULTS: A size of >3 mm was seen in 129 polyps (55.8%). The overall rates of histologic eradication were 90.5% in the CFP group and 93.0% in the CSP group (difference, 2.5%; 95% confidence interval [CI], -9.67 to 4.62). However, when confined to the polyps >3 mm, the histologic eradication rate was 86.8% and 93.4% (95% CI, -17.2 to 3.6), respectively. Polyp size, histology, location, and time taken for polypectomy did not differ between the groups. The failure rate of tissue retrieval was higher in the CSP than in the CFP group (7.8% vs 0.0%, respectively; P =.001). CONCLUSIONS: In this study, >90% of all DCPs were completely resected by using CFP with NBI evaluation of polypectomy sites, showing noninferiority compared with CSP. However, in polyps measuring >3 mm, CFP failed to show noninferiority versus CSP. CFP appears to be the proper method for resection of DCPs 1 to 3 mm in size if no remnant polyp is visible by NBI endoscopy, but CFP is likely to be insufficient for larger polyps. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT02201147.).

Effectiveness of Surgicel® (Fibrillar) in patients with colorectal endoscopic submucosal dissection.

BACKGROUND AND AIMS: Because the invasive procedure of colorectal endoscopic submucosal dissection (ESD) entails a extensive mucosal defect and submucosal exposure, the procedure may have a substantial risk of complications including delayed bleeding, perforation and bacteremia and/or endotoxemia. The aim of our study was to investigate whether Surgicel(®) would be effective in reducing complications after colorectal ESD. PATIENTS AND METHODS: Between 2012 and 2013, 52 consecutive patients who underwent a colorectal ESD were enrolled. After the removal of colorectal epithelial neoplasm, surgicel was sprayed onto the submucosal surface using the wet type of application (Surgicel(®) group). We evaluated tumor type, location, size, histology, procedure time, hospital stay and associated complication. For assessing inflammatory reaction, white blood cells and body temperature were monitored. In assessing the effectiveness of Surgicel(®) application, we retrospectively compared the clinical outcomes with 52 other consecutive large colorectal tumor patients who had previously received conventional ESD, as control group (non-Surgicel(®) group). RESULTS: Of the 52 patients, three patients were excluded. Forty-nine patients were ultimately enrolled in this study. During the follow-up period, rebleeding occurred in 0 (0% in Surgicel(®) group) patients and 4 (7.7% in non-Surgicel(®) group) patients; fever (>37.7) in 2 (4.1%) and 10 (19.2%) patients, respectively (p = 0.019); and leukocytosis in 9 (18.4%) and 16 (30.8%) patients, respectively (p = 0.172). C-reactive protein level was 0.35 ± 0.18 and 9.83 ± 2.44 (p < 0.001). The mean hospitalization period was 4.22 ± 0.94 and 5.13 ± 0.27 days, respectively (p < 0.001). The group (surgicel vs. non-surgicel, p = 0.005, odds ratio 11.114 (2.104-58.718)) was identified as independent predictor for complication such as fever or delayed bleeding by multivariated analysis. CONCLUSIONS: Surgicel(®) application after colorectal ESD may be an effective method to reduce some complications and mean hospitalization period. Therefore, surgicel application may be considered to be a valuable clinical method.

Perforation in colorectal stenting: a meta-analysis and a search for risk factors.

BACKGROUND: Recent studies suggest that there is a substantial risk of perforation after colorectal stent placement. OBJECTIVE: To identify risk factors for perforation from colonic stenting. DESIGN: A meta-analysis of 86 studies published between 2005 and 2011. SETTING: Multicenter review. PATIENTS: All patients who underwent colorectal stent placement. INTERVENTION: Colorectal stent placement. MAIN OUTCOME MEASUREMENTS: The occurrence of perforation with subgroup analyses for stent design, stricture etiology, stricture dilation, and concomitant chemotherapy, including the use of bevacizumab. RESULTS: A total of 4086 patients underwent colorectal stent placement; perforation occurred in 207. Meta-analysis revealed an overall perforation rate of 7.4%. Of the 9 most frequently used stent types, the WallFlex, the Comvi, and the Niti-S D-type had a higher perforation rate (>10%). A lower perforation rate (<5%) was found for the Hanarostent and the Niti-S covered stent. Stenting benign strictures was associated with a significantly increased perforation rate of 18.4% compared with 7.5% for malignant strictures. Dilation did not increase the risk of perforation: 8.5% versus 8.5% without dilation. The subgroup of post-stent placement dilation had a significantly increased perforation risk of 20.4%. With a perforation rate of 12.5%, bevacizumab-based therapy was identified as a risk factor for perforation, whereas the risk for chemotherapy without bevacizumab was 7.0% and not increased compared with the group without concomitant therapies during stent therapy (9.0%). LIMITATIONS: Heterogeneity; a considerable proportion of data is unavailable for subgroup analysis. CONCLUSIONS: The perforation rate of colonic stenting is 7.4%. Stent design, benign etiology, and bevacizumab were identified as risk factors for perforation. Intraprocedural stricture dilation and concomitant chemotherapy were not associated with an increased risk of perforation.

Palliative self-expandable metal stents for acute malignant colorectal obstruction: clinical outcomes and risk factors for complications.

OBJECTIVE: Self-expandable metal stents (SEMSs) have been used as palliative treatment or bridge to surgery for obstructions caused by colorectal cancer (CRC). We assessed the long-term outcomes of palliative SEMSs and evaluated the risk factors influencing complications. MATERIALS AND METHODS: One hundred and seventy-five patients underwent SEMS placement for acute malignant colorectal obstruction. Of the 72 patients who underwent palliative treatment for primary CRC, 30 patients received chemotherapy (CT) for primary cancer (CT group) and 42 underwent best supportive treatment (BST) without CT (BST group). RESULTS: There was a significant difference in late migration between the CT group and the BST group (20.0% in CT group, 2.4% in BST group, p = 0.018). Response to CT influenced the rate of late obstruction (0% in disease control, 35.7% in disease progression, p = 0.014). However, late obstruction was not associated with stent properties, such as diameter or type (≤22 mm vs. >22 mm, 13.5% vs. 14.3%, p = 1.00; uncovered stent vs. covered stent, 15.5% vs. 7.1%, p = 0.675) and migration (≤22 mm vs. >22 mm, 16.2% vs. 2.9%, p = 0.108; uncovered stent vs. covered stent, 8.6% vs. 14.3%, p = 0.615) in palliative SEMS. CONCLUSION: The administration of CT increases the rate of stent migration, and disease control by CT can reduce the risk of obstruction by maintaining the luminal patency of palliative SEMSs.

Clinical usefulness of double balloon enteroscopy in suspected Crohn's disease: the KASID multi-center trial.

BACKGROUND/AIMS: The recently developed double balloon enteroscopy (DBE) may be useful to evaluate small bowel lesions in patients with suspected Crohn's disease (CD). We investigated the findings of DBE, small bowel follow-through and abdominal CT in patients with suspected CD who could not be diagnosed with CD using conventional colonoscopy. METHODOLOGY: Thirty patients (27 males, mean age 32.7±9.27 years) with suspected CD were consecutively enrolled in this study. The main symptoms were abdominal pain, chronic diarrhea, weight loss, obscure bleeding, or anemia. These patients were enrolled from May 2006 to January 2007 at 10 tertiary medical centers participating in the Korean Association for the Study of Intestinal Diseases. RESULTS: The DBE demonstrated definite CD in 24 patients (80.0%) and suspected findings of CD in six patients. The pathology results obtained by endoscopic biopsies revealed a granuloma in six patients (23.1%). The DBE identified additional findings not detected by radiology studies in 24 patients (80%) although the small bowel followthrough and the abdominal CT revealed the abnormal findings (73.1% and 64%). CONCLUSIONS: DBE may be a promising alternative and useful technique for patients with suspected CD. DBE provides biopsy sampling and more detailed information than radiology studies.

Long-term outcomes of endoscopic submucosal dissection for undifferentiated type early gastric cancer over 2 cm with R0 resection.

BACKGROUND: Endoscopic submucosal dissection (ESD) for over 2 cm in size undifferentiated type (UD type) early gastric cancer (EGC) confined to the mucosa is not only challenging, but also long-term outcomes are not well known. AIM: To evaluate the long-term outcomes of ESD done for UD type EGCs confined to the mucosa over 2 cm in size and compare the results with those where the lesions were less than 2 cm. METHODS: 143 patients with UD type EGC confirmed on histology after ESD at a tertiary hospital were reviewed. Cases with synchronous and metachronous lesions and a case with emergency surgery after ESD were excluded. A total of 137 cases were enrolled. 79 cases who underwent R0 resection were divided into 2 cm or less (group A) and over 2 cm (group B) in size. RESULTS: Among 79 patients who underwent R0 resection, the number in group A and B were 51 and 28, respectively. The mean follow-up period (SD) was 79.71 ± 45.42 months. There was a local recurrence in group A (1/51, 2%) and group B (1/28, 3.6%) respectively. This patient in group A underwent surgery while the patient in group B underwent repeated ESD with no further recurrences in both patients. There was no regional lymph node metastasis, distant metastasis, and deaths in both groups. With R0 resection strategy for ESD on lesions over 2 cm, 20.4% (28/137) of patients were able to avoid surgery compared with expanded indication. CONCLUSION: If R0 resection is achieved by ESD, UD type EGCs over 2 cm also showed good and similar clinical outcomes as compared to lesions less than 2 cm when followed for over 5 years. With R0 resection strategy, several patients can avoid surgery.

Clinical Practice Guideline for Percutaneous Endoscopic Gastrostomy.

With an aging population, the number of patients with difficulty swallowing due to medical conditions is gradually increasing. In such cases, enteral nutrition is administered through a temporary nasogastric tube. Long-term use of a nasogastric tube leads to various complications and a decreased quality of life. Percutaneous endoscopic gastrostomy (PEG) is the percutaneous placement of a tube into the stomach, aided endoscopically, which may be an alternative to a nasogastric tube when enteral nutritional is required for 4 weeks or more. This paper is the first Korean clinical guideline for PEG. It was developed jointly by the Korean College of Helicobacter and Upper Gastrointestinal Research and led by the Korean Society of Gastrointestinal Endoscopy. These guidelines aimed to provide physicians, including endoscopists, with the indications, use of prophylactic antibiotics, timing of enteric nutrition, tube placement methods, complications, replacement, and tubes removal for PEG based on the currently available clinical evidence.

Large colonic lipoma with a laterally spreading tumor treated by endoscopic submucosal dissection: A case report.

BACKGROUND: Since fat does not transmit electrical energy well, delayed perforation and post-polypectomy syndrome due to electrical thermal injury are concerns in the endoscopic removal of colonic lipoma. The endoscopic submucosal dissection (ESD) technique concentrates electrical energy conducts to the submucosa, not the adipose tissue. This helps to minimize electrical thermal injury, especially in the case of large colonic lipomas. In rare cases, such as colonic lipomas accompanied by mucosal lesions, it is difficult for endoscopists to decide how to safely remove them. CASE SUMMARY: A 78-year-old man underwent colonoscopy for colorectal cancer screening. During colonoscopy, a yellowish submucosal tumor with positive cushion sign was observed in the ascending colon measuring about 4.5 cm. A nodular mucosal lesion of about 2.5 cm was observed on the mucosal surface of the lipoma. The lipoma was so large that it occupied much of the inside of the colon, making it difficult to see the entire laterally spreading tumor (LST) at once. The LST was confined to the surface of the lipoma, which had a semipedunculated shape with a wide neck. The margin of the LST was not observed at the neck of the lipoma. ESD was performed and the colonic lipoma with the LST was successfully removed without complications. After 3 d of hospitalization, the patient was discharged without any symptoms. The final pathology report showed that the lesion consisted of submucosal lipoma and tubulovillous adenoma with low-grade dysplasia. CONCLUSION: ESD is effective and safe for treating a large colonic lipoma with an LST by minimizing electrical thermal injury.

[Clinical Practice Guideline for Percutaneous Endoscopic Gastrostomy].

With an aging population, the number of patients with difficulty in swallowing due to medical conditions is gradually increasing. In such cases, enteral nutrition is administered through a temporary nasogastric tube. However, the long-term use of a nasogastric tube leads to various complications and a decreased quality of life. Percutaneous endoscopic gastrostomy (PEG) is the percutaneous placement of a tube into the stomach that is aided endoscopically and may be an alternative to a nasogastric tube when enteral nutritional is required for four weeks or more. This paper is the first Korean clinical guideline for PEG developed jointly by the Korean College of Helicobacter and Upper Gastrointestinal Research and led by the Korean Society of Gastrointestinal Endoscopy. These guidelines aimed to provide physicians, including endoscopists, with the indications, use of prophylactic antibiotics, timing of enteric nutrition, tube placement methods, complications, replacement, and tubes removal for PEG based on the currently available clinical evidence.

Clinical practice guidelines for percutaneous endoscopic gastrostomy.

With an aging population, the number of patients with difficulty in swallowing due to medical conditions is gradually increasing. In such cases, enteral nutrition is administered through a temporary nasogastric tube. However, the long-term use of a nasogastric tube leads to various complications and a decreased quality of life. Percutaneous endoscopic gastrostomy (PEG) is the percutaneous placement of a tube into the stomach that is aided endoscopically and may be an alternative to a nasogastric tube when enteral nutritional is required for four weeks or more. This paper is the first Korean clinical guideline for PEG developed jointly by the Korean College of Helicobacter and Upper Gastrointestinal Research and led by the Korean Society of Gastrointestinal Endoscopy. These guidelines aimed to provide physicians, including endoscopists, with the indications, use of prophylactic antibiotics, timing of enteric nutrition, tube placement methods, complications, replacement, and tube removal for PEG based on the currently available clinical evidence.

Korean Guidelines for Postpolypectomy Colonoscopic Surveillance: 2022 revised edition.

Colonoscopic polypectomy is effective in decreasing the incidence and mortality of colorectal cancer (CRC). Premalignant polyps discovered during colonoscopy are associated with the risk of metachronous advanced neoplasia. Postpolypectomy surveillance is the most important method for managing advanced metachronous neoplasia. A more efficient and evidence-based guideline for postpolypectomy surveillance is required because of the limited medical resources and concerns regarding colonoscopy complications. In these consensus guidelines, an analytic approach was used to address all reliable evidence to interpret the predictors of CRC or advanced neoplasia during surveillance colonoscopy. The key recommendations state that the high-risk findings for metachronous CRC following polypectomy are as follows: adenoma ≥10 mm in size; 3 to 5 (or more) adenomas; tubulovillous or villous adenoma; adenoma containing high-grade dysplasia; traditional serrated adenoma; sessile serrated lesion containing any grade of dysplasia; serrated polyp of at least 10 mm in size; and 3 to 5 (or more) sessile serrated lesions. More studies are needed to fully comprehend the patients who are most likely to benefit from surveillance colonoscopy and the ideal surveillance interval to prevent metachronous CRC.

Changes over time in indications, diagnostic yield, and clinical effects of double-balloon enteroscopy.

BACKGROUND & AIMS: We performed a retrospective study to investigate changes between different time periods in the indications, diagnostic yield, and clinical impact of double-balloon enteroscopy (DBE). METHODS: We analyzed records from the database at Soonchunhyang University College of Medicine from all patients undergoing DBE between September 2004 and May 2011 (181 DBEs, 133 patients). We compared DBE-related factors between the first stage (September 2004-August 2006; 117 DBEs, 79 patients) and second stage (September 2006-May 2011; 64 DBEs, 54 patients) of the study period. RESULTS: The number of DBEs performed decreased between stages. Obscure gastrointestinal bleeding was the most common indication for DBE during each stage (65.8% vs 50%; P = .06). Abnormalities in other modalities as the second indication increased significantly in the second stage compared with the first (11.4% vs 29.6%; P = .008). Between stages, use of computed tomography increased (53.8% vs 81.5%; P = .001), along with capsule endoscopy (29.1% vs 44.4%; P = .06). Mucosal lesions were the most common finding in each stage (56% and 53.1%; P = .686). The diagnostic yield of DBE was 89.3% in the first stage and 93.9% in the second (P = .384). In the first stage, DBE identified 86.4% of cases that had negative results from other modalities; in the second, it identified all cases (P = .3). Therapeutic plans were determined in 89.7% of patients only on the basis of results from DBE. CONCLUSIONS: Between the time periods of 2004-2006 and 2006-2011, the clinical indications for DBEs and outcomes did not change. However, the selectivity of the number of patients decreased between stages.

Impact of patient education with cartoon visual aids on the quality of bowel preparation for colonoscopy.

BACKGROUND: High-quality bowel preparation is a prerequisite for colonoscopy. Few studies have evaluated visual aids as a means of improving the quality of bowel preparation. OBJECTIVE: To assess the effect of patient education by using cartoon visual aids on the quality of bowel preparation. DESIGN: An endoscopist-blinded, randomized, controlled trial. SETTING: Tertiary referral center. SUBJECTS: Patients scheduled for screening colonoscopy in a health examination center. INTERVENTIONS: Patients were assigned to receive the existing verbal and written instructions (group A) or a new cartoon visual educational instruction (group B) for colonoscopy. MAIN OUTCOME MEASUREMENTS: The primary endpoint was the quality of bowel preparation, assessed by using the Boston Bowel Preparation Scale (BBPS). Secondary endpoints were the quality of bowel preparation assessed by using the Universal Preparation Assessment Scale; insertion, withdrawal, and workup times; and polyp detection rates in the 2 groups. Logistic regression analysis was performed to determine the factors associated with poor bowel preparation according to a BBPS score less than 5. RESULTS: Group B exhibited better bowel preparation than group A according to BBPS scores (mean BBPS score, 6.12 ± 2.19 vs 7.44 ± 1.87, P ≤ .01; median BBPS score, 6.00 ± 0.00 vs 9.00 ± 0.00, P ≤ .01; good bowel preparation for colonoscopy, BBPS score ≥5, 81.6% vs 93.1%, P = .02). Multivariate analysis revealed that older age (odds ratio 1.07, P ≤ .01) and no use of visual aids (odds ratio 3.08, P = .02) were independent factors associated with poor bowel preparation. LIMITATIONS: Single-center study. CONCLUSIONS: Patient education with cartoons effectively improved bowel preparation for colonoscopy.