Cold snare polypectomy versus cold endoscopic mucosal resection for small colorectal polyps: a multicenter randomized controlled trial.

BACKGROUND: Cold snare polypectomy (CSP) is recommended for the resection of small colorectal polyps. However, few studies have investigated the efficacy of cold endoscopic mucosal resection (cold EMR) for small polyps. Thus, the aim of this study was to investigate the efficacy and safety of cold EMR compared with CSP for small colorectal polyps. METHODS: This was a multicenter, randomized trial conducted in three tertiary centers from January 2018 to February 2021. Patients with polyps sized 6-10 mm were randomized to CSP or cold EMR group. After polypectomy, two additional biopsies were performed to assess the completeness of resection. The primary outcome was complete polyp resection rate. Secondary outcomes were total procedure time and rate of adverse events such as immediate bleeding, delayed bleeding, and perforation. RESULTS: A total of 444 polyps in 327 patients were assessed and randomly assigned to each group. Of those, 425 polyps were finally analyzed based on pathology results. The complete resection rate was not significantly different between cold EMR and CSP groups (91.9% vs 89.8%, p = 0.24). However, the total procedure time was significantly increased in cold EMR (87.6 s vs. 45.8 s, p < 0.001). The rate of polypectomy adverse events was not significantly different between the two groups. No patient had massive bleeding or perforation. CONCLUSIONS: There was no difference in complete resection rate or adverse events between CSP and cold EMR. However, CSP reduced the total procedure time.

Comparison of 2 L Polyethylene Glycol Plus Ascorbic Acid and 4 L Polyethylene Glycol in Elderly Patients Aged 60-79: A Prospective Randomized Study.

BACKGROUND: The bowel-cleansing efficacy and safety of 2 L polyethylene glycol (PEG) with ascorbic acid (2L PEG + Asc) has rarely been studied in the elderly population. In this randomized trial, we compared the bowel cleanliness, safety, and tolerability of 2L PEG + Asc with those of 4 L PEG in an elderly population aged 60-79. METHODS: Study participants were randomized either to 2L PEG + Asc or 4L PEG. The primary endpoint was the success rate of bowel preparation, using the Boston Bowel Preparation Scale. Before colonoscopy, all participants were questioned about adverse events and tolerability regarding purgative ingestion. RESULTS: A total of 347 individuals were enrolled (2L PEG + Asc, 174; 4L PEG, 173). Mean age in the 2L PEG + Asc and the 4L PEG was 69.3 ± 5.6 and 69.3 ± 5.0, respectively (P = 0.917). The rate for successful bowel cleansing was comparable between the 2L PEG + Asc (92%) and the 4L PEG (96%, P = 0.118). Total ingested liquid including purgative and water was lower in the 2L PEG + Asc group (2.9 L) than in the 4L PEG group (4.2 L, P < 0.001). The tolerability of purgative was superior in the 2L PEG + Asc (overall satisfaction, P < 0.001; willingness to reuse, P < 0.001). There were no serious adverse events during the trial. CONCLUSIONS: The bowel-cleansing efficacy of 2L PEG + Asc was comparable to that of 4L PEG. Tolerability was superior in the 2L PEG + Asc group. For older people, 2L PEG + Asc is an efficacious and safe bowel cleanser. (Clinical trial registration number: KCT0004123).

Propofol compared with bolus and titrated midazolam for sedation in outpatient colonoscopy: a prospective randomized double-blind study.

BACKGROUND AND AIMS: The safest and most efficient method of sedation for outpatient colonoscopy remains unclear. This study aimed to compare the efficiency and safety of bolus administration of midazolam compared with titrated administration and propofol administration for patients undergoing outpatient colonoscopy. METHODS: We randomly divided patients undergoing colonoscopy into the propofol group, bolus midazolam group, and titrated midazolam group. We compared total procedure time, induction time, recovery time, and discharge time among the 3 groups. We also compared patient satisfaction and the incidence of adverse events. RESULTS: In total, 267 patients (89 in each study group) were enrolled during the study period. Patients in the propofol group had a shorter total procedure time (39.5 vs 59.4 vs 58.1 minutes; P < .001), induction time (4.6 vs 6.3 vs 7.6 minutes; P < .001), recovery time (11.5 vs 29.5 vs 29.2 minutes; P < .001), and discharge time (20.6 vs 34.9 vs 34.7 minutes; P < .001) than patients in the bolus midazolam group and titrated midazolam group. Patients in the propofol group reported higher degrees of satisfaction than patients in the bolus or titrated midazolam plus meperidine groups (9.9 vs 9.6 vs 9.6 [P = .007] and 4.9 vs 4.7 vs 4.8 [P = .008], respectively). Adverse events were not significantly different between groups. CONCLUSIONS: In this randomized trial, propofol was superior to bolus or titrated midazolam in terms of endoscopy unit efficiency and patient satisfaction during outpatient colonoscopy. (Clinical trial registration number: KCT0002805.).

Effect of prophylactic clip application for the prevention of postpolypectomy bleeding of large pedunculated colonic polyps: a randomized controlled trial.

BACKGROUND AND AIMS: Prophylactic application of a hemoclip has been suggested as an alternative to the use of an endoloop for the prevention of postpolypectomy bleeding (PPB) when resecting large, pedunculated colorectal polyps. Therefore, this multicenter, randomized controlled trial investigated the efficacy of prophylactic hemoclip application to reduce PPB during the resection of large pedunculated polyps. METHODS: Large pedunculated polyps (≥10 mm in head diameter) were eligible for inclusion. Polyps were randomized into a study arm (where clips were applied before resection) and a control arm (without pretreatment). The primary outcome was the rate of PPB in each group. PPB included immediate PPB (IPPB) and delayed PPB (DPPB). IPPB was defined as blood oozing (≥1 minute) or active spurting occurring immediately after polyp resection. DPPB was defined as rectal bleeding, occurring after completion of the colonoscopy. RESULTS: In total, 238 polyps from 204 patients were randomized into the clip arm (119 polyps) or the control arm (119 polyps). Overall bleeding adverse events were observed in 20 cases (IPPB, 16; DPPB, 4). The rate of overall PPB, IPPB, and DPPB was 8.4%, 6.7%, and 1.7%, respectively, for all polyps. The rate of overall PPB (clip 4.2% vs control 12.6%, P = .033) and IPPB (clip 2.5% vs control 10.9%, P = .017) was significantly lower in the clip arm than the control arm. CONCLUSIONS: Prophylactic clipping before resecting large pedunculated polyps can reduce overall PPB and IPPB compared with no prior treatment. Therefore, prophylactic clipping may be considered before resection of large pedunculated polyps. (Clinical trial registration number: NCT02156193.).

Comparison of adenoma detection by colonoscopy between polypectomy performed during both insertion and withdrawal versus during withdrawal only: a multicenter, randomized, controlled trial.

BACKGROUND AND AIM: In standard colonoscopy, the colonoscope is inserted into the cecum, and inspection of the colonic mucosa and polypectomy are performed during withdrawal. The colon configuration can differ between the insertion and withdrawal phases, and some polyps found in the insertion phase can be missed during withdrawal. A few single-center studies investigated whether detection of polyps during the insertion phase affects the adenoma detection rate (ADR). However, the effectiveness of this strategy is unknown because of conflicting results. We aimed to determine whether polypectomy together with careful inspection during insertion increases the ADR compared with standard colonoscopy. METHODS: A randomized, controlled, multicenter trial was conducted at three university hospitals. Patients aged 50 to 80 years were randomly assigned to the study group or control group. For patients in the study group, polypectomy was performed together with careful inspection during both colonoscope insertion and withdrawal. In the control group, polyps were inspected and removed only during colonoscope withdrawal. The primary endpoint was the ADR, which was defined as the percentage of patients with ≥ 1 adenoma. RESULTS: A total of 1142 patients were enrolled (study group, n = 571; control group, n = 571). The ADR was similar in the 2 groups (study group, 44.1%; control group, 43.1%; P = 0.72). In the control group, 12 polyps that had been detected during colonoscope insertion were not found during withdrawal (polyp miss rate: 2.1%, 12/571). CONCLUSION: Polypectomy and careful inspection during both colonoscope insertion and withdrawal did not improve the overall ADR compared with standard colonoscopy (NCT01925833).

Comparison of bowel-cleansing efficacy of split-dose and same-day dose bowel preparation for afternoon colonoscopy in patients with gastrectomy: a prospective randomized study.

BACKGROUND: A split dose (SPD) of purgative is the recommended bowel-preparation method for colonoscopy, although for colonoscopy scheduled for the afternoon, a same-day dose (SDD) of purgative is recommended. However, it has not been determined whether SPD or SDD is better in patients with gastrectomy who are at high risk of suboptimal bowel cleansing. We compared the bowel-cleansing efficacy of SPD and SDD regimens in patients with gastrectomy who underwent colonoscopy in the afternoon. METHODS: This was a prospective, randomized, assessor-blinded study. For the SDD group, polyethylene glycol (PEG) was ingested on the day of colonoscopy starting at 7 AM. In the SPD group, 2 L PEG was ingested at 9 PM the day before colonoscopy, and the remaining 2 L from 10 AM on the day of colonoscopy. Colonoscopy was performed from 1:30 PM. Before colonoscopy, the participants completed questionnaires asking about bowel-movement kinetics, adverse events, tolerability, overall satisfaction, and willingness to reuse the protocol. The bowel-cleansing efficacy was assessed using the Boston Bowel Preparation Scale. RESULTS: A total of 193 subjects were included (SDD, 95; SPD, 98). The rate of successful bowel cleansing was comparable between the two groups (SDD, 92.6% vs. SPD, 95.9%; P = 0.37). The incidence of adverse events (nausea, vomiting, bloating, abdominal pain, and dizziness/headache) was also comparable between the two groups. However, sleep disturbance was higher in the SPD group (SDD, 10.5% vs. SPD, 25.5%; P = 0.01). Tolerability did not differ between the SDD and SPD groups (satisfaction, P = 0.11; willingness to reuse, P = 0.29). CONCLUSIONS: The bowel-cleansing efficacy, safety profile, and patient tolerability of SDD and SPD were comparable. Both SDD and SPD regimens are feasible bowel-preparation methods for patients with gastrectomy who undergo colonoscopy in the afternoon. TRIAL REGISTRATION: Clinical trial registration number: KCT0002699.

Comparison of Bowel Cleansing Efficacy, Safety, Bowel Movement Kinetics, and Patient Tolerability of Same-Day and Split-Dose Bowel Preparation Using 4 L of Polyethylene Glycol: A Prospective Randomized Study.

BACKGROUND: Split-dose bowel preparation is recommended for morning colonoscopy, although a same-day dose regimen is an alternative for afternoon colonoscopy. Same-day preparation for morning colonoscopy has rarely been evaluated. OBJECTIVE: We compared the bowel cleansing efficacy, bowel movement kinetics, safety profile, and patient tolerability of split-dose and same-day preparation using 4-L polyethylene glycol. DESIGN: This was a prospective, randomized, assessor-blinded study. SETTINGS: This study was performed at a tertiary center in Korea. PATIENTS: Study subjects were randomly assigned to the same-day or split-dose groups. For the same-day dose group, 4 L of polyethylene glycol were ingested on the day of colonoscopy starting at 5:00 AM for morning colonoscopy or 7:00 AM for afternoon colonoscopy. In the split-dose group, 2 L of polyethylene glycol were ingested at 9:00 PM the day before colonoscopy, and the remaining 2 L from 7:00 AM for morning colonoscopy or from 10:00 AM for afternoon colonoscopy. Colonoscopy was performed from 10:00 AM. MAIN OUTCOME MEASURES: The efficacy of bowel cleansing was evaluated using the Boston bowel preparation scale. The participants completed questionnaires asking about adverse events, bowel movement kinetics, and tolerability of the preparation before colonoscopy. RESULTS: A total of 339 subjects were included (same-day dose = 172; split dose = 167). One subject in each group did not undergo colonoscopy. The rate of successful cleansing did not differ between the groups (same-day dose = 98.8% vs split dose = 98.2%; p = 0.681). There were no instances of hemodynamic instability or aspiration in either group. Tolerability, including overall satisfaction and willingness to reuse, were comparable between the groups. LIMITATIONS: This was a single-center study. CONCLUSIONS: The bowel cleansing efficacy, safety profile, and tolerability of same-day dosing with polyethylene glycol were comparable with those of split dose. Therefore, same-day dosing with 4 L of polyethylene glycol is a feasible bowel preparation method. See Video Abstract at http://links.lww.com/DCR/B44. COMPARACIÓN DE LA EFICACIA DE LA LIMPIEZA INTESTINAL, LA SEGURIDAD, LA CINÉTICA DEL MOVIMIENTO INTESTINAL Y LA TOLERABILIDAD DEL PACIENTE DE LA PREPARACIÓN INTESTINAL EN EL MISMO DÍA Y EN DOSIS DIVIDIDAS UTILIZANDO 4 L DE POLIETILENGLICOL: UN ESTUDIO PROSPECTIVO ALEATORIZADO: Se recomienda la preparación del intestino en dosis divididas para la colonoscopia de la mañana, aunque un régimen de una sola dosis el mismo día es una alternativa para la colonoscopia en la tarde. La preparación de una sola dosis el mismo día para la colonoscopia matutina rara vez se ha evaluado.Comparamos la eficacia de la limpieza intestinal, la cinética del movimiento intestinal, el perfil de seguridad y la tolerabilidad del paciente de la dosis dividida y la preparación el mismo día utilizando 4 L de polietilenglicol.Este fue un estudio prospectivo, aleatorizado, cegado por el evaluador.Este estudio se realizó en un centro terciario en Corea.Los sujetos del estudio fueron asignados aleatoriamente a el grupo de una dosis en el mismo día o al grupo de dosis dividida. Para el grupo de dosis del mismo día, se ingirieron 4 L de polietilenglicol el día de la colonoscopia a partir de las 5 a.m. para la colonoscopia de la mañana o las 7 a.m. para la colonoscopia de la tarde. En el grupo de dosis dividida, se ingirieron 2 L de polietilenglicol a las 9 p.m. el día anterior a la colonoscopia, y los otros 2 L restantes a partir de las 7 a.m. para la colonoscopia de la mañana o desde las 10 a.m. para la colonoscopia de la tarde. La colonoscopia se realizó a partir de las 10 a.m.La eficacia de la limpieza intestinal se evaluó mediante la escala de preparación intestinal de Boston. Los participantes completaron cuestionarios preguntando sobre los eventos adversos, la cinética del movimiento intestinal y la tolerabilidad de la preparación antes de la colonoscopia.Se incluyeron un total de 339 sujetos (dosis el mismo día, 172; dosis dividida, 167). Un sujeto en cada grupo no se sometió a colonoscopia. La tasa de limpieza exitosa no difirió entre los grupos (dosis el mismo día, 98.8% versus dosis dividida, 98.2%; p = 0.681). No hubo casos de inestabilidad hemodinámica o aspiración en ninguno de los grupos. La tolerabilidad, incluida la satisfacción general y la voluntad de reutilización, fueron comparables entre los grupos.Este fue un estudio de centro único.La eficacia de la limpieza intestinal, el perfil de seguridad y la tolerabilidad de la dosificación en el mismo día con polietilenglicol fueron comparables con los de la dosis dividida. Por lo tanto, la dosificación en el mismo día con 4 L de polietilenglicol es un método factible de preparación intestinal. Vea el video del resumen en http://links.lww.com/DCR/B44.

Treatment of benign perforations and leaks of the esophagus: factors associated with success after stent placement.

BACKGROUND: Self-expanding metal stent (SEMS) is effective and safe for the treatment of benign esophageal perforations or leaks. The purpose of this study was to identify factors associated with clinical success after SEMS placement. METHODS: Patients who received SEMS placement for treatment of benign esophageal perforations or leaks were retrospectively identified. These patients were analyzed for factors associated with clinical success and complications. RESULTS: A total of 31 patients underwent stent insertion for benign esophageal perforations (n = 11) or anastomotic leaks (n = 20). Clinical success was achieved in twenty-three patients (74.2%) after initial stent insertion. In multivariate analysis, early stent insertion within 1 day was identified as a significant independent predictor of successful sealing (Odds ratio = 3.14, 95% CI 1.36-7.24; p = 0.013). The anastomotic leak group needed a longer stent dwelling time (≥ 4 weeks) compared to the perforation group (75.0% vs. 27.3%, p = 0.022). CONCLUSIONS: Clinical success was significantly associated with early stent insertion. The dwelling time of stent was shorter for benign perforations compared to anastomotic leaks.

Randomized clinical trial comparing 10- or 14-day sequential therapy and 10- or 14-day concomitant therapy for the first line empirical treatment of Helicobacter pylori infection.

BACKGROUND AND AIM: Whether concomitant therapy is superior to sequential therapy (ST) as first-line therapy of Helicobacter pylori in areas with high clarithromycin resistance remains controversial. The aim of this study was to compare the efficacy and tolerability of 10- or 14-day ST with 10- or 14-day concomitant therapy (CT). METHODS: This was a prospective randomized study comparing 10- or 14-day ST with 10- or 14-day CT. The ST-10 and ST-14 groups received pantoprazole 40 mg and amoxicillin 1 g twice a day for the first 5 and 7 days followed by pantoprazole 40 mg, clarithromycin 500 mg, and metronidazole 500 mg twice a day for the remaining 5 and 7 days, respectively. The CT-10 and CT-14 groups received pantoprazole 40 mg, amoxicillin 1 g, clarithromycin 500 mg, and metronidazole 500 mg twice daily for 10 and 14 days, respectively. RESULTS: Three hundred forty-one patients were randomly allocated to the four groups. The modified intention-to-treat eradication rates of ST-10, ST-14, CT-10, and CT-14 were 91.7%, 91.2%, 94.2%, and 98.5%, respectively. The corresponding per protocol eradication rates were 91.4%, 91.0%, 95.6%, and 98.5%. There was no difference in compliance and adverse events in the four groups. Eradication rates increased sequentially with statistical significance in the following order: ST-10, ST-14, CT-10, and CT-14 (P = 0.044). CONCLUSIONS: All four regimens achieved eradication rates >90% in per protocol analyses in a country with high clarithromycin resistance. There was no difference in tolerability among the four regimens.

Effect of Dynamic Position Changes on Adenoma Detection During Colonoscope Withdrawal: A Randomized Controlled Multicenter Trial.

OBJECTIVES: Adequate luminal distension is essential for improving adenoma detection during colonoscope withdrawal. A few crossover studies have reported that dynamic position changes maximize luminal distension and increase adenoma detection rates (ADR). We designed a multicenter, randomized, parallel-group trial to verify the effect of dynamic position changes on colonic adenoma detection. METHODS: This study was conducted at the six hospitals of the Catholic University of Korea. Patients aged 45-80 years who underwent a colonoscopy for the first time were included. In the position change group, the position changes during colonoscope withdrawal were as follows: cecum, ascending colon, and hepatic flexure: left lateral position; transverse colon: supine position; splenic flexure, descending colon, sigmoid colon, and rectum: right lateral position. In the control group, the examinations were performed entirely in the left lateral position during colonoscope withdrawal. The primary outcome measure was the ADR, which was defined as the proportion of patients with ≥1 adenoma. RESULTS: A total of 1,072 patients were randomized into the position change group (536 patients) or the control group (536 patients). The ADR was higher in the position change group than in the control group (42.4 vs. 33.0%, P=0.002). More adenomas were detected per subject in the position change group (0.90 vs. 0.67, P=0.01). Increases in the number of adenomas were observed in examinations of the transverse colon (0.22 vs. 0.13, P=0.016) and the left colon (0.37 vs. 0.27, P=0.045). A significant increase in the ADR was observed for endoscopists with a relatively low detection rate. For endoscopists with a high detection rate, non-significant changes in the ADR were observed. CONCLUSIONS: Dynamic position changes during colonoscope withdrawal increased the ADR.

Clinical outcome of endoscopic management of duodenal Dieulafoy's lesions: endoscopic band ligation versus endoscopic hemoclip placement.

BACKGROUND: The most appropriate type of endoscopic hemostasis for bleeding due to duodenal Dieulafoy's lesions (DLs) is not yet established. The aim of this study was to assess the efficacy of mechanical endoscopic hemostasis for duodenal DLs and long-term outcome after successful hemostasis, as well as to compare the efficacy and safety of endoscopic band ligation (EBL) and endoscopic hemoclip placement (EHP). METHODS: Patients admitted to the emergency unit with acute upper gastrointestinal bleeding from duodenal DLs were enrolled in this study. The data were collected prospectively, but data analysis was performed retrospectively. Twenty-four patients with duodenal DLs were treated with EBL (n = 11) or EHP (n = 13). RESULTS: There were no significant differences between groups with respect to clinical or endoscopic characteristics, apart from the number of epinephrine (three cases with EBL vs. 11 cases with EHP; p = 0.011). Primary hemostasis was achieved in all patients. Recurrent bleeding was observed in one patient (9.1 %) from the EBL group and in five patients (38.5 %) from the EHP group (p = 0.166). The recurrent bleeding in the patient from the EBL group was treated by EHP. In the EHP group, all five patients achieved successful secondary hemostasis by endoscopic treatment (EBL in two patients and EHP in three patients). There were no differences in secondary outcomes between the two groups, including the number of endoscopic sessions required, need for angiographic embolization or emergent surgery, transfusion requirements, or length of hospital stay. No complications occurred, and there was no recurrence of bleeding in either group during the follow-up period. CONCLUSIONS: Mechanical endoscopic treatments are effective and safe for the treatment of bleeding duodenal DLs. A large-scale, randomized, controlled study is required to confirm the efficacy and safety of EBL and EHP for the management of bleeding duodenal DLs.

Diagnostic yield of endoscopic ultrasonography-guided single-incision needle knife biopsy for gastric subepithelial tumors: comparison with resected specimens.

BACKGROUND: Several techniques are recommended for the histologic diagnosis of gastric subepithelial tumors (SETs). The purpose of our study was to evaluate the diagnostic yield and safety of endoscopic ultrasonography-guided single-incision needle knife (SINK) biopsy for the diagnosis of gastric SETs. METHODS: A retrospective review of patients who received biopsy for gastric SETs from August 2012 to May 2015 was conducted. Patients who received endoscopic ultrasonography and were found to have a SET originating from the muscularis propria of the stomach were included in the study. The aim of our study was to investigate the safety and diagnostic yield of SINK biopsy for gastric SETs. RESULTS: A total of 31 patients received SINK biopsy for SETs. The diagnostic yield of SINK biopsy was 87 % (95 % CI 75-100 %), and the diagnostic accuracy was 89 % (95 % CI 74-105 %). The sensitivity of SINK biopsy to identify gastrointestinal stromal tumors was 83 % (95 % CI 52-98 %); the specificity was 100 % (95 % CI 59-100 %); the positive predictive value was 100 % (95 % CI 69-100 %); and the negative predictive value was 78 % (95 % CI 40-97 %). There were no procedure-related adverse events during and after procedure. CONCLUSION: The use of SINK biopsy technique in patients with SETs is a good diagnostic tool with high diagnostic yield and accuracy. The method is simple, safe, and associated with few complications.

Efficacy of endoscopic mucosal resections for the management of small gastric adenomas with low-grade dysplasia.

OBJECTIVE: Gastric adenoma with low-grade dysplasia (LGD) can progress to gastric cancer; however, the optimal therapeutic modality for LGD has not been established. The aim of this study was to assess the efficacy, safety of and local recurrence following endoscopic mucosal resection (EMR) for LGD. Specifically, we compared EMR with circumferential precutting (EMR-P) and EMR using a dual-channel endoscope (EMR-D) for the treatment of LGD ≤2 cm. MATERIALS AND METHODS: A total of 158 lesions from 147 patients with LGD treated by EMR were retrospectively analyzed. The en bloc resection rate, complete resection rate, procedure time, complication rate and local recurrence rate were compared between EMR-P and EMR-D. RESULTS: The en bloc resection and complete resection rates of EMR were 91.1% and 90.5%, respectively. The bleeding and perforation rates were 1.3% and 1.3%, respectively. The local recurrence rate following EMR was 2.2%. The en bloc resection and complete resection rates did not differ between EMR-P and EMR-D (88.2% vs. 92.5%, p = not significant (NS); and 90.2% vs. 90.7%, p = NS, respectively). The procedure time was significantly longer for EMR-P compared with EMR-D (16 (5-141) vs. 7 (2-48) min, p < 0.001), and the complication rate was significantly higher for EMR-P (7.8% vs. 0.0%, p = 0.010). Local recurrence was not found in EMR-P, whereas the recurrence rate was 3.2% in EMR-D. CONCLUSION: EMR is an effective method for the treatment of LGD ≤2 cm. Compared with EMR-P, EMR-D appears to be the more effective, technically simple and safer method.

Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy bleeding in pedunculated colonic polyps: a prospective, randomized, multicenter study.

BACKGROUND AND STUDY AIMS: The effectiveness of the prophylactic clip for the prevention of postpolypectomy bleeding in pedunculated colonic polyps has not been confirmed. The aim of this prospective, randomized study was to compare the efficacy of prophylactic clip and endoloop application in the prevention of postpolypectomy bleeding in large pedunculated polyps. PATIENTS AND METHODS: A total of 195 patients who had pedunculated colorectal polyps, with heads ≥ 10 mm and stalks ≥ 5 mm in diameter, were included in the study between July 2010 and January 2013. Polyps were randomized to receive either clips or endoloops. Both devices were applied to the base of the stalk before conventional snare polypectomy. Bleeding complications were analyzed with a noninferiority margin of 5 %. RESULTS: A total of 203 polyps were included in the study (98 in the clip group and 105 in the endoloop group). Bleeding occurred after five polypectomies in the clip group (5.1 %) and after six in the endoloop group (5.7 %) (P = 0.847). Noninferiority of the prophylactic clip to the endoloop could not be confirmed (absolute bleeding rate difference - 0.6 %, 95 % confidence interval - 5.6 % to 6.8 %) due to small sample size. Immediate bleeding episodes occurred in 4/5 polyps in the clip group and 5/6 polyps in the endoloop group. Delayed bleeding occurred in one polyp in each group. CONCLUSIONS: These results suggest that the application of a prophylactic clip is as effective and safe as an endoloop in the prevention of postpolypectomy bleeding in large pedunculated colonic polyps. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT01406379).

Endoscopic clip closure versus surgery for the treatment of iatrogenic colon perforations developed during diagnostic colonoscopy: a review of 115,285 patients.

BACKGROUND: Although the incidence of perforation after endoscopic procedures of the colon is low, the rising number of diagnostic colonoscopies could pose relevant health problems. Optimizing treatment may reduce the probability of severe complications. This study aimed to determine perforation frequency and the management of perforations that occurred during diagnostic colonoscopy. METHODS: A retrospective review of patient records was performed for all patients with iatrogenic colonic perforations after sigmoidoscopy/colonoscopy from 2000 to 2011 in three institutions of The Catholic University of Korea. The patients' demographic data, endoscopic procedure information, perforation location, therapy, and outcomes along with different therapeutic strategies were recorded. RESULTS: In the 12-year period, a total of 115,285 diagnostic sigmoidoscopic/colonoscopic procedures were performed. A total of 27 perforations occurred. Sixteen patients underwent endoscopic clipping, of which three patients failed and were referred for surgery. Fourteen patients in total underwent surgery for perforation. Endoscopic clip closure was successful in 81 % of the patients. No perforation-related major morbidity or mortality occurred. CONCLUSION: Endoscopic repair using clips can be effective for the treatment of colon perforations that occur during diagnostic colonoscopy.

Antimigration property of a newly designed covered metal stent for esophageal stricture: an in vivo animal study.

BACKGROUND: Covered self-expandable metal stents (SEMSs) are associated with a higher migration rate than uncovered SEMSs. OBJECTIVE: The antimigration property of a novel covered SEMS was investigated in a canine esophageal stricture model. DESIGN: The new stent (80 mm in length, 20 or 24 mm in diameter) has multiple protuberances on its body that were designed to be separated from the inner silicone membrane so that they could be embedded into the mucosa after deployment. Twenty-two beagle dogs were subjected to circumferential EMR in the middle esophagus for stricture formation. After 2 weeks, conventional covered stents were inserted in a control group (n = 11), and the newly designed covered SEMSs were inserted in a study group (n = 11). SETTING: Animal laboratory. INTERVENTIONS: Circumferential EMR of the middle esophagus for stricture formation, followed by endoscopic placement of a conventional or newly designed stent. MAIN OUTCOME MEASUREMENTS: Migration, complications, survival, and esophageal histopathology. RESULTS: There was no significant difference in the diameter of the esophageal stricture between the control and study groups (10 mm vs 11 mm, P = .52). Within 3 days, all stents in the control group had migrated, whereas 6 had migrated in the study group (100% vs 55%, P = .035). There were no significant complications directly associated with stent insertion. LIMITATIONS: Complications, survival, and esophageal histopathology could not be compared because all of the conventional stents migrated in the control group within 3 days. CONCLUSIONS: The newly designed covered SEMS is more resistant to migration than the conventional covered SEMS.

Microsatellite instability in young patients with sporadic colorectal adenomas.

BACKGROUND/AIMS: This study was designed to determine the prevalence of microsatellite instability (MSI) among colorectal adenomas detected in patients ≤ 40 years of age and to compare the prevalence of MSI in young (≤ 40 years) and older (>40 years) patients with colorectal adenomas. Additionally, we attempted to identify the underlying cause of MSI in these patients. METHODOLOGY: We prospectively tested for the presence of MSI using five NCI markers in samples from the two patient groups. The frequency of MSI was compared and the underlying causes of MSI were determined by methylation specific PCR and germ-line mutation analysis for mismatch repair genes. RESULTS: The frequency of MSI was higher in the ≤ 40 group than the >40 group (31.4% and 6.4%, respectively, p=0.0004). The MSI-high pattern was also more prevalent in the ≤ 40 group than the >40 group (15.7% and 2.5%, respectively, p=0.014). The hypermethylated hMLH1 gene was demonstrated in 7/8 (87.5%) patients with MSI-high in the ≤ 40 group and in 1/2 (50.0%) patients with MSI-high in the >40 group. No study subject showed a germline mutation of hMLH1 or hMSH2. CONCLUSIONS: MSI-high was more frequent in young (≤ 40 years) patients with colorectal adenoma than in older (>40 years) patients. Hypermethylation of the hMLH1 gene appears to be an important cause of MSI-high in these patients.

Safety of Endoscopy in Peritoneal Dialysis Patients.

INTRODUCTION: Endoscopic procedures can provoke peritonitis in patients receiving peritoneal dialysis (PD). The aim of this study was to assess the development of peritonitis after endoscopic procedures in PD patients. METHODS: We retrospectively reviewed the data from PD patients who underwent endoscopies in 3 tertiary hospitals between 2008 and 2018. The patients were grouped into nonprophylactic, prophylactic, and prior antibiotic therapy groups. The incidence of peritonitis within 7 days of endoscopy was assessed. We also examined the factors associated with peritonitis. RESULTS: There were 1,316 endoscopies performed in 570 PD patients. The peritonitis rate after endoscopy was 3.0%. Specifically, the peritonitis rate was 1.8% for esophagogastroduodenoscopies, 4.2% for the colonoscopy group, and 5.3% for the sigmoidoscopy group. The prior antibiotic therapy group showed a significantly higher risk of peritonitis (odds ratio = 4.6; 95% confidence interval: 2.2-9.6; P < 0.01). Prophylactic antibiotics were not associated with reducing peritonitis. Therapeutic colonoscopies such as polypectomy were associated with an increased risk of developing peritonitis (odds ratio = 6.5; 95% confidence interval: 1.6-25.9). However, biopsies were not associated with an increased risk of peritonitis. DISCUSSION: Prophylactic antibiotics did not reduce the risk of peritonitis after endoscopy in PD patients. Therapeutic colonoscopies such as polypectomy and prior antibiotic therapy before endoscopy were associated with an increased risk of peritonitis.

Predictive Model of Nonneoplastic Pathology after Endoscopic Resection of Gastric Epithelial Neoplasia.

Background/Aims: The rate of nonneoplastic pathology (NNP) after endoscopic resection (ER) of gastric epithelial neoplasia (GEN) has been reported to be 3%-7%. However, to date, the associations of pretreatment characteristics with NNP have not been identified. The aim of this study was to develop a predictive model for NNP after ER. Methods: Among 817 patients who underwent ER for GEN, factors associated with NNP were identified by univariate and multivariate analyses. Weighted points considering the ß coefficient were allocated to each variable that was significant in the multivariate analysis. The predictive score was calculated by the total points. The area under the receiver operating characteristic curve (AUROC) was calculated for the predictive score. Results: The rate of NNP was 8.8%. After multivariate analysis, poor demarcation from the background, no ulceration, a flat appearance, and low-grade dysplasia were significant factors predictive of NNP. One point each was allocated for no ulcer, flat appearance, and low-grade dysplasia. Two points were allocated for poor demarcation from the background. The predictive score ranged from 0 to 5 points. Patients were categorized as being at low risk (0, 1, or 2 points) or high risk (3, 4, or 5 points) for NNP. The AUROC was 0.82 (95% confidence interval, 0.77 to 0.88; p<0.01). With a cutoff value of 2.5, the sensitivity and specificity of the score for predicting NNP were 0.72 and 0.84, respectively. Conclusions: We developed a model to predict NNP after ER. Endoscopic re-biopsy or re-evaluation by pathologists is strongly recommended for the high-risk group.