Usefulness of Acetic Acid Spray with Narrow-Band Imaging for Identifying the Margin of Sessile Serrated Lesions.

BACKGROUND: Sessile serrated lesions (SSLs) are precursors of colon cancer, especially in cases of large, right colon. However, they are difficult to not only detect, but only clarify the margin of the lesion, which can lead to the poor endoscopic treatment outcomes. AIMS: This study evaluated the usefulness of acetic acid spray with narrow-band imaging (A-NBI) for the better visualization of the margin of SSLs. METHODS: From January 2013 to March 2022, patients with superficial elevated polyps suspected of being SSLs ≥ 10 mm with an endoscopic diagnosis that had been endoscopically resected at Hiroshima City Hiroshima Citizens Hospital were enrolled. Endoscopic images with white-light imaging (WLI), narrow-band imaging (NBI), indigo-carmine (IC), and A-NBI were recorded in each lesion and were randomly arranged and assessed by 10 endoscopists. We compared the visibility score (1 to 4) and color differences (ΔE) between inside and outside of the lesions among WLI, NBI, IC, and A-NBI. RESULTS: Forty-one lesions in 33 cases were included, and a total of 164 images were evaluated. As for the visibility score, most of the lesions were scored as 1 or 2 on WLI, whereas most were scored 4 on A-NBI. The median ΔE of A-NBI was also significantly higher than that of WLI, NBI, or IC (20.5 vs. 8.3 vs. 8.2 vs. 12.3, P < 0.01). A significant correlation was observed between the color difference and visibility score (r = 0.53, P < 0.01). CONCLUSIONS: A-NBI may be a useful modality for identifying the margin of SSLs.

Nonrecurrence Rate of Underwater EMR for ≤20-mm Nonampullary Duodenal Adenomas: A Multicenter Prospective Study (D-UEMR Study).

BACKGROUND AND AIMS: Endoscopic resection of nonampullary duodenal adenoma is often challenging, and its technique has not yet been standardized. To overcome the practical difficulty of conventional endoscopic mucosal resection, underwater endoscopic mucosal resection (UEMR) was recently developed; therefore, we investigated the effectiveness and safety of UEMR for nonampullary duodenal adenoma. METHODS: A multicenter, prospective cohort study was conducted at 21 institutions in Japan. We enrolled patients with no more than 2 nonampullary duodenal adenomas ≤20 mm in size, who were planned to undergo UEMR. After UEMR, follow-up endoscopies were scheduled at 2 and 12 months after the procedure, and biopsy specimens were taken from the post-UEMR scars. The primary endpoint was the proportion of patients with histologically proven nonrecurrence at follow-up endoscopy and biopsy. RESULTS: A total of 155 patients with 166 lesions underwent UEMR. One patient with a non-neoplastic lesion in the resected specimen and 10 patients with 10 lesions who were lost to follow-up were excluded. Finally, 144 patients with 155 lesions who received all follow-up endoscopies were analyzed for the primary endpoint. The proportion of patients with proven nonrecurrence was 97.2% (n = 140 of 144; 95% confidence interval, 92.8%-99.1%) which exceeded the predefined threshold value (92%). Two cases of delayed bleeding (1.2%) occurred and they were successfully managed by clips. All recurrences were successfully treated by additional endoscopic treatment. CONCLUSIONS: This multicenter, prospective cohort study demonstrated effectiveness and safety of UEMR for nonampullary duodenal adenomas ≤20 mm in size. (University Hospital Medical Network Clinical Trials Registry, Number: UMIN000030414).

Multicenter survey on mesalamine intolerance in patients with ulcerative colitis.

BACKGROUND AND AIM: Although oral mesalamine is the first-choice drug for treating mild-to-moderate ulcerative colitis (UC), some patients show symptoms of intolerance, including exacerbation of diarrhea and abdominal pain. The present study clarified the current state and clinical courses of patients with mesalamine intolerance. METHODS: Patients who were diagnosed with UC and administered oral mesalamine at eight hospitals in Japan with a follow-up period exceeding 1 year were analyzed. RESULTS: Sixty-seven (11%) of 633 patients showed intolerance to at least one formulation of oral mesalamine. The frequency of mesalamine intolerance has increased in recent years, rising from 5.3% in 2007-2010 to 9.1% in 2011-2013 and 16.2% in 2014-2016. The most common complications were the exacerbation of diarrhea (n = 29), a fever (n = 25), and abdominal pain (n = 22). Readministration of mesalamine/sulfasalazine was attempted in 43 patients, mostly with other types of formulation of mesalamine, and more than half of these patients proved to be tolerant. The risk factors for mesalamine intolerance were female gender (odds ratio [OR] = 1.83; 95% confidence interval [CI], 1.08-3.12), age < 60 years old (OR = 2.82; CI, 1.19-8.33), and pancolitis (OR = 2.09; 95% CI, 1.23-3.60). There were no significant differences in the use of anti-tumor necrosis factor-α agents, colectomy, or steroid-free remission at the last visit between patients with and without mesalamine intolerance. CONCLUSIONS: Mesalamine intolerance is not rare, and its frequency has been increasing recently. The prognosis of patients with mesalamine intolerance did not differ significantly from that of those without intolerance.

Impact of Computed Tomography Evaluation Before Colonoscopy for the Management of Colonic Diverticular Hemorrhage.

GOALS: The purpose of this study was to investigate and summarize our experience of a standardized strategy using computed tomography (CT) followed by colonoscopy for the assessment of colonic diverticular hemorrhage with focus on a comparison of CT and colonoscopy findings in patients with colonic diverticular hemorrhage. BACKGROUND: Colonic diverticular hemorrhage is usually diagnosed by colonoscopy, but it is difficult to identify the responsible bleeding point among many diverticula. STUDY: We retrospectively included 257 consecutive patients with colonic diverticular hemorrhage. All patients underwent a CT examination before colonoscopy. All-cause mortality and rebleeding-free rate after discharge were analyzed by Kaplan-Meier analysis and compared using the log-rank test. RESULTS: In CT examinations, 184 patients (71.6%) had definite diverticular hemorrhage with 31.9% showing intraluminal high-density fluid on plain CT, 39.7% showing extravasation, and 31.1% showing arteriovenous increase of extravasation on enhanced CT. In colonoscopy, 130 patients (50.6%) showed endoscopic stigmata of bleeding with 12.1% showing active bleeding, 17.1% showing a nonbleeding visible vessel, and 21.4% showing an adherent clot. A comparison of the locations of bleeding in CT and colonoscopy showed that the agreement rate was 67.3%, and the disagreement rate was 0.8% when the lesion was identified by both modalities patients with definite diverticular hemorrhage identified by CT had a longer hospital stay, higher incidences of hemodynamic instability and rebleeding events than did patients with presumptive diverticular hemorrhage. CONCLUSION: CT evaluation before colonoscopy can be a good option for managing patients with colonic diverticular hemorrhage.

Long-term outcomes of patients with Crohn's disease who received infliximab or adalimumab as the first-line biologics.

BACKGROUND AND AIM: Although previous studies compared the efficacy of infliximab (IFX) versus adalimumab (ADA) as the first-line biologics for Crohn's disease (CD), the difference in long-term prognosis based on which biologic was used first has scarcely been reported. In particular, the clinical courses after loss of response (LOR) of the first-line biologics are largely unknown. METHODS: A multicenter, retrospective study was performed. Disease courses of biologic-naïve CD patients who were started on IFX or ADA treatment were evaluated, even after LOR of the initial biologics. RESULTS: In total, 263 CD patients were eligible for analysis, 183 were treated with IFX first, and 80 were treated with ADA first. The median observation period was 64.2 months. The cumulative steroid-free remission rates and surgery-free rates did not differ significantly between the patients treated with IFX first and those treated with ADA first (log-rank test P = 0.42 and P = 0.74, respectively). In addition, no significant difference was observed in the rate of occurrence of events associated with ineffectiveness (modification of anti-tumor necrosis factor treatment including intensification, switch, discontinuation, or surgery) between the patient groups (log-rank test P = 0.62). The patients treated with IFX first were likely to discontinue the agent due to adverse events, whereas those treated with ADA first were likely to discontinue due to treatment failure or LOR. CONCLUSIONS: No significant difference was observed in the long-term prognosis between biologic-naïve patients with CD who were started treatment with IFX first and ADA first.

[Gastric type adenoma with submucosal invasive carcinoma:a case study].

A 75-year-old woman visited our hospital for the examination of esophagogastroduodenoscopy (EGD) without any major complaint. The patient's medical history included hypertension, but no carcinoma. EGD revealed a 30-mm elevated lesion located in the anterior wall of the upper region of the stomach. The lesion, which was a 0-IIa+I type lesion with fading-like and light flare-like domains, was surgically removed using endoscopic submucosal dissection (ESD) and then the patient was diagnosed with gastric type adenoma with submucosal invasive carcinoma. To the best of our knowledge, this is the first report of a gastric type adenoma with submucosal invasive carcinoma and may therefore provide significant insights into the malignant potential of gastric type adenoma lesions.

Importance of Second-look Endoscopy on an Empty Stomach for Finding Gastric Bezoars in Patients with Gastric Ulcers.

　Most gastric bezoars can be treated with endoscopic fragmentation combined with or without cola dissolution, whereas laparotomy or laparoscopic surgery is generally inevitable for small intestinal bezoars because they cause small bowel obstruction. Therefore, early diagnosis and management of gastric bezoars are necessary to prevent bezoar-induced ileus. To investigate the incidence of overlooked gastric bezoars during the initial esophagogastroduodenoscopy, we retrospectively reviewed the cases of 27 patients diagnosed with gastrointestinal bezoars. The bezoars were diagnosed using esophagogastroduodenoscopy (n=25), abdominal ultrasonography (n=1), and barium follow-through examination (n=1). Bezoars were overlooked in 9/25 patients (36.0%) during the initial endoscopy examination because the bezoars were covered with debris in the stomach. Of the 9 patients, 8 had concomitant gastric ulcers, and the other patient had gastric lymphoma. Although a computed tomography (CT) scan was performed before the second-look endoscopy in 8 of the 9 patients, the bezoars were mistaken as food debris on CT findings and were overlooked in these patients. In conclusion, gastric bezoars may not be discovered during the initial esophagogastroduodenoscopy and CT scan. In cases with debris in the stomach, second-look endoscopy is essential to detect bezoars.

Feasibility of a novel colonoscope with extra-wide angle of view: a clinical study.

BACKGROUND AND STUDY AIMS: Lesions may be missed during colonoscopy because of anatomical features such as mucosal folds. This feasibility study assessed the safety and efficacy of a novel colonoscope with extra-wide angle of view, which provides a simultaneous lateral-backward view to complement the forward view. PATIENTS AND METHODS: Consecutive patients undergoing colonoscopy using the prototype colonoscope were enrolled in this multicenter, single-arm study. The number of adverse events, and the first detection of adenomas during withdrawal by the lateral-backward view and the forward view were evaluated. RESULTS: A total of 47 patients underwent colonoscopy examination to the cecum. The mean insertion and withdrawal times were 6.4 ±â€Š4.9 minutes and 8.6 ±â€Š4.2 minutes, respectively. Of 47 detected polyps, 28 adenomatous polyps were found (mean size 3.3 ±â€Š3.1 mm). A total of 29 polyps (61.7 %) and 16 adenomatous polyps (57.1 %) were first detected with the lateral-backward view. The lateral-backward view first detected 5/6 adenomatous polyps (83.3 %) in the ascending colon and all (2/2) adenomatous polyps in the sigmoid colon. No adverse events occurred during the study. CONCLUSIONS: This exploratory study suggested that a novel colonoscope with extra-wide angle of view is safe and feasible, and has the potential to improve colorectal adenoma detection. TRIAL REGISTER: UMIN000016450.

Predictive factors for technically difficult endoscopic submucosal dissection in the colorectum.

BACKGROUND AND STUDY AIMS: Because of technical difficulty, colorectal endoscopic submucosal dissection (CR-ESD) is not widely performed. We aimed to determine risk factors for such technical difficulty as defined by long procedure duration (≥  150 min), perforation, and piecemeal resection. PATIENTS AND METHODS: Patients with consecutive colorectal tumors treated with ESD between April 2006 and December 2010 were enrolled in a prospective cohort study. For prediction of technical difficulty, three types of factor were investigated: tumor location, tumor type, and colonoscopy-related. Cases were subsequently categorized into earlier and later periods (April 2006 - August 2008, 123 lesions; September 2008 - December 2010, 124 lesions). Variables were analyzed using multiple logistic regression, with subgroup analyses for each period. RESULTS: 247 lesions were analyzed. Flexure location was an independent risk factor for technical difficulty as measured by longer procedure duration (odds ratio [OR] 4.1, 95 % confidence interval [95 %CI] 1.1 - 14.9), piecemeal resection (4.7, 1.1 - 17.2), or perforation (8.8, 1.1 - 56.8). Tumor with scarring or locally recurrent was a risk factor for longer procedure duration (4.7, 1.7 - 13.7), and for piecemeal resection (7.8, 2.4 - 25.0). Tumor of size  ≥  50 mm or spreading across ≥  2 folds was the strongest independent risk factor for longer duration (6.3, 2.8 - 15.4), and was an independent risk factor for longer duration in both time periods (earlier, 3.3, 1.1 - 10.4; later, 27.4, 7.4 - 138.0). Flexure location was an independent risk factor for perforation (13.9, 1.5 - 129.1) and for piecemeal resection (5.1, 0.9 - 25.2) in the earlier but not the later period. CONCLUSIONS: Factors predicting technical difficulty of CR-ESDs were clarified. Their importance was influenced by the increasing experience of the endoscopist.

Cap-fitted ultrathin endoscope-assisted endoscopic retrograde cholangiopancreatography (ERCP) for patients with hidden papillae in duodenal diverticula.

Hayashi and colleagues developed a novel salvage technique using a cap-fitted ultrathin endoscope to cannulate the bile duct when a papilla concealed within a duodenal diverticulum is inaccessible with conventional methods. It can be a useful and safe option for endoscopic retrograde cholangiopancreatography in patients with papillae hidden in duodenal diverticula.

Proton-Pump Inhibitors and Risk of Bloodstream Infection without an Identifiable Source: a Hospital-Based Case-Control Study.

The association between proton-pump inhibitor (PPI) use and systemic infections caused by bacterial translocation is unclear. This study aimed to investigate whether patients receiving PPI therapy have a higher risk of bloodstream infections (BSI) without an identifiable source of infection. We conducted a hospital-based case-control study which enrolled all patients aged 20 years and older who were hospitalized in Ichinomiya Nishi Hospital with BSI confirmed by two sets of positive blood cultures in 2019. Patient data were collected from medical records, and the bacterial translocation-type (BT-type) BSI group was defined as patients with BSI without an identifiable source of infection, whereas those with a BSI from an identifiable source were assigned to the control group based on the diagnostic criteria for each infectious disease. Data from 309 patients, including 66 cases and 243 controls, were analyzed. Compared with PPI non-users, PPI users had a 2.4-fold higher risk of developing BT-type BSI after controlling for potential confounders (adjusted odds ratio: 2.41, 95% confidence interval: 1.29-4.51, P = 0.006). In conclusion, PPI use is associated with a higher risk of BSI without an identifiable source; therefore, PPI use might increase the risk of BSI secondary to bacterial translocation.

A novel extra-wide-angle-view colonoscope: a simulated pilot study using anatomic colorectal models.

BACKGROUND: A major factor that may contribute to a higher adenoma miss rate during colonoscopy is undetected lesions located behind haustral folds, flexures, or rectal valves. OBJECTIVE: To assess the efficacy of a prototype, novel, extra-wide-angle-view colonoscope that provides a simultaneous lateral-backward view that complements the forward view lens. DESIGN: A simulated pilot study of two anatomic colorectal models, each prepared with 8 polyps positioned in obvious locations and 8 polyps placed behind folds. Thirty-two endoscopists with different levels of experience performed examinations on models in a random order by using the extra-wide-angle-view colonoscope and a standard colonoscope. MAIN OUTCOME MEASUREMENTS: The detection rates of simulated polyps. RESULTS: The mean detection rate for all simulated polyps with the extra-wide-angle-view colonoscope was significantly higher than that with the standard colonoscope (68% vs 51%; P < .0001). The detection rate for polyps behind folds was significantly higher in the extra-wide-angle-view colonoscope than in the standard colonoscope (61.7% vs 46.9%; P = .0009). LIMITATIONS: Not a clinical study. CONCLUSION: The novel, extra-wide-angle-view colonoscope may represent an advancement in colorectal polyp detection. The value of the colonoscope for clinical use awaits further study.

[A case of diversion colitis successfully treated with 5-aminosalicylic acid].

An 84-year-old man was admitted to our hospital because of blood in the stool. He had previously undergone a subtotal colectomy and ileostomy with a mucous fistula of the sigmoid colon because of a large bowel hemorrhage of unknown origin. Five years later, a minor hemorrhage developed in the remnant rectum. The clinical history, colonoscopic findings, and the histology of the diverted colon specimens were suggestive of diversion colitis. Treatment was initiated with short-chain fatty acid enema, but slight blood loss through the stool continued;thus, the patient was administered 5-aminosalicylic acid (5-ASA) enema. Subsequently, his symptoms and endoscopic findings improved. 5-ASA enema appears to be both safe and effective in the treatment of diversion colitis following intestinal tract surgery.

[Classification of the bleeding pattern in colonic diverticulum is useful to predict the risk of bleeding or re-bleeding after endoscopic treatment].

We examined the re-bleeding rate after endoscopic hemostasis according to the bleeding pattern in patients with an acute lower gastrointestinal hemorrhage from colonic diverticula in 34 patients with active bleeding (Type 1) and 49 patients with exposed vessels and/or erosions in the base of diverticulum and no active bleeding (Type 2). Endoscopic hemostasis was performed by clipping the exposed vessel or erosions (direct method) or the entire diverticular orifice (reefing method). The incidence of re-bleeding was significantly higher in the Type 1 group than in the Type 2 group (p=0.002). All Type 1 cases were treated by the reefing method. In contrast, 14 of the 49 Type 2 cases were treated by the direct method, and no re-bleeding was observed in these cases. Of the other 35 Type 2 cases treated by reafing, rebleeding was seen in 5 cases. More effective endoscopic treatment is needed to prevent early re-bleeding, especially for Type 1 patients. The direct method may therefore reduce the rate of re-bleeding in Type 2 patients.

Analysis of K-ras, BRAF, and PIK3CA mutations in laterally-spreading tumors of the colorectum.

BACKGROUND AND AIMS: Laterally-spreading tumors (LST) are a newly-recognized category of colorectal neoplasia, and are defined as lesions larger than 10 mm in diameter and extending circumferentially rather than vertically. However, genetic features of this new category of tumors are not fully elucidated. The aim of this study was to evaluate genetic alterations in LST. METHODS: We examined K-ras, BRAF, and phosphoinositide-3-kinase catalytic-α polypeptide (PIK3CA) mutations in 101 LST, including 68 LST-granular type (LST-G) and 33 LST-non-granular type by direct sequencing. As controls, we examined these gene mutations in 66 protruded colon adenomas (10 mm or larger) and 44 advanced colon cancers. RESULTS: K-ras, BRAF, and PIK3CA mutations were observed in 59 (58%), zero (0%), and three (3%) LST, respectively. LST-G morphology in the right-sided colon was significantly correlated with the existence of K-ras mutations, whereas a size of 20 mm or larger was the only predictor of mutations in the left-sided colorectum. The frequency of K-ras mutations in LST was particularly marked in the left-sided colorectum compared to protruded adenomas or advanced cancers (LST vs protruded adenomas, P < 0.001; LST vs advanced cancers, P = 0.002), whereas in the right-sided colon, K-ras mutations were equally frequent. PIK3CA mutations were not familiar in either LST (3%) or advanced cancers (9%). CONCLUSIONS: K-ras mutations were involved in colorectal LST in different manners according to tumor location.

Colorectal endoscopic submucosal dissection for elderly patients at least 80 years of age.

BACKGROUND: Endoscopic submucosal dissection (ESD) has been used recently for successful en bloc resection of even large lesions, although no consensus appears in medical literature concerning its application to elderly patients. This prospective cohort study aimed to evaluate the efficacy and safety of colorectal ESD for patients 80 years of age or older. METHODS: Colorectal ESD procedure findings were compared with clinical outcomes, including associated complications and mortalities, for two age groups totaling 196 consecutive patients with 202 colorectal lesions. Of the 196 patients, 31 patients (16%) were 80 years of age or older (group E), and 165 patients (84%) were younger than 80 years (group Y). RESULTS: The median ages were 82 years in group E and 68 years in group Y. The frequency of chronic concomitant diseases was significantly higher in group E (65%) than in group Y (27%) (p = 0.003). No significant pressure decrease or need for oxygenation was observed in either group. In addition, groups E and Y did not differ significantly in terms of mean lesion sizes (40.9 vs. 39.7 mm) en bloc resection rates (84% vs. 93%), curative rates (78% vs. 84%), median procedure times (65 vs. 70 min), or associated complications (no perforation or delayed bleeding cases [0%] vs. 5 perforations [3%]) The median postprocedure hospitalization period was 3 days in both groups. Except for 10 cases requiring subsequent lymph node dissection surgery, follow-up colonoscopy examinations showed no recurrences or ESD-related mortalities in either group. CONCLUSION: Colorectal ESD is a safe and effective treatment for elderly patients (age ≥ 80 years) despite a significantly higher frequency of chronic concomitant diseases than among younger patients.