Submucosal Injection Using Epinephrine-Added Saline in Cold Snare Polypectomy for Colorectal Polyps Shortens Time Required for Resection: A Randomized Controlled Study.

AIMS: Immediate bleeding after cold snare polypectomy (CSP) for colorectal polyps might interfere with confirmation of residuals and prolong the time required for resection. We investigated whether submucosal epinephrine-added saline injection reduces the time required for the CSP procedure. METHODS: We conducted a single-center, prospective, randomized controlled trial (clinical trial registration number: UMIN000046770). Patients with colorectal polyps ≤ 10 mm were randomly allocated to either CSP with epinephrine-added submucosal injection (CEMR group) or conventional CSP (CSP group). The primary outcome was the time required for resection defined as the time from the initiation of resection (the first insertion of the snare in the CSP group or the injection needle in the CEMR group) to the end of resection (confirming complete resection endoscopically after recognizing the cessation of immediate bleeding) in each lesion, and the secondary outcome was the time to spontaneous cessation of immediate bleeding after resection defined as the time from ensnaring the lesion to confirming the spontaneous cessation of immediate bleeding. RESULTS: A total of 126 patients were randomly assigned. Finally, 261 lesions in 118 patients (CEMR group, n = 59; CSP group, n = 59) were analyzed. The time required for resection calculated using the least-square mean was significantly shorter in the CEMR group (106.3 s, 95% CI 97.5 to 115.4 s) than in the CSP group (130.9 s, 95% CI 121.2 to 140.7 s) (P < 0.001). The time to spontaneous cessation of immediate bleeding was also significantly shorter in the CEMR group (20.4 s, 95% CI 14.3 to 26.5 s) than in the CSP group (74.2 s, 95% CI 67.6 to 80.7 s) (P < 0.001). Neither group had cases requiring hemostasis, perforation, or delayed bleeding. CONCLUSIONS: CEMR shortened the time for resection by shortening the time to cessation of immediate bleeding compared with conventional CSP in colorectal polyps ≤ 10 mm.

Management of colorectal high-grade dysplasia or cancer resected by cold snare polypectomy: a multicenter exploratory study.

BACKGROUND: The clinical course and surveillance strategy for patients who undergo cold snare polypectomy (CSP) for high-grade dysplasia (HGD) or cancer is unclear. We investigated the management of colorectal HGDs and cancers following CSP. METHODS: This Japanese nationwide multicenter exploratory study was retrospectively conducted on patients who had undergone CSP for colorectal HGDs or cancers and follow-up colonoscopy at least once from 2014 to 2020. We investigated the detection rate of CSP scars, local recurrence rate (LRR), risk factors for local recurrence, and follow-up strategy. This study was registered with the University Hospital Medical Information Network (UMIN) Clinical Trials Registry (UMIN000043670). RESULTS: We included 155 patients with 156 lesions. CSP scars were identified in 22 (31.4%), 41 (54.7%), and 10 (90.9%) patients with curative, borderline, and non-curative resection, respectively. Among them, residual tumors were observed in one (4.5%), six (14.6%), and three (30.0%) cases, respectively. The total LRR was 13.7% (95% confidence interval: 6.8-23.8). R1 resection cases (either horizontal or vertical margins positive for tumors) were associated with local recurrence (p = 0.031). Salvage endoscopic and surgical resections were performed on 21 and 10 patients, respectively. Among them, the proportion of endoscopically suspected residual tumors was significantly higher (p < 0.001) in the residual tumor-positive group (100%) than in the residual tumor-negative group (28.6%). CONCLUSIONS: LRR after CSP for HGDs or cancers was 13.7% based on scar-identified cases. Salvage endoscopic or surgical resection should be performed according to the curability of the lesion and endoscopic findings during colonoscopic surveillance.

Randomized controlled trial comparing conventional and traction endoscopic submucosal dissection for early colon tumor (CONNECT-C trial).

OBJECTIVES: Endoscopic submucosal dissection (ESD) is a widely used treatment for early gastrointestinal cancer. However, colon ESD remains challenging. Previous studies on colon ESD using the traction method used a small sample, single-center design, providing insufficient evidence of this procedure's efficacy. We thus aimed to investigate the efficacy and safety of the traction method in colon ESD in this multicenter randomized trial. METHODS: We conducted a prospective, multicenter, randomized, two-arm controlled trial at 10 facilities in Japan. A 1:1 allocation was conducted for the conventional ESD (C-ESD) and traction ESD (T-ESD) groups. The primary end-point was ESD procedure time. RESULTS: We included 128 C-ESD and 123 T-ESD cases from April 2020 to August 2021. The median procedure times for C-ESD and T-ESD were 61 (40-100) and 53 (40-76) min (P = 0.18), respectively, and no significant differences were observed between the groups. Subgroup analysis showed that the median procedure times for patients with a lesion diameter of ≥30 mm in the C-ESD and T-ESD groups were 89 (57-80) and 69 (50-104) min (P = 0.05), respectively, and for nonexpert operators were 81 (62-120) and 64 (52-109) min (P = 0.07), respectively. CONCLUSIONS: The traction method did not contribute to a significantly shortened ESD procedure time. However, this method may be useful when the tumor diameter is large or if the procedure is conducted by nonexpert endoscopists.

Small intestinal bleeding and stricture caused by Meckel's diverticulum.

A 44-year-old man presented to our hospital with lower gastrointestinal bleeding. We performed balloon-assisted enteroscopy, which revealed diverticulum and stricture at the ileum. The patient underwent segmental small bowel resection and diagnosed with Meckel's diverticulum. We should keep in mind the possibility of intestinal stricture due to Meckel's diverticulum.

Risk Factors Indicating Difficulty During Gastric Endoscopic Submucosal Dissection for Inexperienced Endoscopists: A Retrospective Study.

AIM: Factors that may make endoscopic submucosal dissection (ESD) difficult for operators have been evaluated according to results based on the performance of experienced endoscopists. This study aimed to verify the predictors of difficult gastric ESD for ESD beginners. METHODS: From January 2015 to December 2021, 466 superficial gastric neoplasms were treated with ESD at Showa University Hospital. Excluding 103 lesions that performed ESD by experts who experienced more than 80 ESDs, a total of 363 lesions were included. The lesions were divided into two groups according to the ESD performance experience of the operator: ESD beginner (EB; ESD experience≤30 cases) and ESD intermediate (EI; ESD experience 31-80 cases) groups. Relationships between difficult ESD (having at least one of the following: procedure time>60 min, incomplete resection, change of operator, and occurrence of severe complications) and clinicopathological findings of the lesion were analyzed. RESULTS: The complete resection rates and the difficult ESD rates in the EB and EI groups were 99.3%, 94.8%, and 61.2%, 50.7%, respectively. In the EB group, univariate analysis showed that difficult ESD rate was significantly higher in the non-lower third lesions, the lesser curvature lesions, and cancerous lesions. In the EI group, univariate analysis showed that difficult ESD rate was significantly higher in lesion with ≥20 mm size, lesser curvature lesions, lesions with ulcers, and submucosal cancers. Multivariate analysis showed that the lesser curvature location and cancerous histology in the EB group and ≥20 mm lesion size, the lesser curvature location and submucosal invasion in the EI group were independent predictors of difficult ESD. CONCLUSIONS: The lesser curvature location is recognized as independent ESD difficulty factor for both beginners and intermediates. Cases with lesions located in the lesser curvature should not be selected for gastric ESD training by beginners.

Reduced Intravenous Fluorescein Dose for Upper and Lower Gastrointestinal Tract Probe-Based Confocal Laser Endomicroscopy.

BACKGROUND/AIMS: Probe-based confocal laser endomicroscopy (pCLE) requires the administration of intravenous (IV) fluorescein. This study aimed to determine the optimal dose of IV fluorescein for both upper and lower gastrointestinal (GI) tract pCLE. METHODS: Patients 20 to 79 years old with gastric high-grade dysplasia (HGD) or colorectal neoplasms (CRNs) were enrolled in the study. The dose de-escalation method was employed with five levels. The primary endpoint of the study was the determination of the optimal dose of IV fluorescein for pCLE of the GI tract. The reduced dose was determined based on off-line reviews by three endoscopists. An insufficient dose of fluorescein was defined as the dose of fluorescein with which the pCLE images were not deemed to be visible. If all three endoscopists determined that the tissue structure was visible, the doses were de-escalated. RESULTS: A total of 12 patients with gastric HGD and 12 patients with CRNs were enrolled in the study. Doses were de-escalated to 0.5 mg/kg of fluorescein for both non-neoplastic duodenal and colorectal mucosa. All gastric HGD or CRNs were visible with pCLE with IV fluorescein at 0.5 mg/kg. CONCLUSION: In the present study, pCLE with IV fluorescein 0.5 mg/kg was adequate to visualize the magnified structure of both the upper and lower GI tract.

Case of Colorectal Cancer After Cold Snare Polypectomy Successfully Salvaged on Endoscopic Submucosal Dissection.

Cold snare polypectomy is a well-established method for the resection of colorectal polyps measuring less than 10 mm in size. It may be performed in patients with early colorectal cancers because of the difficulty of endoscopic diagnosis. However, the therapeutic effect of cold snare polypectomy on cancers is unknown, and the need for appropriate surveillance and additional treatment for these patients remains to be fulfilled. Endoscopic submucosal dissection has been reported as a safe and effective method for treating recurrent or residual colorectal neoplasia following hot endoscopic mucosal resection. This report is of a case of a colorectal tumor measuring 8 mm that was treated using cold snare polypectomy and resulted in residual cancer. Endoscopic submucosal dissection was selected as salvage treatment for the residual lesion, and histopathological examination revealed free horizontal and vertical margins. We believe that performing endoscopic submucosal dissection at the site of the cancer resected with cold snare polypectomy ensured that there was no residual cancer left. It may be hypothesized that endoscopic submucosal dissection could evolve as the treatment of choice for patients with colorectal cancer after cold snare polypectomy.

Successful Management of Pharyngeal Perforation Caused by Overtube Insertion During Endoscopic Submucosal Dissection.

A woman in her 70s underwent endoscopic submucosal dissection (ESD) for gastric-type adenoma in the anterior wall of the upper gastric body with intravenous anesthesia. We decided to use an overtube to control the air volume in the stomach. The overtube was inserted under endoscopic guidance using a sufficient amount of lubricating jelly. We encountered resistance when the top of the overtube was advanced to the pharynx; therefore, we stopped the overtube insertion and pulled the tube out immediately. We observed a linear injury in the posterior wall of the hypopharynx. The injury was deep and diagnosed as a pharyngeal perforation. Computed tomography (CT) revealed free air in the neck, with mediastinal emphysema. Conservative treatment was initiated after consultation with the otorhinolaryngologist; the patient received nothing per mouth and was administered intravenous antibiotics. The patient did not develop a fever and no signs of inflammation were observed. CT performed on postoperative day (POD) 5 revealed the disappearance of the mediastinal emphysema and a soft diet was introduced. The patient was discharged on POD 7. The ESD was postponed to two months later and was performed successfully. The scar of the perforation site was confirmed. In this report, we describe an extremely rare adverse event associated with overtube insertion. Although the incidence of pharyngeal perforation is low and its management is controversial, it was done without surgical intervention in the present case.

The Diagnostic Performance for Colorectal Neoplasms Using Magnified Endoscopy Differs between Experts and Novice Endoscopists: A Post Hoc Analysis.

INTRODUCTION: Magnified endoscopy is difficult for novice endoscopists because it requires both knowledge and skill of endoscopic diagnosis. The aim of this study was to examine the diagnostic performance of novice endoscopists on determining the invasive depth of colorectal neoplasms and compare it with that of experts. METHODS: The present study was conducted as a post hoc analysis. Thirty expert and 30 novice endoscopists who use magnifying endoscopy (narrow-band imaging [NBI] and pit pattern analysis) were recruited for the online survey. Novice endoscopist was defined as one who has <5 years of experience in magnifying endoscopy. Three outcomes were assessed: (a) diagnostic accuracy of both novice and expert endoscopists in determining the depth of invasion; (b) additional diagnostic accuracy of novice endoscopists in determining the depth of invasion with magnifying NBI or pit pattern compared with nonmagnifying white light imaging (WLI); (c) difference in confidence on diagnosis among each modality between novice and expert endoscopists. RESULTS: The area under the curve (AUC) of expert endoscopists was significantly higher than that of novice endoscopists. The AUC of the pit pattern was significantly higher than that of WLI regardless of lesion characteristics as determined by novice endoscopists. The proportion of answers with high confidence was significantly higher with expert endoscopists than with novice endoscopists. CONCLUSIONS: Aside from learning basic diagnosis of colorectal neoplasms, magnifying endoscopy may have substantial clinical benefit for novice endoscopists.

Capsule Endoscopy after Hematopoietic Stem Cell Transplantation Can Predict Transplant-Related Mortality.

BACKGROUND AND OBJECTIVES: Allogenic hematopoietic stem cell transplantation (allo-SCT) is a curative therapy for hematological malignancies, but transplant-related mortality (TRM) remains a concern. This study aimed to determine the efficacy of capsule endoscopy (CE) by evaluating the correlation between inflammatory findings on CE and TRM. METHODS: The data of patients after allo-SCT were retrospectively collected. The association between findings on CE and TRM at 100 days from the CE was evaluated. RESULTS: Of the 94 patients included in the study, 47 showed inflammatory findings on CE. The findings were diagnosed as graft-versus-host disease (GVHD; n = 17), cytomegalovirus (CMV) infection (n = 14), and GVHD with CMV infection (n = 16). Of the 47 patients, 13 (28%) had TRM. Endoscopic diagnoses of these TRM cases were GVHD (n = 4), CMV infection (n = 0), and GVHD with CMV infection (n = 9). In contrast, in the remaining 47 patients who showed no inflammatory findings on CE, 2 patients (4%) had TRM. The proportion of TRM was higher in patients with inflammatory findings than in those without it (28 vs. 4%, p < 0.01). CONCLUSIONS: CE may predict TRM in patients who developed gastrointestinal symptoms after allo-SCT.

Newly-developed colonoscope (PCF-PQ260L) is useful for patients with difficult colons.

BACKGROUND/AIMS: Preforming total colonoscopy (TCS) is sometimes difficult due to adhesions or long colons. The PCF-PQ260L (PQL) was developed to overcome TCS-related difficulties. The aim of this study was to investigate the performance and usefulness of PQL for difficult colon cases. MATERIALS AND METHODS: This was a retrospective single center observational cohort study investigating differences in patient characteristics and examination performance between patients examined with PQL, versus standard (SD), scopes. Secondly, we directly compared PQL and SD scopes in patients treated with both types of scope. RESULTS: The PQL was used with 105 patients and SD scopes were used with 1119 patients. Patients in the PQL group were significantly shorter (157cm vs 163cm, p< 0.01) and lighter, compared to the SD group (52 kg vs 58 kg, p< 0.01). There were no significant statistical differences with regard to cecal intubation rate, cecal intubation time, and adenoma detection. Direct comparison of use of PQL and SD scopes on the same patients revealed shorter average cecal intubation time (7 min vs 10 min, p< 0.01), and significantly increased numbers of patients reporting no pain (66 % vs 20 %, p< 0.01) and needing no sedative drugs (48% vs 25 %, p< 0.01) associated with PQL use. CONCLUSION: The examination performance of the PQL scope was similar to the SD scope. The PQL may be a good option for patients who with difficult colons.

Efficacy of linked colour imaging in magnifying chromoendoscopy with crystal violet staining: a pilot study.

PURPOSE: Diagnosis of the depth of invasion is crucial in the endoscopic management of early colorectal cancer. Image-enhanced endoscopy (IEE) is a method for easily evaluating the depth of invasion. Linked colour imaging (LCI) is an IEE method that enables clearer identification of neoplastic lesions and mucosal inflammation. The aim of this experimental study was to explore the efficacy of LCI in vessel and pit pattern recognition when used in magnifying chromoendoscopy with crystal violet staining for superficial colorectal neoplasms. METHODS: This was an experimental study. Colour difference (CD) values between the surrounding mucosa and vessels and pits were measured on white light (WLI), blue laser (BLI), and LCI images. The CD values of 10 neoplastic lesions were calculated and compared between WLI and the other techniques. RESULTS: The CD value was 9.8 (interquartile range, 7.3-12.4) for WLI, 9.7 (6.7-13.4) for LCI, and 6.8 (5.1-9.3) for BLI. The CD value was statistically different between WLI and BLI but not between WLI and LCI. With regard to vessel description, the CD value was 7.5 (4.0-11.0) for WLI, 15.6 (11.6-23.9) for LCI, and 23.3 (15.8-30.4) for BLI. CONCLUSIONS: LCI provides more diagnostic information than other light modes. Further, it is superior to the other techniques in terms of vessel visibility and is comparable to them in terms of pit recognition. These unique features of LCI may lead to its use as an alternative to WLI and BLI for pit and vessel pattern evaluation in the future.

Feasibility of endoscopic resection using bipolar snare for nonampullary duodenal tumours in familial adenomatous polyposis patients.

The management of duodenal and colorectal tumours is important in patients with familial adenomatous polyposis (FAP). Endoscopic resection (ER) should be carefully performed because the risk of complications during or after (ER) of nonampullary duodenal tumours is higher than that of stomach or colorectal lesions in general. Thus, we evaluated the feasibility of endoscopic resection using bipolar snare (ERB) for nonampullary duodenal tumours in FAP patients. Eleven FAP patients who underwent ERB for nonampullary duodenal tumours at our hospital between October 2013 and December 2016 were retrospectively analysed based on clinicopathological features. ER was generally indicated for endoscopically diagnosed tumours > 20 mm, biopsy-confirmed high-grade dysplasia or carcinomas > 10 mm, and multiple tumours. Nineteen endoscopic treatments were performed and 134 nonampullary duodenal tumours were resected. The median patient age at initial treatment was 40 years (range 20-64), and median size of the largest tumour in each procedure was 16 mm (range 9-40). Of the 101 pathologically evaluated lesions, 10 tumours were high-grade tubular adenomas, 87 were low-grade tubular adenomas, 1 was an adenocarcinoma, and 3 were non-neoplastic mucosal polyps. No intraoperative or delayed perforations were observed. Melena was encountered in one patient and managed without emergent endoscopic intervention. ERB for nonampullary duodenal tumours of FAP patients is feasible and effective, even for large lesions with high-grade dysplasia. Long-term outcomes of ERB, including local recurrence and prognosis, should be monitored.

Predictive relevance of lymphovascular invasion in T1 colorectal cancer before endoscopic treatment.

BACKGROUND AND AIM: The depth of tumor invasion is currently the only reliable predictive risk factor for lymph node metastasis before endoscopic treatment for colorectal cancer. However, the most important factor to predict lymph node metastasis has been suggested to be lymphovascular invasion rather than the depth of invasion. Thus, the aim of this study was to investigate the predictive relevance of lymphovascular invasion before endoscopic treatment. METHODS: The data on pT1 colorectal cancers that were resected endoscopically or surgically from 2007 to 2015 were retrospectively reviewed. The cases were categorized into two groups: positive or negative for lymphovascular invasion. The following factors were evaluated by univariate and multivariate analyses: age and sex of the patients; location, size, and morphology of the lesion; and depth of invasion. RESULTS: The positive and negative groups included 229 and 457 cases, respectively. Younger age ( P  < 0.01), smaller lesion size ( P  = 0.01), non-LST (LST: laterally spreading tumor) ( P  < 0.01), presence of depression ( P  < 0.01), and pT1b ( P  < 0.01) were associated with lymphovascular invasion. In multivariate analysis, younger age (comparing patients aged ≤ 64 years with those aged > 65 years, OR, 1.81; 95 %CI, 1.29 - 2.53), presence of depression (OR, 1.97; CI, 1.40 - 2.77), non-LST features (OR, 1.50; CI, 1.04 - 2.15), and pT1b (OR, 3.08; CI, 1.91 - 4.97) were associated with lymphovascular invasion. CONCLUSION: Younger age, presence of depression, T1b, and non-LST are associated with lymphovascular invasion. Therefore, careful pathological diagnosis and surveillance are necessary for lesions demonstrating any of these four factors.

Depressed-type submucosal invasive colorectal cancer in a patient with Lynch syndrome diagnosed using short-interval colonoscopy.

Although regular colonoscopy surveillance is recommended for patients with Lynch syndrome (LS) who underwent partial colectomy, the appropriate interval has not been determined. We report a case of colorectal cancer (CRC) detected by short-interval surveillance colonoscopy (SC) in a patient with LS having a past history of partial colectomy. A 65-year-old man underwent sigmoidectomy for advanced CRC. His family history revealed that his two younger brothers had CRC in their twenties and thirties, respectively, and the patient met with the criteria in the Revised Bethesda Guidelines. After confirming the loss of MSH2 protein expression in the primary tumor, subsequent genetic testing showed germline mutation with a large deletion of exon 7-14 in the MSH2 gene, indicating a diagnosis of LS. After the diagnosis of LS, the patient underwent annual SC. Three years after the initial surgery, superficial submucosal invasive cancer was detected. Subsequently, SC after a 6-month interval revealed a deep submucosal invasive cancer (7 mm in diameter). Although additional surgery was recommended, considering his comorbidities, regular SC rather than colectomy was selected. Even shorter-interval SC carried out within a year is not sufficient to detect endoscopically resectable tumors in some high-risk LS cases.

Successful endoscopic closure of a colonic perforation one day after endoscopic mucosal resection of a lesion in the transverse colon.

A 73-year-old man underwent endoscopic mucosal resection (EMR) of a 20-mm flat elevated lesion on the transverse colon. The morning after the procedure, he started to have severe right upper quadrant pain after his first meal. A computed tomography scan revealed free air and a stomach filled with food. He was diagnosed to have delayed post-EMR intestinal perforation. He underwent emergent colonoscopy and clipping of the perforated site. He was discharged 8 d after the endoscopic closure without the need for surgical intervention. The meal was not the cause of the colon transversum perforation.

STEC:O111-HUS complicated by acute encephalopathy in a young girl was successfully treated with a set of hemodiafiltration, steroid pulse, and soluble thrombomodulin under plasma exchange.

We report a 14-year-old girl, who developed shigatoxin-producing E. coli (STEC)-HUS complicated by encephalopathy. She was successfully treated with hemodiafiltration, high-dose methylprednisolone pulse therapy, and soluble recombinant thrombomodulin under plasma exchange. von Willebrand factor multimers analysis provides potential insights into how the administered therapies might facilitate successful treatment of STEC-HUS.