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We aimed to determine the optimal timing of colonoscopy and factors that benefit patients who undergo early colonoscopy for acute lower GI bleeding.We identified 10,342 patients with acute hematochezia (CODE BLUE-J study) admitted to 49 hospitals in Japan. Of these, 6270 patients who underwent a colonoscopy within 120 hours were included in this study. The inverse probability of treatment weighting method was used to adjust for baseline characteristics among early (≤24 hours, n = 4133), elective (24-48 hours, n = 1137), and late (48-120 hours, n = 1000) colonoscopy. The average treatment effect was evaluated for outcomes. The primary outcome was 30-day rebleeding rate.The early group had a significantly higher rate of stigmata of recent hemorrhage (SRH) identification and a shorter length of stay than the elective and late groups. However, the 30-day rebleeding rate was significantly higher in the early group than in the elective and late groups. Interventional radiology (IVR) or surgery requirement and 30-day mortality did not significantly differ among groups. The interaction with heterogeneity of effects was observed between early and late colonoscopy and shock index (shock index 1, odds ratio [OR], 2.097; shock index ≥1, OR, 1.095; P for interaction = .038) and performance status (0-2, OR, 2.481; ≥3, OR, .458; P for interaction = .022) for 30-day rebleeding. Early colonoscopy had a significantly lower IVR or surgery requirement in the shock index ≥1 cohort (OR, .267; 95% confidence interval, .099-.721) compared with late colonoscopy.Early colonoscopy increased the rate of SRH identification and shortened the length of stay but involved an increased risk of rebleeding and did not improve mortality and IVR or surgery requirement. Early colonoscopy particularly benefited patients with a shock index ≥1 or performance status ≥3 at presentation.

Treatment strategies for colonic diverticular bleeding (CDB) based on stigmata of recent hemorrhage (SRH) remain unstandardized, and no large studies have evaluated their effectiveness. We sought to identify the best strategy among combinations of SRH identification and endoscopic treatment strategies.We retrospectively analyzed 5823 CDB patients who underwent colonoscopy at 49 hospitals throughout Japan (CODE-BLUE J-Study). Three strategies were compared: find SRH (definitive CDB) and treat endoscopically, find SRH (definitive CDB) and treat conservatively, and without finding SRH (presumptive CDB) treat conservatively. In conducting pairwise comparisons of outcomes in these groups, we used propensity score-matching analysis to balance baseline characteristics between the groups being compared.Both early and late recurrent bleeding rates were significantly lower in patients with definitive CDB treated endoscopically than in those with presumptive CDB treated conservatively (30 days, 19.6% vs 26.0% [P .001]; 365 days, 33.7% vs 41.6% [P .001], respectively). In patients with definitive CDB, the early recurrent bleeding rate was significantly lower in those treated endoscopically than in those treated conservatively (17.4% vs 26.7% [P = .038] for a single test of hypothesis; however, correction for multiple testing of data removed this significance). The late recurrent bleeding rate was also lower, but not significantly, in those treated endoscopically (32.0% vs 36.1%, P = .426). Definitive CDB treated endoscopically showed significantly lower early and late recurrent bleeding rates than when treated conservatively in cases of SRH with active bleeding, nonactive bleeding, and in the right-sided colon but not left-sided colon.Treating definitive CDB endoscopically was most effective in reducing recurrent bleeding over the short and long term, compared with not treating definitive CDB or presumptive CDB. Physicians should endeavor to find and treat SRH for suspected CDB.

Background and Aims The number of colorectal endoscopic submucosal dissections (ESDs) for early colorectal cancer is expected to increase in the future; therefore, cost reduction is a clinically important issue. The SOUTEN snare (Kaneka Medics, Tokyo, Japan) is a novel multifunctional snare developed for hybrid ESD at a low price. If ESD can be performed safely using the SOUTEN snare, the same therapeutic effect can be obtained as with conventional ESD at a lower cost. The aim of this prospective, pilot, clinical feasibility study was to evaluate the safety and efficacy of ESD using the SOUTEN snare (SOUTEN-ESD). Methods From October 2018 to January 2019, 119 consecutive patients (121 ESD procedures, 137 colorectal neoplasms) were prospectively enrolled and treated by SOUTEN-ESD at NTT Medical Center Tokyo and Omori Red Cross Hospital. The outcomes of SOUTEN-ESD were evaluated. Results Among 137 neoplasms, SOUTEN-ESD was completed in all cases. No cases required conversion to hybrid ESD or to a dedicated ESD device. The mean procedure time was 26.1 ± 14.3 minutes. Both the en-bloc resection rate and R0 resection rate were 100%. The rate of perforation was 0%, the rate of delayed bleeding was 2.2%, and the rate of post-ESD coagulation syndrome was 2.9%. Conclusions SOUTEN-ESD was safe and had good outcomes. Although further studies are required to examine indications for SOUTEN-ESD and confirm the results of this study, effective ESD with this novel knife is feasible. The SOUTEN snare is a realistic option for colorectal ESD. (Clinical trial registration number: UMIN 000034299.)

GI peristalsis during GI endoscopy commonly requires intravenous or intramuscular injection of antispasmodic agents, which sometimes cause unexpected adverse reactions.Our ultimate goal was to evaluate whether the antiperistaltic effect of L-menthol-based preparations facilitates endoscopic examinations in a clinical setting.Multicenter, randomized, double-blind, placebo-controlled study.Six Japanese referral centers.A total of 87 patients scheduled to undergo upper GI endoscopy were randomly assigned to receive 160 mg of L-menthol (n=45) or placebo (n=42). Both treatments were sprayed endoscopically on the gastric mucosa. The degree of gastric peristalsis was assessed by an independent committee.The proportion of subjects with no peristalsis 90 to 135 seconds after administration and at the end of the endoscopic examination (complete suppression of gastric peristalsis). Other outcomes were the proportion of subjects with no or mild peristalsis (adequate suppression of gastric peristalsis) and the ease of intragastric observation as evaluated by the endoscopist who performed the procedure.Gastric peristalsis was completely suppressed in 35.6% (21.9, 51.2) of the L-menthol group compared with only 7.1% (1.5, 19.5) of the placebo group (P.001). In the L-menthol group, 77.8% (62.9, 88.8) (35/45 subjects) of the subjects had no or mild peristalsis at the completion of endoscopy. Minor peristalsis interfered with intragastric examination in only 1 of these 35 patients (2.9%). The incidence of adverse events did not differ significantly between the groups (P=.512).Small sample size.During upper GI endoscopy, L-menthol sprayed on the gastric mucosa significantly suppresses peristalsis with minimal adverse drug reactions compared with placebo. (NCT00742599.).

Background Colorectal endoscopic submucosal dissection (ESD) has made it possible to resect large specimens in an en bloc fashion. However, this can lead to postoperative adverse events, such as perforation and bleeding. Prevention of adverse events after colorectal ESD is therefore an important goal. Objective To evaluate the utility of a shielding method using polyglycolic acid (PGA) sheets and fibrin glue to manage ulcers after colorectal ESD. Design Prospective, single-arm, pilot study. Setting Single tertiary care center for colorectal ESD in Japan. Patients Ten patients with 10 colorectal tumors scheduled for ESD were enrolled between September and November 2012. Interventions Just after ESD, we placed PGA sheets on the mucosal defect with biopsy forceps. After the whole defect was covered, we sprayed fibrin glue through a special double-lumen spraying tube. We sprayed fibrinogen through 1 lumen and then thrombin through the other lumen. Main Outcome Measurements Success rate, mean procedure time, and adverse events associated with the covering technique and the persistence of PGA sheets at follow-up colonoscopy. Results All 10 tumors were successfully resected. Mean tumor size was 39.7 ± 15.2 mm. All mucosal defects were successfully covered with PGA sheets. Mean procedure time was 18.7 ± 15.9 minutes. No procedure-related adverse events occurred. Upon colonoscopy 9 to 12 days after ESD, the PGA sheets were still fixed on the whole defect in 8 patients. Limitations Small sample size. Conclusions Our technique, which uses PGA sheets and fibrin glue, appears to shield mucosal defects, and it may be effective in reducing postoperative adverse events.

Background Several articles have reported the usefulness of large-balloon dilation after endoscopic sphincterotomy in removing bile duct stones. Its histological effect on the duodenal papilla and the lower bile duct, however, is not well established. Objective To elucidate the histological consequence of large-balloon dilation. Design Animal experiment. Setting A referral center. Materials and Interventions After the evaluation of normal anatomy of the major duodenal papilla and the lower bile duct in resected specimens from pigs, large-balloon dilation (12-20 mm) after small sphincterotomy was performed, and serial tissue sections were assessed for morphological changes. Main Outcome Measurements Macroscopic and microscopic findings of the duodenal papilla and the lower bile duct after large balloon dilation, with special interest in ductal wall disruption and perforation. Results The porcine specimens were comparable in size to humans. Balloons with diameters 12 mm or larger caused disruption of the ductal walls, and those 15 mm or larger resulted in perforation of the surrounding adipose tissue. The frequency of disruption and perforation increased in proportion to the balloon diameters. Limitations Other sequelae including hemorrhage, pancreatitis, acute inflammatory changes, and late fibrosis could not be investigated in our ex vivo porcine model. Conclusions Dilation with large balloons can tear the bile duct wall and cause potential impairment of sphincter function and overdilation of small extrahepatic bile ducts.

Background Endoscopic mucosal resection with a cap-fitted panendoscope (EMRC) such as a soft prelooped hood is a useful, effective, and safe technique. One problem with this method is that the lesion cannot always be maintained in the center of the cap because the procedure is performed blindly after aspiration. Objective We developed a 2-channel prelooped hood that facilitates EMRC while simultaneously allowing both grip of the center in the lesion and irrigation of the aspiration site and evaluated the usefulness of this end hood for early gastric cancer. Design Retrospective study. Setting Between August 2003 and October 2004, patients underwent our novel EMR. Patients Twelve cases of early gastric cancer. Interventions Two side holes were fabricated by drilling in the cap portion of a conventional soft prelooped hood, and then the irrigation tube and the accessory channel tube were glued to the exterior surface of the holes. We placed the fabricated transparent hood at the tip of the endoscope and performed grasping forceps–assisted endoscopic aspiration mucosectomy. Main Outcome Measurements Accurate aspiration and the rate of en bloc resection. Results We obtained a satisfactory field of view and accurate aspiration in the center of the tumor in all lesions. The rate of en bloc resection was 91.7% (11/12). Limitations Gastric intramucosal cancer. Conclusion Grasping forceps–assisted endoscopic mucosal resection with a novel 2-channel prelooped hood is safe and useful for mucosal resection of intramucosal cancers less than 20 mm and may help center the lesion in the cap before resection.

Background EMR with a cap-fitted endoscope, including a soft, prelooped hood, is a useful, effective, and safe technique. One problem with this method, however, is that the lesion cannot always be kept in the center of the cap because the procedure is performed blindly after aspiration. A soft, prelooped hood with attached irrigation tube was developed. The usefulness of this device for EMR of upper-GI intramucosal cancers was evaluated. Methods The end-hood piece was fabricated by drilling a side hole in the cap portion of a conventional soft, prelooped hood and then attaching an irrigation tube with glue to the exterior surface of the hole. The fabricated transparent hood was placed at the tip of an endoscope, and aspiration mucosectomy under irrigation was performed in 15 patients with upper-GI intramucosal cancer. When the field of view at the aspiration site was obscured by oozing blood, the site was irrigated. Results A satisfactory view was obtained of all lesions. The mean diameter of specimens was 24.5 mm (interquartile range: 15-35). The proportion of en bloc resected lesions was 86.7% (13/15). Bleeding was the only complication (4/15; 26.7%) and was controlled by using endoscopic hemostatic techniques under irrigation. Conclusions EMR when using the soft, prelooped hood with irrigation tube is effective and safe for intramucosal cancers 20 mm or less in diameter.

Tu1696 Safety of Endoscopic Submucosal Dissection for Esophageal Cancer in Elderly Patients Akiko Ono*, Ken Ohata, Takafumi Ito, Hideyuki Chiba, Yosuke Tsuji, Nobuyuki Matsuhashi Gastroenterology, NTT Medical Center Tokyo, Shinagawa-ku Tokyo, Japan Background and Aims: Endoscopic submucosal Dissection (ESD) is an noninvasive treatment for early esophageal cancer. With increasing elderly population, the number of those who need esophageal ESD has increased. However, the safety of ESD for elderly patient is still unclear. The aim of this study was to investigate the treatment outcome and evaluate the safety of ESD in patients over 75 years old. Methods: Between July 2007 and February 2011, 149 patients underwent esophageal ESD for early esophageal cancer in NTT Medical Center Tokyo. 29 patients were 75 y.o. or over (group A), and 120 patients were under 75 y.o. (group B). We retrospectively reviewed the medical records of each group to analyze age, underlying disease, pathological findings, complete en-bloc resection rate, size of resected tumor and specimen, operation time, length of hospital stay and complications (bleeding, perforation, fever above 38 degrees, pneumonia, infection requiring antibiotics, and hypoxemia after ESD). Results: The rate of subjects with underlying diseases was significantly higher in group A than in group B (A/B:18/36 P 0.002). Complete en-bloc resection rate was 100% in both groups. The size of the tumor (A/B:26.6/20.8mm) and the specimen (A/B:39.6/36.0mm) and operation time (A/B:68.1/60min) did not differ significantly between A and B. Complications including bleeding (A/B:0/0%), perforation (A/B:10/3.3%), fever above 38 degrees (A/B:10.3/14.2%), pneumonia(A/B:3.5/0.8%), infection requiring antibiotics (A/B:13.8/8.3%), hypoxemia after ESD(A/B:6.9/3.3%), the total length of hospital stay (A/B:7.3/ 7.6days) did not differ significantly between A and B. During follow up period (average 34 months,range:9-52), no patients died of esophageal cancer, but death for the other disease (1 cancer of other organ in each group, 1 rupture of abdominal aortic aneurysm in group A) occurred more frequently in group A. Concerning histological tumor invasion depth, 3 (10.3%) and 31 cases (25.8%) were MM/SM1/SM2 in group A and B (2/1/0 and 16/1/4 in A and B, respectively). AT was not performed for EP-LPM cases. In group A, 1 case with lymphovascular invasion among the 2MM cases underwent radiotherapy (RT), and the remaining 2 cases (MM/SM:1/1) were followed up without AT. In group B, 1 case among the 16MM cases was treated by RT, and another case was treated by chemoradiation therapy (CRT). 14 cases were followed up without AT.1 and 4 patients among the 5 SM1/SM2 cases underwent CRT and thoracoscopic surgery, respectively. All cases except for the 3 cases dead from other diseases are alive without recurrence. Conclusions: Though elderly patients have more underlying disease, the treatment outcome and complications of esophageal ESD in elderly patient were not significantly different from those in younger patients. Esophageal ESD in elderly patients can be safe and effective. Tu1697 Can the Gastric ESD Be Improved Further? A Review of Outcomes of a High Volume Institution With More Than Ten Years and Thousand Cases Experience Atsushi Hoshino*, Kazuki Sumiyama, Akira Dobashi, Tomohiko R. Ohya, Noboru Yoshimura, Hirobumi Toyoizumi, Kenichi Goda, Tomohiro Kato, Seiji Arihiro, Hisao Tajiri Department of Internal Medicine, Division of Gastroenterology and Hepatology, The Jikei Univesity School of Medicine, Tokyo, Japan; Department of Endoscopy, The Jikei Univesity School of Medicine, minatoku, Tokyo, Japan Background: Endoscopic submucosal dissection (ESD) allows us to radically remove mucosal-based lesions as en bloc regardless of lesion size. To date, the technique and the instrumentation have been steadily improved. Thereby, ESD is now recognized as a first-line therapeutic option for early stage gastric cancer in Japan. However, due to procedural challenges currently associated with ESD, the technique is only performed in some East Asian countries and at few restricted academic centers in Western countries. Further technical improvement is still imperative to gain the international acceptance of the procedure. However, it is unclear if the technique still leaves room for sophistication or has been already reached a plateau of the improvement after a large volume of clinical experiences. Aims: To investigate if the ESD technique could have been still improved at a high volume center with over ten years experience of ESD. Methods: Medical records and endoscopic findings of all patients who underwent gastric ESD at Jikei University hospital from Feb 2000 to May 2011 were reviewed (n 1009). The operation time, the tumor and the specimen sizes, the pathology, the en bloc resection rate, and the rate of perforation in recent 7 years (from Apr 2004 to Mar 2011) were analyzed separately for the earlier 2 yrs (n 221) and the later 5 yrs periods (n 683). The data in the later period were also yearly compared (chronologically subdivided into phase 1 to 5). Results: Overall, 840 eligible patients (213/627, earlier/later) were analyzed. The operation time of ESD has been steadily shortened thorough the entire study periods (Table 1). There were significant differences in the operation time between the earlier and the later periods (mean: 83.56/62min), and also phase 1 (mean: 70.98min, n 109) and phase 5 (mean: 41.82 min, n 114), phase 2 (mean: 70.98min, n 142) and phase 3 (mean: 70.98min, n 143), and phase 4 (mean: 70.98 min, n 114) and phase 5 in the later period (p 0.05). There were no significant differences in patients’ backgrounds and other measurements between the groups. Conclusions: The technical developments in ESD enabled the operation time to be consistently hastened in these 7 years in our institution and this trend is still under way. However, factors which had a greater contribution to the favorable outcome, are yet to be investigated.