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Objectives: Diagnostic ability of sessile serrated lesions (SSL) and SSL with dysplasia (SSLD) using blue laser/light imaging (BLI) has not been well examined. We analyzed the diagnostic accuracy of BLI for SSL and SSLD using several endoscopic findings compared to those of narrow band imaging (NBI)., Materials and Methods: This was a subgroup analysis of prospective studies. 476 suspiciously serrated lesions of ≥2 mm on the proximal colon showing serrated change with magnified NBI or BLI in our institution between 2014 and 2021 were examined histopathologically. After propensity score matching, we evaluated the diagnostic ability of SSL and SSLD of the NBI and BLI groups regarding various endoscopic findings. For WLI findings, granule, depression, and reddish were examined for diagnosing SSLD. For NBI/BLI findings, expanded crypt opening (ECO) or thick and branched vessels (TBV) were examined for diagnosing SSL. Network vessels (NV) and white dendritic change (WDC) defined originally were examined for diagnosing SSLD., Results: Among matched 176 lesions, the sensitivity of lesions with either ECO or TBV for SSL in the NBI/BLI group was 97.5%/98.5% ( p = 0.668). Those with either WDC or NV for diagnosing SSLD in the groups were 81.0%/88.9% ( p = 0.667). Regarding the rates of endoscopic findings among 30 SSLD and 290 SSL, there were significant differences in WDC (66.4% vs. 8.6%, p < 0.001), NV (55.3% vs. 1.4%, p < 0.001), and either WDC or NV (86.8% vs. 9.0%, p < 0.001)., Conclusions: The diagnostic ability of BLI for SSL and SSLD was not different from NBI. NV and WDC were useful for diagnosing SSLD., Competing Interests: Yoshida N is an editor of Gastroenterology Research and Practice. Yoshida N and Dohi O received a research grant from Fujifilm Co. Yoshida N received payment for lectures from Fujifilm Co. The other authors declare no conflicts of interest., (Copyright © 2024 Reo Kobayashi et al.)

Objectives: Oral sulfate solution (OSS) is used for bowel preparation (BP) during colonoscopy. The way of taking this agent can be used a same-day regimen (only on the day of colonoscopy) and split regimen (the day before and on the day of colonoscopy) for receiving it. In this study, we analyzed the efficacy of a same-day regimen of 480 ml OSS for insufficient bowel preparation (BP) with high-concentrated polyethylene glycol (H-PEG)., Materials and Methods: This multicenter retrospective study was conducted from December 2021 to December 2022 at three related institutions on patients aged ≥ 20 years with a fair or poor Aronchick score of BP with 1 l H-PEG in previous colonoscopy. All patients received a low-residual diet and 10 ml of 0.75% picosulfate sodium a day before the colonoscopy and 480 ml of OSS and ≥1 l of water 3 hours before the colonoscopy. We analyzed the rate of improvement with OSS compared to H-PEG and other efficacies, and adverse events (AE)., Results: We evaluated 125 cases (77 males) with an average age of 72.1 ± 8.8 years. The completion rate of 480 ml of OSS was 97.6% (122/125). The improvement rate of BP showing good or excellent score with OSS was 70.4% (88/125). Compared OSS with previous H-PEG, the insertion time (min) was 7.0 ± 4.8 vs. 8.1 ± 6.0 ( p = 0.01), and the adenoma detection rates were 67.2% vs. 63.2% ( p = 0.05). The cleansing time (min) was 131 ± 46 vs. 165 ± 53 ( p < 0.01). The rate of AE with OSS was 10.4% (13/125). There were no significant differences about AE in age and gender. The tolerance of OSS compared with H-PEG (good/similar/bad) was 72.0%/24.8%/3.2% (amounts), 26.4%/39.2%/34.4% (taste), and 76.8%/10.4%/12.8% (overall preference), respectively., Conclusions: The same-day regimen of 480 ml OSS effectively improved the insufficient BP of 1 l H-PEG., Competing Interests: Yoshida N is an editor of Gastroenterology Research and Practice. All other authors declare no conflicts of interest., (Copyright © 2023 Naohisa Yoshida et al.)

Background : A compact and cost-effective light source-processor combined 3-color light-emitting diode (LED) endoscopic system (ELUXEO-Lite: EP-6000, Fujifilm Co., Tokyo) with a magnified colonoscope (EC-6600ZP, Fujifilm Co.) has been released. Aims : In this study, we analyzed the efficacy of this system for colorectal tumor characterization with magnified blue light imaging (BLI-LED) and image's subjective and objective evaluations, compared to a magnified blue laser imaging (BLI-LASER) using a standard LASER endoscopic system. Methods : We retrospectively reviewed 37 lesions observed with both BLI-LED and BLI-LASER systems from 2019 using the Japanese narrow band imaging classification. Two representative magnified images, one BLI-LED and one BLI-LASER, of the same area of a lesion were evaluated for diagnostic accuracy and visualization quality by three experts and three non-experts. Their color difference values (CDVs) and brightness values (BVs) were also calculated as objective indicators. Results : Among 37 lesions, mean tumor size was 18.9 ± 13.1 mm, and 21 lesions were nonpolypoid. Histopathology revealed 14 sessile serrated lesions, 7 adenomas, 12 high-grade dysplasias and T1a cancers, and 4 T1b cancers. The diagnostic accuracy rates of BLI-LED/BLI-LASER of experts and non-experts were 90.1% and 87.4% ( p = 0.52) and 89.2% and 89.2% ( p = 0.99). The percentages of instances where BLI-LED images were better, the two imaging types were equivalent, or BLI-LASER images were better were 16%/83%/1% for experts and 19%/58%/23% for non-experts ( p < 0.001). CDVs and BVs between BLI-LED and BLI-LASER were not significantly different (CDVs: p = 0.653, BVs: p = 0.518). Conclusions : BLI-LED using the compact system was noninferior to BLI-LASER for colorectal tumor characterization and image quality., Competing Interests: Naohisa Yoshida and Osamu Dohi received a research grant from Fujifilm Co. (J162001222). The system was rent from Fujifilm Co. The other authors have no conflicts of interest to declare., (Copyright © 2022 Ken Inoue et al.)

Background: We frequently encounter early gastric cancer (EGC) that could not be detected in the previous esophagogastroduodenoscopy even if the procedure was annually performed. However, little evidence exists regarding the characteristics of false-negative EGCs. Our aim was to reveal the clinical features of false-negative EGCs., Methods: We retrospectively reviewed cases of endoscopic submucosal dissection (ESD) for EGCs in Fukuchiyama City Hospital between January 2013 and May 2019. False-negative EGCs were defined as EGCs within 3 years of negative endoscopy. We evaluated the clinical characteristics of false-negative and initially detected EGCs and the difference in the detected and last missed endoscopy in false-negative EGCs. The miss rates of false-negative EGCs were compared between trainees (nonboard-certified endoscopists) and experienced endoscopists (board-certified endoscopists); thereafter, the characteristics of false-negative EGCs missed by trainees were investigated., Results: Of 219 cases, 119 were classified as false-negative EGCs. False-negative EGCs were characterized as smaller lesions, which presented with normal color or gastritis-like appearance, and were diagnosed after ESD and H. pylori eradication ( P < 0.01). The rate of trainees in the last missed endoscopy was significantly higher than that in the detected endoscopy. The miss rate of false-negative EGC by trainees was higher than that of experienced endoscopists but not significantly different (0.70% vs. 0.57%, P = 0.08). The false-negative EGCs missed by trainees were characterized as reddish or well-differentiated lesions, which were located in the lower or lesser curvature of the stomach ( P < 0.05)., Conclusion: The characteristics of false-negative EGCs were similar to those of H. pylori -eradicated EGC. Procedures with shortened examination time and those performed by trainees were risk factors of missing false-negative EGCs. Trainees should pay attention to reddish or well-differentiated EGCs located in the lower or lesser curvature of the stomach., Competing Interests: Kohei Oka, Naoto Iwai, Takashi Okuda, Tasuku Hara, Yutaka Inada, Toshifumi Tsuji, Toshiyuki Komaki, Junichi Sakagami, Yuji Naito, Keizo Kagawa, and Yoshito Itoh have no conflicts of interest pertaining to this study., (Copyright © 2021 Kohei Oka et al.)

Materials and Methods: This multicenter retrospective study was conducted from September 2019 to September 2020 at 5 related institutions among patients ≥ 20 years old diagnosed with chronic constipation whose previous colonoscopic BP had had a fair or poor Aronchick score. Two or four sachets of PEG+E (13.7 or 27.4 g/day) were prescribed for 1 week before colonoscopy. We analyzed the rate of improvement in BP, effect-related factors, spontaneous bowel movements (SBMs), stool consistency, improvement of constipation symptoms, and adverse events., Results: We evaluated 106 cases (56 males) with an average age of 69.5 ± 9.4 years old (≤74 years old: 68 cases, ≥75 years old: 38 cases). The improvement rate of BP was 72.6%, and the insertion time and pain score also improved. A performance status of 1 or 2 was associated with poor BP. SBMs (times/week) increased from 4.0 ± 1.9 to 6.1 ± 2.6 ( p < 0.001). The overall improvement rates of SBMs, stool consistency, symptoms of constipation, and rate of adverse events were 58.5%, 90.6%, 59.4%, and 6.6%, respectively, showing no significant differences with regard to age or gender., Conclusions: Short-duration PEG+E was effective for improving poor BP and chronic constipation., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Naohisa Yoshida et al.)

Materials and Methods: This was a multicenter retrospective cohort study. The subjects were patients aged ≥20 years treated for chronic constipation from May 2018 to November 2019 at 12 related institutions. Patients were divided into ≤74 years and ≥75 years old. Elobixibat at 10 mg/day was prescribed for two weeks. We then analyzed the discontinuation due to ineffectiveness, change of spontaneous bowel movements (SBM), stool consistency, the time until the first SBM, adverse events, and effect-related factors., Results: There were 140 cases (61 males) evaluated, with an average age of 72.1 ± 13.6 years (≤74 years: 71 cases; ≥75 years: 69 cases). The discontinuation rate was 7.9%. The SBM (times/week) increased from 2.86 to 6.08 ( p < 0.001). The overall SBM improvement rate was 74.0% (≤74 years: 78.2% vs. ≥75 years: 68.9%, p = 0.31; male: 75.0% vs. female: 73.3%, p = 0.78). The overall improvement rate of stool consistency was 59.6% (≤74 years: 62.9%, ≥75 years: 56.1%, p = 0.42). The time until the first SBM (hours) for those ≤74 years and ≥75 years was 17.2 ± 14.3 and 11.2 ± 8.4 ( p = 0.04). Adverse event rates for those ≤74 years and ≥75 years were 28.2% and 10.1% ( p < 0.01). There were no significant effect-related factors for gender, age, and use of laxatives., Conclusions: Short-period elobixibat is shown to be effective also for the elderly and male., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Akira Tomie et al.)

Backgrounds and Aims: Recently, direct oral anticoagulants (DOACs) have become widely used for preventing thromboembolism. However, postoperative hemorrhage (POH) is a major complication associated with endoscopic mucosal resection (EMR) for colorectal lesions. In this multicenter study, we analyzed the incidence of POH after EMR associated with DOACs and explored the associated risk factors., Materials and Methods: This study was a multicenter retrospective cohort study conducted at 8 Japanese institutions. A total of 2062 cases that underwent EMR for colorectal lesions at these 8 institutions from October 2016 to September 2017 were analyzed. The cases were divided into 4 groups: the DOAC group (63 cases), warfarin group (34 cases), antiplatelet group (185 cases), and no antithrombotics group (1780 cases). In all lesions of the DOAC and warfarin groups, endoscopic clipping was performed after EMR. The rate of POH in the DOAC group, patients' clinical characteristics, the risk factors of POH, and the rate of thromboembolism due to stopping DOACs were compared with other groups., Results: The rates of POH were 7.9% ∗ (5/63), 2.9% (1/34), 3.2% (6/185), and 0.6% ∗∗ (11/1780) in the DOAC, warfarin, antiplatelet, and no antithrombotics groups, respectively ( ∗ vs. ∗∗ , p < 0.001). Regarding risk factors, the tumor size with POH (mm) was significantly bigger than that without POH (16.2 ± 8.3 vs. 7.2 ± 4.9, p < 0.001). There were no significant differences in the rates of POH based on the type of DOAC. In addition, no thromboembolisms occurred due to stopping of DOAC treatment., Conclusions: Patients receiving DOACs had significantly higher rates of POH after EMR than those without antithrombotics., Competing Interests: All authors have no conflicts of interest to declare., (Copyright © 2019 Ritsu Yasuda et al.)

Background and Aims: Various risk factors for lymph node metastasis (LNM) have been reported in colorectal T1 cancers. However, the factors available are insufficient for predicting LNM. We therefore investigated the utility of the new histological factor "pure well-differentiated adenocarcinoma" (PWDA) as a safe factor for predicting LNM in T1 and T2 cancers., Materials and Methods: We reviewed 115 T2 cancers and 202 T1 cancers in patients who underwent surgical resection in our center. We investigated the rates of LNM among various clinicopathological factors, including PWDA. PWDA was defined as a lesion comprising only well-differentiated adenocarcinoma. The consistency of the diagnosis of PWDA was evaluated among two pathologists. In addition, 72 T1 cancers with LNM from 8 related hospitals over 10 years (2008-2017) were also analyzed., Results: The rates of LNM and PWDA were 23.5% and 20.0%, respectively, in T2 cancers. Significant differences were noted between patients with and without LNM regarding lymphatic invasion (81.5% vs. 36.4%, p < 0.001), poor histology (51.9% vs. 19.3%, p = 0.008), and PWDA (3.7% vs. 25.0%, p = 0.015). The rates of LNM and PWDA were 8.4% and 36.1%, respectively, in T1 cancers. Regarding the 73 PWDA cases and 129 non-PWDA cases, the rates of LNM were 0.0% and 13.2%, respectively ( p < 0.001). Among the 97 cases with lymphatic or venous invasion, the rates of LNM in 29 PWDA cases and 68 non-PWDA were 0% and 14.7%, respectively ( p = 0.029). The agreement of the two pathologists for the diagnosis of PWDA was acceptable (kappa value > 0.5). A multicenter review showed no cases of PWDA among 72 T1 cancers with LNM., Conclusions: PWDA is considered to be a safe factor for LNM in T1 cancer.

Background and Aims: Missed polyps are a pitfall of colonoscopy. In this study, we analyzed the efficacy of an additional 30 seconds observation using linked color imaging (LCI) for detecting adenoma and sessile serrated adenoma/polyp (SSA/P)., Materials and Methods: We enrolled patients undergoing colonoscopy from February to October 2017 in two institutions. In all patients, the cecum and ascending colon were observed with white light imaging (WLI) first. The colonoscope was inserted again, and the cecum and ascending colon were observed for an additional 30 seconds using either LCI or WLI. The method for the 30 sec observation was to insufflate the cecum and ascending colon sufficiently and observe them in a distant view, because the length of the second observation was determined to be precisely 30 sec. For the second observation, LCI was performed for the first 65 patients and WLI for the next 65. Adenoma and SSA/P detection rate (ASDR) in the second observation were examined in both groups. According to a pilot study, the sample size was estimated 65., Results: In the first observation, ASDR were 30.7% in the LCI group and 32.2% in the WLI group ( p = 0.85). For the second observation, 13 polyps were detected in the LCI group and 5 polyps in the WLI group ( p = 0.04). Additionally, ASDR for the second observation were 18.5% and 6.1%, respectively ( p = 0.03). There were no significant differences between the LCI and WLI groups with respect to morphology (ratio of polypoid) (38.5% versus 60.0%, p = 0.52) and histology (ratio of adenoma) (92.3% versus 100.0%, p = 0.91). Total adenoma and SSA/P number were 48 in the LCI group and 36 in the WLI group ( p = 0.02)., Conclusion: The 30 seconds additional observation with LCI improved the detection of adenoma and SSA/P in the right-sided colon.

Backgrounds: With respect to the knife's design in colorectal endoscopic submucosal dissection (ESD), diameter, water jet function, and electric power are important because these relate to efficient dissection. In this study, we analyzed a novel, narrow ball tip-typed ESD knife with water jet function (Flush knife BT-S, diameter: 2.2 mm, length: 2000 mm, Fujifilm Co., Tokyo, Japan) compared to a regular diameter knife (Flush knife BT, diameter: 2.6 mm, length: 1800 mm)., Methods: In laboratory and clinical research, electric power, knife insertion time, vacuum/suction amount with knife in the endoscopic channel, and water jet function were analyzed. We used a knife 2.0 mm long for BT-S and BT knives., Results: The BT-S showed faster mean knife insertion time (sec) and better vacuum amount (ml/min) compared to the BT (insertion time: 16.7 versus 21.6, p < 0.001, vacuum amount: 38.0 versus 14.0, p < 0.01). Additionally, the water jet function of the BT-S was not inferior. In 39 colorectal ESD cases in two institutions, there were mean 4.7 times (range: 1-28) of knife insertion. Suction under knife happened 59% (23/39) and suction of fluid could be done in 100%., Conclusions: Our study showed that the narrow knife allows significantly faster knife insertion, better vacuum function, and effective clinical results.

Purpose. The aim of this study was to examine the characteristics of difficult cases and the learning curve in colorectal endoscopic submucosal dissection (ESD). Methods. We studied 518 colorectal tumors treated by ESD. Patients were divided into 2 groups such as the difficult ESD group and non-difficult ESD group in view of procedure time and procedure speed, respectively. The clinical features in each group were analyzed, and we also examined cases with severe fibrosis. Furthermore, we divided all cases into 5 periods according to experience of ESDs and investigated the rates of difficult and perforation cases. Results. In view of both procedure time and procedure speed, there were significant differences about mean tumor size, rates of severe fibrosis and perforation, and en bloc resection rate between the two groups. Severe fibrosis was detected in protruding tumors >40 mm in diameter. With respect to the learning curve, the rate of difficult and perforation cases decreased significantly in the late periods compared to the first period. Conclusions. Large tumor size, high rates of severe fibrosis and perforation, and low rate of en bloc resection are related with difficult ESD cases. The increasing of experiences can decrease the rate of difficult cases and perforation.