Bleeding after endoscopic submucosal dissection: Risk factors and preventive methods

Endoscopic submucosal dissection(ESD) has become widely accepted as a standard method of treatment for superficial gastrointestinal neoplasms because it enables en block resection even for large lesions or fibrotic lesions with minimal invasiveness, and decreases the local recurrence rate. Moreover, specimens resected in an en block fashion enable accurate histological assessment. Taking these factors into consideration, ESD seems to be more advantageous than conventional endoscopic mucosal resection(EMR), but the associated risks of perioperative adverse events are higher than in EMR. Bleeding after ESD is the most frequent among these adverse events. Although post-ESD bleeding can be controlled by endoscopic hemostasis in most cases, it may lead to serious conditions including hemorrhagic shock. Even with preventive methods including administration of acid secretion inhibitors and preventive hemostasis, post-ESD bleeding cannot be completely prevented. In addition high-risk cases for post-ESD bleeding, which include cases with the use of antithrombotic agents or which require large resection, are increasing. Although there have been many reports about associated risk factors and methods of preventing post-ESD bleeding, many issues remain unsolved. Therefore, in this review, we have overviewed risk factors and methods of preventing post-ESD bleeding from previous studies. Endoscopists should have sufficient knowledge of these risk factors and preventive methods when performing ESD.

Endoscopic diagnosis for colorectal sessile serrated lesions

BACKGROUND Hyperplastic polyps are considered non-neoplastic, whereas sessile serrated lesions(SSLs) are precursors of cancer via the ‘‘serrated neoplastic pathway’’. The clinical features of SSLs are tumor size(> 5 mm), location in the proximal colon, coverage with abundant mucus called the ‘‘mucus cap’’, indistinct borders, and a cloud-like surface. The features in magnifying narrow-band imaging are varicose microvascular vessels and expanded crypt openings. However, accurate diagnosis is often difficult.AIM To develop a diagnostic score system for SSLs.METHODS We retrospectively reviewed consecutive patients who underwent endoscopic resection during colonoscopy at the Toyoshima endoscopy clinic. We collected data on serrated polyps diagnosed by endoscopic or pathological examination. The significant factors for the diagnosis of SSLs were assessed using logistic regression analysis. Each item that was significant in multivariate analysis was assigned 1 point, with the sum of these points defined as the endoscopic SSL diagnosis score. The optimal cut-off value of the endoscopic SSL diagnosis score was determined by receiver-operating characteristic curve analysis.RESULTS Among 1288 polyps that were endoscopically removed, we analyzed 232 diagnosed as serrated polyps by endoscopic or pathological examination. In the univariate analysis, the location(proximal colon), size(> 5 mm), mucus cap, indistinct borders, cloud-like surface, and varicose microvascular vessels were significantly associated with the diagnosis of SSLs. In the multivariate analysis, size(> 5 mm;P = 0.033), mucus cap(P = 0.005), and indistinct borders(P = 0.033) were independently associated with the diagnosis of SSLs. Size > 5 mm, mucus cap, and indistinct borders were assigned 1 point each and the sum of these points was defined as the endoscopic SSL diagnosis score. The receiver-operating characteristic curve analysis showed an optimal cut-off score of 3, which predicted pathological SSLs with 75% sensitivity, 80% specificity, and 78.4% accuracy. The pathological SSL rate for an endoscopic SSL diagnosis score of 3 was significantly higher than that for an endoscopic SSL diagnosis score of 0, 1, or 2(P < 0.001).CONCLUSION Size > 5 mm, mucus cap, and indistinct borders were significant endoscopic features for the diagnosis of SSLs. Serrated polyps with these three features should be removed during colonoscopy.

Endoscopy-based Kyoto classification score of gastritis related to pathological topography of neutrophil activity

BACKGROUND Endoscopy-based Kyoto classification for gastritis and pathological topographic distribution of neutrophil infiltration are correlated with gastric cancer risk.AIM To investigate the association between Kyoto classification and the topographic distribution of neutrophil activity.METHODS Kyoto classification score,ranging from 0 to 8,consisted of atrophy,intestinal metaplasia,enlarged folds,nodularity,and diffuse redness.Neutrophil activity was scored according to the updated Sydney System using biopsy samples obtained from the greater curvature of the corpus and the antrum.The participants were divided into four categories,inactive stomach,antrumpredominant gastritis,pangastritis,and corpus-predominant gastritis,based on the topographic distribution of neutrophil activity.Effects of sex,age,body mass index,drinking habit,smoking habit,family history of gastric cancer,serum Helicobacter pylori(H.pylori)antibody,and Kyoto score on topography of neutrophil infiltration were analyzed.RESULTS A total of 327 patients(comprising 50.7%women,with an average age of 50.2 years)were enrolled in this study.H.pylori infection rate was 82.9%with a mean Kyoto score of 4.63.The Kyoto score was associated with the topographic distribution of neutrophil activity.Kyoto scores were significantly higher in the order of inactive stomach,antrum-predominant gastritis,pangastritis,and corpuspredominant gastritis(3.05,4.57,5.21,and 5.96,respectively).Each individual score of endoscopic findings(i.e.,atrophy,intestinal metaplasia,enlarged folds,nodularity,and diffuse redness)was correlated with the topographic distribution of neutrophil activity.On multivariate analysis,the Kyoto score,age,and serum H.pylori antibody were independently associated with the topographic distribution of neutrophil activity.CONCLUSION The Kyoto classification score was associated with the topographic distribution of neutrophil activity.

Sessile serrated adenoma detection rate is correlated with adenoma detection rate

AIM To investigated the association between adenoma detection rate(ADR) and sessile serrated ADR(SSADR) and significant predictors for sessile serrated adenomas(SSA) detection.METHODS This study is a retrospective, single-center analysis. Total colonoscopies performed by the gastroenterologists at the University of Tokyo Hospital between January and December 2014 were retrospectively identified. Polyps were classified as low-grade or high-grade adenoma, cancer, SSA, or SSA with cytological dysplasia, and the prevalence of each type of polyp was investigated. Predictors of adenoma and SSA detection were examined using logistic generalized estimating equation models. The association between ADR and SSADR for each gastroenterologist was investigated by calculating a correlation coefficient weighted by the number of each gastroenterologist's examination.RESULTS A total of 3691 colonoscopies performed by 35 gastroenterologists were assessed. Overall, 978 (26.5%) low-and 84 (2.2%) high-grade adenomas, 81 (2.2%) cancers, 66 (1.8%) SSAs, and 2 (0.1%) SSAs with cytological dysplasia were detected. Overall ADR was 29.5%(men 33.2%, women 23.8%) and overall SSADR was 1.8%(men 1.7%, women 2.1%). In addition, 672 low-grade adenomas (68.8% of all the detected lowgrade adenomas), 58 (69.9%) high-grade adenomas, 29 (34.5%) cancers, 52 (78.8%) SSAs, and 2 (100%) SSAs with cytological dysplasia were found in the proximal colon. Adenoma detection was the only significant predictor of SSA detection (adjusted OR: 2.53, 95%CI: 1.53-4.20; P < 0.001). The correlation coefficient between ADR and SSADR weighted by the number of each gastroenterologist's examinations was 0.606(P < 0.001).CONCLUSION Our results demonstrated that ADR is correlated to SSADR. In addition, patients with adenomas had a higher prevalence of SSAs than those without adenomas.

Evaluation of preferable insertion routes for esophagogastroduodenoscopy using ultrathin endoscopes

AIM:To evaluate the discomfort associated with esophagogastroduodenoscopy(EGD)using an ultrathin endoscope through different insertion routes.METHODS:This study(January 2012-March 2013)included 1971 consecutive patients[male/female(M/F),1158/813,57.5±11.9 years]who visited a single institute for annual health checkups.Transnasal EGD was performed in 1394 patients and transoral EGD in 577.EGD-associated discomfort was assessed using a visual analog scale score(VAS score:0-10).RESULTS:Multivariate analysis revealed gender(M vs F:4.02±2.15 vs 5.06±2.43)as the only independent predictor of the VAS score in 180 patients who underwent EGD for the first time;whereas it revealed gender(M vs F 3.60±2.20 vs 4.84±2.37),operator,age group(A:<39 years;B:40-49 years;C:50-59years;D:60-69 years;E:>70 years;A/B/C/D/E:4.99±2.32/4.34±2.49/4.19±2.31/3.99±2.27/3.63±2.31),and type of insertion as independent predictors in the remaining patients.Subanalysis for gender,age group,and insertion route revealed that the VAS score decreased with age regardless of gender and insertion route,was high in female patients regardless of age and insertion route,and was low in males aged over60 years who underwent transoral insertion.CONCLUSION:Although comprehensive analysis revealed that the insertion route may not be an independent predictor of the VAS score,transoral insertion may reduce EGD-associated discomfort in elderly patients.