Balloon-assisted endoscopic submucosal dissection for treating small intestinal lipomas:Report of two cases

BACKGROUND Most small intestinal lipomas are treated surgically,and some require repeated surgeries for multiple lipomas.However,application of endoscopic submucosal dissection(ESD)technology in the deep small intestine is rarely reported owing to the special anatomical structure of the small intestine,medical equipment limitations,and the lack of relevant experience among endoscopists.CASE SUMMARY Two patients with small intestinal lipomas treated at the Air Force Medical Center from November 2015 to September 2019 were selected to undergo balloonassisted ESD to treat the lipomas and explore the technical feasibility and safety of ESD for treating small intestinal lipomas.The two patients successfully underwent balloon-assisted ESD to treat four small intestinal lipomas,with a complete resection rate of 100%(4/4),without intraoperative or postoperative bleeding,perforation,or other complications.After 3-6 mo of postoperative follow-up,the clinical symptoms caused by the lipomas were significantly relieved or disappeared after treatment.CONCLUSION Balloon-assisted ESD is a safe and reliable new method for treating deep intestinal lipomas and shows good clinical feasibility.

Role of second look endoscopy in endoscopic submucosal dissection and peptic ulcer bleeding:Meta-analysis of randomized controlled trials

BACKGROUND Second-look endoscopy(SLE)to prevent recurrent bleeding in patients with peptic ulcer disease(PUD)and those undergoing endoscopic submucosal dissection(ESD)is routinely being performed.Conflicting evidence exists regarding efficacy,risk,benefit,and cost-effectiveness.AIM To identify the role and effectiveness of SLE in ESD and PUD,associated rebleeding and PUD-related outcomes like mortality,hospital length of stay,need for endoscopic or surgical intervention and blood transfusions.METHODS A systematic review of literature databases PubMed,Cochrane,and Embase was conducted from inception to January 5,2023.Randomized controlled trials that compared patients with SLE to those who did not have SLE or evaluated the role of prophylactic hemostasis during SLE compared to other conservative interventions were included.The study was conducted per PRISMA guidelines,and the protocol was registered in PROSPERO(ID CRD42023427555:).RevMan was used to perform meta-analysis,and Mantel-Haenszel Odds ratio(OR)were generated using random effect models.RESULTS A total of twelve studies with 2687 patients were included in our systematic review and meta-analysis,of which 1074 patients underwent SLE after ESD and 1613 patients underwent SLE after PUD-related bleeding.In ESD,the rates of rebleeding were 7%in the SLE group compared to 4.4%in the non-SLE group with OR 1.65,95%confidence intervals(CI)of 0.96 to 2.85;P=0.07,whereas it was 11%in the SLE group compared to 13%in the non-SLE group with OR 0.895%CI:0.50 to 1.29;P=0.36.The mean difference in the blood transfusion rates in the SLE and no SLE group in PUD was OR 0.01,95%CI:-0.22 to 0.25;P=0.91.In SLE vs non-SLE groups with PUD,the OR for Endoscopic intervention was 0.29,95%CI:0.08 to 1.00;P=0.05 while it was OR 2.03,95%CI:0.95 to 4.33;P=0.07,for surgical intervention.The mean difference in the hospital length of stay was-3.57 d between the SLE and no SLE groups in PUD with 95%CI:-7.84 to 0.69;P=0.10,denoting an average of approximately 3 fewer days of hospital stay among patients with PUD who underwent SLE.For mortality between SLE and non-SLE groups in PUD,the OR was 0.88,95%CI:0.45 to 1.72;P=0.70.CONCLUSION SLE does not confer any benefit in preventing ESD and PUD-associated rebleeding.SLE also does not provide any significant improvement in mortality,need for interventions,or blood transfusions in PUD patients.SLE decreases the hospital length of stay on average by 3.5 d in PUD patients.

Endoscopic characteristics of small intestinal malignant tumors observed by balloon-assisted enteroscopy

BACKGROUND Capsule endoscopy and balloon-assisted enteroscopy(BAE) enable visualization of rare small bowel conditions such as small intestinal malignant tumors.However,details of the endoscopic characteristics of small intestinal malignant tumors are still unknown.AIM To elucidate the endoscopic characteristics of small intestinal malignant tumors.METHODS From March 2005 to February 2017,1329 BAE procedures were performed at Keio University Hospital. Of these procedures,malignant tumors were classified into three groups,Group 1: epithelial tumors including primary small intestinal cancer,metastatic small intestinal cancer,and direct small intestinal invasion by an adjacent organ cancer; Group 2: small intestinal malignant lymphoma; and Group 3,small intestinal gastrointestinal stromal tumors. We systematically collected clinical and endoscopic data from patients' medical records to determine the endoscopic characteristics for each group.RESULTS The number of patients in each group was 16(Group 1),23(Group 2),and 6(Group 3),and the percentage of solitary tumors was 100%,43.5%,and 100%,respectively(P < 0.001). Patients' clinical background parameters including age,symptoms,and laboratory data were not significantly different between the groups. Seventy-five percent of epithelial tumors(Group 1) were located in the upper small intestine(duodenum and ileum),and approximately 70% of gastrointestinal stromal tumors(Group 3) were located in the jejunum. Solitary protruding or mass-type tumors were not seen in malignant lymphoma(Group2)(P < 0.001). Stenosis was seen more often in Group 1,(68.8%,27.3%,and 0%;Group 1,2,and 3,respectively; P = 0.004). Enlarged white villi inside and/or surrounding the tumor were seen in 12.5%,54.5%,and 0% in Group 1,2,and 3,respectively(P = 0.001).CONCLUSION The differential diagnosis of small intestinal malignant tumors could be tentatively made based on BAE findings.

Submucosal tunnel endoscopy:Peroral endoscopicmyotomy and peroral endoscopic tumor resection

Peroral endoscopic myotomy(POEM) is an innovative,minimally invasive, endoscopic treatment for esophageal achalasia and other esophageal motility disorders, emerged from the natural orifice transluminal endoscopic surgery procedures, and since the first human case performed by Inoue in 2008, showed exciting results in international level, with more than 4000 cases globally up to now. POEM showed superior characteristics than the standard 100-year-old surgical or laparoscopic Heller myotomy(LHM), not only for all types of esophageal achalasia [classical(Ⅰ), vigorous(Ⅱ), spastic(Ⅲ), Chicago Classification], but also for advanced sigmoid type achalasia(S1 and S2), failed LHM, or other esophageal motility disorders(diffuse esophageal spasm, nutcracker esophagus or Jackhammer esophagus). POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction(EGJ) and myotomy. Finally the mucosal entry is closed with endoscopic clip placement. POEM permitted relatively free choice of myotomy length and localization. Although it is technically demanding procedure, POEM can be performed safely and achieves very good control of dysphagia and chest pain. Gastroesophageal reflux is the most common troublesome side effect, and is well controllable with proton pump inhibitors. Furthermore, POEM opened the era of submucosal tunnel endoscopy, with many other applications. Based on the same principles with POEM, in combination with new technological developments, such as endoscopic suturing, peroral endoscopic tumor resection(POET), is safely and effectively applied for challenging submucosal esophageal, EGJ and gastric cardia tumors(submucosal tumors), emerged from muscularis propria. POET showed up to know promising results, however, it is restricted to specialized centers. The present article reviews the recent data of POEM and POET and discussed controversial issues that need further study and future perspectives.

Second-look endoscopy with prophylactic hemostasis is still effective after endoscopic submucosal dissection for gastric neoplasm

AIM: The clinical value of second-look endoscopy(SLE) after endoscopic submucosal dissection(ESD) has been doubted continuously. The aim of this study was to assess the effectiveness of SLE based on the risk of delayed bleeding after ESD. METHODS: A total of 310 lesions of gastric epithelial neoplasms treated by ESD were reviewed. The lesions were divided into two groups based on the risk of postprocedural bleeding estimated by Forrest classification. The high risk of rebleeding group(Forrest?Ⅰa,?Ⅰb and Ⅱa) required endoscopic treatment, while the low risk of rebleeding group(Forrest Ⅱb, Ⅱc and Ⅲ) did not. Delayed bleeding after ESD was investigated. RESULTS: Sixty-six lesions were included in the high risk of rebleeding group and 244 lesions in the low risk of rebleeding group. There were no significant differences in delayed bleeding between the high risk group(1/66) and the low risk group(1/244)(P = 0.38). The high risk of rebleeding group tended to be located more often in the mid-third and had higher appearance of flat or depressed shape than the low risk group(P = 0.004 and P = 0.006, respectively). CONCLUSION: SLE with pre-emptive prophylactic endoscopic treatment is still effective in preventing delayed bleeding after ESD.

Premedication with pronase or N-acetylcysteine improves visibility during gastroendoscopy: An endoscopist-blinded, prospective, randomized study

AIM： To assess the efficacy of premedicaton with pronase or N-acetylcysteine （NAC） at 20 min before upper gastrointestinal （UGI） endoscopy and to determine whether pronase or NAC pretreatment influences the reliability of the rapid urease test. METHODS： A total of 146 patients were prospectively and randomly assigned into the study groups according to different premedications before endoscopy. One endoscopist assessed mucosal visibility （MV） with scores ranged from 1 to 4 at four sites in the stomach. The sum of the MV scores from these four locations was defined as the total mucosal visibility （TMV） score. Identification of Hpylori was performed using CLO test, histology, and serology. RESULTS： The Group with pronase premedication had a significantly lower TMV score than did the groups with gascon and gascon water （P 〈 0.001 and P 〈 0.01, respectively）. The group with NAC had a significantly lower TMV score than the group with gascon （P 〈 0.01） and a trend of a lower MV score than the group with gascon water （P = 0.06）. The THV score did not significantly differ between the group with pronase and the group with NAC （P = 0.39 and P = 0.14, respectively）. The sensitivity and specifidty of the CLO test were 92.5% and 93.9%, respectively, in groups premedicated with pronase and NAC together.CONCLUSION： Premedication with pronase or NAC at 20 min before UGI endoscopy improves the mucosal visibility of the stomach. Neither pronase nor NAC produces any obvious interference with the CLO test for the identification of H pylori infection.

Serrated polyps of the colon and rectum: Endoscopic features including image enhanced endoscopy

In this review, I outline the characteristic endoscopic findings of serrated lesions of the colorectum based on image enhanced endoscopy(IEE). Histopathologically, lesions with serrated structures are typically classified into the following three types based: hyperplastic polyps(HPs), traditional serrated adenomas(TSAs), and sessile serrated adenoma/polyps(SSA/Ps). Both HP and SSA/P often present as dark-green colors on auto fluorescence imaging(AFI) colonoscopy that are similar to the normal surrounding mucosa. In contrast, TSAs often have elevated shapes and present as magenta colors that are similar to the tubular adenomas. The superficial type of TSA also includes many lesions that present as magenta colors. When SSA/Ps are associated with cytological dysplasia, many lesions present with magenta colors, whereas lesions that are not associated with cytological dysplasia present with dark-green colors. When observed via narrow band imaging(NBI), many SSA/P include lesions with strong mucous adhesions. Because these lesions are observed with reddish mucous adhesions, we refer to them as "red cap sign" and place such signs among the typical findings of SSA/P. Because the dilatation of the pit in SSA/P is observed as a round/oval black dot on magnified observations, we refer to this finding as Ⅱ-dilatation pit(Ⅱ-D pit) and also positioned it as a characteristic finding of SSA/P. In contrast, dilatations of the capillary vessels surrounding the glands, such as those that occur in tubular adenoma, are not considered to be useful for differentiating HPs from SSA/Ps. However, in cases in which SSA/P is associated with cytological dysplasia, the dilatation of capillary vessels is observed in the same area. When submucosal layer invasion occurs in the same area, the blood flow presents with irregularities that are similar to those of common colorectal cancer at an early stage and disappears as the invasion proceeds deeply. The surface pattern of invasive cancer that is observed at the tumor surface is also likely to disappear. Based on the above results, we considered that the differentiations between HP and TSA, between TSA and SSA/P, and between HP and SSA/P might become easier due to the concomitant use of white light observation and IEE. We also concluded that AFI and NBI can be useful modalities for SSA/P lesions associated with cytological dysplasia.

Utility of endoscopic ultrasound and endoscopy in diagnosis and management of hepatocellular carcinoma and its complications: What does endoscopic ultrasonography offer above and beyond conventional cross-sectional imaging?

Hepatocellular carcinoma constitutes over 90% of the primary liver tumors, the rest being cholangiocarcinoma. It has an insidious presentation, which is responsible for the delayed presentation. Hence, the management strategy relies on screening to diagnose it an early stage for curative resection and/or treatment with local ablative techniques or chemotherapy. However, even with different screening programs, more than 60% of tumors are still detected at an advanced stage, leading to an unchanged mortality rate, thereby implying a room for improvement in the screening and diagnostic process. In the last few years, there has been evolution of utility of endoscopy, specifically endoscopic ultrasonography along with Fine needle aspiration, for this purpose, which we comprehensively review in this article.

Management of gastric variceal bleeding:Role of endoscopy and endoscopic ultrasound

Gastric varices(GVs)are notorious to bleed massively and often difficult to manage with conventional techniques.This mini-review addresses endoscopic management principles for gastric variceal bleeding,including limitations of ligation and sclerotherapy and merits of endoscopic variceal obliteration.The article also discusses how emerging use of endoscopic ultrasound provides optimism of better diagnosis,improved classification,innovative management strategies and confirmatory tool for eradication of GVs.

Percutaneous endoscopic gastrostomy under steadypressure automatically controlled endoscopy:First clinicalseries

AIM: To elucidate the safety of percutaneous endoscopic gastrostomy(PEG) under steady pressure automatically controlled endoscopy(SPACE) using carbon dioxide(CO_2).METHODS: Nine patients underwent PEG with a modified introducer method under conscious sedation. A T-tube was attached to the channel of an endoscope connected to an automatic surgical insufflator. The stomach was inflated under the SPACE system. The intragastric pressure was kept between 4-8 mmH g with a flow of CO_2 at 35 L/min. Median procedure time, intragastric pressure, median systolic blood pressure, partial pressure of CO_2, abdominal girth before and immediately after PEG, and free gas and small intestinal gas on abdominal X-ray before and after PEG were recorded. RESULTS: PEG was completed under stable pneumostomach in all patients, with a median procedural time of 22 min. Median intragastric pressure was 6.9 mmH g and median arterial CO_2 pressure before and after PEG was 42.1 and 45.5 Torr(NS). The median abdominal girth before and after PEG was 68.1 and 69.6 cm(NS). A mild free gas image after PEG was observed in two patients, and faint abdominal gas in the downstream bowel was documented in two patients.CONCLUSION: SPACE might enable standardized pneumostomach and modified introducer procedure of PEG.

Image-enhanced endoscopy for diagnosis of colorectal tumors in view of endoscopic treatment

Recently,image-enhanced endoscopy(IEE) has been used to diagnose gastrointestinal tumors.This method is a change from conventional white-light(WL) endoscopy without dyeing solution,requiring only the push of a button.In IEE,there are many advantages in diagnosis of neoplastic tumors,evaluation of invasion depth for cancerous lesions,and detection of neoplastic lesions.In narrow band imaging(NBI) systems(Olympus Medical Co.,Tokyo,Japan),optical filters that allow narrow-band light to pass at wavelengths of 415 and 540 nm are used.Mucosal surface blood vessels are seen most clearly at 415 nm,which is the wavelength that corresponds to the hemoglobin absorption band,while vessels in the deep layer of the mucosa can be detected at 540 nm.Thus,NBI also can detect pit-like structures named surface pattern.The flexible spectral imaging color enhancement(FICE) system(Fujifilm Medical Co.,Tokyo,Japan) is also an IEE but different to NBI.FICE depends on the use of spectral-estimation technology to reconstruct images at different wavelengths based on WL images.FICE can enhance vascular and surface patterns.The autofluorescence imaging(AFI) video endoscope system(Olympus Medical Co.,Tokyo,Japan) is a new illumination method that uses the difference in intensity of autofluorescence between the normal area and neoplastic lesions.AFI light comprises a blue light for emitting and a green light for hemoglobin absorption.The aim of this review is to highlight the efficacy of IEE for diagnosis of colorectal tumors for endoscopic treatment.

Ling classification describes endoscopic progressive process of achalasia and successful peroral endoscopy myotomy prevents endoscopic progression of achalasia

AIM To verify the hypothesis that the Ling classification describes the endoscopic progressive process of achalasia and determine the ability of successful peroral endoscopic myotomy (POEM) to prevent endoscopic progression of achalasia. METHODS We retrospectively reviewed the endoscopic findings, symptom duration, and manometric data in patients with achalasia. A total of 359 patients (197 women, 162 men) with a mean age of 42.1 years (range, 12-75 years) were evaluated. Symptom duration ranged from 2 to 360 mo, with a median of 36 mo. Patients were classified with Ling type I (n = 119), II a (n = 106),II b (n = 60),II c (n = 60), or III (n = 14), according to the Ling classification. Of the 359 patients, 349 underwent POEM, among whom 21 had an endoscopic follow-up for more than 2 years. Pre-treatment and post-treatment Ling classifications of these 21 patients were compared. RESULTS Symptom duration increased significantly with increasing Ling classification (from I to III) (p < 0.05), whereas lower esophageal sphincter pressure decreased with increasing Ling type (from I to III) (p < 0.05). There was no difference in sex ratio or onset age among the Ling types, although the age at time of diagnosis was higher in Ling types I c and III than in Ling types I, IIa, and I b. Of the 21 patients, 19 underwent high-resolution manometry both before and after treatment. The mean preoperative and postoperative lower esophageal sphincter pressure were 34.6 mmHg (range, 15.3-59.4 mmHg) and 15.0 mmHg (range, 2.1-21.6 mmHg), respectively, indicating a statistically significant decrease after POEM. All of the 21 patients were treated successfully by POEM (postoperative Eckardt score <= 3) and still had the same Ling type during a mean follow-up period of 37.8 mo (range, 24-51 mo). CONCLUSION The Ling classification represents the endoscopic progressive process of achalasia and may be able to serve as an endoscopic assessment criterion for achalasia. Successful POEM (Eckardt score <= 3) seems to have the ability to prevent endoscopic evolvement of achalasia. However, studies with larger populations are warranted to confirm our findings.

Magnifying endoscopy in upper gastroenterology for assessing lesions before completing endoscopic removal

Any prognosis of gastrointestinal (GI) cancer is closely related to the stage of the disease at diagnosis.Endoscopic submucosal dissection (ESD) and en bloc endoscopic mucosal resection (EMR) have been performed as curative treatments for many early-stage GI lesions in recent years.The technologies have been widely accepted in many Asian countries because they are minimally invasive and supply thorough histopathologic evaluation of the specimens.However,before engaging in endoscopic therapy,an accurate diagnosis is a precondition to effecting the complete cure of the underlying malignancy or carcinoma in situ.For the past few years,many new types of endoscopic techniques,including magnifying endoscopy with narrow-band imaging (MENBI),have emerged in many countries because these methods provide a strong indication of early lesions and are very useful in determining treatment options before ESD or EMR.However,to date,there is no comparable classification equivalent to "Kudo's Pit Pattern Classification in the colon",for the upper GI,there is still no clear internationally accepted classification system of magnifying endoscopy.Therefore,in order to help unify some viewpoints,here we will review the defining optical imaging characteristics and the current representative classifications of microvascular and microsurface patterns in the upper GI tract under ME-NBI,describe the accurate relationship between them and the pathological diagnosis,and their clinical applications prior to ESD or en bloc EMR.We will also discuss assessing the differentiation and depth of invasion,defying the lateral spread of involvement and targeting biopsy in real time.

Conventional colonoscopy and magnified chromoendoscopy for the endoscopic histological prediction of diminutive colorectal polyps: A single operator study

AIM： To accurately differentiate the adenomatous from the non-adenomatous polyps by colonoscopy. METHODS： All lesions detected by colonoscopy were first diagnosed using the conventional view followed by chromoendoscopy with magnification. The diagnosis at each step was recorded consecutively. All polyps were completely removed endoscopically for histological evaluation. The accuracy rate of each type of endoscopic diagnosis was evaluated, using histological findings as gold standard. RESULTS： A total of 240 lesions were identified, of which 158 （65.8%） were non-neoplastic and 82 （34.2%） were adenomatous. The overall diagnostic accuracy of conventional view, and chromoendoscopy with magnification was 76.3% （183/240） and 95.4% （229/240）, respectively （P〈 0.001） CONCLUSION： The combination of colonoscopy and magnified chromoendoscopy is the most reliable nonbiopsy method for distinguishing the non-neoplastic from the neoplastic lesions.

Outcome of non-variceal acute upper gastrointestinal bleeding in relation to the time of endoscopy and the experience of the endoscopist: A two-year survey

AIM: To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital.METHODS: All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered.RESULTS: Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience.Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8±0.6 vs 3.0±1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy.On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy.CONCLUSION: Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.

Endoscopic shielding technique, a new method in therapeutic endoscopy

Prevention of late complications after large endoscopic resection is inefficient with current methods.Endoscopic shielding,as a simple and safe technique,has been proposed to improve the incidence of these events.Different methods,sheets or hydrogels,have showed proven efficacy in the prevention of late bleeding and perforation,as well as the improvement of tissue repair,in experimental models and in clinical practice.

Evolving roles of magnifying endoscopy and endoscopic resection for neoplasia in inflammatory bowel diseases

Magnifying endoscopy is a useful technique to differentiate neoplasia from non-neoplastic lesions. Data regarding the clinical utility of magnifying endoscopy for neoplasia in patients with inflammatory bowel disease(IBD) has been emerging.While Kudo’s pit pattern types Ⅲ-Ⅴ are findings suggestive of neoplasia in non-IBD patients, these pit patterns are predictive of IBD-associated neoplasia as well.However, active chronic inflammatory processes, particularly regenerative changes, can mimic neoplastic pit patterns and may affect a meticulous evaluation of pit pattern diagnosis in patients with IBD. The clinical evidence regarding the utility of magnifying endoscopy with narrow band imaging or endocytoscopy has also been evolving in regard to the diagnosis of IBD-associated neoplasia. These advanced endoscopic techniques are promising for multiple reasons;not only for making an accurate diagnosis of neoplasia, but also in determining if endoscopic resection is appropriate for such lesions in patients with IBD. In this review, we discuss the diagnostic accuracy and limitations of magnifying endoscopy in assessing IBD-associated neoplasia and examine the feasibility and outcomes of endoscopic resection for these lesions.

Third-look endoscopy prevents delayed bleeding after endoscopic submucosal dissection under antithrombotic therapy

BACKGROUND Postoperative delayed bleeding(PDB) after gastric endoscopic submucosal dissection(ESD) is the most common adverse event in patients receiving antithrombotics even with second-look endoscopy. Moreover, with the increasing prevalence of cardiovascular and cerebrovascular diseases in an aging population with associated lifestyle-related diseases, an increasing number of patients receive antithrombotics. Several attempts have been made to prevent PDB in aging population;however, a consensus has yet to be reached.AIM To examine the efficacy of third-look endoscopy(TLE) for PDB prevention.METHODS One hundred patients with early gastric neoplasms receiving antithrombotics were prospectively enrolled and subjected to ESD with TLE between February 2017 and July 2019. The primary endpoint was PDB rate, which was compared with our preset threshold. Furthermore, we divided the bleeding period into early-and late-onset PDB(E-PDB and L-PDB, respectively) and analyzed its rate. As a secondary analysis, we compared PDB rates with those of a historical control group, using propensity score matching, and calculated the PDB rates per antithrombotic agent use in each group.RESULTS In total, 96 patients and 114 specimens were finally evaluated. The overall PDB rate was 7.9%(9/114) [90%CI: 4.7-13.1, P = 0.005], while the late-and early-onset PDB rates(L-PDB and E-PDB) were 5.3% [90%CI: 2.7-9.9, P < 0.0001] and 2.6% [90%CI: 1.1-6.4, P = 0.51], respectively. Propensity score matching generated 58 matched pairs for TLE and control groups. No differences were found in overall PDB incidence(10.3% vs 20.7%, P = 0.12), whereas L-PDB occurrence significantly differed(5.2% vs 17.2%, P = 0.04) between groups. Considering antithrombotics' use, the overall PDB rate was higher for direct oral anticoagulants and multiple antithrombotics in the control group, while L-PDB incidence was lower in the TLE group for these agents(8.7% vs 23.1% and 5.0% vs 29.4%, respectively).CONCLUSION TLE for gastric ESD reduces overall PDB, and especially L-PDB incidence, among patients receiving antithrombotics.

Usefulness of magnifying endoscopy in post-endoscopic resection scar for early gastric neoplasm:A prospective short-term follow-up endoscopy study

AIM： To investigate the relationship between postendoscopic resection （ER） scars on magnifying endoscopy （ME） and the pathological diagnosis in order to validate the clinical significance of ME. METHODS： From January, 2007 to June, 2008, 124 patients with 129 post-ER scar lesions were enrolled. Mucosal pit patterns on ME were compared with conventional endoscopy （CE） findings and histological results obtained from targeted biopsies. RESULTS： CE findings showed nodular scars （53/129）, erythematous scars （85/129）, and ulcerative scars （4/129）. The post-ER scars were classified into four pit patterns of sulci and ridges on ME： （ Ⅰ ） 47 round; （Ⅱ） 54 short rod or tubular; （Ⅲ） 19 branched or gyrus-like;and （Ⅳ） 9 destroyed pits. Sensitivity and specificity were 88.9% and 62.5%, respectively, by the presence of nodularity on CE. Erythematous lesions were high sensitivity （100%）, but specificity was as low as 36.7%. The range of the positive predictive va ue （PPV） on CE was as low as 10.6%-25%. Nine type N pit patterns were diagnosed as tumor lesions, and 120 cases of type Ⅰ-Ⅲ pit patterns revealed non-neoplastic lesions. Thus, the sensitivity, specificity, and the PPV of ME were 100%. CONCLUSION： ME findings can detect the presence of tumor in post-ER scar lesions, and make evident the biopsy target site in short-term follow-up. Further large-scale and long-term studies are needed to determine whether ME can replace endoscopic biopsy.

Endoscopic non-technical skills team training:The next step in quality assurance of endoscopy training

AIM: To investigate whether novel, non-technical skills training for Bowel Cancer Screening (BCS) endoscopy teams enhanced patient safety knowledge and attitudes.