Cancer risk in patients with Peutz-Jeghers syndrome in Korea: a retrospective multi-center study

Background/Aims@#There have been little research on the cancer risks of patients with Peutz-Jeghers syndrome (PJS) in Korea. We aimed to investigate the clinical features of PJS patients and their cancer incidence rate. @*Methods@#Patients with PJS from nine medical centers were enrolled. In those patients diagnosed with cancer, data obtained included the date of cancer diagnosis, the tumor location, and the cancer stage. The cumulative risks of gastrointestinal cancers and extra-gastrointestinal cancers were calculated using the Kaplan-Meier method. @*Results@#A total of 96 PJS patients were included. The median age at diagnosis of PJS was 23.4 years. Cancer developed in 21 of the 96 patients (21.9%). The age of PJS diagnosis was widely distributed (0.9 to 72.4 years). The most common cancers were gastrointestinal cancer (n = 12) followed by breast cancer (n = 6). The cumulative lifetime cancer risk was calculated to be 62.1% at age 60. The cumulative lifetime gastrointestinal cancer risk was 47.1% at age 70. The cumulative lifetime extra- gastrointestinal cancer risk was 40.3% at age 60. @*Conclusions@#PJS onset may occur at any age and the risks of gastrointestinal and extra-gastrointestinal cancer are high. Thorough surveillance of PJS patients for malignancies is vital.

Enteroscopy in Crohn’s Disease: Are There Any Changes in Role or Outcomes Over Time? A KASID Multicenter Study

Background/Aims@#Although balloon-assisted enteroscopy (BAE) enables endoscopic visualization of small bowel (SB) involvement in Crohn’s disease (CD), there is no data on the changes in outcomes over time. We therefore investigated the changes in BAE use on CD patients over different time periods in terms of its role and clinical outcomes. @*Methods@#We used a multicenter enteroscopy database to identify CD patients with SB involvement who underwent BAE (131 procedures, 116 patients). We compared BAE-related factors and outcomes between the first period (70 procedures, 60 patients) and the second period (61procedures, 56 patients). The specific cutoff point for dividing the two periods was 2007, when BAE guidelines were introduced. @*Results@#Initial diagnosis of SB involvement in CD was the most common indication for BAE during each period (50.0% vs 31.1%, p=0.034). The largest change was in the number of BAE uses for stricture evaluation and/or treatment, which increased significantly in the latter period (2.9% vs 21.3%, p=0.002). The diagnostic yield in patients with suspected CD was 90.7% in the first period and 95.0% in the second (p=0.695). More endoscopic interventions were performed in the second period than in the first (5.1% vs 17.6%, p=0.041). Enteroscopic success rates were high throughout (100% in the first period vs 80.0% in the second period, p>0.999). In the first and second periods, therapeutic plans were adjusted in 62.7% and 61.4% of patients, respectively. @*Conclusions@#The overall clinical indications, outcomes, and effectiveness of BAE were constant over time in CD patients with SB involvement, with the exception that the frequency of enteroscopic intervention increased remarkably.

Clinical Significance of Residual Nonrectal Inflammation in Ulcerative Colitis Patients in Clinical Remission

Background/Aims@#The treatment goal of ulcerative colitis (UC) has been changed to achieve endoscopic remission (ER). However, there is insufficient clinical evidence to determine whether a step-up treatment should be performed to achieve ER in clinical remission (CR) without ER, and there are inadequate data on the need to consider the distribution and severity of residual inflammation. This retrospective study aimed to evaluate the prognostic significance of the distribution and severity of residual inflammation in UC patients in CR. @*Methods@#A total of 131 UC patients in CR who underwent endoscopic evaluation for more than three times between January 2000 and December 2018 were reviewed. The patients were allocated by the endoscopic healing state and the distribution of inflammation to ER (n=31, 23.7%), residual nonrectal inflammation with patchy distribution (NRI) (n=17, 13.0%) or residual rectal involvement with continuous or patchy distribution (RI) (n=83, 63.3%) groups. We reviewed clinical characteristics, endoscopic findings, and factors associated with poor outcome-free survival (PFS). @*Results@#In UC patients in CR, PFS was significantly higher in the ER and NRI groups than in the RI group (p=0.003). Patients in the ER and NRI groups had similar PFS (p=0.647). Cox proportional hazard model showed only RI (hazard ratio, 5.76; p=0.027) was associated with a higher risk of poor outcome. @*Conclusions@#We suggest that escalation of treatment modalities may be selectively performed in consideration of the residual mucosal inflammation pattern, even if ER has not been achieved, in UC patients with CR.

Long-term Prognosis of Localized Lymphoid Hyperplasia of the Rectum

Background/Aims@#Although localized lymphoid hyperplasia (LLH) of the rectum is occasionally observed, its clinical implications are unclear. This study aimed to investigate the clinical course and significance of LLH of the rectum. @*Methods@#We identified 65 patients diagnosed with LLH of the rectum using a histopathologic examination and who received follow-up endoscopies between January 2009 and June 2015. Patients with a history of inflammatory bowel disease, lymphoma, familial adenomatous polyposis, or uncontrolled malignancy and patients who underwent scar biopsy after endoscopic resection or surgery were excluded. Endoscopic findings and clinical courses were analyzed. @*Results@#During the median follow-up of 31 months (interquartile range, 19 to 40 months), 81.5% (53/65) of LLHs of the rectum were resolved. Clinically significant diseases, including ulcerative colitis (UC, n=5) and mucosa-associated lymphoid tissue (MALT) lymphoma (n=1), were diagnosed in 9.2% of patients (6/65). The other six patients showed no significant changes in the lesion (n=3) or a waxing and waning appearance (n=3). According to endoscopic findings, all of the 47 polypoid types showed resolution or waxing and waning patterns. Five of the 11 nodular types (45.5%) developed into UC. One of the seven submucosal tumor (SMT)-like types (14.3%) developed into MALT lymphoma. @*Conclusions@#LLH of the rectum with persistent symptoms or the endoscopic appearance of the nodular or SMT-like type may lead to clinically significant disease. Risk stratification according to endoscopic findings and careful surveillance are required for these lesions.

Enteroscopy in Crohn’s Disease: Are There Any Changes in Role or Outcomes Over Time? A KASID Multicenter Study

Background/Aims@#Although balloon-assisted enteroscopy (BAE) enables endoscopic visualization of small bowel (SB) involvement in Crohn’s disease (CD), there is no data on the changes in outcomes over time. We therefore investigated the changes in BAE use on CD patients over different time periods in terms of its role and clinical outcomes. @*Methods@#We used a multicenter enteroscopy database to identify CD patients with SB involvement who underwent BAE (131 procedures, 116 patients). We compared BAE-related factors and outcomes between the first period (70 procedures, 60 patients) and the second period (61procedures, 56 patients). The specific cutoff point for dividing the two periods was 2007, when BAE guidelines were introduced. @*Results@#Initial diagnosis of SB involvement in CD was the most common indication for BAE during each period (50.0% vs 31.1%, p=0.034). The largest change was in the number of BAE uses for stricture evaluation and/or treatment, which increased significantly in the latter period (2.9% vs 21.3%, p=0.002). The diagnostic yield in patients with suspected CD was 90.7% in the first period and 95.0% in the second (p=0.695). More endoscopic interventions were performed in the second period than in the first (5.1% vs 17.6%, p=0.041). Enteroscopic success rates were high throughout (100% in the first period vs 80.0% in the second period, p>0.999). In the first and second periods, therapeutic plans were adjusted in 62.7% and 61.4% of patients, respectively. @*Conclusions@#The overall clinical indications, outcomes, and effectiveness of BAE were constant over time in CD patients with SB involvement, with the exception that the frequency of enteroscopic intervention increased remarkably.

Clinical Significance of Residual Nonrectal Inflammation in Ulcerative Colitis Patients in Clinical Remission

Background/Aims@#The treatment goal of ulcerative colitis (UC) has been changed to achieve endoscopic remission (ER). However, there is insufficient clinical evidence to determine whether a step-up treatment should be performed to achieve ER in clinical remission (CR) without ER, and there are inadequate data on the need to consider the distribution and severity of residual inflammation. This retrospective study aimed to evaluate the prognostic significance of the distribution and severity of residual inflammation in UC patients in CR. @*Methods@#A total of 131 UC patients in CR who underwent endoscopic evaluation for more than three times between January 2000 and December 2018 were reviewed. The patients were allocated by the endoscopic healing state and the distribution of inflammation to ER (n=31, 23.7%), residual nonrectal inflammation with patchy distribution (NRI) (n=17, 13.0%) or residual rectal involvement with continuous or patchy distribution (RI) (n=83, 63.3%) groups. We reviewed clinical characteristics, endoscopic findings, and factors associated with poor outcome-free survival (PFS). @*Results@#In UC patients in CR, PFS was significantly higher in the ER and NRI groups than in the RI group (p=0.003). Patients in the ER and NRI groups had similar PFS (p=0.647). Cox proportional hazard model showed only RI (hazard ratio, 5.76; p=0.027) was associated with a higher risk of poor outcome. @*Conclusions@#We suggest that escalation of treatment modalities may be selectively performed in consideration of the residual mucosal inflammation pattern, even if ER has not been achieved, in UC patients with CR.

How to Choose the Optimal Bowel Preparation Regimen for Colonoscopy / 이화의대지

Colonoscopy is commonly used to screen for and diagnose colorectal disease, and adequate bowel preparation is crucial to its quality. As bowel preparation regimens vary, it is important that clinicians understand each and select the proper one for each patient.Accordingly, here we investigated recent studies and describe how to choose the optimal bowel preparation regimen. We detail composition, dosages, efficacy, contraindications, and precautions of commonly used regimens including 4 L polyethylene glycol (PEG), 2 L PEG+ascorbic acid, 1 L PEG+ascorbic acid, trisulfate (oral sulfate solution/ tablets), and sodium picosulfate/magnesium citrate. Here we describe that the most recently introduced 1 L PEG and oral sulfate tablets, which were developed to improve convenience and compliance, differ in composition and efficacy between South Korea and foreign countries. This review presents new evidence of and differences among products to increase clinician understanding.

Roles of Capsule Endoscopy and Device-Assisted Enteroscopy in the Diagnosis and Treatment of Small-Bowel Tumors

With the development of capsule endoscopy (CE) and device-assisted enteroscopy (DAE), the incidence of small-bowel tumors has increased and the characteristics of these tumors have changed. In addition, the diagnostic and therapeutic approaches for small-bowel tumors have diversified. CE is a simple, noninvasive method that aid in the visualization the entire small bowel. CE is considered the initial approach for small-bowel tumors. DAE can be used to perform endoscopic procedures such as bleeding control, polypectomy, stent insertion, and tattooing, as well as for diagnosis through visualization or tissue sampling. Therapeutic intervention with DAE is particularly useful in polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome. This review will discuss the roles of CE and DAE in the diagnosis and treatment of small-bowel tumors.

Usefulness of Personal Bowel Habits as a Predictive Factor for Inadequate Bowel Preparation for Colonoscopy: A Prospective Questionnaire-Based Observational Study

BACKGROUND/AIMS: The quality of bowel preparation is important for optimal colonoscopy. It is influenced by medical and personal factors. We aimed to evaluate the effect of bowel habit on the quality of bowel preparation and to identify predictors of inadequate bowel preparation among bowel habit factors. METHODS: From June 2017 to September 2017, 90 volunteers were enrolled in this study. Each participant answered a questionnaire consisting of multiple questions about personal bowel habits, including stool form, frequency of bowel movements per week, duration, and degree of straining for bowel movement. Then, all volunteers underwent colonoscopic exam. Eleven endoscopists performed colonoscopies and used the Boston Bowel Preparation Scale (BBPS) as the index for bowel preparation. Two expert endoscopists simultaneously reviewed all colonoscopic images to confirm the final BBPS. Univariate and multivariate logistic regression analyses were performed to verify the correlation between bowel preparation adequacy and bowel habit. RESULTS: Among the 90 participants, 20 (22.2%) had inadequate bowel preparation (total BBPS ≤6 or any segmental BBPS ≤1). In univariate analysis, infrequent bowel movement (0–2/week) (odds ratio [OR], 12.60; 95% confidence interval [CI], 1.22 to 129, p=0.03) and moderate straining (more than 1/4 of defecations) (OR, 4.40; 95% CI, 1.44 to 13.39; p=0.01) were significantly associated with inadequate bowel preparation. However, only moderate straining was significantly associated with inadequate bowel preparation in multivariate analysis (OR, 3.99; 95% CI, 1.26 to 12.65; p=0.02). CONCLUSIONS: Straining is a significant predictor for inadequate bowel preparation. For patients with straining during bowel movements, an intensified preparation regimen should be considered.

Management of Complications of Colorectal Submucosal Dissection

Endoscopic submucosal dissection (ESD) is a useful procedure for the treatment of superficial gastrointestinal neoplasm. Compared with endoscopic mucosal resection (EMR), ESD has several benefits, which include resectability of various difficult lesion, accurate histologic assessment of specimen, and lower recurrence rate. However, the risk of procedure- related complications is higher with ESD than with EMR. Moreover, because the colon has a thin wall and limited endoscopic maneuverability, ESD is considered a more challenging and risky procedure when performed in the colon than in the stomach. ESD-related complications are more likely to occur. The significant complications associated with ESD are bleeding, perforation, coagulation syndrome and stenosis, most of which can be treated and prevented by endoscopic intervention and preparation. Therefore, it is important to know how to occur and manage the ESD related complication.

How to Detect Sessile Serrated Adenoma/Polyps

No abstract available.

Comparison of the Efficacy and Safety of Single- versus Double-Balloon Enteroscopy Performed by Endoscopist Experts in Single-Balloon Enteroscopy: A Single-Center Experience and Meta-Analysis

BACKGROUND/AIMS: Studies concerning the efficacy and safety of single-balloon enteroscopy (SBE) compared with that of double-balloon enteroscopy (DBE) often appear to be conflicting. However, previous studies were performed by endoscopists who were less experienced in SBE compared with DBE. METHODS: We performed a retrospective analysis of SBE and DBE data performed by a single enteroscopist, with expertise in SBE, using a prospective balloon-assisted enteroscopy registry from 2013 to 2015. Furthermore, we performed a comprehensive literature search and meta-analysis of available studies, including the current study, to clarify the efficacy and safety of SBE versus DBE. RESULTS: A total of 65 procedures in 44 patients with SBE and 74 procedures in 69 patients with DBE were analyzed. There were no significant differences in diagnostic yield (61.1% vs 77.3%, respectively, p=0.397), therapeutic yield (39.1% vs 31.8%, respectively, p=0.548), and complication rate (4.4% vs 2.3%, p=1.000). In the meta-analysis, which included four randomized controlled trials and three observational studies, there were no significant differences in the pooled relative risk and odds ratio for diagnostic and therapeutic yield and complications of SBE compared with those of DBE. CONCLUSIONS: The performance of SBE appears to be similar to that of DBE in terms of diagnostic and therapeutic yield and complications.

Clinical characteristics of patients with serrated polyposis syndrome in Korea: comparison with Western patients

BACKGROUND/AIMS: Serrated polyposis syndrome (SPS) has been shown to increase the risk of colorectal cancer (CRC). However, little is known about the characteristics of Asian patients with SPS. This study aimed to identify the clinicopathological features and risk of CRC in Korean patients with SPS as well as the differences between Korean and Western patients based on a literature review. METHODS: This retrospective study included 30 patients with SPS as defined by World Health Organization classification treated at Samsung Medical Center, Korea, between March 1999 and May 2011. RESULTS: Twenty patients (67%) were male. The median patient age at diagnosis was 56 years (range, 39–76 years). A total of 702 polyps were identified during a median follow-up of 43 months (range, 0–149 months). Serrated polyps were noted more frequently in the distal colon (298/702, 55%). However, large serrated polyps and serrated adenomas were mainly distributed throughout the proximal colon (75% vs. 25% and 81% vs. 19%, respectively); 73.3% had synchronous adenomatous polyps. The incidence of CRC was 10% (3/30 patients), but no interval CRC was detected. A total of 87% of the patients underwent esophagogastroduodenoscopy and 19.2% had significant lesions. CONCLUSIONS: The phenotype of SPS in Korean patients is different from that of Western patients. In Korean patients, SPS is more common in men, there were fewer total numbers of serrated adenoma/polyps, and the incidence of CRC was lower than that in Western patients. Korean patients tend to more frequently have abnormal gastric lesions. However, the prevalence of synchronous adenomatous polyps is high in both Western and Korean patients.

Current practices in endoscopic submucosal dissection for colorectal neoplasms: a survey of indications among Korean endoscopists

BACKGROUND/AIMS: The indications for colorectal endoscopic submucosal dissection (ESD) vary in clinical practice. To establish colorectal ESD as a standard treatment, standard indications are essential. For establishing standard indications for colorectal ESD, we surveyed the preferences and criteria of endoscopists for colorectal ESD in their practices. METHODS: A multiple-choice questionnaire was sent to 27 members of the Korean Society of Gastrointestinal Endoscopy/ESD group. The indications of endoscopists for selecting ESD as a treatment for colorectal tumors ≥2 cm in diameter were surveyed. RESULTS: On the basis of the preprocedural assessment of histology, adenoma with high-grade dysplasia, mucosal cancer, and shallow submucosa invasive cancer were included in the indication for ESD. Based on gross morphology, laterally spreading tumor (LST) granular nodular mixed type, LST-nongranular (LST-NG) flat elevated type, and LST-NG pseudodepressed type were included. On the basis of the pit pattern by Kudo classification, types III, IV, and V-I were included. Based on the narrow band imaging pattern by Sano classification, types II and III-a were included. Other lesions, such as sporadic localized tumors in chronic inflammation and local residual early carcinoma after endoscopic resection, were also included in the indication for ESD. CONCLUSIONS: The indications of Korean endoscopists for colorectal ESD are broader than those in recent guidelines, and tend to include more benign-looking tumors. To find the appropriate indications for colorectal ESD, systematic data collection and analysis are required to reach a consensus in a timely manner.

Endoscopic Findings of Enteropathy-Associated T-Cell Lymphoma Type II: A Case Series

Enteropathy-associated T-cell lymphoma (EATL) is a rare extranodal T-cell lymphoma arising from the intestine. Two types of EATL have been reported. In contrast to the classic EATL type I, EATL type II occurs sporadically, is unrelated to celiac disease, and comprises 10% to 20% of all EATL cases. A total of five cases of EATL type II were diagnosed at our clinic from January 2009 to September 2012. Four of the five patients were diagnosed with the help of endoscopy. Among the four patients, two of the cases involved both the small and large intestines, whereas in the other two patients, EATL was limited to the small intestine. Common endoscopic findings included innumerable fine granularities (also called mosaic mucosal patterns) and diffuse thickening of the mucosa with a semicircular shallow ulceration in the lesions of the small bowel. In contrast, the endoscopic findings of the colon were nonspecific and could not distinguish EATL type II from other diseases. There are only few published reports regarding the representative endoscopic findings of EATL. Here, we present the clinical and endoscopic findings of four cases of EATL type II diagnosed by endoscopy.

Wernicke's encephalopathy after total parenteral nutrition in patients with Crohn's disease

Micronutrient deficiencies in Crohn's disease (CD) patients are not uncommon and usually result in a combination of reduced dietary intake, disease-related malabsorption, and a catabolic state. Decreased serum thiamine levels are often reported in patients with CD. Wernicke's encephalopathy (WE) is a severe form of thiamine deficiency that can cause serious neurologic complications. Although WE is known to occur frequently in alcoholics, a number of non-alcoholic causes have also been reported. Here, we report two cases of non-alcoholic WE that developed in two severely malnourished CD patients who were supported by prolonged total parenteral nutrition without thiamine supplementation. These patients complained of sudden-onset ophthalmopathy, cerebellar dysfunction, and confusion. Magnetic resonance imaging allowed definitive diagnosis for WE despite poor sensitivity. The intravenous administration of thiamine alleviated the symptoms of WE dramatically. We emphasize the importance of thiamine supplementation for malnourished patients even if they are not alcoholics, especially in those with CD.

Enteral Nutritional Support in Gastrointestinal and Liver Diseases / 대한소화기학회지

Nutritional support is important because malnutrition is a major contributor to increased morbidity and mortality, decreased quality of life, increased length of hospital stay, and higher healthcare costs. Patients with gastrointestinal disease are at an increased risk of nutritional deterioration due to therapeutic dietary restriction, fasting for the diagnostic tests, loss of appetite due to anorexia or altered nutritional requirement caused by the disease itself. Therefore, it is important that gastroenterologists are aware of the nutritional status of patients and plan a treatment strategy considering patient's nutritional status. Enteral nutrition is preferred to parenteral nutrition as it is more physiologic, has fewer complications, help to prevent mucosal atrophy and maintain gut barrier function, which decrease intestinal bacterial translocation. Hence, enteral nutrition has been considered to be the most effective route for nutritional support. In this article, we will review enteral nutrition (oral nutritional supplements, enteral tube feeding) as a treatment for the patients with gastrointestinal, liver and pancreatic disease at risk of malnutrition.

Uric Acid Is a Risk Indicator for Metabolic Syndrome-related Colorectal Adenoma: Results in a Korean Population Receiving Screening Colonoscopy / 대한소화기학회지

BACKGROUND/AIMS: An association between serum uric acid and cancer risk has been noted over the past few decades. There is ongoing debate about whether hyperuricemia represents an independent risk factor for colorectal neoplasm. We investigated the association between serum uric acid and prevalence of colorectal adenoma considering numerous confounding factors. METHODS: A cross-sectional study was performed with individuals who underwent a routine health check-up examination, including a screening colonoscopy and blood chemistry. The association between serum uric acid and prevalence of colorectal adenoma was estimated from the results of a logistic regression analysis. RESULTS: Of the 1,066 participants, 402 had colorectal adenoma (37.7%). In univariate models, the prevalence of colorectal adenoma was higher in participants in the fourth quartile uric acid level, compared to those in the first quartile uric acid level (OR, 1.67; 95% CI, 1.17-2.42; p=0.004). However, no significant association was detected between serum uric acid and prevalence of colorectal adenoma in multiple logistic regression analysis. A number of metabolic syndrome components exhibited a strong association with the prevalence of colorectal adenoma in the multivariate model (OR, 3.46 for highest vs. lowest; 95% CI, 1.30-9.20; p=0.021). Moreover, serum uric acid was strongly associated with metabolic syndrome-associated variables, including waist circumference, fasting blood glucose, systolic blood pressure, diastolic blood pressure, triglyceride, and high-density lipoprotein. CONCLUSIONS: Uric acid is not an independent risk factor for colorectal adenoma but is a risk indicator for metabolic syndrome-related colorectal adenoma.

Establishment of a Daily E-mail Learning Program Using Intranet and It's Initial Evaluation

BACKGROUND/AIMS: We started a daily web-based E-mail learning program about gastrointestinal (GI) endoscopy. We surveyed the opinion of the E-mail recipients about the usefulness of the daily E-mail learning program. MATERIALS AND METHODS: Using the intranet system, PDF-file based education materials about interesting endoscopic cases were sent to 144 members of Samsung Medical Center every day. It included every resident of the Department of Medicine, and every fellow of the Division of Gastroenterology. They were invited to answer the questionnaires using E-mail. RESULTS: A total of 92 subjects replied the questionnaire (response rate: 64%). About half of the members (47%) answered that they read the education material in the morning. They answered that they read about more than 75% of the material (48%). It took less than 5 minutes to read a daily material (87%). However, only 13 percent answered that they have sent questions to the editor of the program via E-mail. The members wanted more information about GI pharmacologic treatment (54%). Also, they wanted more cases of benign and malignant upper GI diseases (54%). CONCLUSIONS: In our endoscopy unit, we have successfully established a daily E-mail learning program. It seems to be very useful for teaching and learning interesting cases during busy working hours.

Usefulness of Ready-to-Use 0.4% Sodium Hyaluronate (Endo-Ease) in the Endoscopic Resection of Gastrointestinal Neoplasms

BACKGROUND/AIMS: Commercially available sodium hyaluronate solutions are usually too thick to inject through catheters and need dilution with normal saline (NS) before use, which increases the risk of contamination. We evaluated the usefulness of ready-to-use 0.4% sodium hyaluronate, Endo-Ease (EE; UNIMED Pharm. Inc., Seoul, Korea). METHODS: We performed a prospective multicenter randomized study from May 2011 to September 2012. Patients requiring endoscopic resection (ER) for gastric or colorectal neoplasm at two referral hospitals were enrolled. RESULTS: One hundred fifty-four patients (72 with a gastric neoplasm and 82 with a colorectal neoplasm) were included in intention-to-treat analysis. Thirty-seven gastric neoplasms and 43 colorectal neoplasms were enrolled in the EE group. The usefulness rate was significantly higher in the EE group than in the NS group (89.2% vs. 60.0% for gastric neoplasms and 95.3% vs. 67.7% for colorectal neoplasms, p<0.001). In the EE group, the ease of mucosal resection was significantly higher than in the NS group (p<0.001). The injected volume was smaller in the EE group than in the NS group (p<0.05). CONCLUSIONS: The use of EE reduced the need for additional injections and improved the ease of ER. A submucosal injection of EE is useful for the ER of both gastric and colorectal neoplasms.