Reducing adenoma miss rate of colonoscopy assisted by artificial intelligence: a multicenter randomized controlled trial.

BACKGROUND: We have developed the computer-aided detection (CADe) system using an original deep learning algorithm based on a convolutional neural network for assisting endoscopists in detecting colorectal lesions during colonoscopy. The aim of this study was to clarify whether adenoma miss rate (AMR) could be reduced with CADe assistance during screening and surveillance colonoscopy. METHODS: This study was a multicenter randomized controlled trial. Patients aged 40 to 80 years who were referred for colorectal screening or surveillance at four sites in Japan were randomly assigned at a 1:1 ratio to either the "standard colonoscopy (SC)-first group" or the "CADe-first group" to undergo a back-to-back tandem procedure. Tandem colonoscopies were performed on the same day for each participant by the same endoscopist in a preassigned order. All polyps detected in each pass were histopathologically diagnosed after biopsy or resection. RESULTS: A total of 358 patients were enrolled and 179 patients were assigned to the SC-first group or CADe-first group. The AMR of the CADe-first group was significantly lower than that of the SC-first group (13.8% vs. 36.7%, P < 0.0001). Similar results were observed for the polyp miss rate (14.2% vs. 40.6%, P < 0.0001) and sessile serrated lesion miss rate (13.0% vs. 38.5%, P = 0.03). The adenoma detection rate of CADe-assisted colonoscopy was 64.5%, which was significantly higher than that of standard colonoscopy (53.6%; P = 0.036). CONCLUSION: Our study results first showed a reduction in the AMR when assisting with CADe based on deep learning in a multicenter randomized controlled trial.

Long-term outcomes of patients with recurrent squamous cell carcinoma of the esophagus undergoing salvage endoscopic resection after definitive chemoradiotherapy.

BACKGROUND: Salvage endoscopic resection (ER) has been reported to be effective for patients with local failure of esophageal squamous cell carcinoma (ESCC) after definitive chemoradiotherapy (dCRT). This study aimed to evaluate the long-term outcomes of salvage ER for patients with local failure of ESCC and to identify risk factors associated with disease recurrence after salvage ER. METHODS: This study included 45 patients undergoing salvage ER after dCRT during 2000 to 2017. After ER, all patients were required to undergo surveillance esophagogastroduodenoscopy (EGD) once or twice every year, and a computed tomography (CT) examination was repeated every 3 to 6 months. We assessed short-term outcomes and long-term outcomes. RESULTS: Of the 45 patients in this study, the baseline clinical T stage before dCRT was T1 in 80%, 66% of the patients did not have nodal metastasis. The median time from CRT to the detection of local failure was 11 months (range 2-130 months). The en-bloc resection rate was 46%, and the R0 resection rate was 38%, respectively. Stricture occurred after salvage ER for one case, while adverse events such as bleeding or perforation and ER-related death did not occur. After a median observation period of 57 months, recurrence free survival at 3 years was 58%, overall survival was 72%, and disease specific survival was 81%. In multivariate analysis, clinical N stage before CRT was the only independent risk factor of recurrence after salvage ER (p = 0.04). CONCLUSIONS: Salvage ER might be effective local treatment in patients with local failure after dCRT. For the patients with clinical N stage, frequent surveillance should be performed.

Endoscopic Closure Utilizing Endoloop and Endoclips After Gastric Endoscopic Submucosal Dissection for Patients on Antithrombotic Therapy.

OBJECTIVES: Antithrombotic therapy is a well-known independent risk factor for bleeding after endoscopic submucosal dissection (ESD) of early gastric cancer (EGC). A novel method of ulcer base closure using an endoloop and endoclips has been reported. This study aimed to evaluate the effectiveness of endoscopic closure using an endoloop and endoclips in preventing post-ESD bleeding in patients undergoing gastric ESD on antithrombotic therapy. METHODS: This was a single center, retrospective study. Patients on antithrombotic therapy who underwent gastric ESD were divided into two groups, the closure group and the non-closure group. We analyzed procedural outcomes, post-ESD bleeding rate and factors associated with post-ESD bleeding. RESULTS: Among 400 ESDs with EGCs in 311 patients, 131 ESDs in 110 patients were in the closure group, and 269 ESDs in 217 patients were in the non-closure group (16 patients were overlapped in both groups). Post-ESD bleeding rate was 11.5% (15/131) in the closure group, and 11.9% (32/269) in the non-closure group (p = 0.89). Total sustained closure rate during second look endoscopy was 47.8% (33/69). Post-ESD bleeding rate tended to be lower in the closure group than in the non-closure group for lesions located in the greater curvature (3.6% vs. 11.1%, p = 0.11). In addition, sustained closure rate was significantly higher in the greater curvature than in the lesser curvature (72.0% vs. 34.1%, p < 0.01). Multivariate analysis revealed resection size > 40 mm and heparin bridge were the independent risk factor for post-ESD bleeding. CONCLUSION: Ulcer base closure using endoloop and endoclips did not prevent post-ESD bleeding in patients on antithrombotic therapy.

A novel endoscopic hand-suturing technique for defect closure after colorectal endoscopic submucosal dissection: a pilot study.

BACKGROUND: This study aimed to demonstrate the feasibility of endoscopic hand-suturing (EHS) and attainability of sustained closure after colorectal endoscopic submucosal dissection (ESD). METHODS: EHS was defined as uninterrupted endoscopic suturing of the mucosal defect after colorectal ESD using an absorbable barbed suture and a through-the-scope needle holder. Following individual EHS training using an ex vivo porcine colonic model, two experienced endoscopists performed EHS. Repeat colonoscopy was performed on the third or fourth day after ESD to examine the EHS site. The primary end point was the complete EHS closure rate, and secondary end points were sustained closure and post-ESD bleeding rates. RESULTS: 11 lesions were included. Median size of the mucosal defect was 38 mm (range 25 - 55 mm) and the lesion characteristics were as follows: lower rectum/upper rectum/ascending colon/cecum = 3/3/2/3, and 0-IIa/0-Is + IIa/others = 5/4/2. EHS was not attempted in two patients owing to difficulty in colonoscope reinsertion after ESD and intraoperative perforation, respectively. EHS was performed for nine lesions, and the complete EHS closure rate was 73 %. Median procedure time for suturing was 56 minutes (range 30 - 120 minutes) and median number of stitches was 8 (range 6 - 12). Sustained closure and post-ESD bleeding rates were 64 % and 9 %, respectively. CONCLUSIONS: EHS achieved complete and sustained closure in the colorectum. However, EHS is not currently clinically applicable given the long procedure time. Further modifications of the technique and devices are desirable.

Efficacy of Current Traction Techniques for Endoscopic Submucosal Dissection.

This systematic review aimed to assess the efficacy of the current approach to tissue traction during the endoscopic submucosal dissection (ESD) of superficial esophageal cancer, early gastric cancer, and colorectal neoplasms. We performed a systematic electronic literature search of articles published in PubMed and selected comparative studies to investigate the treatment outcomes of tractionassisted versus conventional ESD. Using the keywords, we retrieved 381 articles, including five eligible articles on the esophagus, 13 on the stomach, and 12 on the colorectum. A total of seven randomized controlled trials and 23 retrospective studies were identified. Clip line traction and submucosal tunneling were effective in reducing the procedural time during esophageal ESD. The efficacy of traction methods in gastric ESD varied in terms of the devices and strategies used depending on the lesion location and degree of submucosal fibrosis. Several prospective and retrospective studies utilized traction devices without the need to reinsert the colonoscope. When pocket creation is included, the traction devices and methods effectively shorten the procedural time during colorectal ESD. Although the efficacy is dependent on the organ and tumor locations, several traction techniques have been demonstrated to be efficacious in facilitating ESD by maintaining satisfactory traction during dissection.

Comparison Between Linked Color Imaging and Blue Laser Imaging for Improving the Visibility of Flat Colorectal Polyps: A Multicenter Pilot Study.

INTRODUCTION: Linked color imaging (LCI) and blue laser imaging-bright (BLI-b) improve the visibility of gastrointestinal lesions. In this multicenter study, we compared the effects of LCI and BLI-b on the visibility of flat polyps with visibility scores and color difference (CD) values, including fast-withdrawal and large-monitor observation. METHODS: We recorded 120 videos of 40 consecutive flat polyps (2-20 mm), adenoma, and sessile serrated adenoma and polyp (SSA/P), using white light imaging (WLI), BLI-b, and LCI from July 2017 to December 2017. All videos were evaluated by eight endoscopists according to a published polyp visibility score of 4 (excellent) to 1 (poor). Additionally, 1.5 ×faster and 1.7 ×sized videos were evaluated. Moreover, we calculated the CD values for each polyp in three modes. RESULTS: The mean LCI scores (3.1 ± 0.9) were significantly higher than the WLI scores (2.5 ± 1.0, p < 0.001) but not significantly higher than the BLI-b scores (3.0 ± 1.0). The scores of faster videos on LCI (3.0 ± 1.1) were significantly higher than WLI (2.0 ± 1.0, p < 0.001) and BLI-b (2.8 ± 1.1, p = 0.03). The scores of larger-sized videos on LCI were not significantly higher than those of WLI or BLI-b. The CD value of LCI (18.0 ± 7.7) was higher than that of WLI (11.7 ± 7.0, p < 0.001), but was not significantly higher than that of BLI-b (16.6 ± 9.6). The CD value of LCI was significantly higher than that of BLI-b for adenoma, but the CD value of BLI-b was significantly higher than that of LCI for SSA/P. CONCLUSIONS: The superiority of LCI to BLI-b was proven for the visibility of adenoma and fast observation.

Multiple Acute Infection by Anisakis: A Case Series.

The ingestion of raw seafood infected with nematode larvae of the Anisakidae family can lead to gastric anisakiasis. The majority of the infections involve a single larva, however, there have been instances of multiple infection. The incidence rate and the characteristics of multiple infection by Anisakis remain poorly understood. We herein present a case of parasitization by multiple Anisakis larvae and describe 14 cases of multiple parasitization representing the largest reported case series to date. Endoscopists should therefore be aware of the potential for multiple infection by Anisakis and the need for a thorough inspection of all parts of the stomach when encountering such cases.

Endoscopic band ligation for colonic diverticular bleeding: possibility of standardization.

BACKGROUND AND AIMS: Endoscopic band ligation (EBL) has been used to achieve hemostasis in patients with colonic diverticular bleeding. The safety and effectiveness of EBL when performed by non-expert endoscopists have not been sufficiently verified. This study aimed to elucidate the feasibility of the EBL technique when performed by non-expert endoscopists and of considering EBL as a standard treatment for colonic diverticular bleeding. PATIENTS AND METHODS: A retrospective cohort study was conducted in a tertiary referral center in Tokyo, Japan, between June 2009 and October 2014. A total of 95 patients treated with EBL were included in the study and were divided into two groups according to whether they had been treated by expert or non-expert endoscopists. Comorbidities, medications, shock index, hemoglobin level on admission, location of the bleeding diverticula, rate of bowel preparation, procedure time, and EBL-associated adverse events were evaluated in each group. Multivariate linear regression analyses were used to investigate factors related to EBL procedure time, which is the time elapsed between marking the site of bleeding with hemoclips and completion of the band release. RESULTS: A total of 47 (49.5 %) procedures were performed by expert endoscopists. In a bivariate analysis, the median EBL procedure times in the expert and non-expert groups were 15 minutes (range 4 - 45) and 11 minutes (range 4 - 36), respectively (P = 0.03). When a multivariate linear regression model was used, EBL for right-sided diverticula was the factor most significantly affecting EBL procedure time. No adverse events were encountered. CONCLUSION: EBL can be safely and effectively performed by non-expert endoscopists. A right-sided location of diverticula was the factor most significantly affecting EBL procedure time.

Risk factors for early rebleeding after endoscopic band ligation for colonic diverticular hemorrhage.

BACKGROUND AND STUDY AIMS: Endoscopic band ligation (EBL) has been used for hemostasis of colonic diverticular hemorrhage. However, early rebleeding (< 30 days after EBL) has been reported in some cases. The aim of this study was to elucidate risk factors for early rebleeding after EBL in treatment of colonic diverticular hemorrhage. PATIENTS AND METHODS: A total of 101 patients with definite diverticular hemorrhage treated using EBL from June 2009 to October 2014 were included in the retrospective cohort study and divided into rebleeding and non-rebleeding groups, depending on the presence or absence of early rebleeding. Patients' ages, comorbid diseases, stigmata of recent hemorrhage (SRH) [active bleeding (AB), non-bleeding visible vessel (NBVV), or adherent clot (AC)], locations of bleeding diverticula, and eversions of the diverticula after EBL were retrospectively evaluated in each group. RESULTS: Early rebleeding occurred in 15 cases. The median time (range) of early rebleeding occurrence was 5 days (range, 2 h to 26 days). Early rebleeding could be managed conservatively and/or endoscopically, except in one case in which surgery was done. Multivariate analysis revealed that age under 50 (adjusted OR, 8.7; 95 % CI 1.6 - 52.5; P = 0.014) and AB (adjusted OR, 4.21; 95 % CI 1.15 - 18.1; P = 0.03) were shown to be significant risk factors. The right side of the colon carried less risk than did the left side (adjusted OR, 0.21; 95 % CI 0.04 - 0.84; P = 0.028). CONCLUSIONS: Younger age, AB of SRH, and leftsided lesions were identified as the risk factors for early rebleeding after EBL in the treatment of colonic diverticular hemorrhage.

Comparison of long-term outcomes between endoscopic band ligation and endoscopic clipping for colonic diverticular hemorrhage.

BACKGROUND AND STUDY AIMS: Long-term outcomes of endoscopic band ligation (EBL) for colonic diverticular hemorrhage have not been reported to date. The aim of this study was to determine the long-term outcomes of EBL and to retrospectively compare them with those of endoscopic clipping (EC) in the treatment of colonic diverticular hemorrhage. PATIENTS AND METHODS: The study included patients with colonic diverticular hemorrhage who were treated with EBL or EC from January 2004 to November 2014 and followed up more than 1 year (61 patients in the EBL group and 39 patients in the EC group). Time-to-event analysis of rebleeding was performed with the Kaplan-Meier method. A follow-up colonoscopy was performed to confirm the disappearance of the banded diverticula in the EBL group. RESULTS: Rebleeding occurred in 21 patients in the EBL group and in 26 patients in the EC group. The cumulative incidence of rebleeding at 1, 12, 24, and 36 months after first treatments was 14 %, 23 %, 26 %, and 41 % in the EBL group and 38 %, 49 %, 59 %, and 68 % in the EC group, respectively. Time-to-event analysis revealed statistically significant data (Log-rank test, P = 0.0036). Scar formation with fold convergence at the previously banded site was observed in 11 of 24 patients who underwent follow-up colonoscopy (46 %). However, late rebleeding (rebleeding more than 30 days after EBL) occurred in five of these 11 cases. CONCLUSIONS: EBL was superior to EC in the treatment of colonic diverticular hemorrhage. However, the risk of rebleeding was not avoided even after the diverticula had been resolved using EBL.

Endoscopic band ligation for bleeding lesions in the small bowel.

AIM: To investigate the safety and efficacy of endoscopic band ligation (EBL) for bleeding lesions in the small bowel. METHODS: This is a retrospective study evaluating EBL in six consecutive patients (three males, three females, 46-86 years of age) treated between May 2009 and February 2014: duodenal vascular ectasia; 1, jejunal bleeding diverticulum; 1, ileal Dieulafoy's lesion; 1 and ileal bleeding diverticula; 3. The success of the initial hemostasis was evaluated, and patients were observed for early rebleeding (within 30 d after EBL), and complications such as perforation and abscess formation. Follow-up endoscopies were performed in four patients. RESULTS: Initial hemostasis was successfully achieved with EBL in all six patients. Eversion was not sufficient in four diverticular lesions. Early rebleeding occurred three days after EBL in one ileal diverticulum, and a repeat endoscopy revealed dislodgement of the O-band and ulcer formation at the banded site. This rebleeding was managed conservatively. Late rebleeding occurred in this case (13 and 21 mo after initial EBL), and re-EBL was performed. Follow-up endoscopies revealed scar formation and the disappearance of vascular lesions at the banded site in the case with a duodenal bleeding lesion, and unresolved ileal diverticula in three cases. Surgery or transarterial embolization was not required without any complications during the median follow-up period of 45 (range, 2-83) mo. CONCLUSION: EBL is a safe and effective endoscopic treatment for hemostasis of bleeding lesions in the small bowel.