Yoshikazu Inagaki

Background and study aims: Post-endoscopic submucosal dissection (ESD) coagulation syndrome (PECS) is defined as abdominal pain with inflammatory responses, requiring careful differentiation from delayed perforation (DP). This study aimed to evaluate clinical and biochemical characteristics associated with PECS and DP following ESD, and to develop a scoring system for predicting PECS. Patients and methods: We retrospectively analyzed 318 consecutive patients who underwent colorectal ESD at our institution between January 2022 and June 2024. Patients were classified into three groups: PECS (n=32), DP (n=7), and no-PECS/no-DP (NPD) (n=279). Multivariate analysis was performed to identify predictors of PECS for clinical factors and values such as C-reactive protein (CRP), white blood cell (WBC) count, and body temperature. Based on significant predictors, we constructed a five-variable PECS-predictive scoring system (FPSS) for early post-procedure prediction of PECS. Results: Among 318 patients, the incidence of PECS and DP was 10.1% and 2.2%, respectively. DP cases demonstrated greater CRP elevation (p<0.001) and higher leukocytosis (p=0.011) compared with PECS, while PECS cases showed significantly higher WBC (p<0.001) and CRP (p<0.001) than the NPD group. Multivariate analysis identified five independent predictors of PECS: right colon (OR=3.54; p=0.004), female gender (OR=2.10; p=0.018), body temperature ≥37.6°C (OR=16.70; p8,000/µL on day 1 (OR=13.78; p24 mm (OR=3.03; p=0.003). The FPSS (range 0–9) achieved an AUC of 0.881, with high negative predictive value (97.4%). Conclusion: The characteristics of PECS were clarified in comparison with NPD and DP, and the newly developed FPSS demonstrated excellent diagnostic performance of PECS.

Background and Objectives: Bowel bubble formation during colonoscopy can impair mucosal visualization and reduce procedural efficiency. However, its clinical significance remains incompletely characterized. This study aimed to evaluate the prevalence of severe bowel bubbles in the proximal colon and their impact on colonoscopic quality in patients undergoing bowel preparation with oral sulfate solution (OSS), using either a same-day regimen (SAR) with 480 mL OSS or a split-day regimen (SPR) with 960 mL OSS. Methods: This retrospective study was conducted between October 2024 and December 2025 across two affiliated institutions. Patients who underwent colonoscopy with OSS-based bowel preparation were included. SAR was used for screening, symptomatic evaluation, and surveillance colonoscopy. SPR was applied exclusively to patients with a prior history of sodium picosulfate-related abdominal pain or inadequate bowel preparation with SAR. Sodium picosulfate was prescribed on the day before colonoscopy in the SAR group and a low-residual diet was administered in both the SAR and SPR groups. The prevalence of severe bubbles in the proximal colon was evaluated, and their impact on colonoscopic quality was examined. Results: A total of 176 SAR cases and 51 SPR cases were analyzed. The rate of severe bubbles in the proximal colon was identical between both regimens (17.6%). Compared with cases without severe bubbles, those with severe bubbles had significantly longer cecal insertion times (median [IQR]: 7.0 [5.0–10.0] vs. 9.0 [7.0–13.0] min, p = 0.018) and total procedure time (20.0 [16.0–25.0] vs. 24.0 [19.0–30.0] min, p = 0.024). Preparation-to-colonoscopy time was also longer in cases with severe bubbles (5.0 [4.0–5.5] vs. 5.0 [5.0–6.0] h, p = 0.041). Adenoma detection rates were 73.2% in cases without severe bubbles and 67.5% in those with severe bubbles (p = 0.571). Conclusions: Severe bowel bubble formation tended to be associated with longer cecal insertion and total procedure times, and was more frequently observed with a longer preparation-to-colonoscopy interval.

Background and Aim: Delayed bleeding after colorectal ESD is a significant adverse event, particularly in patients receiving anticoagulants. However, the optimal timing for resuming anticoagulant therapy remains unclear. This study aimed to determine the optimal timing for resuming anticoagulants after colorectal ESD. Methods: We retrospectively analyzed data from 1309 colorectal ESD cases including 957 on direct oral anticoagulants (DOACs) and 365 on warfarin from the ABCD‐J study, which included 34 450 colorectal ESD cases across 47 Japanese institutions. Patients were categorized into two groups based on the timing of anticoagulant resumption: early (resumption within 1 day post‐ESD) and late (resumption two or more days post‐ESD). After propensity score matching, delayed bleeding, delayed perforation, and thromboembolic events were compared between groups. Results: Overall, 334 matched cases were analyzed in the early and late groups. There was no significant difference in the overall delayed bleeding rate between the two groups (9.6% vs. 6.6%, p = 0.201). In the entire cohort, before resumption, the bleeding rate was significantly lower in the early group (1.18% vs. 3.23%, p = 0.013). Conversely, after resumption, it was significantly higher in the early group (9.42% vs. 6.02%, p = 0.041). Additionally, there was no significant difference in thromboembolic event rates between the groups (0% vs. 0%, p = 1.000). Subgroup analyses showed no significant difference in delayed bleeding rates within the matched groups for DOAC (210 cases; 9.0% vs. 6.2%, p = 0.358) or warfarin (105 cases; 11.4% vs. 6.7%, p = 0.336). Conclusions: The early resumption of anticoagulants within 1 day post‐ESD did not significantly increase delayed bleeding.

Background/Objectives: White light imaging (WLI) of colonoscopy has a 26% adenoma miss rate. We aimed to evaluate the effectiveness of an additional 30 s (Add-30s) observation of the right-sided colon using a novel system (EVIS X1; Olympus Co.) with texture and color enhancement imaging (TXI). Methods: We reviewed 515 patients who underwent colonoscopy with Add-30s TXI between February 2021 and December 2023 at three affiliated hospitals. After initial right-sided colon observation with WLI, the colonoscope was reinserted into the cecum, and the right-sided colon was re-observed with Add-30s TXI. Adenoma and sessile serrated lesion (SSL) detection rate (ASDR) and adenoma detection rate (ADR) were examined. Multivariate analysis identified factors influencing lesion detection using the Add-30s TXI. The difference in WLI and TXI between the novel and previous scopes was performed using propensity score matching (PSM). The efficacy of WLI with the novel system was compared to that of the previous system. Results: Among the 515 cases, Add-30s TXI observation increased right-sided ADR and ASDR by 7.4% and 9.5%, respectively. The multivariate analysis showed novel scope as an independent factor for adenoma and SSL detection (odds ratio: 2.41, p < 0.01). Right-sided ADR and ASDR for Add-30s TXI were significantly higher in the novel scope than the previous scope (ADR, 25.2% vs. 15.3%; p = 0.04; ASDR, 32.4% vs. 18.9%; p = 0.02). ASDR for WLI observation was significantly higher in the novel system than the previous system (34.8% vs. 25.9%; p < 0.01). Conclusions: Add-30s TXI significantly improved the detection of missed adenomas and SSLs in the right-sided colon.

Background and Aim: Injection solution is important for achieving submucosal elevation in endoscopic submucosal dissection (ESD) and various viscous solutions categorized as low‐concentration injection solution (LCS) or high‐concentration injection solution (HCS) are used. We analyzed the difference between LCS and HCS in colorectal ESD.Methods: This was a prospective, randomized controlled trial at six Japanese institutions. Patients with early neoplastic lesions of ≥ 20 mm were enrolled from March 2022 to September 2023. Sodium alginate (Liftal K, Kaigen Pharma Co., Osaka, Japan) was used as the injection solution, and the concentration of HCS and LCS was set at 0.6% and 0.3%, respectively. Participants were randomized to HCS or LCS groups and the primary endpoint was the noninferiority about ESD procedure time of LCS compared to HCS.Results: The LCS and HCS groups consisted of 79 and 82 cases, respectively. The ESD procedure time (min, mean ± standard deviation) was significantly noninferior between the LCS and HCS groups (p < 0.001) and was significantly shorter in the LCS group than in the HCS group (61.9 ± 39.2 vs. 76.9 ± 67.5, p = 0.044). There were no significant differences in en bloc resection (98.7% vs. 100.0%, p = 0.985), perioperative perforation (2.5% vs. 2.4%, p = 0.639), and delayed bleeding (1.3% vs. 1.2%, p = 0.493). In the subgroup analysis, the ESD procedure times were significant for lesions of ≥ 40 mm (74.3 ± 30.4 vs. 125.3 ± 107.2, p = 0.031) and experts (51.5 ± 29.2 vs. 69.4 ± 58.9, p = 0.046). Additionally, injection volumes (mL) were not significant (38.0 ± 20.2 vs. 33.0 ± 27.0, p = 0.098) in the two groups.Conclusion: LCS was noninferior to HCS in terms of procedure time and significantly reduced it.Trial Registration: University Hospital Medical Information Network Clinical Trials Registry number: UMIN000048661.

In the above-mentioned article the affiliaton number 7 has been corrected. Correct is: Hepatology and Gastroenterology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt. This was corrected in the online version on November 13, 2024. Article published online: 13 November 2024 © 2024. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

The MANTIS Closure Device (MCD; Boston Scientific, Marlborough, Massachusetts, USA) is a reopenable clip with a sharp claw used for closure after endoscopic submucosal dissection (ESD). We evaluated the effectiveness of the MCD for fast and complete closure after colorectal ESD.Cases involving closure with the MCD after ESD of 20–60-mm colorectal lesions between April 2023 and January 2024 were reviewed. The primary end point was complete closure of the ESD defect with the MCD. Secondary end points included closure time, delayed bleeding, delayed perforation, and post-ESD coagulation syndrome (PECS). MCD application involved: 1) grasping the mucosa on the anal-side of the defect; 2) pushing the clip toward the oral-side mucosa and deploying it; 3) adding other reopenable clips for complete closure.61 cases involving MCD were analyzed. Mean tumor size was 32.3 (SD 9.2) mm. Complete closure rate was 98.4% and mean closure time was 6.9 (SD 2.6) minutes. The mean number of MCDs and other clips used was 1.0 (SD 0.1) and 4.7 (SD 1.4), respectively. Rates of delayed bleeding, delayed perforation, and PECS were 0%, 0%, and 9.8%, respectively.Fast and complete closure after colorectal ESD was successfully achieved using the MCD.

Background and study aims We previously demonstrated the efficacy of an additional-30-seconds (Add-30s) observation with linked color imaging (LCI) or narrow band imaging (NBI) of the cecum and ascending colon (right-sided colon) after white light imaging (WLI) observation for improving adenoma detection rate (ADR) by 3% to 10%. We herein compared Add-30s LCI with Add-30s NBI in a large number of cases. Patients and methods We retrospectively collected 1023 and 1011 cases with Add-30s LCI and NBI observation for right-sided colon in 11 affiliated institutions from 2018 to 2022 and propensity score matching was performed. Add-30s observation was as follows. First observation: WLI observation of the right-sided colon as first observation. Second observation: Reobservation of right-sided colon by Add-30s LCI or NBI. The comparison of the mean numbers of adenoma+sessile serrated lesions (SSLs) and adenomas per patient (MASP and MUTYH-associated polyposis) were analyzed in the Add-30s LCI/NBI groups. The increase in right-sided ADR was also analyzed in the groups. Results Among 748 matched cases in the Add-30s LCI/NBI groups, the MASP and MAP were 0.18/0.19 (P = 0.54) and 0.14/0.15 (P = 0.70). Among experts, they were 0.17/0.22 (P = 0.16) and 0.15/0.21 (P = 0.08). Among non-experts, they were 0.13/0.12 (P = 0.71) and 0.12/0.07 (P = 0.04). The right-sided ADRs of the first+second observations in the LCI and NBI groups were 32.2% and 28.9% (P = 0.16) and the increase of ADRs were 7.5% and 7.2% (P = 0.84). Conclusions In right-sided colon, the detection of adenoma/SSL did not differ between Add-30s LCI and NBI. Both of them significantly increased ADR.

Background and Aim: A hemostatic gel, PuraStat (3‐D Matrix, Tokyo, Japan), is used for various gastrointestinal hemostasis. In this study, we analyzed the efficacy of PuraStat for perioperative bleeding (POB) and prevention of delayed bleeding (DB) to colorectal cold snare polypectomy (CSP) with continuous anticoagulant.Methods: This was a single‐center, retrospective study. Subjects were lesions of 2–9 mm under continuous anticoagulant from 2021 to 2023 and treated with PuraStat for POB. The definition of POB was bleeding which did not stop spontaneously by 1.0–1.5 min after resection and needed hemostasis. Successful hemostasis was defined as cessation of bleeding within 1.0–1.5 min after spraying PuraStat and the rate of it and risk factors of POB were analyzed. For comparison, cases receiving previous CSP without PuraStat were extracted from all cases with CSP (2018‐2021), and POB and DB rate (DBR) were analyzed after propensity score matching.Results: One hundred twenty‐two lesions (91: direct oral anticoagulant (DOAC), 31: warfarin) with anticoagulant were analyzed and the rate of successful hemostasis with PuraStat was 92.6% (DOAC/warfarin: 93.4%/80.6%, P = 0.01). The rate of DB was 0.0%. Multivariate analysis showed that significant risk factors about unsuccessful hemostasis for POB with PuraStat were lesion size 8–9 mm (P < 0.01), warfarin (P = 0.01), and combination of antiplatelet (P = 0.01). Regarding the comparison about CSP with/without PuraStat, the clipping rate and DBR were 8.5%/94.9% (P < 0.01) and 0%/1.7% (P = 1.0).Conclusion: The effects of PuraStat for POB and DB in colorectal CSP with continuous anticoagulant were acceptable.