ObjectiveTo investigate the success rate of cold snare polypectomy (CSP) for complete resection of 4–9 mm colorectal adenomatous polyps compared with that of hot snare polypectomy (HSP).DesignA prospective, multicentre, randomised controlled, parallel, non-inferiority trial conducted in 12 Japanese endoscopy units. Endoscopically diagnosed sessile adenomatous polyps, 4–9 mm in size, were randomly assigned to the CSP or HSP group. After complete removal of the polyp using the allocated technique, biopsy specimens from the resection margin after polypectomy were obtained. The primary endpoint was the complete resection rate, defined as no evidence of adenomatous tissue in the biopsied specimens, among all pathologically confirmed adenomatous polyps.ResultsA total of 796 eligible polyps were detected in 538 of 912 patients screened for eligibility between September 2015 and August 2016. The complete resection rate for CSP was 98.2% compared with 97.4% for HSP. The non-inferiority of CSP for complete resection compared with HSP was confirmed by the +0.8% (90% CI −1.0 to 2.7) complete resection rate (non-inferiority p<0.0001). Postoperative bleeding requiring endoscopic haemostasis occurred only in the HSP group (0.5%, 2 of 402 polyps).ConclusionsThe complete resection rate for CSP is not inferior to that for HSP. CSP can be one of the standard techniques for 4–9 mm colorectal polyps. (Study registration: UMIN000018328)

INTRODUCTION: The bleeding source of hematochezia is unknown without performing colonoscopy. We sought to identify whether colonoscopy is a risk-stratifying tool to identify etiology and predict outcomes and whether presenting symptoms can differentiate the etiologies in patients with hematochezia. METHODS: This multicenter retrospective cohort study conducted at 49 hospitals across Japan analyzed 10,342 patients admitted for outpatient-onset acute hematochezia. RESULTS: Patients were mostly elderly population, and 29.5% had hemodynamic instability. Computed tomography was performed in 69.1% and colonoscopy in 87.7%. Diagnostic yield of colonoscopy reached 94.9%, most frequently diverticular bleeding. Thirty-day rebleeding rates were significantly higher with diverticulosis and small bowel bleeding than with other etiologies. In-hospital mortality was significantly higher with angioectasia, malignancy, rectal ulcer, and upper gastrointestinal bleeding. Colonoscopic treatment rates were significantly higher with diverticulosis, radiation colitis, angioectasia, rectal ulcer, and postendoscopy bleeding. More interventional radiology procedures were needed for diverticulosis and small bowel bleeding. Etiologies with favorable outcomes and low procedure rates were ischemic colitis and infectious colitis. Higher rates of painless hematochezia at presentation were significantly associated with multiple diseases, such as rectal ulcer, hemorrhoids, angioectasia, radiation colitis, and diverticulosis. The same was true in cases of hematochezia with diarrhea, fever, and hemodynamic instability. DISCUSSION: This nationwide data set of acute hematochezia highlights the importance of colonoscopy in accurately detecting bleeding etiologies that stratify patients at high or low risk of adverse outcomes and those who will likely require more procedures. Predicting different bleeding etiologies based on initial presentation would be challenging.

Background/Aims Evidence that general anesthesia (GA) reduces the operative time of esophageal endoscopic submucosal dissection (ESD) is currently insufficient. This study aims to evaluate the efficacy and safety of esophageal ESD under GA. Methods A total of 227 lesions from 198 consecutive patients with superficial esophageal neoplasms treated by ESD at 3 Japanese institutions between April 2011 and September 2017 were included in this retrospective study. For ESD, GA and deep sedation (DS) were used in 102 (51.5%, GA group) and 96 patients (48.5%, DS group), respectively. Results There were no statistically significant differences in age, sex, or comorbidities between the groups. In the GA group, the tumor size was larger (21 [3–77] mm vs. 14 [3–63] mm, p <0.001), luminal circumference was larger (≥2/3; 13.9% vs. 5.4%, p =0.042), procedure time was shorter (28 [5–202] min vs. 40 [8–249] min, p <0.001), and submucosal dissection speed was faster (25.2 [7.8–157.2] mm 2 /min vs. 16.2 [2.4–41.3] mm 2 /min, p <0.001). The rates of intraoperative perforation and aspiration pneumonia were lower in the GA group, but the difference did not achieve statistical significance ( p =0.242 and p =0.242). Conclusions GA shortens the procedure time of esophageal ESD.

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BackgroundThe value of endoscopy for acute lower GI bleeding (ALGIB) remains unclear, given few large cohort studies. We aim to provide detailed clinical data for ALGIB management and to identify patients at risk for adverse outcomes based on endoscopic diagnosis.MethodsWe conducted a multicenter, retrospective cohort study, named CODE BLUE J-Study, in 49 hospitals throughout Japan and studied 10,342 cases admitted for outpatient-onset of acute hematochezia.ResultsCases were mostly elderly, with 29.5% hemodynamic instability and 60.1% comorbidity. 69.1% and 87.7 % of cases underwent CT and colonoscopy, respectively. Diagnostic yield of colonoscopy reached 94.9%, revealing 48 etiologies, most frequently diverticular bleeding. During hospitalization, the endoscopic therapy rate was 32.7%, mostly using clipping and band ligation. IVR and surgery were infrequently performed, for 2.1% and 1.4%. In-hospital rebleeding and death occurred in 15.2% and 0.9%. Diverticular bleeding cases had higher rates of hemodynamic instability, rebleeding, endoscopic therapy, IVR, and transfusion, but lower rates of death and surgery than other etiologies. Small bowel bleeding cases had significantly higher rates of surgery, IVR, and transfusion than other etiologies. Malignancy or upper GIB cases had significantly higher rates of thromboembolism and death than other etiologies. Etiologies that have favorable outcomes were ischemic colitis, infectious colitis, and post-endoscopy bleeding.ConclusionsLarge-scale data of patients with acute hematochezia revealed high proportions of colonoscopy and CT, resulting in high endoscopic therapy rates. We highlight the importance of colonoscopy in detecting accurate bleeding etiologies that stratify patients at high or low risk of adverse outcomes.

Background and Aim: The mechanisms responsible for impaired regenerative ability after hepatic resection observed in chronic liver disease are not fully understood. We have examined the relationships between an altered expression of cell cycle-related proteins in regenerating liver after partial hepatectomy and the impaired regenerative process observed in fibrotic and cirrhotic rats. Methods: We performed 70% partial hepatectomy in both control and porcine serum-induced fibrotic rats, and 45% partial hepatectomy in thioacetamide-induced cirrhotic rats because of the high mortality associated with 70% partial hepatectomy. Liver regeneration was monitored by proliferating cell nuclear antigen labeling index and the expression of G1 regulatory cell cycle-related proteins was determined by immunoblot analysis. Results: Compared with controls, hepatocyte DNA synthesis, and induction of cyclin D1 and p21 CIP1 proteins were delayed but not suppressed in porcine serum-induced fibrotic rats and markedly inhibited in thioacetamide-induced cirrhotic rats. p27 KIP1 protein levels were unaffected by partial hepatectomy and did not differ among all three groups. Conclusion: Two distinct rat models of liver fibrosis and cirrhosis showed markedly different proliferative responses after partial hepatectomy. The delay or failure of cyclin D1 induction, but not the increase of p21 CIP1 or p27 KIP1 might be responsible for their impaired liver regeneration.

Background and study aims: Prior studies have shown the effectiveness of endoscopic band ligation (EBL) and clipping for colonic diverticular hemorrhage (CDH) but have been small and conducted at single centers. Thus, we investigated which was the more effective and safe treatment in a multicenter long-term cohort study. Patients and methods: We reviewed data for 1,679 patients with CDH who were treated with EBL (n=638) or clipping (n=1,041) between January 2010 and December 2019 at 49 hospitals across Japan (CODE BLUE-J Study). Logistic regression analysis was used to compare outcomes between the two treatments. Results: In multivariate analysis, EBL compared with clipping was independently associated with reduced risk of early rebleeding (adjusted odds ratio [AOR] 0.46; p<0.001) and late rebleeding (AOR 0.62; p<0.001). These significantly lower rebleeding rates with EBL were evident regardless of active bleeding or early colonoscopy. No significant difference was found between the treatments in the rate of initial hemostasis or mortality. EBL compared with clipping independently reduced the risk of need for interventional radiology (IVR) (AOR 0.37; p=0.006) and prolonged length of hospital stay (LOS) (AOR 0.35; p<0.001), but not need for surgery. Diverticulitis developed in 1 patient (0.16%) following EBL and 2 patients (0.19%) following clipping. Perforation occurred in 2 patients (0.31%) following EBL and none following clipping. Conclusions: Analysis of our large endoscopy dataset suggests that EBL is an effective and safe endoscopic therapy for CDH offering the advantages of lower early and late rebleeding rates, reduced need for IVR, and shorter LOS.

Our findings suggest that endoscopic ligation is an easy and effective method of treatment for patients with gastrointestinal hemorrhage not from esophageal varices, and is safe even in patients with poor general health.