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Despite its longer procedure time and higher perforation rate, ESD resulted in higher en bloc resection and curative rates compared with EMR and all ESD perforations were successfully managed by conservative endoscopic treatment.

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Depth of invasion in early invasive colorectal cancer is considered an important predictive factor for lymph node metastasis. However, no large-scale reports have established the relationship between invasion depth of pedunculated type early invasive colorectal cancers and risk of lymph node metastasis. The aim of this retrospective cohort study was to clarify the risk of lymph node metastasis in pedunculated type early invasive colorectal cancers in a large series. Patients with pedunculated type early invasive colorectal cancer who underwent endoscopic or surgical resection at seven referral hospitals in Japan were enrolled. Haggitt's line was used as baseline and the invasion depth was classified into two groups, head invasion and stalk invasion. The incidence of lymph node metastasis was investigated between patients with head and stalk invasion. We analyzed 384 pedunculated type early invasive colorectal cancers in 384 patients. There were 154, 156, and 74 endoscopic resection cases, endoscopic resection followed by surgical operation, and surgical resection cases, respectively. There were 240 head invasion and 144 stalk invasion lesions. Among the lesions treated surgically, the overall incidence of lymph node metastasis was 3.5% (8 ⁄ 230). The incidence of lymph node metastasis was 0.0% (0 ⁄ 101) in patients with head invasion, as compared with 6.2% (8 ⁄ 129) in patients with stalk invasion. Pedunculated type early invasive colorectal cancers pathologically diagnosed as head invasion can be managed by endoscopic treatment alone. (Cancer Sci 2011; 102: 1693-1697 I t has been reported that intramucosal colorectal cancers show no lymph node metastasis and are good candidates for endoscopic resection.(1,2) In contrast, 6-12% of early invasive colorectal cancers (i.e. cancer cells invade through the muscularis mucosae into the submucosal layer but do not extend into the muscularis propria) are associated with lymph node metastasis requiring surgical resection including lymph node dissection for curative treatment.(3-7) Recently, increasing evidence suggests that lesions with submucosal invasion limited to <1000 lm without lymphovascular invasion and ⁄ or poorly differentiated components do not metastasize to lymph nodes.(8) Endoscopic resection is an appropriate treatment for early stage colorectal cancers, however, the resected specimen must be examined to determine whether there is a clinically significant risk of lymph node metastasis that would warrant additional surgery. Colorectal lesions can be subdivided according to endoscopic appearance using the Paris classification (Fig. S1), whereas Haggitt's classification is frequently used to define the depth of invasion of pedunculated lesions.(9) Haggitt and colleagues stratified the level of cancer invasion according to the following criteria: level 0, carcinoma in situ (i.e. has not extended below the muscularis mucosae); level 1, carcinoma invading through the muscularis mucosae but limited to the head of the polyp (i.e. above the junction between the aden...

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.

This study suggests that CO(2) insufflation is safe for patients receiving a lengthy colorectal ESD under conscious sedation.

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Objectives Endoscopic mucosal resection (EMR) is the gold standard for the treatment of noninvasive large colorectal lesions, despite challenges associated with nonlifting lesions and a high rate of local recurrence. Endoscopic submucosal dissection (ESD) offers the possibility of overcoming these EMR limitations. However, a higher risk of complications and longer procedure time prevented its dissemination. As ESD now provides more stable results because of standardized techniques compared with those used earlier, this study aimed to quantify the rates of en bloc and curative resections, as well as ESD complications, in the present situation. Methods A multicenter, large‐scale, prospective cohort trial of ESD was conducted at 20 institutions in Japan. Consecutive patients scheduled for ESD were enrolled from February 2013 to January 2015. Results ESD was performed for 1883 patients (1965 lesions). The mean procedure time was 80.6 min; en bloc and curative resections were achieved in 1759 (97.0%) and 1640 (90.4%) lesions, respectively, in epithelial lesions ≥20 mm. Intra‐ and postprocedural perforations occurred in 51 (2.6%) and 12 (0.6%) lesions, respectively, and emergency surgery for adverse events was performed in nine patients (0.5%). Conclusions This trial conducted after the standardization of the ESD technique throughout Japan revealed a higher curability, shorter procedure time, and lower risk of complications than those reported previously. Considering that the target lesions of ESD are more advanced than those of EMR, ESD can be a first‐line treatment for large colorectal lesions with acceptable risk and procedure time. (Clinical Trial Registration: UMIN000010136).