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BACKGROUND AND AIM Accurate polyp size estimation is essential in deciding the therapeutic strategy of colorectal polyps and endoscopic surveillance intervals. However, many endoscopists frequently make incorrect size estimations without being aware of their errors. This cross-sectional study aimed to clarify the characteristics of endoscopists associated with inaccurate estimation. METHODS We previously conducted a web trial involving 261 endoscopists in 51 institutions in Japan to assess their ability to estimate polyp size. Participants answered questions about polyp size using visual estimates in a test involving images of 30 polyps. Here, we investigated the relationships between inaccurate size estimation and the backgrounds of participants. The rates of overestimation and underestimation of polyp size were also compared to clarify any trends in the answers of participants with low accuracy (

It is important to accurately diagnose the depth of colorectal neoplasia invasion. We aimed to evaluate the usefulness of a new forward-viewing radial-array echoendoscope (FRE), relative to the pit pattern method.In this prospective study, the invasion depth of suspected early-stage carcinoma was diagnosed using the pit pattern and FRE methods. The diagnoses were classified as T1a (submucosal invasion distance 1,000 μm) or shallower and T1b (≥ 1,000 μm) or deeper. Pathological diagnoses were used to compare the diagnostic capabilities of the two methods.The final analyses included 110 lesions. The FRE was successfully inserted to the lesion in all cases. There were no significant differences between the two methods regarding the correct prediction rate (79.1% vs. 75.5%, P = 0.57), accuracy (81.3% vs. 79.0%, P = 0.68), specificity (81.3% vs. 70.8%, P = 0.135), positive predictive value (65.0% vs. 60.4%, P = 0.649), negative predictive value (91.0% vs. 98.1%, P = 0.108), or frequency of unevaluable cases (2.7% vs. 4.5%, P = 0.471). The correct prediction rate was calculated by adding the number of unevaluable cases to the denominator of accuracy. Relative to the pit pattern method, the FRE method offered significantly higher sensitivity for predicting T1b or deeper invasion (81.3% vs. 97.0%, P = 0.048). The pit pattern method had significantly poorer accuracy for large lesions ( 36 mm) than for smaller lesions (≤ 36 mm). In contrast, the accuracy of the FRE method did not differ significantly with lesion size. When using the FRE method, no cases were unevaluable because of attenuation. The FRE method provided correct diagnoses in 2 of 3 cases that were unevaluable using the pit pattern method.The pit pattern and FRE methods offered similar diagnostic performance for invasion depth. Furthermore, the FRE method may be used to correctly diagnose cases that are unevaluable using the pit pattern method.

Background and Aim Endoscopic submucosal dissection (ESD) is a challenging procedure. A dissection speed of ≥9 cm2/h has been acknowledged as a mark for expertise, alongside a complication rate of ≤5% and en bloc resection rate of ≥90%. However, there is lack of objective information on whether the three measures correlate with each other. This study aims to evaluate the dissection speed, safety, and efficacy of colorectal ESDs performed by experts and trainees. Methods Consecutive patients undergoing colorectal ESD at a Japanese hospital (2006–2017) were included in a prospectively collected database. Information on patient demographics, proceduralist, and intra‐/postprocedure data was retrieved. The primary outcome was the comparison in dissection speed. The secondary outcomes included differences in safety and efficacy. Log‐linear regression models adjusted for confounders (e.g. R0 resection) were used to assess the differences in dissection speed. Results Five hundred ninety procedures (514 patients) performed by 26 endoscopists were analyzed. Experts performed a higher number of difficult lesions (e.g. F2 fibrosis) but achieved higher dissection speed (10.3 vs 6.7 cm2/h). The difference was statistically significant for both unadjusted and adjusted models (P, Endoscopic submucosal dissection (ESD) expertise is commonly measured through dissection speed, en bloc resection, and complication rates. However, it is unclear whether the slower pace during ESD training is necessarily accompanied by worst outcomes regarding efficacy and safety. This study found that colorectal ESD can be safely and efficaciously performed by ESD trainees.

Sound speed correction (SSC) is a non-invasive modality that quantifies the hardness of neoplasms. The aim of our study was to evaluate the usefulness of SSC for the diagnostic accuracy of colorectal neoplasms and to differentiate the depth of invasion. Forty colorectal neoplasms, contributed by 40 patients, were included in the analysis. The primary outcome was the diagnostic ability of SSC for the depth of invasion of colorectal neoplasms, with the secondary endpoint being the clinical efficacy of SSC to distinguish between a neoplasm and normal mucosa. The median sound speeds for colorectal neoplasms and normal mucosa were 1580 m/s and 1515 m/s, respectively (p < 0.001), with a median sound speed of 1583 m/s for lesions with a depth shallower than that of the muscularis propria and 1610 m/s for depths deeper than that of the muscularis propria (p = 0.002). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 80.0%, 100%, 100%, 83.3%, 90.0%, and 100%, respectively, for the diagnosis of neoplasms (using a cut-off sound speed of 1557 m/s) and 100%, 77.8%, 33.3%, 100%, 80.0%, respectively, for the diagnosis of the depth of invasion (using a cut-off of 1590 m/s). We identified absolute sound speeds for colorectal neoplasms and the depth of invasion of neoplasms which yielded a good diagnostic performance. SSC provides an objective evaluation of colorectal neoplasms and the depth of invasion of neoplasms and, thus, might be a useful modality in practice. UMIN000038235 , Date of registration; October 8, 2019

Introduction: We aimed to compare the efficacy of endoscopic ultrasound elastography (EUS-EG) with that of magnifying chromoendoscopy (MCE) and endoscopic ultrasonography (EUS) for the diagnosis of the depth of invasion in colorectal neoplasms. This is an important clinical issue as the depth of invasion is associated with the risk of metastasis. Methods: Consecutive patients with suspected superficial colorectal neoplasms, evaluated by MCE, EUS, and EUS-EG, for whom endoscopic submucosal dissection was considered, were enrolled in 2018 (derivation study) and in 2019–2020 (validation study). The primary clinical endpoint was the diagnostic yield differentiating intramucosal and shallow submucosal neoplasms from deep submucosal (dSM) and advanced colorectal cancers. In addition, inter- and intra-observer agreements of the elastic score of colorectal neoplasm (ES-CRN) were evaluated by 2 expert and 2 non-expert endoscopists. Results: Thirty-one (33 lesions) and 50 (55 lesions) patients were enrolled in the derivation and validation studies, respectively. Sensitivity, specificity, positive, and negative predictive values, and accuracy of assessment of the depth of submucosal or deeper invasion in the derivation and validation groups were as follows: EUS-EG, 100/88.2/86.7/100/93.3% and 77.8/86.1/73.7/88.6/83.3%; MCE, 66.7/94.4/90.9/77.3/81.8% and 84.2/91.4/84.2/91.4/88.9%; and EUS, 93.3/77.8/77.8/93.3/84.8% and 89.5/65.7/58.6/92.0/74.1%, respectively. For the 2 expert endoscopists, interobserver agreement for the ES-CRN (first and second assessments) in the derivation group was 0.84 and 0.78, respectively; these values were 0.73 and 0.49, respectively, for the 2 non-expert endoscopists. Discussion/Conclusion: All 3 modalities presented similar diagnostic yield. Inter- and intra-observer agreements of the ES-CRN were substantial, even for non-expert endoscopists. Therefore, EUS-EG may be a useful modality in determining the depth of invasion in colorectal neoplasms.

Background and Aims The feasibility of magnetic anchor–guided endoscopic submucosal dissection (MAG-ESD) using a neodymium magnet for gastric lesions has not been clarified. The aim of study was to evaluate the feasibility of MAG-ESD using neodymium magnets while treating gastric lesions. Methods This prospective trial was conducted at the Yamashita Hospital. MAG-ESD was performed for 50 gastric lesions using an insulated-tip knife. The magnetic anchor consisted of an internal neodymium magnet attached to a hemoclip with 3-0 silk. The external and internal magnets were made from the neodymium magnet. The feasibility of traction using MAG-ESD, en bloc resection rate, complete en bloc resection rate, time required for preparation and attaching the magnetic anchor, procedure time, rate of retrieval of the magnetic anchors, and adverse events were evaluated. Results Fifty patients (median lesion size, 20 mm [range, 5-100]) were enrolled. MAG-ESDs were successfully performed for all 50 gastric lesions. Adequate counter-traction was obtained using the external magnet. En bloc resections were achieved and complete en bloc resections confirmed in all cases without adverse events. Attaching the magnetic anchor required a median of 6 minutes (range, 2-14). The median procedure time was 49 minutes (range, 15-301), and the magnetic anchors could be retrieved in all cases. Conclusions This study clearly demonstrated the feasibility of this MAG-ESD in the stomach. We hope this procedure will facilitate the resection of difficult lesions. (Clinical trial registration number: UMIN000024100.)

Background: Endoscopic injection sclerotherapy (EIS) is one of the most commonly applied techniques in the treatment of patients with bleeding esophageal varices (EV). However, the role of EIS in the long-term management of patients with EV bleeding remains controversial. We conducted a retrospective 30-year survey of EIS in patients with EV bleeding. Patients and Methods: Sclerosant with radiological contrast agent was endoscopically injected into the distal EV under fluoroscopic observation. The endpoint of injection was to fill the EV, including the supplying venous complex, which comprises the left and the short gastric veins. Results: Of the 367 patients reviewed, 350 had liver cirrhosis and 17 had idiopathic portal hypertension. The Child-Pugh classification was A in 92 patients, B in 121, and C in 154. Fifty-seven patients had hepatocellular carcinoma (HCC) at the initial EIS. The primary successful hemostasis rate was 95.5%. The numbers of re-bleeding EV episodes were 61 at 0 to 1 year, 34 at 1 to 3 years, 21 at 3 to 6 years, 2 at 6 to 9 years, and 0 over 10 years from the initial EIS intervention. EV was eradicated in 87% of patients and re-bleeding EV was markedly reduced after eradication of EV. Complications were generally mild, serious events were rare after 2000, included renal failure (3.3%), liver failure (3.3%), and esophageal stricture, and shock (1.6%), esophageal ulcer bleeding (1.6%). The causes of death were established in 278 patients, included liver failure (51.8%), HCC (20.9%), bleeding EV (7.9%), and procedure-related mortality (4.3%). The median survival time for all patients was 3.3 years, while 1-, 10-, 20-, and 30-year cumulative survival rates were 72.8%, 7.8%, 3.2%, and 3.2%, respectively. Conclusion: Our EIS treatment for bleeding EV was effective in reducing bleeding death over the long term. Improved survival requires amelioration of liver function and control of HCC.

Objectives: A phase II study was performed to investigate the safety and efficacy of concurrent chemoradiotherapy (CCRT) combined with an orally active fluoropyrimidine, S-1, plus cisplatin for locally advanced esophageal cancer (LAEC). Methods: CCRT comprised 2 courses, a 30-Gy radiotherapy over 3 weeks plus daily oral S-1 (80 mg/m2/day) for 2 weeks and a 24-hour cisplatin infusion (70 mg/m2) on day 8, and an identical course administered after a 2-week break. Results: One hundred and sixteen patients, 12 with stage II, 71 with stage III, and 33 with stage IVa LAEC participated, and 106 of them (91.4%) completed the CCRT course. The most serious toxicity was myelosuppression: grade 3 and 4 neutropenia occurred in 28.4 and 9.5% of patients, respectively. Nonhematologic toxicity was moderate. Complete response rates in patients with stage II, III, and IVa LAEC were 91.7, 67.6, and 36.4%, respectively. The overall median survival time was 2.3 years and that of patients with stage II, III, and IVa cancer was 7.0, 2.6, and 1.3 years, respectively. Conclusions: CCRT combined with S-1 plus cisplatin showed promising safety and efficacy. Potentially, this combination therapy could become a baseline medication for patients with LAEC.