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doi:10.1111/jgh.13187

Poster Endoscopy

Colonoscopy # 1069 Analyses of delayed postprocedural bleeding after colonoscopic tumor resection (EMR or ESD) Authors: SHINYA OOMORI; ADEL BADRAN; KAZUYOSHI YAMASHITA Affiliation: Department of Gastroenterology and General Internal Medicine, Japanese Red Cross Sendai Hospital, Sendai City, Japan Background and Aim: There still is a considerable number of cases who present with postprocedural bleeding 4 days or more after resection. We aimed to assess the delayed postprocedural bleeding in patients undergoing colonoscopic tumor resection. Methods: Among 1796 cases who underwent colonoscopic tumor resection (endoscopic mucosal resection and endoscopic submucosal dissection), there were 185 cases who presented with postprocedural bleeding for which urgent colonoscopy was deemed necessary between January 2009 and January 2014. We defined initial bleeding after postoperative day (POD) 4 as “delayed postprocedural bleeding.” The 185 cases were divided into two groups (Group A: 171 patients with bleeding within 3 days and Group B: 14 patients with delayed postprocedural bleeding). We (i) analyzed the clinical profiles of Group B and (ii) compared clinical features between the two groups. Results: (i) In Group B, the number of cases presenting with bleeding on POD 4, 5, 6, and 7 were 8, 3, 2, and 1, respectively. There were three cases on antithrombotic agents, all of them presented with bleeding on POD 4. One case with bleeding on POD 7 was under regular hemodialysis treatment. (ii) The frequency of cases whose target lesions were located at regions with difficulty for endoscopists to operate (e.g. flexional parts and far side parts of the haustra) was significantly higher in Group B than that in Group A (P < 0.05). Conclusions: Delayed postprocedural bleeding may be frequently associated with insufficient techniques, owing to unfavorable operational conditions. Patients undergoing colonoscopic tumor resection performed under difficult procedural circumstances should be closely observed in respect to delayed postprocedural bleeding. # 1084 The effect of patients-judging dose adjustment of bowel cleansing agent for bowel preparation by using smartphone camera application: a pilot study Authors: SEUNGHYUN PARK; TAE OH KIM; JONGHA PARK; JUN HYUK CHOI; SUNG YEON YANG; NAE-YUN HEO; YOUNG-SOO MOON; SO CHONG HUR Affiliation: Haeundaepaik Hospital, Inje University College of Medicine, Busan, Korea Background and Aim: High-quality bowel preparation leads to a comfort and complete colonoscopy. According to the individual’s condition, there is some difference in the optimal dosage of bowel cleansing agent. The aim of this study was to assess

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the effect of smartphone camera application for bowel cleansing through the optimal dosage of polyethylene glycol (PEG). Methods: Patients were assigned to use the application (app group, n = 19) or receive the existing written instructions (control group, n = 24). The app group used the application which was programmed to judging the bowel preparation condition automatically from the stool appearance. Results: A total of 43 patients were randomized between two groups. The primary outcome was the quality of bowel preparation based on blinded ratings by the Ottawa bowel preparation score. We performed bivariate analyses to compare mean scores between these groups using t-test. The secondary outcomes were the difference of dosage for bowel cleansing between two groups and the acceptability of the application in the app group. In a bivariate analysis of the primary outcome, there was no statistically significant difference between the app group and the control group (mean Ottawa bowel preparation score 2.53 ± 1.264 vs 2.38 ± 1.789, P = 0.757). The secondary outcomes revealed that the app group took lower dosage of PEG for bowel cleansing than the control group (mean dosage [mL]: 3700 ± 402.768 vs 3991.67 ± 28.233, P ≤ 0.01). The acceptability of the application showed good response. (5-point Likert scale; 1 = not acceptable and 5 = very acceptable; mean score 4.37 ± 0.697, P ≤ 0.01). Conclusion: The bowel preparation by the smartphone camera application showed the similar quality for bowel preparation through taking lower dose PEG and the patients’ good acceptability. This is a pilot study, so we will test and evaluate with more samples and contents in future research.

# 1100 The miss rates of colorectal polyps as determined by second colonoscopy for polypectomy Authors: YS KIM; SW PARK; DY KIM; YH LEE; SI BAE; SO KWON; WJ YOON; JS MOON Affiliation: Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea Background and Aim: Colonic polypectomy is a well-known secondary preventive measure of colorectal cancer. However, substantial missed polyps are reported, and it may cause the interval cancer. This study is aimed to evaluate the factors that affect on the miss rates of colorectal polyps during colonoscopy. Methods: A retrospective study was conducted on 659 patients whose colorectal polyps were detected by colonoscopy (primary exam) performed in Health Checkup Center at Seoul Paik Hospital from March 2007 to December 2014. They underwent colorectal polypectomy (secondary exam) within 6 months and evaluated the existence of missed polyps. Results: The average age of the patients is 51.4 ± 8.7 years, and the proportion of males is 81.2% (n = 535). The intervals between the primary and secondary examinations are 20.9 ± 29.1 days (range 0 to 172). The miss rates of polyp in primary examination are 38.6%. The number of missing polyps is 1.46 ± 0.96 (range 1 to 6), and the size is measured as 5.28

Journal of Gastroenterology and Hepatology 2015; 30 (Suppl. 4): 160–322 © 2015 The Authors. Journal of Gastroenterology and Hepatology © 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd

Poster endoscopy

± 2.29 mm (range 1 to 15). The most common sites of missed colorectal polyps are sigmoid colon (33.3%), ascending colon (18.8%), and transverse colon (14.5%). The miss rates of colorectal polyps did not correlate with the withdrawal time (P = 0.18) and bowel preparation (P = 0.76); however, as the number of polyps on the primary examination is increased, the miss rates of colorectal polyp increased significantly (P = 0.005). Conclusions: There are significant miss rates of colorectal polyps in routine clinical practice, especially in patients with multiple colorectal polyps. The most common site of missed polyps is the sigmoid colon. Careful attention should be paid to reduce the miss rates of colorectal polyps during colonoscopy. Keywords: colonoscopy, missing polyp, polypectomy # 1123 The frequency and endoscopic findings of colonic CMV reactivation in corticosteroid naïve patients with active UC: evaluation of mucosal CMV-PCR Author: T FUKUCHI; S UBUKATA; T IWATSUBO; S KOYAMA R KITADA; T EGUCHI; H YAMASHITA; A OKADA Affiliation: Department of Gastroenterology and Hepatology, Osakafu Saiseikai Nakatsu Hospital, Osaka, Japan Background and Aim: Detection of colonic reactivation in active ulcerative colitis (UC) refractory to corticosteroid (CS) has been focused because ongoing immunosuppressive therapies under intestinal inflammation are considered to be involved in cytomegalovirus (CMV) reactivation. It was reported that real-time polymerase chain reaction using colonic mucosa (mucosal-PCR) was promising for detection of colonic CMV reactivation in the point of its high sensitivity. However, there are few reports on frequency of CMV reactivation in colonic tissues and the characteristics of endoscopic finding related to CMV reactivation in CS naïve patients with active UC. The aim of this study is to investigate frequency and endoscopic findings of colonic CMV reactivation in CS naïve patients with active UC. Methods: Ninety-nine patients with active moderate–severe CS-naïve UC were examined. Colonoscopy was performed in all patients, and biopsy specimens from inflamed colonic mucosa were taken. (i) Colonic CMV reactivation was examined by mucosal-PCR and immunochemistry (IHC). (ii) Endoscopic findings using by ulcerative colitis endoscopic index of sensitivity (UCEIS) were compared between CMV positive and negative. Results: (i) Twenty-six (26.3%) of ninety-nine CS-naïve patients were diagnosed as positive for CMV reactivation by mucosal-PCR. On the other hand, IHC was positive in only five patients (5.1%). (ii) There was no significantly difference in mean of UCEIS score between two group (8.2 ± 0.1 vs 8.2 ± 0.1, P = 0.921). Conclusion: Our data demonstrated that 26.3% of CS-naïve patients with active UC were diagnosed as positive for CMV reactivation. However, we consider that early distinction for endoscopic findings positive or negative for CMV can be difficult.

# 1131 Analysis of postoperative hemorrhage about colorectal endoscopic submucosal dissection in anti-coagulated therapy Authors: TAKAAKI MURAKAMI; NAOHISA YOSHIDA; KIYOSHI OGISO; RYOHEI HIROSE; YUJI NAITO; YOSHITO ITOH Affiliation: Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan Background and Aim: Colorectal endoscopic submucosal dissection (ESD) is thought to have a higher risk for postoperative hemorrhage especially in patients with antithrombotic therapy. In this study, we analyzed the status of postoperative hemorrhage after colorectal ESD in cases with anticoagulant and antiplatelet. Methods: We analyzed 616 patients who received colorectal ESD in Kyoto Prefectural University of Medicine from 2009 to 2014. We divided them into three groups such as (A) cases with antiplatelet (59 patients), (B) cases with anticoagulant (19 patients), and (C) cases without them (538 patients). We analyzed the rate and status of postoperative hemorrhage among the three groups. As a comparison, we analyzed the postoperative hemorrhage rate of 25 patients who took anticoagulant and antiplatelet out of 324 patients receiving EMR last 9 months. Results: The median age and the rates of men in the groups A + B and C were 73.5 versus 67.2 (P < 0.01) and 69.5% versus 55.6% (P < 0.05). There were no significant differences with respect to rate of en bloc resection, procedure time, and rate of perforation in the three groups. The rates of postoperative hemorrhage in the groups A + B and C were 6.4 versus 2.0 (P < 0.05). In the group A, three patients (5.1%) received ESD with aspirin, and the rest (94.9%) without antiplatelet. In the group B, four patients (21.1%) received ESD with replacing heparin from anticoagulant and the rest only without anticoagulant. Two hemorrhagic cases out of three in the group B took antiplatelet. The median period of postoperative hemorrhage in the groups A and B was 7.4 days after ESD, and all events occurred after re-prescribing antiplatelet and anticoagulant. As a comparison, the rate of postoperative hemorrhage in EMR cases was 2.5%. Conclusion: The risk of postoperative hemorrhage with antiplatelet and anticoagulant in colorectal ESD was high. # 1146 Clinical outcomes of follow-up colonoscopic surveillance for patients with sessile serrated adenomas Authors: SUNG JAE PARK; HYUK YOON; IN SUB JUNG; CHEOL MIN SHIN; YOUNG SOO PARK; NA YOUNG KIM; DONG HO LEE Affiliation: Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea Background and Aim: Sessile serrated adenomas (SSAs) are known to be precursors to colorectal cancer (CRC). The purpose of this study is to determine the proper interval of colonoscopic surveillance in patients diagnosed with SSAs to search for occurrence of new CRC. Methods: This study is a retrospective chart review of patients with SSAs diagnosed at colonoscopy from 2007 to 2011, who received one or more follow-up colonoscopies. Abstracted information included patient basal characteristics, SSAs


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characteristics, and colonoscopy information. Results: From 2007 to 2011, 152 SSAs and 8 synchronous adenocarcinomas were identified in 138 patients. The mean age of patient was 56.4 years, and 60% were male. SSAs were located in the right colon (from proximal to the hepatic flexure) in 68.4%. In eight synchronous adenocarcinomas, four cases showed well differentiation, and the others showed moderate differentiation. Two cases of cancer were treated with colectomy, and the others were treated with snare polypectomy. At the first follow-up, 27 SSAs were identified in 138 patients, and the first mean follow-up interval was 20.2 months; 66.7% of SSAs were located in the right colon. At the second follow-up, six SSAs were identified in 65 patients, and the second mean follow-up interval was 21.4 months; 66.7% of SSAs were located in the right colon. At the third and fourth follow-ups, 21 and 11 of each patient received colonoscopy, and no SSAs were detected. The mean follow-up interval was 15.9 and 18.2 months. At the fifth follow-up, no patients received colonoscopy. The total mean follow-up duration was 33.9 months. The total number of SSAs was 185. The mean size of SSAs was 8.1 ± 5 mm. The most common site of SSAs was the right colon (126/185, 68.1%). The mean size of SSAs detected with synchronous adenocarcinoma was 9.25 ± 8.75 mm, and the other was 8.13 ± 5.01 mm. The difference of size was not statistically significant (t-test, P-value: 0.554). During follow-up colonoscopic surveillance, no cancer was detected. Conclusions: According to our study, an annual follow-up colonoscopic surveillance is not efficient in view of costeffectiveness to search for occurrence of new CRC in patients diagnosed with SSAs. We suggest that the proper interval of follow-up colonoscopy for SSAs is that every 2–3 years. Also, SSAs occur more frequently in the right colon at initial and follow-up colonoscopy; the right colon is examined more carefully. # 1153 Submucosal tunneling endoscopic resection for rectal submucosal tumors originating from the muscularis propria layer: a preliminary, single center study Authors: JW HU; C ZHANG; MD XU Affiliation: Endoscopy Center, Zhongshan Hospital, Shanghai, China Background and Aim: To evaluate the clinical value of submucosal tunneling endoscopic resection (STER) for the treatment of submucosal tumors (SMTs) originating from the muscularis propria (MP) in the rectum. Methods: Twelve cases with rectal SMTs originating from the MP layer underwent STER in our center from January 2012 to June 2014. The clinicopathological data were analyzed retrospectively. En bloc resection rate, complications, lesion residual, and recurrence during the follow-up period were evaluated. Results: Clinicopathologic data of 12 patients who underwent STER for rectal SMTs originating from the MP layer were listed in Table 1. Clinicopathologic data of patients with rectal submucosal tumors treated with STER were listed in Table 2. En bloc resection was achieved successfully in all cases. The median size of resected specimens was 1.2 cm (range 1.0–3.0 cm). The median procedure time was 45.0 min (range 40–70 min). Three patients developed low fever

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Table 1 Demographic data, clinicopathologic features, complications, and follow-up information of 12 patients who underwent STER for rectal SMTs originating from the MP Patients (n = 12) Median age, years (range) Male/female ratio Median tumor size, cm (range) Tumor location Extraperitoneal rectum,% (n) Intraperitoneal rectum,% (n) EUS Superficial MP layer, % (n) Deep MP layer En bloc resection, % (n) Median STER procedure time, min (range) Complications, % (n) of patients Low fever Mucosa perforation Subcutaneous emphysema Median hospital stays, days (range) Median follow-up time, months Lesion residual, n Lesion recurrence, n Histology assessment, % (n) Stromal tumor Schwannoma Leiomyoma Proliferation of collagen fibers nodular degeneration

53.5 (41–84) 1/3 1.2 (1.0–3.0) 91.7 (11/12) 8.3 (1/12) 16.7 (2/12) 83.3 (10/12) 100 (12/12) 45.0 (40–70) 25.0 (3/12) 8.3 (1/12) 8.3 (1/12) 3.0 (2–8) 27.5 (4–33) 0/12 0/12 41.7 (5/12) 25 (3/12) 16.7 (2/12) 16.7 (2/12)

MP, muscularis propria; SMTs, submucosal tumors; STER, submucosal tunneling endoscopic resection.

(25%, 3/12) after the operation, and all recovered after receiving intravenous antibiotics. One of these three cases developed mucosa perforation (8.3%, 1/12), which was closed immediately with several metal clips. One patient developed subcutaneous emphysema (8.3%, 1/12) in one lower limb, which disappeared with conservative treatments 2 weeks after the STER procedure. The median hospital stays was 3.0 days (range 2–8 days). Postoperative pathological outcomes revealed schwannoma in three cases, leiomyoma in two cases, stromal tumor in five cases, and proliferation of collagen fibers nodular degeneration in two cases. No lesion residual or recurrence was found during postoperative follow-up of 4–33 months. Conclusions: STER was a feasible, safe, and effective method for treating SMTs originating from the MP layer in the rectum. A high en bloc resection rate could be achieved using this technique. Long-term outcome of STER for rectal SMTs arising from the MP layer in a larger sample size deserves further study.


Poster endoscopy

Table 2 Clinicopathologic data of patients with rectal submucosal tumors treated with STER Tumor location, from the anal verge (cm)

EUS

1/F/82

10

Deep MP

2/F/51 3/F/66 4/M/80

6 5 7

5/F/43 6/F/41 7/F/79 8/M/43 9/M/50 10/F/55 11/F/52 12/F/84

Case/sex/ age (year)

Size (cm) Average

Operation time (min) Average

1.4

49.5

Hypoechoic

1.0

70

No

3

Superficial MP Superficial MP Deep MP

Hypoechoic Mixed Mixed

1.5 1.2 1.1

45 40 50

5 6 5

Deep MP Deep MP Deep MP

Hypoechoic Mixed Mixed

1.6 3.0 1.2

60 70 45

5 5 7 6 5

Deep Deep Deep Deep Deep

Hypoechoic Hypoechoic Hypoechoic Hypoechoic Hypoechoic

1.0 1.5 1.2 1.2 1.6

40 40 50 45 40

No Mucosa perforation Low fever and Mucosa perforation No No Subcutaneous emphysema No No No No No

Layer

Echo

MP MP MP MP MP

Complication

Hospital stay Average

Pathologic diagnosis

3.1

Follow-up time ‡ (month) 22.7

2 3 4

Proliferation of collagen fibers nodular degeneration Leiomyoma Leiomyoma Schwannoma

33

32 30 28

3 2 8

Leiomyoma Schwannoma Schwannoma

27 30 29

2 3 2 2 3

GIST GIST GIST GIST GIST

18 20 6 15 4

MP, muscularis propria; STER, submucosal tunneling endoscopic resection.

# 1185 Effect of high BMI on colonoscopy performance Authors: ASIF HUSSAIN; NATALIE SMITH; ALI ZAD; ANDREW TUNG Affiliation: Ballarat Health Services, Ballarat, Australia Background and Aim: There is limited evidence regarding the quality of bowel preparation and an association with high body mass index (BMI).1 Previous studies have suggested that low BMI is a predisposing factor for prolonged intubation time,2 but there are insufficient data to suggest that high BMI is also a risk factor. Given the prevalence of high BMI in regional communities, this association may impact on the already limited resources within regional hospitals. The aim of this study is to determine if there is an effect of high BMI on bowel preparation and colonoscopy performance. Methods: A prospective single centre cohort study at a regional teaching hospital in Ballarat, Victoria, Australia, between May 2012 and November 2014. All patients undergoing colonoscopy for any indication were included. Patients were divided into two groups, BMI ≥ 25 (high) or BMI < 25 (normal). Colonoscopies were performed by 17 experienced endoscopists, and the data collected by trained endoscopy nurses. Bowel preparation was assessed using the Ottawa Bowel Preparation Scale. Colonoscopy performance was assessed using caecal intubation times (short up to 6 min, intermediate = 7–9 min, and long ≥ 10 min). Chi-square statistical analysis was used to determine significance (P = 0.05). The multivariate COX regression model disclosed the age per increased for 1 year (hazard ratio = 1.04, P = 0.008), cases with colorectal cancer post-endoscopic resection (hazard ratio = 59.01, P = 0.003), adenoma with HGD (hazard ratio = 20.30, P = 0.020), and polyp with over-expression of DNMT3B (hazard ratio = 5.53, P = 0.004) to be independent factors of an early HRA development in surveillance scope. Conclusion: Patients with advanced age, with colorectal cancer post endoscopic resection, adenoma with HGD, or polyp with over-expression of DNMT3B in the baseline colonoscopy should be concerned to receive an earlier surveillance to detect HRA.


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# 1288 Predictive relevance of lymphovascular invasion in colorectal cancer before endoscopic treatment Authors: KAZUYA INOKI[1]; TAKU SAKAMOTO[1]; HIROYUKI TAKAMARU[1]; MASAU SEKIGUCHI[1]; MASAYOSHI YAMADA[1]; MINORI MATSUMOTO[1]; TAKESHI NAKAJIMA[1]; YASUO KAKUGAWA[1]; TAKAHISA MATSUDA[1]; HIROKAZU TANIGUCHI[2]; SHIGEKI SEKINE[2]; YUKIHIDE KANEMITSU[3]; YUTAKA SAITO[1] Affiliations: [1]Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan [2]Pathology Division, National Cancer Center Hospital, Tokyo, Japan [3]Colorectal Surgery Division, National Cancer Center Hospital, Tokyo, Japan Background and Aim: The depth of tumor invasion is currently the only reliable predictive risk factor for lymph node metastasis before endoscopic treatment for colorectal cancer. However, the most important factor to predict lymph node metastasis has been suggested as lymphovascular invasion rather than the depth of invasion. Thus, the aim of this study was to investigate the predictive relevance of lymphovascular invasion before endoscopic treatment. Methods: We retrospectively reviewed the data of pT1 colorectal cancers that were resected endoscopically or surgically from 2007 to 2014. We categorized the cases into two groups: positive and negative for lymphovascular invasion. The following factors were evaluated by univariate and multivariate analyses: age and sex of the patients; location, size, and morphology of the lesion; and depth of invasion. Results: The positive and negative groups included 212 and 443 cases, respectively. Univariate analysis showed that younger age (P = 0.001), rectum involvement (P = 0.037), smaller lesion size (P = 0.009), non-LST (P < 0.001), presence of depression (P < 0.001), and pT1b (P < 0.001) were associated with lymphovascular invasion. In multivariate analysis, younger age (comparing patients aged ≤ 64 years with those aged > 75 years, OR: 1.80, P = 0.02), presence of depression (OR: 1.87, P = 0.001), and pT1b (OR: 3.02, P < 0.001) were associated with lymphovascular invasion. Conclusion: Younger age, depression, and T1b are associated with lymphovascular invasion. Therefore, careful pathological diagnosis is necessary to predict treatment outcomes of lesions demonstrating any of these three factors. # 1289 A single-center experience of endoscopic submucosal dissection for colorectal neoplasm: 1200 ESD cases Authors: T TASHIMA; K OHATA; H TSUNASHIMA; Y MISUMI; E SAKAI; T MURAMOTO; Y MATSUYAMA; M TAKITA; Y MINATO; K NONAKA; N MATSUHASHI Affiliation: Gastroenterology, NTT Medical Center Tokyo, Tokyo, Japan Background and Aim: Recently, endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for early gastric neoplasms in Asian countries. But colorectal ESD is not widely used yet because of its technical difficulties and the possibility of complications. The aim of this study was to evaluate the clinical outcomes, efficacy, and safety of colorectal ESD in a single center of a general hospital. Methods: Between April 2007 and April 2015, 1200 colorectal neoplasms in 1144 consecutive patients were treated by ESD at NTT Medical Center Tokyo.

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Results: The average procedure time was 61.2 ± 46.9 min (range 2–390). The mean resected tumor size and the mean sample size was 33.2 ± 16.5 mm (range 3–155) and 42.4 ± 17.4 mm (range 10–165), respectively. En bloc resection rate and R0 resection rate were 99.6% (1195/1200) and 92.1%(1105/1200), respectively. Complications included 27 perforations (2.3%) and 17 bleedings (1.4%). Though one immediate perforation and two delayed perforations needed emergency surgery, others could be successfully closed with endoscopic clips and followed up conservatively. Of the 1200 neoplasms, there were 434 tubular adenomas (36.2%), 578 mucosal cancers (48.2%), 104 SM1 cancers (8.7%), and 84 cancer lesions invading SM 1000 μm or deeper (7.0%). Considering the risk of lymph node metastasis, 95 patients (8.3%) were subjected to additional surgical resection with lymph node dissection. Fourteen patients (1.2%) were followed up without additional surgery at the patient’s decision. There were one local recurrence and one lymph node metastasis in all cases. Conclusions: Although ESD is technically difficult, it brings about high en bloc resection rates and enables us to examine the specimen in detail regardless of lesion size. Colorectal ESD, if performed under the supervision of an expert even in a general hospital, has become a safe and effective treatment option. # 1297 Endoscopic ulcer closure using hemoclips prevent delayed bleeding after endoscopic submucosal dissection for colorectal neoplasms Authors: Y SAKATA[1]; R SHIMODA[1]; S MATSUURA [1]; R SHIRAISHI[1]; H ENDO[2]; T KOYAMA[3]; A WATANABE[4]; K MATSUNAGA[5]; M NAKAYAMA[6]; A ONO[1]; H SAKATA[1]; R SONODA[1]; R IWAKIRI[1]; K FUJIMOTO[1] Affiliations: [1]Department of Internal Medicine and Gastroenterology, Saga Medical School, Saga, Japan [2] Saiseikai Karatsu Hospital, Saga, Japan [3]Toyoura Hospital, Yamaguchi, Japan [4]Taku City Hospital, Saga, Japan [5]Oda Hospital, Saga, Japan [6]Saga Central Hospital, Saga, Japan Background and Aim: Endoscopic submucosal dissection (ESD) technique has recently been applied to the treatment of colorectal neoplasms. Although delayed bleeding is a major complication of ESD, few reports have assessed the factors to reduce delayed bleeding after colorectal ESD. The aims of this study were to identify risk factors for delayed bleeding after colorectal ESD and investigate the effect of endoscopic ulcer closure using hemoclips on prevention of delayed bleeding. Methods: This was a retrospective case-controlled study performed at Saga Medical School Hospital in Saga, Japan. Between 2008 and 2015, we have performed colorectal ESD for 329 lesions in 307 patients. We analyzed the relationship between delayed bleeding after ESD and the following factors: age, gender, presence of comorbidities, use of antithrombotic drugs, lesion size, resected size, lesion location, lesion morphology, lesion histology, procedure time, and endoscopic ulcer closure using hemoclips. Results: Delayed bleeding occurred in 15 (4.6%) of 329 lesions, and all cases were successfully treated by endoscopic procedures. Univariate analysis revealed that lesion histology (OR = 4.308, 95% CI: 1.179–15.742, P = 0.017), procedure time (OR = 1.008, 95% CI: 1.001–1.014, P = 0.024), and endoscopic ulcer closure using hemoclips (OR = 0.119,


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95% CI: 0.015–0.914, P = 0.015) were significantly associated with delayed bleeding. Multivariate analysis indicated that significant factors for delayed bleeding were adenocarcinoma (OR = 4.471, 95% CI: 1.228–16.2785, P = 0.023) and endoscopic ulcer closure using hemoclips (OR = 0.126, 95% CI: 0.016– 0.979, P = 0.048). Conclusions: Endoscopic ulcer closure using hemoclips reduced the risk of delayed bleeding after colorectal ESD. Carcinoma was an independent risk factor for delayed bleeding. # 1328 Technical feasibility of endoscopic submucosal dissection for lower rectal tumors Authors: XIAOWEI TANG[1,2]; YUTANG REN[2]; SILIN HUANG[1]; JIEQIONG ZHOU[1]; BO JIANG[1,2]; WEI GONG[1] Affiliations: [1]Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China [2]Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China Background and Aim: Large (> 2 cm) rectal adenomas are usually treated by transanal endoscopic microsurgery or endoscopic piecemeal mucosal resection (EPMR). Recently, endoscopic submucosal dissection (ESD) has demonstrated to be effective for the en bloc resection of colorectal lesions. We aimed to investigate the feasibility and safety of ESD for lower rectal tumors. Methods: Between June 2009 and August 2014, 39 patients with lower rectal tumors (≥ 2 cm) were treated by ESD at our department. Data were examined and analyzed retrospectively according to database and histopathological reports, with respect to histopathological diagnosis, procedure time, en bloc resection rate, and complications. Results: The mean adenoma size was 45.6 ± 24.4 mm, and the mean distance from the anal verge was 33.5 ± 16.2 mm. Among

all the lesions, 26 (66.6%) were laterally spreading tumors (granular type), including 2 homogeneous type (5.1%) and 24 nodular mixed type (61.5%) lesions, and the most frequent histological type was tubulovillous adenoma (17/34, 50.0%) (Table 1). The mean procedure time was 100.1 ± 64.3 min. En bloc resection and en bloc R0 resection were achieved in 92.3% (36/39) and 87.1% (34/39) of patients, respectively. Perforation occurred in two patients (5.1%), which was treated by endoclip. Postoperative bleeding occurred in two patients (5.1%) and was managed conservatively (Figure 1 and Table 2). Conclusions: ESD is safe and feasible for the treatment of non-invasive lower rectal tumors, with a low complication rate. To prove its long-term efficacy, a multicenter prospective study with large volume should be conducted in the future. Table 2 Clinical outcomes and complications Procedure time (min), mean ± SD En bloc resection, n (%) En bloc R0 resection, n (%) Complications, n (%) Perforation Delaying bleeding Proctostenosis

100.1 ± 64.3 36 (92.3%) 34 (87.1%) 2 (5.1%) 2 (5.1%) 1 (2.6%)

Table 1 Clinical features of lower rectal lesions (n = 39) Age (mean ± SD; years) (range) Sex (female/male) Tumor size (mean ± SD; mm) (range) Distance from anal verge (mean ± SD; mm) Lesions involved to the dentate line, n (%) Macroscopic view, n (%) LST (granular type) Homogeneous Nodular mixed

63.2 ± 13.2 (35–90) 17/22 45.6 ± 24.4 (20–140) 33.5 ± 16.2 4 (9.8)

Protruding Histology, n (%) Adenoma Type Tubular adenoma Tubulovillous adenoma Villous adenoma Not specified Dysplasia Low-grade dysplasia High-grade dysplasia Non-invasive carcinoma

13 (33.3%)

26 (66.6%) 2 (5.1%) 24 (61.5%)

34 (87.2%) 0 17 8 9

(0%) (50.0%) (23.5%) (26.5%)

16 (40.0%) 18 (46.2%) 5 (12.8%)

LST, laterally spreading tumor.

Figure 1 Endoscopic submucosal dissection for a laterally spreading tumor close to the dentate line. (a) Colonoscopic views of the laterally spreading tumor granular type (nodular mixed type) in the lower rectum close to the dentate line. (b) Chromoendoscopic view with indigo carmine dye, showing demarcation of the margin of the lesion. (c) Circumferential mucosal incision was made with a Flush knife. (d) Deep dissection of the lesion by using the transparent hood in place to help better visualize the tissue planes for dissection. (e) Artificial ulcer was observed after removal of tumor. (f) Resected specimen measured 5 × 8 cm.


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# 1329 Endoscopic submucosal dissection for rectal laterally spreading tumors ≥ 40 mm Authors: XIAOWEI TANG[1,2]; YUTANG REN[2]; JIEQIONG ZHOU[1,2]; ZHENGJIE WEI[2]; SILIN HUANG [1]; BO JIANG[1,2]; WEI GONG[1] Affiliations: [1]Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China [2]Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China

Table 2 Clinical outcomes of ESD Procedure time (min), mean ± SD En bloc resection, n (%) En bloc R0 resection, n (%) Follow-up time (month), mean ± SD Local recurrence, n (%) Complications, n (%) Perforation Delaying bleeding Proctostenosis

125.8 ± 61.4 33 (91.7%) 31 (86.1%) 18.7 ± 4.2 3 (8.6%) 3 (8.6%) 1 (2.9%) 1 (2.9%)

ESD, endoscopic submucosal dissection.

Background and Aim: Endoscopic submucosal dissection (ESD) has been developed to allow en bloc resection of early neoplasia of the gastrointestinal tract, including colorectal tumor. The aim of the present study was to evaluate the safety and efficacy of ESD for rectal laterally spreading tumors (LSTs) with diameters of 40 mm or more. Methods: Between January 2010 and October 2014, a total of 36 LSTs tumors measuring ≥ 40 mm in 35 patients were included in this study. Clinicopathological characteristics and clinical outcomes were examined and analyzed (Tables 1 and 2). Results: The mean procedure time was 125.8 ± 61.4 min, and the mean size of the tumors was 59.4 ± 19.8 mm (Figure 1). The rates of en bloc resection and en bloc R0 resection were 91.7% (33/36) and 86.1% (31/36), respectively. Perforation occurred in three patients (8.6%), which was managed conservatively. Postoperative bleeding occurred in one patient (2.9%) and was treated by endoscopic hemostasis. Excluding eight patients, who either underwent additional surgery (n = 1) or lost during follow-up time (n = 7), three patients (11.1%) presented with a small adenoma recurrence, and the remaining patients (n = 24) with LSTs were free of recurrence during a mean follow-up period of 18.7 months (range 12 to 43 months). Conclusions: Our results indicated that endoscopic submucosal dissection is an effective and safe therapeutic option with high curative rates for rectal laterally spreading tumors ≥ 40 mm. To prove its long-term efficacy, a multicenter prospective study with large volume should be conducted in the future.

Table 1 Clinicopathological features of LSTs Age (years), mean ± SD (range) Sex (female/male) Tumor size (mm), mean ± SD (range) Macroscopic view, n (%) Granular type Homogeneous Nodular mixed Non-granular type Histology, n (%) Adenoma Tubular adenoma Tubulovillous adenoma Villous adenoma Low-grade dysplasia High-grade dysplasia Non-invasive carcinoma LST, laterally spreading tumor.

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63.3 ± 12.8 (38–90) 16/19 59.4 ± 19.8 (40–140) 36 6 30 0

(100%) (16.7%) (83.3%) (0%)

33 1 19 13 22 11 3

(91.7%) (3.0%) (57.6%) (39.4%) (61.1%) (30.6%) (8.3%)

Figure 1 ESD for a large LST in the rectum. (a) Colonoscopic views of the laterally spreading tumor; (b) chromoendoscopic view with indigo carmine dye, showing demarcation of the margin of the lesion; (c) submucosal injection was made at 5 mm from the edge of the lesion; (d) Submucosal dissection with circumferential mucosal incision was made with a Hybrid knife; (e) Artificial ulcer was observed after removal of tumor; (f) resected specimen measured 9 × 10 cm; and (g) histopathological examination showed a tubulovillous adenoma with high-grade dysplasia.

# 1331 Endoclip with a water-jet scope for the management of massive bleeding from a rectal Dieulafoy lesion Authors: XIAOWEI TANG[1,2]; SILIN HUANG[1]; YUTANG REN[2]; BO JIANG[1,2]; WEI GONG[1] Affiliations: [1]Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China [2]Department of Gastroenterology, Beijing Tsinghua Changgung Hospital Medical Center, Tsinghua University, Beijing, China


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Background and Aim: Dieulafoy lesion is a submucosal arteriole that protrudes through small erosion in otherwise normal mucosa that can cause massive bleeding and account for 1–2% of cases of acute gastrointestinal bleeding. At present, GI endoscopy has proven to be highly effective diagnostic and therapeutic tool in the management of this lesion. Case description: A 56-year-old man with massive hematochezia was admitted in our hospital. His past medical history was significant for hypertension. He has no previous history of bleeding. On arrival, his systolic blood pressure was 70 mmHg with a pulse rate of 108 beats per minute, and the hemoglobin level was 40 mg/dL. His abdominal and rectal examinations were unremarkable. Emergent colonoscopy was performed without bowel preparation, and a colon full of melena was observed without an active bleeding point. A water-jet scope was applied to clean the colon. With continuous washing of the colon, the view of the mucosa became clear. An abnormal visible vessel with an adherent clot was found in the rectum, which is consistent with a Dieulafoy lesion. The lesion was managed by application of four hemostatic clips (Figure 1). The patient was discharged without complications and had no more bleeding in the follow-up period. In our case, a water-jet scope was used to manage massive bleeding from a Dieulafoy lesion. Although there were large amount of melena in the colon, the view of the endoscopy became clear by using the irrigation system of this scope. After placement of haemostatic clips, the lesion was treated successfully. To our knowledge, this is the first report of endoclip and a water-jet scope in the treatment of rectal Dieulafoy lesion, which is considered to be safe and effective.

# 1345 A randomized controlled trial of an educational video to improve quality of bowel preparation for colonoscopy Authors: HYUNGKIL KIM; JINSEOK PARK; MINSU KIM; KYESOOK KWON Affiliation: Inha University Hospital, Incheon, Korea Background and Aim: High-quality bowel preparation is necessary for colonoscopy. A few studies have been conducted to investigate improvement in bowel preparation quality through patient education. The reported methods for patient education on bowel preparation are various however have not been well studied. The aim of this study is to evaluate the effect of our own educational video for bowel preparation. Methods: A randomized and prospective study was conducted. All patients received regular instruction for bowel preparation during a pre-colonoscopy visit. Those scheduled for colonoscopy were randomly assigned to view an educational video instruction (video group) on the day before the colonoscopy, or to a non-video (control) group. Qualities of bowel preparation using the Ottawa Bowel Preparation Quality Scale (Ottawa score) were compared between the video and nonvideo groups. In addition, factors associated with poor bowel preparation were investigated. Results: A total of 502 patients were randomized, 250 to the video group and 252 to the non-video group. The video group exhibited better bowel preparation (mean Ottawa total score: 3.03 ± 1.9) than the non-video group (4.21 ± 1.9; P < 0.001) and had poorer bowel preparation (total Ottawa score ≥ 6: 91.6% vs 78.5%; P < 0.001). Multivariate analysis revealed that males (odds ratio [OR] = 1.95, P = 0.029), diabetes mellitus patients (OR = 2.79, P = 0.021), and non-use of visual aids (OR = 3.09, P < 0.001) were associated with poor bowel preparation. Conclusion: The addition of an educational video significantly improved the quality of bowel preparation. # 1348 Pathological evaluation of sessile serrated adenoma/polyps by using cold snare polypectomy Authors: HIRONORI WADA; TAKUJI KAWAMURA; YUSUKE OKADA; KOJI UNO; KENJIRO YASUDA Affiliation: Kyoto Second Red Cross Hospital, Kyoto, Japan

Figure 1 (a) Emergent colonoscopy discovered a colon full of melena; (b) the mucosa became clear after continuous washing of the colon; (c) endoscopy disclosed a Dieulafoy lesion in the rectum; and (d) the lesion was managed by application of four haemostatic clips.

Background and Aim: Cold snare polypectomy (CSP) gained popularity as a treatment for small colorectal adenomatous polyps. In our facility, we performed CSP for colorectal adenomatous polyps and sessile serrated adenomas/polyps (SSA/P). However, only few studies investigated its usefulness for small SSA/P removal. We aimed to clarify this from the standpoint of pathological evaluation. Methods: We retrospectively analyzed cases of CSP for SSA/P, in comparison with adenomatous polyps, in our hospital between October 2013 and July 2014. Resected polyps were suctioned through the scope into a trap immediately after polypectomy. To evaluate base and lateral margins, retrieved polyps were stuck onto a firm sponge. The specimens were cut into 2-mm sections after formalin fixation and stained with hematoxylin–eosin for microscopic examination. Chi-square test was used to compare the negative lateral/base margin rate between in the resected SSA/P specimens and adenomatous polyps. Results: We performed CSP for 740 small polyps (< 10 mm) in 391 patients and successfully retrieved 724 lesions (97.8%), including adenomatous polyps (n = 604, 83.4%), SSA/P (n = 80, 11.1%), hyperplastic polyp (n = 30, 4.1%), and others (n = 10, 1.4%). Excluding piecemeal resection, we


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targeted 583 adenomatous polyps and 72 SSA/P. In the resected SSA/P and adenomatous polyp specimens, the negative lateral margin rates were 16.7% (12/72) and 48.5% (283/583), respectively (P < 0.01), and the negative base margin rates were 63.9% (46/72) and 93.0% (542/583), respectively (P < 0.01). Conclusion: Therefore, more attention should be given to residual tumors than to adenomatous polyps. # 1350 Is retroflexion helpful in detecting adenomas in right colon? Authors: HS LEE; SW JEON Affiliation: Department of Gastroenterology, Kyungpook National University School of Medicine, Daegu, Korea Background and Aim: Colonoscopy is less effective in the rightsided compared with the left-sided colon. Retroflexion during colonoscopy is expected to improve the detection rate of colorectal adenomas. The aim of the present study was to evaluate the usefulness of the right-sided colon retroflexion in routine colonoscopic examinations. Methods: From April 2013 to November 2013, a total of 398 patients were enrolled. For each patient, cap-assisted colonoscopic examination was performed. After cecal intubation, a colonoscopic examination of the cecum to the hepatic flexure was performed in the first forward view with removal of all identified polyps. The colonoscope was reinserted to the cecum, and a careful examination of the cecum to the hepatic flexure was performed in the second forward view with removal of additional polyps. The colonoscope was then reinserted to the cecum and retroflexed, and the third colonoscopic examination was performed to the hepatic flexure in retroflexion with removal of additional polyps. Total numbers and characteristics of polyps were compared with two forward examinations and retroflexion. Results: Retroflexion was successful in 90.2% of patients. The two forward viewing examinations found 213 right-sided colon polyps and 143 adenomas, and retroflexion identified an additional 35 polyps and 24 adenomas. Of these 35 polyps, 27 (77.1%) were small-sized polyps (5 mm) and 24 (71.4%) were adenomas. Finding additional adenomas on retroflexion was associated with older age. Conclusions: Colon retroflexion is helpful in detecting cecum and ascending colon adenomas, especially small-sized adenomas and is useful in older patients. Keywords: adenoma detection rate, colonoscopy, retroflexion # 1352 Terminal ileum imaging with colonoscopy to evaluate acute graft-versus-host disease severity after allogeneic bone marrow transplantation Authors: YUUSAKU SUGIHARA[1]; SAKIKO HIRAOKA[2]; SHIHO TAKASHIMA[2]; DAISUKE TAKEI[2]; INOKUCHI TOSHIHIRO[2]; ASUKA NAKARAI[2]; MASAHIRO TAKAHARA[2]; KEITA HARADA[2]; HIROYUKI OKADA [2]; NOBUHARU FUJII[2] Affiliations: [1]Department of Gastroenterology and Hepatology [2]Department of Hematology and Oncology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan Background and Aim: Graft-versus-host disease (GVHD) is a common complication of allogeneic bone marrow transplantation (BMT). Endoscopic biopsy can provide definitive diagnosis, but

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the optimal endoscopic approach to the diagnosis remains uncertain. This study evaluated whether terminal ileum imaging predicted acute GVHD (aGVHD) severity after allogeneic BMT. Methods: Consecutive patients, who underwent BMT, were referred to the Okayama University Graduate School of Medicine between May 2008 and March 2014, and diagnosed with aGVHD by pathological diagnosis, were included. Based on colonoscopy findings for the terminal ileum, patients were divided into the three groups based on degree of membrane atrophy: severe (S), moderate (M), or no atrophy (N). Results: GVHD was identified in 18 (35%; 10 male patients and 8 female patients) patients of 51 patients, with a mean age of 49 years (range 10–64), and acute myeloid leukemia was the most frequent diseases requiring transplantation. There were four, three, five, and six patients with GVHD clinical grades I, II, III, and IV. Grade IV GVHD occurred in 2/4 in group S, 4/9 in group M, and 0/5 in group N. Steroid refractory GVHD were 3/4 in group S, 4/9 in group M, and 1/5 in group N. Conclusions: This study shows that severe atrophy of the terminal ileum predicts severe clinical aGVHD that is more likely to be refractory to steroid treatment. Thus, terminal ileum atrophy severity may serve as a tool to predict clinically severe aGVHD. # 1363 Solitary rectal ulcer syndrome mimicking rectal cancer: a case report Authors: YOUNG MIN CHOI[1]; HYUN JOO SONG[1]; DA HEE HEO[1]; YOO-KYUNG CHO[1]; MIN JUNG KIM[2]; WEON YOUNG CHANG[2]; BONG SOO KIM[3]; CHANG LIM HYUN[4] Affiliations: [1]Department of Internal Medicine [2]Surgery [3]Radiology, and [4]Pathology, Jeju National University School of Medicine, Jeju, Korea Background and Aim: Solitary rectal ulcer syndrome (SRUS) is a rare benign and chronic rectal disease that has a wide spectrum of clinical presentations and variable endoscopic findings. We report a case of a 68-year-old man who presented with an ulcerated mass of the rectum representing an SRUS variant. Case description: A 68-year-old man was referred to our hospital with anal pain and difficulty in passing stools. The patient had a history of hypertension and hemorrhoid. Rectal examination revealed an irregular broad-based ulcerated mass on the rectum (Figure 1). Colonoscopy showed a hemorrhagic ulcerated mass in the rectum. Abdominopelvic computed tomography (CT) exhibited an area of rectal wall thickening with perirectal fatty infiltration and multiple small mesocolic lymph nodes enlargement, being consistent with rectal cancer. However, two repeated biopsy results showed ulceration with inflammatory reactions. There was no evidence of malignancy. Both magnetic resonance imaging and positron emission tomography were suggestive of a high possibility of rectal cancer (SUVmax 15.4) with intense FDG uptake in multiple lymph nodes (SUVmax 8.1). He underwent rebiopsy under spinal anesthesia. Incision biopsy showed a central ulcerated lesion invading the muscle layer with the surrounding edematous lesion. A third biopsy also exhibited ulceration with inflammatory reactions. Two months after conservative management, the patient improved in clinical symptoms, and follow-up colonoscopy showed that the lesion markedly improved with remnant ulcer scar. Therefore, we report a case of an SRUS patient who had a central


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ulcerated mass lesion that mimicked rectal cancer in colonoscopic and radiologic findings. Keywords: rectal cancer, solitary rectal ulcer syndrome.

rates of HP + SSA/P, adenoma, and intramucosal cancer were 50.0% (2/4), 25.0% (1/4), and 25.0% (1/4), respectively. Additional histopathological examination in 319 resected polyps, 80 polyps (25.1%), was resected in lamina propia and no muscularis mucosa were resected. Conclusions: Our study showed that cold polypectomy is a safe procedure; however, high rate of unclear and positive in histopathological margin may cause residual tumor. # 1392 The medical treatment of sigmoid volvulus over 3 years in our hospital Author: HISAKAZU MATSUMOTO Affiliation: Department of Gastroenterology, Japanese Red Cross Wakayama Medical Center, Wakayama City, Wakayama Prefecture, Japan

Figure 1

# 1382 Histopathological examination of colorectal polyps treated by cold snare polypectomy Authors: YUTAKA INADA; NAOHISA YOSHIDA; TAKAAKI MURAKAMI; KIYOSHI OGISO; RYOHEI HIROSE; TOMOHISA TAKAGI; YUJI NAITO; AKIO YANAGISAWA; YOSHIHITO ITOH Affiliation: Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan Background and Aim: Cold snare polypectomy is a widely used procedure in resection of small colorectal polyps (< 10 mm). But some problems are pointed in retrieval and histopathological examination of resected polyps. The aim of this study was to investigate the histopathological characteristics of specimen treated by cold snare polypectomy. Methods: We examined 560 polyps of 213 patients treated from April 2014 to February 2015 in two related hospitals, University Hospital and North Medical Center, Kyoto Prefectural University of Medicine. Colorectal polyps up to 12 mm were resected by cold snare. The overall clinical outcomes of procedure and histopathological characteristics of specimen were examined. Results: The mean polyp size was 5.4 mm (2–12 mm), and rate of en bloc resection was 99.8%. In addition, although the 13.1% (28/213) of patients underwent anticoagulation therapy, the rate of postoperative hemorrhage was 0%. In histopathological examination, the retrieval rate of specimen was 97.5% (546/560), and the rates of HP + SSA/P, adenoma, and intramucosal cancer were 18.3% (100/546), 80.8% (441/546), and 0.9% (5/546), respectively. The diagnosis of histopathological margin were negative in 69.2% (378/546), unclear in 27.3% (149/ 546), and positive in 3.5% (19/546). In 19 polyps diagnosed as margin positive, four polyps were positive in vertical margin. The mean size of those four polyps was 7.8 mm (2–12 mm), and the

Abstract: Sigmoid volvulus causes intestinal obstruction and requires emergency treatment. However, minimally invasive therapies that provide a complete cure are essential because the patients are mainly elderly people and neuropsychiatric patients. We clinically investigated 37 patients (56 cases) with a history of sigmoid volvulus to evaluate the treatment selection and the results over 3 years from September 2011 to August 2014. The mean age of onset was 70.7 years, and the male/female ratio was 26/11. There were no mortalities. For 34 patients, we chose to initiate the primary treatment using colonoscopy. Two of the remaining three patients underwent urgent surgical treatment after decompression with an ileus tube. One recovered spontaneously without treatment. In 53 cases, we proceeded with endoscopic therapy: 29 cases treated using only endoscopic decompression (decompression group) and 24 cases treated using endoscopic reduction (reduction group). The decompression group required more endoscopic treatments than the reduction group. But the decompression group is safer than the reduction group because two cases of the reduction group observed serious complications such as perforation. We report the medical treatment of sigmoid volvulus over 3 years in our hospital as an addition to clinical studies. # 1411 Analysis of the bleeding after the endoscopic mucosal resection (EMR) for the colorectal neoplasm for the patients who take anti-thrombotic agents Authors: MASAYOSHI ORIUCHI; DAISUKE OKAMOTO; MASAKI TOSA Affiliation: Iwaki Kyoritsu General Hospital, Iwaki, Japan Background and Aim: Recently, EMR for the patients with many complication increases. Anti-thrombotic therapy is usually used to prevent cerebro-cardiovascular events. Delayed bleeding is one of the major complications of EMR; however, little is known about the influence of anti-thrombotic therapy. In this study, we aimed to analyze delayed bleeding rate after colorectal EMR for the patients who take the anti-thrombotic agents. Methods: This is the retrospective study about consecutive patients treated in our center from January 2013 to March 2015. Furthermore, we divided the patients who take anti-thrombotic drug into the three groups and compared it with control group about a bleeding rate and clinical background. [A]: Anti-coagulant continuation group, [B]: heparin or anti-coagulant single agent replacement group, and [C]: anti-coagulant discontinuation group. Results: We treated 613 patients with 1293 colorectal neoplasms


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by EMR, and delayed bleeding rate was 1.3% (17/1293) of the neoplasm. One hundred and twenty-five patients (20.0%) with 279 neoplasms (21.6%) received anti-thrombotic therapy and divided into three groups, [A]: 42/82, [B]: 45/95, and [C]: 38/102 (patients/neoplasm). Patients who took the anti-coagulant agent tended to be older than control group. We found no significant differences to delayed bleeding rate when we compared each group with the control group (12/1014; 1.2%). In addition, cerebrocardiovascular events did not occur in all cases during clinical course after EMR. Conclusion: We thought that this study could become one material of the safe endoscope treatment procedure. # 1413 Validation study of a new colorectal magnifying NBI classification in Japan Authors: MINEO IWATATE; YASUSHI SANO; HIRONORI SUNAKAWA; TAKAHIRO UTUMI; HIDEKAZU KOSAKA; SANTA HATTORI; WATARU SANO; NORIAKI HASUIKE; TARO IKUMOTO; MASAHITO KOTAKA; TAKAHIRO FUJIMORI Affiliation: Sano Hospital, Kobe, Japan Background and Aim: NBI international colorectal endoscopic (NICE) classification proposed in 2008 can be available with or without magnification. Based on the NICE classification, we developed a new colorectal magnifying NBI classification by the Japan NBI Expert Team (JNET) in 2014. The aim of this study is to validate the JNET classification prospectively in a single center. Methods: Consecutive adult patients who underwent colposcopy with a magnifying colonoscope between February 2015 and May 2015 in Sano Hospital were recruited. The optical diagnosis for each polyp was evaluated using JNET classification (types 1, 2A, 2B, and 3), and a level of confidence (high or low) was assigned to each prediction. Results: One hundred and seventythree patients with 227 polyps diagnosed with high confidence were analyzed. Of all 227 polyps, 35 were hyperplastic polyp (HP), 178 were low-grade adenoma (LGA), 8 were high-grade adenoma (HGA)/SM slightly invasive cancer (SM-s), and 6 were SM deeply invasive cancer (SM-d). Predictive value of type 1 for HP was 84%, type 2A for LGA was 92.3%, type 2B for HGA/SM was 80%, and type 3 for SM-d was 100%. Performance characteristics of the JNET classification were as follows. The sensitivity of JNET type 2A/2B/3 for neoplastic lesion was 98%, the specificity 60%, and accuracy 92%. While the sensitivity of JNET type 2B/3 for HGA/invasive cancer was 42.9%, the specificity was 99.5%, and the accuracy was 96.0%. Conclusion: The JNET classification was feasible to use clinically for predicting histology. # 1455 The effect of discontinuation of antiplatelet agents on colonoscopic postpolypectomy bleeding Authors: CC YAO[1]; KL WU[1,2]; YC CHIU[1,2]; ML HU [1]; WC TAI[1]; YP CHOU[1]; CM LIANG[1]; LS LU[1]; SK CHUAH[1,2] Affiliations: [1]Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan [2]Chang Gung University College of Medicine, Kaohsiung, Taiwan Background and Aim: Bleeding is the most common complication after colonoscopic polypectomy. Several factors associated

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with postpolypectomy bleeding have been discussed, but whether antiplatelet agents increase the risk remains controversial. To discontinue antiplatelet agents before polypectomy is still unclear. We plan to assess discontinuation of antiplatelet agents on postpolypectomy bleeding and identify the risk factors associated with postpolypectomy bleeding. Methods: Patients undergoing colonoscopic polypectomy between November 2013 and September 2014 were recruited in the retrospective study. Patients’ demographics, clinical parameters, polyp characteristics, using of antiplatelets, and the prevalence of immediate or delay postpolypectomy bleeding were reviewed from electronic medical records. Multiple regression analysis was performed to identify independent risk factors associated with postpolypectomy bleeding. Results: Four hundred and ninety-six patients and 845 polyps were removed in this study. The bleeding rate was significantly higher in patients with antiplatelet therapy (14.9% vs 6.5%, P = 0.017). In multiple logistic regression analysis, antiplatelet users (hazard ratio: 5.97; 95% confidence interval: 1.37–26.02, P = 0.017) and bigger polyp removal (cut level 11.5 mm, hazard ratio: 1.42; 95% confidence interval: 1.19–1.71, P < 0.000) were the significant factors. In antiplatelet users, discontinuation of antiplatelet agents 5–7 days before polypectomy was the independent protective factor of bleeding (hazard ratio: 0.12, 95% confidence interval: 0.02–0.84, P = 0.03), especially when polyp ≧ 12 mm. Conclusions: Our study confirmed that use of antiplatelets and bigger polyp size are associated with colonoscopic postpolyectomy bleeding. Discontinuation of antiplatelet 5–7 days before polypectomy could decrease the bleeding while size is more than 12 mm. # 1477 Characteristics of colorectal cancer in elderly people among Asian bilateral countries Authors: NAOHISA YOSHIDA[1]; SUN-YOUNG LEE[2]; SANG PYO LEE[2]; TAKAAKI MURAKAMI[1]; KIYOSHI OGISO[1]; RYOHEI HIROSE[1]; YUTAKA INADA[1]; OSAMU DOHI[2]; YUJI NAITO[1]; ITOH YOSHITO[1] Affiliations: [1]Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan [2]Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea Background and Aim: Proportion of elderly population among newly diagnosed cancers is rapidly increasing these days due to aging. On the other hand, colorectal cancer (CRC) is one of them, and CRC deaths are increasing in the world. However, there are limited bilateral studies about CRC. In this study, we analyzed the characteristics of CRC in two Asian countries. Methods: We retrospectively analyzed consecutive early CRC (Tis and T1) patients who were newly diagnosed with adenocarcinoma between January 2010 and December 2014 at Kyoto Prefectural University of Medicine (Kyoto, Japan) and Konkuk University (Seoul, Korea). Various clinical characteristics including elderly people’s CRC and T1 cancers were analyzed. Results: Eight hundred and seventy-five CRCs (726 Japanese and 149 Korean patients) were included. The proportion of < 65-year-old patients, 65–74-year-old patients, ≥ 75-year-old patients were 37.6% (329), 37.8% (331), and 24.6% (215), respectively. There were significant differences about the rates of surgical operation for CRC among the three groups (29.8% vs


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19.6% vs 17.6%, P = 0.002). Additionally, the rates of right-sided colon were higher in < 65-year-old patients and 65–74-year-old patients than those of ≥ 75-year-old group (29.1% vs 37.2% vs 44.4%, P = 0.01). There were significant differences about the rates of patients with antithrombotics among three groups (3.2% vs 13.7% vs 22.2%, P = 0.02). On the other hand, the rates of vascular invasion and lymphatic invasion in T1 cancer were higher in Japan than those in Korea (vascular invasion, 13.7% vs 1.4%, P = 0.002, and lymphatic invasion, 27.7% vs 13.7%, P = 0.01). Conclusions: Our Asian bilateral study showed that the clinicopathological characteristics of CRC differed according to the age groups. Additionally, there were differences about histological evaluation in two countries. Further analysis about these differences should be performed to decrease CRC death in the world.

“size up” is likely to be malignant, so we recommend that it should be resected early.

# 1484 The evaluation of gastric cancer in familial adenomatous polyposis (FAP) Authors: KENJIRO MORISHIGE[1]; CHINO AKIKO[1]; TERUHITO KISHIHARA[2]; AKIYOSHI ISHIYAMA[1]; YOSHIRO TAMEGAI[1]; JUNKO FUJISAKI[1]; MASAHIRO IGARASHI[1] Affiliations: [1]Cancer Institute Hospital, Tokyo, Japan [2]Japanese Foundation for Cancer Research, Tokyo, Japan

Background and Aim: The pocket-creation method (PCM) is a new strategy for ESD of colorectal laterally spreading tumors (LST). The key feature of the PCM is creation of a large submucosal pocket using a small-caliber-tip transparent hood. The aim of this study is to assess the usefulness of PCM for colorectal LST compared with the conventional method (CM). Methods: A total of 440 patients underwent ESD for superficial colorectal tumors from April 2012 to February 2015. We retrospectively reviewed 270 lesions larger than 20 mm diameter and divided them into a PCM group (n = 139) and a CM group (n = 131). Results: Tumor diameter (mm): average ± SD, PCM:40 ± 21 versus CM:39 ± 23, P = 0.34, submucosal fibrosis (F0:1:2); 62:71:6 versus 50:67:14, P = 0.11, en bloc resection rate: 98.6% (137/139) versus 96.2% (126/131) P = 0.96, en bloc R0 resection: 92.7% (127/137) versus 92.9% (117/126) P = 0.96, en bloc curative resection: 89.1% (122/ 137) versus 90.5% (114/126) P = 0.70, perforation: 0.7% (1/139) versus 0.8% (1/131) P = 0.50, postoperative bleeding: 2.2% (3/139) versus 2.3% (3/131) P = 0.94. For lesions resected en bloc, dissection time (min): 76.6 ± 58.8 versus 88.0 ± 69.8 P = 0.31, dissection speed (mm2/min): 25.8 ± 13.1 versus 22.6 ± 13.0 P = 0.03. Conclusions: Dissection speed using PCM resection is significantly faster than CM ensuring a good ESD outcome. PCM achieves an efficiently reliable resection of colorectal LST.

Background and Aim: Familial adenomatous polyposis (FAP) is an autosomal dominant hereditary disease leading to the development of numerous colorectal adenomas with malignant potential. Extra-colonic neoplasms are observed often in patients with FAP. It is noticed that relatively large number of gastric cancers (2–3%) is associated with FAP in East Asia, but it is not known in the reality and surveillance. The aim of this study is to evaluate the gastric cancer frequency, the surveillance, and indication for endoscopic resection. Methods: We experienced 45 FAP cases in April 2005 to December 2014 in our hospital. Forty FAP cases (male 26 cases, female 14 cases, and average 41.7 years old) underwent esophagogastroduodenoscopy (EGD) registered among them. We revealed the gastric cancer frequency, clinical, and endoscopic findings retrospectivity and evaluated the surveillance and indication for endoscopic resection. Results: Extra-colonic neoplasms were gastric cancer seven cases (15%), duodenal cancer one case (2%), small intestine cancer one case (2%), thyroid cancer one case (2%), and desmoid tumor eight cases (17%). In 40 FAP cases underwent EGD, fundic gland polyposis 31 cases (77%), adenoma 6 cases (15%); 15 lesions, cancer 7 cases (17%); 12 lesions were seen (overlapping). Adenoma progressed to cancer in eight cancer cases out of 12. The locations of cancers were upper (eight lesions), middle (two lesions), and lower (two lesions) of the stomach, the types were 0-IIc (six lesions), 0-IIa (five lesions), and 0-I (one lesion), and pathological findings were all well-differentiated adenocarcinoma. We performed endoscopic submucosal dissection (ESD) for 16 lesions (adenoma 4 lesions and cancer 12 lesions). The treatment opportunities were biopsy (10 cases), size up (8 cases), shape change (1 case), and others (1 lesion) (overlapping). Seven of eight lesions with “size up” were cancer in the final pathological findings. Conclusion: In this study, gastric neoplasms with FAP were located in several areas of the stomach. The adenoma tended to progress to cancer; therefore, we need to carefully observe gastric adenoma with FAP. The lesions with

# 1505 Usefulness of the pocket-creation method of ESD for colorectal laterally spreading tumors Authors: HISASHI FUKUDA[1]; YOSHIKAZU HAYASHI[1]; MASAHIRO OKADA[1]; CHIHIRO IWASHITA[1]; HARUO TAKAHASHI[1]; MANABU NAGAYAMA[1]; TAKAHITO TAKEZAWA[1]; YUJI INO[1]; YOSHIMASAMIURA[1]; HIROTSUGU SAKAMOTO[1]; HIROYUKISATO[1]; TOMONORI YANO[1]; KEIJIRO SUNADA[1]; HIROYUKI OSAWA[1]; ALAN K LEFOR[2]; HIRONORIYAMAMOTO[1] Affiliations: [1]Department of Medicine, Division ofGastroenterology, Jichi Medical University, Shimotsuke, Japan [2]Department of Surgery, Jichi Medical University, Shimotsuke, Japan

# 1507 Impact of bowel habits on colonoscopy preparation Authors: DONG-WON LEE; JA SEOL KOO; SEUNG YOUNG KIM; JONG JIN HYUN; SUNG WOO JUNG; HYUNG JOON YIM; SANG WOO LEE Affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea. Background and Aim: The effectiveness of colonoscopy is highly dependent on the quality of bowel preparation. Although many studies have previously evaluated the role of cleansing methods and dosing regimens, few have examined the association between bowel habits and subsequent bowel preparation. Here, we aimed to evaluate the impact of bowel habits on the quality of bowel preparation. Methods: A total of 404 patients who underwent a total colonoscopy and completed a personal bowel habit questionnaire at Korea University Hospital between


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December 2012 and December 2013 were enrolled in this study. The usual stool form of patients was classified into seven categories according to the Bristol Stool Scale (BSS). The quality of bowel preparation was determined during colonoscopy according to the Ottawa Bowel Preparation Scale (OBPS). Segment scores of ≥ 3 or total OBPS scores of > 7 were defined as a poor bowel preparation. Results: Poor bowel preparation was reported in 9.4% of observed colonoscopies. The odds ratios (ORs) associated with low bowel movement (< 4/week) were 5.13 (95% CI: 2.00– 13.18) for the right colon and 6.53 (95% CI: 2.29–18.57) for the total colon (P < 0.05). The ORs associated with BSS types 1 and 2 were 3.84 (95% CI: 1.38–10.65) for the right colon, 9.33 (95% CI: 1.27–68.68) for the mid colon, and 4.11 (95% CI: 1.47– 11.49) for the total colon (P < 0.05). After adjusting for age, sex, diabetes mellitus, and bowel preparation regimen, low bowel movement (< 4/week) was significantly associated with poor bowel preparation. Conclusion: Low bowel movement (< 4/ week) was significantly associated with poor bowel preparation, whereas hard stool formation was associated with an increased risk for poor bowel preparation.

# 1521 Systematic review and meta-analysis of patient-controlled sedation versus intravenous sedation for colonoscopy Authors: YI LU; LI-XIAO HAO; LU CHEN; ZHENG JIN; BIAO GONG Affiliations: Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; Department of Hepatobiliary Surgery, Chinese PLA the 455st Hospital, Shanghai, China Yi Lu and Li-xiao Hao contributed equally to this manuscript. Background and Aim: Patient-controlled sedation (PCS) has been suggested as an alternative method for sedative colonoscopy. However, as in any new techniques, PCS introduction as potential alternative to traditional intravenous sedation (IVS) has brought about challenges. To evaluate the advantages and disadvantages between PCS and IVS more comprehensively, we conducted a systematic review and meta-analysis of the published literature. Methods: Several databases were searched from inception to 1 April 2015, for trials comparing PCS with IVS for colonoscopy. The outcomes of interest included time for preparation, time for cecal intubation, time for total colonoscopy, rate of complete colonoscopy, dose of sedative drugs used, pain scores, recovery time, and complications. Inconsistency was quantified using I2 statistics. Results: All in all, 12 trials were finally selected (1091 patients, with 545 in the PCS group and 546 in the IVS group). The total propofol used, time for cecal intubation and total procedure, the rate of complete colonoscopy, and pain score had no statistical difference between the two groups. However, the recovery time, incidence of oxygen desaturation and hypotension in the PCS group was reduced in the PCS group. The rates of other complications and patients’ willingness to repeat the same sedation had no statistical difference between the two groups. Conclusion: PCS is as feasible and effective as the traditional IVS for colonoscopy, and there is a tendency that PCS shows its superiority in recovery time, incidence for oxygen saturation, and hypotension.

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# 1526 Proximal lesions in screening colonoscopies are associated with increased age and females Authors: SE LEE[1]; R WONG[1,2]; WK CHEONG[3]; YY DAN[2]; LL LIM[2]; C KOH[2]; J LEE[2]; B CHOO[1]; F ZHU [1]; WL QUAN[4]; S TSAO[4]; C VU[4]; WL YANG[4]; SS FONG[5]; KG YEOH[1,2] Affiliations: [1]Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore [2]Division of Gastroenterology and Hepatology, University Medicine Cluster, National University Health System, Singapore, Singapore [3]Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore [4]Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore, Singapore [5]Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore Background and Aim: Studies have reported proximal shift of colorectal cancers with increased age and in females. We aimed to identify independent factors associated with the anatomical distribution of lesions detected in screening colonoscopies at two tertiary hospitals in Singapore. Methods: Demographics, endoscopy findings, and biopsy histology from colonoscopies in 2012–2014 were prospectively collected; screening colonoscopies were selected for analysis. The splenic flexure and more proximal segments were defined as proximal colon. Advanced adenomas were defined as adenomas > 10 mm, villous characteristics, high-grade dysplasia, or adenocarcinoma. Logistic regression was performed, with clustered standard errors for patients with multiple lesions. Factors examined were age, gender, ethnicity, and lesion pathology (adenoma, advanced adenoma, or cancer). The relationship between adenomas and a proximal location was modelled separately from advanced adenomas, as well as cancers. Results: Out of 30 370 colonoscopies indexed, 5480 were screening colonoscopies; 3300 lesions (1437 proximal, 44%) were found in 2065 screening colonoscopies. Mean age was 58.5 ± 10.4 years with 2580 (47%) males. Increasing age, females, and adenomas were independently associated with proximal lesions, with ORs (95% CI) of 1.01 (1.01–1.02), 1.17 (1.01– 1.36), and 1.70 (1.43–2.01), respectively. Similar ORs were observed in the two other models; however, ORs (95% CI) for advanced adenomas and cancers were 0.51 (0.42–0.62) and 0.37 (0.22–0.61), respectively. Conclusions: Increased age and female gender were independently associated with proximal lesions. Adenomas were more likely to be found in the proximal colon; however, advanced adenomas and cancers were more likely to be found in the distal colon. Colonoscopies, rather than flexible sigmoidoscopy, should be ordered for the elderly, especially in females, in order not to miss proximal lesions. Keywords: adenoma, colonoscopy, distal, distribution, polyps, proximal. # 1539 Endoscopic submucosal dissection for colorectal tumors in the oldest-old Author: YOHEI TERAKADO Affiliation: Sapporo Kosei General Hospital, Sapporo, Japan Background and Aim: With the aging of society, the number of endoscopic procedures being performed for colorectal tumors is


Poster endoscopy

increasing. Endoscopic submucosal dissection (ESD) enables en bloc resection of colorectal tumors, regardless of their size and shape; however, this procedure is technically difficult to perform. Therefore, evaluation of the safety of ESD in the oldest-old is necessary. The present study aimed to evaluate the safety and effectiveness of ESD for colorectal tumors in patients aged > 85 years. Methods: We retrospectively reviewed the data of eight patients (nine lesions) aged > 85 years with colorectal tumors who underwent ESD at our hospital between April 2009 and February 2015. The endpoints were the en bloc resection rate and occurrence of complications. Results: Among the eight patients, six were men and two were women. The mean age of the patients was 87.0 years (range 85–92 years). Of the nine lesions, two were located in the cecum, one in the ascending colon, two in the transverse colon, two in the sigmoid colon, and two in the rectum. The mean resection size was 30.2 mm, and the mean procedure time was 52 min. The mean period until oral food intake after ESD was 2.1 days, and the mean length of hospital stay after ESD was 7.0 days. En bloc resection was performed in all patients. No serious complications, such as postoperative bleeding and perforation, were noted, and emergency surgery was not performed. Conclusions: ESD is safe and effective for early colorectal tumors in the oldest-old.

# 1541 Endoscopic resection of colorectal granular cell tumors: 11 cases Authors: SHI QIANG; ZHONG YUN-SHI Affiliation: Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China Background and Aim: Endoscopic resection is a relatively new but widely used minimal invasive technique that has been used to remove colorectal submucosal tumors (SMT). This study aimed to determine the feasibility and effectiveness of endoscopic resection for treating colorectal granular cell tumors. Methods: This was a retrospective study performed at a single institution. From January 2008 to April 2015, we examined a total of 11 lesions in 11 patients who were treated by endoscopic procedure for colorectal granular cell tumors in Endoscopy Center, Zhongshan Hospital, Fudan University. For endoscopic resection, endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) was used. Preoperative and postoperative conditions and followup of these patients were evaluated. Results: Of the 11 lesion presented in the 11 patients, two were located in the cecum, four were in the ileocecal junction, four were in the ascending colon, and two were in the rectum. The median maximum diameter of the tumor size was 0.81 cm (range 0.4–1.2 cm). The en bloc rate was

Figure 1 Preoperative examination and ESD.

100%; complete resection was 90.9% (10/11). There was no perforation or delayed perforation. No emergency surgery was required for the complication. Conclusion: Endoscopic treatment performed by endoscopists with sufficient experience appears to be feasible and effective for colorectal granular cell tumors. # 1555 Systematic review and meta-analysis: sodium picosulfate/magnesium citrate versus polyethylene glycol for colonoscopy preparation Authors: ZHENG JIN; YI LU; BIAO GONG Affiliation: Digestive Endoscopy Center, Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China Background and Aim: Previous studies comparing sodium picosulfate/magnesium citrate (SPMC) with polyethylene glycol (PEG) drew inconsistent conclusions. We conducted a metaanalysis to compare the performance of the two agents for colonoscopy preparation. Methods: A search of randomized controlled trials (RCTs) up to July 2015 was acquired, using MEDLINE, EMBASE, the Cochrane Library, and Google Scholar. We calculated the pooled estimates of bowel cleanliness, polyp/adenoma detection rate (PDR/ADR), completion of preparation, willingness to repeat identical bowel preparation, and adverse events by using relative risk (RR) with random-effects models. Potential publication bias was assessed. Results: A total of 25 studies were qualified for analysis. There was no statistical difference between the two agents in bowel cleanliness (RR 0.93; 95% CI: 0.86–1.01, P = 0.07), PDR (RR 0.94; 95% CI: 0.82–1.08, P = 0.37), and ADR (RR 0.88; 95% CI: 0.74–1.05, P = 0.16). However, a higher proportion of patients were likely to complete SPMC preparation (RR 1.08; 95% CI: 1.04–1.13, P < 0.0003) and were willing to repeat the preparation (RR 1.44; 95% CI: 1.25–1.67, P < 0.00001). Besides, the total number of adverse events was significantly decreased in SPMC group when compared to PEG group (RR 0.78; 95% CI: 0.66–0.93, P = 0.004). Publication bias were detected but had no significant influence on the results. Conclusion: SPMC had similar bowel cleansing efficacy and PDR/ADR compared to PEG, with better tolerability and less frequent adverse events. Large-scale, well-organized, head-to-head studies are warranted.

# 1601 Risk factors for perforation and delayed bleeding associated with endoscopic submucosal dissection for colorectal neoplasms Authors: TATSUYA TOYOKAWA; JOICHIRO HORII; KAZUO WATANABE; ISAO FUJITA; JUN TOMODA Affiliation: Department of Gastroenterology, National Hospital Organization Fukuyama Medical Center, Fukuyama, Japan Background and Aim: Endoscopic submucosal dissection (ESD) is a useful technique for the treatment of colonic neoplasms. This study aimed to evaluate cases that experienced perforation and delayed bleeding associated with ESD and to elucidate the risk factors for these complications. Methods: This study investigated 113 lesions (114 cases) in colorectal neoplasms treated by ESD. A comparison between patients with and without perforation or delayed bleeding


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was made based on the following patient characteristics: size, type, and location of lesions; procedure time; and treatment results. Results: Perforations occurred in 15 cases (13%), and five cases (4.4%) exhibited delayed bleeding complications. None of the cases required salvaged surgery. Univariate analysis indicated that the risk factor for perforation was large lesion size, and the probable risk factors were granular type, combination of ulcer or ulcer scar, and lesions located at transverse or ascending colon. Multivariate analysis indicated that large lesion size was associated with significantly higher risk of perforation (odds ratio: 1.07, 95% confidence interval: 1.02–1.12). The en bloc and curative resection rates of the lesions with perforation were significantly lower and the procedure time was significantly longer than those without perforation. Univariate analysis indicated that the probable risk factors for delayed bleeding were combination of ulcer or ulcer scar and lesions located at the rectum. Multivariate analysis indicated that there are no risk factors for delayed bleeding. Conclusions: This study demonstrated that large lesion size is a risk factor for perforation. Furthermore, perforation is associated with clinical outcomes of ESD. These results should guide and influence performing ESD for colorectal neoplasms. # 1606 A case of ulcerative colitis in a patient with Takayasu’s arteritis, Sjogren’s syndrome, and Hashimoto’s thyroiditis Authors: HW PARK; HS LEE Affiliation: Department of Gastroenterology, Kyungpook National University School of Medicine, Daegu, Korea Background and Aim: Takayasu’s arteritis (TA) and ulcerative colitis (UC) are chronic inflammatory disease with unknown etiology. UC is sometimes related with other autoimmune diseases or extraintestinal symptoms. TA is speculated to be an autoimmune disease in the spectrum of collagen vascular diseases. Sjogren’s syndrome (SS) is an autoimmune disease with chronic inflammation in the salivary and lacrimal gland, and it is occasionally accompanied by Hashimoto’s thyroiditis (HT). Because the likelihood of these four diseases simultaneously occurring is considered to be extremely rare, we report a case of a patient with TA, SS, and HT who developed UC. There are published cases of combinations of UC and TA that suggest a genetic mechanism plays an important role in the diseases due to the high frequency of specific human leukocyte antigen typing for both diseases. The combination of these four diseases together suggests the possibility that they all may have a common pathophysiologic background. Case description: A 31-year-old woman was admitted to our hospital for frequent hematochezia for 1 month. In her medical history, she had been diagnosed with TA 15 years ago which was treated with acetylsalicylic acid to prevent vascular thrombosis. She also received treatment with xipamide, amlodipine, and bisoprolol due to renovascular hypertension. Subsequently, she was diagnosed with Hashimoto’s thyroiditis and had been taking levothyroxine to combat hypothyroidism. One month prior to her hospitalization, she was diagnosed with SS and was treated with hydroxychloroquine. Colonoscopic findings were as follows: absent vascular patterns and erythematous mucosa with exudates that started in the rectum and extended to the cecum. A biopsy was taken from multiple locations. Pathological findings revealed chronic colitis with crypt abscess which was compatible with the diagnosis of UC. She was treated with

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mesalazine (3000 mg/day) for a month, and then her hematochezia disappeared. # 1615 The “pocket-creation method” facilitates ESD of recurrent colorectal lesions Authors: KOZUE MURAYAMA; KEIJIRO SUNADA; YOSHIKAZU HAYASHI; HISASHI FUKUDA; MASAHIRO OKADA; HARUO TAKAHASHI; MANABU NAGAYAMA; TAKAHITO TAKEZAWA; HIROTSUGU SAKAMOTO; INO YUJI; YOSHIMASA MIURA; TOMONORI YANO; HIROYUKI SATO; HIROYUKI OSAWA; ALAN K. LEFOR; HIRONORI YAMAMOTO Affiliation: Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Tochigi, Japan Background and Aim: Endoscopic submucosal dissection (ESD) of recurrent lesions is associated with technical difficulties because of severe submucosal fibrosis. We developed the pocket-creation method (PCM) as a standard strategy for colorectal ESD. The PCM is effective for overcoming the difficulties associated with ESD of these lesions. This study aims to evaluate the safety and efficacy of the PCM for recurrent colorectal lesions. Methods: From July 2013 to May 2015, 15 recurrent colorectal lesions were treated using ESD with PCM at Jichi Medical University Hospital. The key feature of PCM is to create a submucosal pocket under the lesion using an ST hood. If there is severe fibrosis, the pocket is created on both sides of the fibrotic area first. Dissection of the fibrotic area is made along an imaginary line connecting both sides of the pockets. PCM has advantages including maintenance of a thick submucosal layer with a minimal mucosal incision preventing leakage of injected solution, and providing good traction. Results: The mean tumor size was 24.8 mm. Lesions were located in the cecum (n = 2), the ascending colon (n = 3), the sigmoid colon (n = 4), and the rectum (n = 6). Histology included adenocarcinoma (n = 6), adenoma (n = 7), and NET G1 (carcinoid, n = 2). Fibrosis was F0: 0, F1:7, and F2: 8. Mean procedure time was 65 min (16–634). The en bloc resection rate was 93.3% (14/15). One lesion over 10 cm was divided into two pieces intentionally. The R0 resection rate was 86.7% (13/ 15). There were no perforations and two episodes of post-ESD bleeding. Both patients had received antithrombotic drugs. Conclusion: This retrospective study suggests that the PCM allows safe and reliable ESD, even for recurrent colorectal lesions. # 1649 Colorectal ESD remains safe with widespread use Authors: H TAKAMARU; Y SAITO; M YAMADA; S ABE; T SAKAMOTO; T NAKAJIMA; T MATSUDA Affiliation: National Cancer Center Hospital, Tokyo, Japan Background and Aim: Endoscopic submucosal dissection (ESD) for colon tumors is now accepted as a minimally invasive therapy. However, its safety continues to be evaluated as its use becomes more widespread. Starting in 2012, more novice endoscopists (< 30 ESD cases performed) began to perform ESD at our institution as the volume of procedures performed increased. Our aim was to assess the overall safety and efficacy profile of ESD performance before and after 2012. Methods: Consecutive 1333 lesions (1268 patients) that underwent ESD at our institution


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from June 1998 to May 2015 were analyzed retrospectively. We evaluated the number of discontinued ESD, resected size, en bloc resection rate, curative resection rate, perforation rate, postoperative bleeding rate, and experience of operator and compared results before and after 2012. Results: Among 1333 ESDs that were completed, 766 performed in 1998–2012 and then 567 performed after 2012. Overall, mean procedure time was 101 min, en bloc resection rate was 91.5%, and curative resection rate was 87.0%. According to experience of operators, eight experts performed 1027 ESDs, and 33 novices performed 306 ESDs under expert supervision. The perforation rate was 2.7%, and postoperative bleeding rate was 2.0%. After 2012, a significantly higher proportion of novice endoscopists performed ESD (18% vs 30%, P < 0.01). Complication rates before and after 2012 remained similar, as shown in Table 1. Conclusions: Our institution has the world’s largest ESD experience, and our data demonstrate that we can maintain a low rate of complications and a high efficacy rate while increasing overall ESD volume and expanding training to more endoscopists.

Table 1 The result of ESD before and after 2012

Completed ESDs Resected size (mean, range [mm]) Number of operators Number of ESDs by experts Number of ESDs by trainees En bloc resection rate Curative resection rate Perforation rate Postoperative bleeding rate

Before 2012

After 2012

P-value

766 38.3 (7–150)

565 38.3 (8–152)

0.98

25 629 137 90.1% 86.3% 3.3% 2.0%

26 396 171 93.5% 88.0% 1.94% 0.21%

45 mm and LST-G > 35 mm are technically difficult (Sen = 0.857, spe = 0.72, PPV = 0.632, NPV = 0.900, accuracy = 0.769, PLR = 3.0612). Conclusion: Combining morphology and size can predict the technical difficulty of resecting type 0-Is and LST-G lesions in endoscopists with limited experience.

Table 1 Easy (n = 39) Morphology 0-Is LST-NG LST-G Location Rectum Sigmoid Descending Transverse Ascending Cecum ESD duration Mean (min) SD (min) Median (min) Non-lifting Fibrosis F0 F1 F2 Success Fail En bloc EPMR Device Dual knife Flush knife IT-nano Specimen size Mean (mm) SD (mm) Median (mm) Tumor size Mean (mm) SD (mm) Median (mm) Hospital 1 2 Criteria 0-Is ≤ 45 mm or LSTG ≤ 35 mm 0-Is > 45 mm or LSTG > 35 mm

Difficult (n = 24)

P

0.5018 10 14 15

3 10 11

12 8 2 6 9 2

5 7 1 4 6 1

0.9538

134 mg/dL), and age (> 56 years old) were significant factors for decision of the personalized interval of next screening colonoscopy. For example, for male patient, who had adenoma at fist screening, the predicted risk of adenoma is 50% after 25 months. Conclusion: Our study can provide personalized time interval of next screening colonoscopy according to patients’ individual clinical data.


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# 1942 Effect of functional relaxation on outpatients undergoing colonoscopy: a randomized controlled trial Authors: JEONG-SEON JI[1]; YOUNG-SEOK CHO[2] Affiliations: [1]Division of Gastroenterology, Departments of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea [2]Division of Gastroenterology, Departments of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Background and Aims: Several methods have been reported to reduce patient discomfort during colonoscopy, including use of pediatric colonoscope, variable stiffness colonoscope, gastroscope, insufflation of carbon dioxide, and music. Although a potential benefit from some of these methods has been suggested, none are currently recommended by clinical practice. For functional relaxation, there was no study assessing the efficacy in reducing discomfort during colonoscopy. The aim of this trial was to evaluate the effectiveness of functional relaxation on outpatients undergoing colonoscopy. Methods: A total of 90 patients were randomized to functional relaxation group (45 patients) or control group (45 patients). In the study group, functional relaxation was carried out by listening and following recorded functional relaxation education tape before and during colonoscopy. In control group, no education was carried out. Patients were given analgesics (50 mg of meperidine) before colonoscopy. Additional meperidine and midazolam were given on demand. Primary outcome measure was pain measured on linear analogue scale from 0 to 10. Results: Mean pain score was significantly reduced by functional relaxation from 4.7 ± 2.7 to 2.9 ± 2.1 (P = 0.003). Overall satisfaction (7.3 ± 2.3 vs 9.0 ± 1.4, P = 0.002) and willingness to repeat the procedure (75.0% vs 95.7%, P = 0.007) were significantly improved by functional relaxation. Also, there was a significant reduction of the proportion of patients requiring additional analgesics and sedation in the relaxation group (16.7% vs 4.3%, P = 0.047). On a subgroup analysis, functional relaxation was more effective in the highly educated or female patients. Conclusions: Functional relaxation significantly reduces abdominal pain and could be offered to patients undergoing colonoscopy. # 1944 Novel probe-based quantitative image of mitochondria using multiphoton microscopy in live colon cancer tissues Authors: ES KIM; HJ CHUN; IK YOU; SH KIM; JM LEE; HS CHOI; B KEUM; YT JEEN Affiliation: Gastroenterology, Korea University College of Medicine, Seoul, Korea Background and Aim: Multiphoton endomicroscopy is the recently updated technique for endoscopy and virtual image and optical sectioning. However, optimized probe has not been established for multiphoton endomicroscopic image. Therefore, we developed novel probe for mitochondria and applied for colon neoplasm tissues. In cancer cells, abnormally increased mitochondrial replication is related to mitochondrial dysfunction and Warburg effect. Methods: We used newly developed multiphoton probes for mitochondria imaging which are made using benzofuran derivative (BFP, maximal multiphoton fluorescence at 570 nm; Figure 1). Fresh mucosal tissues of colonic adenoma

and adenocarcinoma were obtained from endoscopic biopsy. Multiphoton probe BFP for mitochondria was stained for tissues, and imaging performed using multiphoton microscopy. Results: BFP shows high enhancement factor upon binding mitochondria, good selectivity, and cell permeability and can readily detect mitochondria in human tissues by multiphoton microscopy. Mitochondria were detected in human colon mucosa tissues. Calculated mitochondria area was increased in adenocarcinoma tissues compared to normal mucosal tissues. Conclusions: Newly developed multiphoton probes for mitochondria are usable to image human live colon tissues. Keywords: colon cancer, live tissue, mitochondria, multiphoton microscopy

# 1949 Feasibility and efficacy of new closure technique with repositionable clips for a large mucosal defect after colonic endoscopic submucosal dissection Authors: T AKIMOTO; O GOTO; S SAGARA; A FUJIMOTO; Y OCHIAI; MAEHATA; T NISHIZAWA; T URAOKA; N YAHAGI Affiliation: Cancer Center, Keio University, School of Medicine, Tokyo, Japan Background and Aim: To prevent complications after colonic endoscopic submucosal dissection (ESD), we developed a new closure technique using repositionable clips. We retrospectively investigated the feasibility and efficacy of this technique. Methods: From February 2015, three experienced endoscopists in colonic ESD attempted to close post-ESD mucosal defects. The mucosal defects were linearly closed by grasping one side of the defect border with the repositionable clip, QuickClipPro™ (Olympus Medical Systems, Co. Ltd.), pushing the endoscope, gently reopening the clip on the oral border, regrasping both borders, and clipping them together. After getting close to each other enough, conventional hemoclips were placed on the rest of intervals to complete the closure. We assessed the feasibility of this technique, as well as the efficacy of a defect closure, by comparing postoperative complications in this closure group to that in a nonclosure group which included consecutive 57 cases of colonic ESD from March 2014 to January 2015 performed by the same three endoscopists. Results: In 24 lesions in the closure group, the closure was not attempted due to the location on the ileocecal valve in two, long procedural time of preceding ESD in one, possibly deep invasion into the submucosa in one, and a candidate of colectomy for other lesion in one, each. The closure was tried in 19 lesions and was successfully completed in 18 (94.7%). It failed in one lesion because of poor maneuverability. The average closure time was 8.3 ± 7.2 min. Neither delayed bleeding nor perforation occurred (0/18, 0%), whereas 12 postoperative bleedings (including minor bleeding) and 2 delayed perforations occurred in the control group (14/57, 24.6%) with a significant difference (P = 0.0158). Conclusions: The new closure technique using repositionable clips was feasible and may be effective for the prevention of complications after colonic ESD.


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# 1967 Findings on repeat colonoscopies in a repeat fecal immunochemical tests for CRC screening population Authors: CHIH-CHIN LIU[1]; CHIUNG-KAI WANG[1]; YUMIN LIN[1,2]; KUANG-EN CHU[1]; LEE-WON CHONG[1]; HUNG-CHUEN CHANG[1,2]; JAW-TOWN LIN[1,2]; KUOCHING YANG[1] Affiliations: [1]Division of Gastroenterology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan [2]School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan Background and Aim: We examined the endoscopic findings of individuals with repeat positivity of fecal immunochemical tests (FITs) and repeat confirmation colonoscopies to understand the quality of the colorectal cancer (CRC) screening program. Methods: We retrospectively enrolled individuals that attended the biennial FIT-based CRC screening in a single hospital between January 2010 and December 2013. Stool specimen was analyzed by immunochemical tests (Kyowa, Tokyo, Japan) with cutoff point 30 ng/mL g. Colonoscopy was recommended to FIT ≥ 30 ng/mL g subjects. Colonoscopies repeated in individuals with repeat positivity of FIT in two rounds of screening were analyzed. Results: A total of 42 559 stool tests were done in the study period, and 4032 (9.5%) showed positive results (FIT ≥ 30 ng/mL g). There were 2983 (74.0%) colonoscopies performed for confirmation. Among 2983 examinations, 75 (2.5%) were repeat colonoscopies and were enrolled for subsequent analysis. The median age of the cohort was 65 (range 55–74) years with 51 (68%) men. The adenoma detection rate and cancer detection rate revealed no significant difference between the initial and repeat colonoscopies. New findings were yielded on 12 (16.0%) repeat colonoscopies including 10 high-risk adenomas and 2 cancers. Conclusions: Repeat colonoscopies on the basis of the FIT results could reach a significant yield. The new findings on the repeat colonoscopies may reveal either missed or “de novo” pathology. Regular audit on the findings of repeat colonoscopies could be regarded as a novel quality indicator of the screening colonoscopy. # 1985 A study of the necessity for total colonoscopy and endoscopic resection for the elderly aged 80 years and older Authors: YU OMATA; AKIHIKO TSUCHIYA; KO NISHIKAWA; MASAMI YAMANAKA Affiliation: Department of Gastroenterology, Ageo Central General Hospital, Saitama, Japan Background and Aim: Japan has become an aging society. The number of elderly persons undergoing total colonoscopy (TCS) and endoscopic resection is increasing. We studied the need for TCS and endoscopic resection for elderly patients. Method: Subjects were 204 elderly people aged 80 years and older who tested positive FOBT, during the period between 2011 and 2015, and underwent EMR for colorectal polyps during TCS, with a mean age of 82.2 years old. We studied the relationship between histopathology of the polyps and their sites and size. Result: A total of 492 polyps (male : female, 370:122) were identified in 204 patients (male : female, 147:57). The ratio of polyps by histopathological type was as follows: low-grade adenoma, 66.3%; high-grade adenomas, 16.3%; carcinoma in adenoma, 7.9%; adenocarcinoma,

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1.6%; and others, 7.9%. Table 1 shows the relationship between the sites and histopathology of the polyps. Table 2 shows the relationship between the size and histopathology of the polyps. Conclusion: High-grade adenoma, carcinoma in adenoma, and adenocarcinoma were mainly detected in the left side of the colon, but they were also detected in the right side. Therefore, TCS should be performed for elderly persons. We detected a slightly higher number of polyps measuring ≥ 11 mm than those measuring ≤ 10 mm in cases of carcinoma in adenoma and adenocarcinoma; further, we frequently detected small polyps measuring ≤ 10 mm in cases of high-grade adenoma. Therefore, it was considered that precancerous lesions are also found in small polyps. Therefore, endoscopic resection should be performed even for small polyps.

Table 1 The relationship between the sites and histopathology of the polyps

Others Low-grade adenoma High-grade adenoma Carcinoma in adenoma Adenocarcinoma Total

Right side

Left side

P-value

10 (25%) 205 (63%) 38 (47.5%) 9 (23%) 3 (37.5%) 265 (54%)

30 (75%) 120 (37%) 42 (52.5%) 30 (77%) 5 (62.5%) 227 (46%)

3/4 (P = 0.001), lymph vascular involvement (P = 0.004), postoperative stricture (P = 0.02), and combined with other cancer (P = 0.030) were independent predictors of recurrence. The 5-year progression-free survival rate was 72%, for HGD, EP/LPM, MM and SM1 were 82.5%, 67.1%, 74.6%, and 54.2%, respectively (P = 0.003). Metastases were observed in 10 (2.91%) patients, and 7 were lymph node metastasis. The 5-year overall survival rate was 95% and for HGD, EP/LPM, MM and SM1 were 97.40%, 87.30%, 92.62%, and 78.60%, respectively (P = 0.008). There were 14 (4.1%) patients died. Death due to esophageal cancer occurred in six patients (1.74%). The circumferential range > 3/4 (P = 0.000), combined with other cancer (P = 0.000), and infiltration depth of lesion (P = 0.010) were independent predictors of overall survivals. Conclusions: Endoscopic submucosal dissection is efficient to treat EESCC. The risk of recurrence after ESD were mainly associated with longitudinal length ≥ 3 cm, lymph vascular involvement, circumferential lesion > 3/4, combining with other cancer, and postoperative stricture. Overall survival was affected by circumferential lesion > 3/4, combining with other cancer and infiltration depth of lesion.

# 1221 Endoscopic removal of foreign bodies from the gastrointestinal tract: retrospective analysis of 284 patients Authors: HOSOTANI KAZUYA; INOKUMA TETURO Affiliations: Department of Gastroenterology & Hepatology, Kobe City Medical Center General Hospital, Kobe, Japan Backgroud: Patients with foreign bodies lodged in the gastrointestinal (GI) tract frequently present to emergency departments. We investigated the clinical characteristics of these foreign bodies and evaluated the clinical usefulness of endoscopic therapy for their removal. Methods: We retrospectively examined 284 patients who underwent endoscopy at our hospital to remove a foreign body from the GI tract between September 2008 and April 2014. We analyzed patient’s age and sex, type and location of the foreign body, method of removal, and success rate and complications of endoscopic therapy. Results and discussion: Our review identified 192 patients (70 men, 122 women, mean age 66 years) who underwent endoscopic therapy to remove an unobstructed foreign body from the upper GI tract. Press through packages were the most common foreign body, followed by food, dentures, bones, Anisakis, coins, and batteries. Most were lodged in the esophagus. Another 61 patients with obstruction underwent endoscopic therapy to remove impacted food. Twenty patients less than 15 years old underwent endoscopic treatment, including 16 under general anesthesia. Grasping forceps and polyp recovery nets were used for endoscopic removal. Overtubes and transparent hoods were used to prevent injury to the esophagus by foreign bodies. Endoscopy was successful in removing 186 foreign bodies from 192 patients. Another two patients, with dentures, required surgery for their removal. Complications included esophageal perforation, mucosal injury, and cervical abscess. Conclusions: Endoscopic therapy is useful and safe in removing most foreign bodies from the GI tract, but serious complications may occur in rare cases. # 1222 Comparative study of gastric lesions in association with endoscopic findings Authors: DR S.SHARMA; DR R.M.SHRESTHA Affiliations: Department of Pathology, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal Background: Human gastrointestinal tract is an important site for wide varity of lesions. To facilitate diagnosis of different lesions, endoscopic and histology are complementary. The aim of this study is to correlate the histopathological pattern of endoscopic biopsy with distribution of gastric lesions according to age and sex. Methods: Retrospective study of 50 cases over a 1-year period in the Department of Pathology, Dhulikhel Hospital, Kathmandu University hospital were taken for the study. Results: Among the 50 cases, 29 (58%) were men, and 21 (42%) were women. The male–female ratio was 1.3:1. Of 50 cases, 17 of the endoscopically suspected carcinoma correlated histologically as adenocarcinoma, and majority presented as an ulcerating fungating growth. Of 12 cases endoscopically diagnosed erosion, four (33%) were normal, four (33%) showed Helicobacter pylori (H. pylori)-induced chronic gastritis, three (25%) showed chronic gastritis, and one (8%) showed carcinoma. Of 16 cases diagnosed as gastric ulcer. four (25%) were normal, five (31%) cases were chronic gastritis, four (25%) cases were H. pylori-induced


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gastritis, and 1 ( 6%) case was ulcer, metaplasia, and carcinoma, respectively. Of five cases of erythematous patches, two (40%) were diagnosed normal, one (20%) as chronic gastritis, and two (40%) were diagnosed H. pylori-induced gastritis. Conclusion: It was observed that endoscopic diagnosis poorly correlated with histopathological diagnosis. # 1243 Endoscopic treatment options for rectal neuroendocrine tumor: ESD versus EMR Authors: TY JUN; BG SONG; KL HWANG; DH BAEK; HK JEON; GH KIM; GA SONG Affiliations: Internal Medicine, Pusan National University School of Medicine, Busan, Korea, (the Republic of) Background: Rectal carcinoid tumors < 10 mm in diameter and limited to the submucosal layer demonstrate a low frequency of lymph node and distant metastasis and are suitable for endoscopic treatment. Method: From January 2011 to December 2012, we retrospectively enrolled patients with rectal carcinoid tumors less than 10 mm in diameter and with no regional lymph node enlargement shown by computed tomography or endoscopic ultrasound. Results: The endoscopic mucosal resection with a ligation device (EMR-L) group contained 68 patients, and the (endoscopic submucosal dissection) ESD group contained 10 patients. The en bloc resection rate was 100% in both the EMR-L group and the ESD group. The histologically complete resection rate was 92.6% (63 of 68) in the EMR-L group and 90% (9 of 10) in the ESD group (P = .769). Resection time was longer in the ESD group than in the EMR-L group (21.7 ± 13.0 min vs 7.3 ± 5.8 min, P = .001). There were no perforation and bleeding after EMR-L or ESD. Recurrence was not observed during the mean follow-up period of 12 months (range 1–39 months). Conclusion: Compare with ESD, EMR-L had a similar rate of complete resection, diameters of resected submucosal layer. However, ESD took longer to perform. Therefore, EMR-L appears to be a safe and effective treatment for rectal carcinoid tumors measuring ≤ 10 mm in diameter and confined to the submucosal layer. # 1245 Negative pathology after endoscopic resection of gastric epithelial neoplasms: Review of histopathological features and importance of pit dysplasia Authors: JONGWOOK LEE; BYEONGGU SONG; TAEYOUNG JUN; DONGHOON BAEK; GWANGHA KIM; GEUNAM SONG Affiliations: Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea Background/Aims: Issues regarding discrepancy between forceps biopsy and endoscopic resection (ER) specimens or negative pathologic diagnosis (NPD) after ER have been rising. We aimed to review clinicopathologic features of cases with NPD after ER for early gastric neoplasms and to evaluate the role of pit dysplasia (PD) in these cases. Methods: From January 2006 to September 2013, 29 NPD lesions after ER, which had (i) available pretreatment forceps biopsy specimen, (ii) correct targeting during ER, and (iii) no cautery artifact on resection specimen, were included. Pretreatment forceps biopsy and ER slides were reviewed by two expert pathologists. Results: Initial pretreatment forceps biopsy diagnoses of 29 NPD lesions were low-grade dysplasia (LGD) in

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17 lesions, high-grade dysplasia (HGD) in 7 lesions, and adenocarcinoma in 5 lesions. Reviewed diagnoses of forceps biopsy were PD in 19 lesions, LGD in 4 lesions, adenocarcinoma in 2 lesions, and NPD in 4 lesions. Taken together, of 29 NPD lesions after ER, 9 lesions (31%) were removed by forceps biopsy, 4 NPL lesions (14%) were initially mis-interpretated as neoplastic lesions, and 16 PD lesions (55%) were mis-interpretated as NPD lesions in ER slides. Conclusions: In about half of lesions initially interpreted as NPD after ER, they were diagnosed as LGD or HGD on initial biopsy specimen, and their final diagnoses were changed into PD. Therefore, the use of PD as a subtype of gastric dysplasia could narrow diagnostic discrepancy between initial forceps biopsy and ER and could lessen the frequency of NPD. # 1248 The incidence of synchronous and metachronous gastric cancer after endoscopic resection of early gastric cancer according to the degree of differentiation of the primary gastric cancer Authors: YOUNG WOON CHANG; JIHYEOK NAM; JUNGWOOK KIM; SOOJUNG KIM; JAE YOUNG JANG Affiliations: Department of Gastroenterology, Kyung Hee University Hospital, Seoul, Korea Introduction: Endoscopic resection (ER) is widely used as a standard treatment for early gastric cancer (EGC) these days. However, gastric cancer can develop synchronously or metachronously after ER treatment. Aims & Methods: The aims of this study were to investigate the predictors of recurrence of EGC after ER, especially regarding to the degree of the differentiation of primary gastric cancer. We enrolled a total of 293 patients who met the extended criteria for ER and underwent this procedure from January 2007 to December 2012 at Kyung Hee University Hospital in Seoul, Korea. And we retrospectively analyzed baseline characteristics and clinicopathological information about primary gastric cancer. Patients were classified into two groups, the differentiated group and the undifferentiated group. Annually, we followed up the patients with esophagogastroduodenoscopy (EGD) after ER. We excluded the patients whose follow-up period was less than 6 months after ER. Synchronous gastric cancer (SGC) and metachronous gastric cancer (MGC) were counted in each group and then performed analysis which factor can influence the development of gastric cancer. Results: Of the 293 patients, SGC developed in 41 patients (15.2%) in the differentiated group and only one patients (4.2%) in the undifferentiated group (P = 0.221). MGC developed in 19 patients (7.1%) in the differentiated group and none in the undifferentiated group (P = 0.382). Intestinal metaplasia was seen in 91.5 % of the patients in the differentiated group and 58.3 % of the patients in the undifferentiated group (P = 0.001). Although age was the only significant predictor of SGC in both univariate (P = 0.047) and multivariate analysis (odds ratio 3.193; P = 0.010), it did not show significance in occurrence of MGC. Alcohol showed significant difference between the non-metachronous group and the metachronous group with P-value 0.036 in univariate analysis but failed to show significant result in multivariate analysis (P = 0.077). Other factors including sex, smoking, Helicobacter pylori infection, and baseline gastric mucosal atrophy did not show any statistical significance. Conclusions: Differentiated type of gastric cancer may be a predictor of occurrence of SGC and MGC because of its high portion of intestinal


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metaplasia. We should consider the degree of differentiation of primary cancer, age, and history of alcohol consumption together with scheduled follow-up EGD after ER. Furthermore, large scale, prospective, long-term follow-up study will be needed to validate our results. Keywords: adenocarcinoma of stomach, differentiation, metachronous, synchronous # 1287 Bacteremia after esophageal endoscopic submucosal dissection Authors: NOBORU KAWATA; MASAKI TANAKA; NAOMI KAKUSHIMA; KOHEI TAKIZAWA; SAYO ITO; KENICHIRO IMAI; KINICHIHOTTA; HIROYUKI MATSUBAYASHI; HIROYUKI ONO Affiliations: Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan Background and Aims: Although high incidence of bacteremia after esophageal endoscopic procedures has been reported, the incidence of bacteremia associated with esophageal endoscopic submucosal dissection (ESD) remains unknown. Therefore, we investigated the incidence of bacteremia associated with esophageal ESD. Patients and Methods: From April 2013 to March 2014, patients who underwent esophageal ESD were enrolled prospectively. Two sets of blood cultures were collected from patients at the following time points: (i) immediately after ESD; (ii) the morning following ESD; and (iii) when fever ≥38°C was present after ESD. Results: A total of 424 blood culture sets were collected from 101 patients. Six patients had positive blood cultures immediately after ESD (3.5%, 7/202 sets). Another patient had a positive blood culture the morning following ESD (0.5%, 1/202 set). Ten patients (10%) developed a post-ESD fever ≥38°C, and blood cultures from these patients were all negative (0/20 set). The seven patients with positive blood cultures had no post-ESD fever or infectious symptoms. Only one patient (1%) with positive blood cultures grew Bacteroides thetaiotaomicron immediately after ESD and was diagnosed with transient bacteremia. The other six patients were considered to have contaminants in their blood cultures. Thus, the incidence of bacteremia after esophageal ESD was 1% (95% confidence interval: 0–5%). No patients had infectious symptoms, and none required antibiotics after ESD. Conclusions: The incidence of bacteremia after esophageal ESD was low, and post-ESD fever was not associated with bacteremia. We conclude that use of routine prophylactic antibiotics in esophageal ESD is unnecessary. # 1315 Risk factors of submucosal or lymphovascular invasion in early gastric cancer resected by endoscopic submucosal dissection Authors: TW LIM; JH JEON; WC KIM; JH LEE; HS NAM; KANG SJ KIM; SB PARK; CW CHOI; HW KIM; DH KANG Affiliations: Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea

though, accurate diagnosis of the invasion depth prior to ESD remains a challenge and can only be confirmed by final pathologic report following ESD. The purpose of the study is to investigate the risk factors for SM/LV invasion in EGC. Methods: We retrospectively reviewed clinicopathological data of patients underwent ESD from January 2009 to May 2014 and presenting EGC of 2.0 cm or smaller in size, a differentiated-type adenocarcinoma, and without ulceration. Results: Among 409 lesions consecutively resected by ESD, 309 lesions in 297 patients were included in this study. SM/LV invasions were detected in 35 lesions. Multivariate analysis revealed two independent risk factors for SM/LV invasions: Histology of moderate-differentiated (odds ratio (OR) 4.072; 95% CI 1.925–8.616; P = 0.000), location of upper and middle third (U/M) of stomach (OR 2.817, 95% CI 1.310– 6.058; P = 0.008). Conclusion: Histology of moderatedifferentiated adenocarcinoma and location of U/M were identified as independent risk factors of SM/LV invasion in EGC meeting absolute criteria for ESD. Keywords: Early gastric cancer, endoscopic submucosal dissection, lymphovascular invasion

# 1317 Association between gastroesophageal flap valve grading and gastroesophageal reflux status Authors: TW LIM; DI JEONG; DG RYU; JH LEE; YY CHOI; SJ KIM; SB PARK; CW CHOI; HW KIM; DH KANG Affiliations: Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea Introduction: Previous studies have shown that the endoscopic grading of gastroesophageal flap valve (GEFV) is a good indicator for gastroesophageal reflux disease (GERD) status. In this study, we have investigated the association between GEFV and GERD status of Korean patients using endoscopy and 24-h pH monitoring. Methods: From May 2008 to December 2014, endoscopy and 24-hr pH monitoring was performed on a total of 57 patients (28 men and 29 women; mean age 53.6 years) with GERD symptoms. GEFV was graded from I to IV using the Hill’s classification then categorized into two groups: the normal GEFV group (Hill grades I and II) and the abnormal GEFV group (Hill grades III and IV). Endoscopic findings and ambulatory pH monitoring outcomes were compared between groups. Results: Forty patients had normal GEFV and 17 patients had abnormal GEFV. After adjusting for age, sex and smoking, abnormal endoscopic GEFV grading revealed near 4.5-fold increase in GERD defined by 24h ambulatory pH monitoring (odds ratio 5.1 [95% CI, 13–21.7]). Conclusion: In agreement with previous reports, abnormal endoscopic GEFV grading showed positive correlation with poor GERD status. Keywords: GERD, GEFV

Introduction: The possibility of lymph node metastasis is critical to the assessment of the indication for endoscopic submucosal dissection (ESD). Submucosal invasion (SM) and lymphovascular (LV) invasion are thought to be independent risk factor of lymph node metastasis in early gastric cancer resected by ESD. Even


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# 1320 Pneumatic balloon dilatation without fluoroscopy for management of primary achalasia Authors: TW LIM; DG RYU; TS KIM; DI JUNG; YI CHOI; SJ KIM; SB PARK; CW CHOI; HW KIM; DH KANG Affiliations: Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea Introduction: Pneumatic balloon dilation is a most safe and effective nonoperative treatment to improve functional obstruction of the gastroesophageal junction in achalasia. Access to fluoroscopic equipment is limited in some endoscopic unit, which leads to delays in management or in transfer to other centers for balloon dilation. This present study describes a simple method for pneumatic balloon dilation for primary achalasia without fluoroscopy. Methods: This observational, retrospective, single-arm case study conducted at a tertiary care hospital during a 38-month period included five patients (5 women, mean age 49 years, age range 33–57 years) with primary symptomatic achalasia (diagnosed by endoscopy, clinical presentation, barium esophagogram, and manometry). Remission was assessed by a structured interview and a previous symptoms score. Results: Symptoms were dysphagia (n = 5, 100%), regurgitation (n = 4, 80%), chest pain (n = 2, 40%), and weight loss (n = 2, 40%). Four patients (80%) underwent a first dilation, and one patient (20%) was on a second dilation. No patient was required an additional procedure within a median of 17.2 months (range 4–37 month). The mean duration of symptoms prior to treatment was 16.0 ± 13 month. Relief of dysphagia was obtained for all patients, and symptom score decreased from 2.4 before dilation to 0.1 at 1 month. Major complication (perforation and bleeding) after dilation was not occurred. Table 1. Comparison of mean symptom score at baseline and follow-up visit (P = 0.001)

Regurgitation Vomitting Chest pain Noctural cough Heartburn Dysphagea score

Baseline

1 month

2.0 ± 1.1 0.9 ± 0.9 0.3 ± 0.6 0.2 ± 0.4 0.3 ± 0.6 2.4 ± 0.5

0 0 0.1 ± 0.3 0 0.1 ± 0.3 0.1 ± 0.4

Frequency and severity of symptoms were scored for dysphagia, chest pain, regurgitation ,night cough, and heartburn. Scores were assigned on a scale of 0–4 (0, none; 1, less than one per month; 2, several times a month; 3, several times a week; 4, daily). Dysphagea score 0: The patient can swallow eat normal diet. 1: The patient can swallow soft diet, but cannot swallow solid diet. 2: The patient can swallow liquid diet, but cannot swallow soft diet. 3: The patient can swallow water, but cannot swallow liquid diet. 4: The patient cannot swallow water. Conclusion: Pneumatic dilatation can be effectively and safely underwent without fluoroscopy for treatment of primary achalasia Keywords: Primary achalasia, Pneumatic balloon dilatation, Esophagoscopy

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# 1321 Endoscopic mucosal resection with cap in resection of rectal neuroendocrine tumors is more effective than endoscopic submucosal dissection Authors: TW LIM; JH JEON; TS KIM; DI JEONG; HS NAM; SJ KIM; SB PARK; CW CHOI; HW KIM; DH KANG Affiliations: Department of Internal Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea Introduction: Incidence of rectal neuroendocrine tumors (NETs) are increasing nowadays. There are various treatment methods for rectal NETs: conventional endoscopic mucosal resection (EMR), EMR with a ligation device (EMR-L), EMR with a cap (EMRC), and endoscopic submucosal dissection (ESD). This study was conducted to compare the outcomes of EMR-C with those of ESD for the resection of rectal NETs. Methods: One hundred fifteen lesions in 112 patients with rectal NETs resected with EMR-C or ESD were included in the study. This study was conducted at Pusan National University Yangsan Hospital between June 2009 and July 2014. Endoscopic complete resection rate, histologic complete resection rate, procedure time, and adverse events in the EMR-C (n = 61) and ESD (n = 51) groups were analyzed. And subgroup analysis by tumor size was performed. Results: Mean (standard deviation) tumor size was 4.52 (1.61) mm in the EMR-C group and 7.53 (3.11) mm in the ESD group (P > 0.001). Endoscopic complete resection rate was 100% in both groups. Histologic complete resection rate was significantly higher in the EMR-C group (91.2%) than in the ESD group (79.1%) (P = 0.042). Mean procedure time was significantly longer in the ESD group (14.13 [7.06] min) than in the EMR-C group (3.73 [1.10] min) (P > 0.001). Histologic complete resection rate were similar for tumor diameter ≤5 mm (EMR-C, 97%; ESD, 100%; P = 0.482),in cases of 30 min) were related to

the pain. Conclusions: In women, the lesion in antrum and anterior wall side and procedure time (>30 min) were predictive factors for the post-ESD pain. Keywords: pain, endoscopic submucosal dissection, gastric epithelial neoplasm # 1452 Differences in the tumor specimen size between surgical resection and endoscopic submucosal dissection for early gastric cancer Authors: JS KWON; JK PARK; SJ LEE; HI SEO; KH HAN; YD KIM; WJ JEONG; GJ CHEON Affiliations: Department of internal Medicine,Division of gastroenterology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, South Korea Background/Aims: The expanded criteria for endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) were based on surgical specimens. However, ESD and surgical specimens differ in size, because the former are subjected to stretching when they are pinned to styrofoam plates, and the latter show coagulation and tissue atrophy. This study aimed to compare the sizes of ESD and surgical specimens of EGC patients. Methods: Twenty-one EGC patients (mean age, 68.8 years) who immediately (