RARE CAUSE OF OBSCURE GASTROINTESTINAL BLEEDING DUE TO PYOGENIC GRANULOMA IN THE ILEUM DETECTED BY CAPSULE ENDOSCOPY AND TREATED WITH DOUBLE BALLOON ENDOSCOPY

Pyogenic granuloma is a lobular capillary hemangioma that occurs mostly on the skin, and occasionally on the mucosal surface of the oral cavity, but very rarely in the gastrointestinal tract. We report the case of a 63‐year‐old woman who suffered from palpitations, and iron deficiency anemia for 5 years. Esophagogastroduodenoscopy and colonoscopy could not reveal significant bleeding focus. She had not received medical treatment except for oral iron. Capsule endoscopy revealed a bleeding focus in the small intestine. Afterwards, we carried out double balloon endoscopy to treat the lesion. We found a subpedunculated polyp in the small intestine at 100 cm away from ileocecal valve by double balloon endoscopy and resected it endoscopically. The histological features of the polyp were consistent with pyogenic granuloma. Anemia had improved gradually without giving oral iron after polypectomy.     

CURRENT STATUS OF DOUBLE BALLOON ENDOSCOPY

Yamamoto and colleagues have developed a novel insertion method of the endoscope, the ‘double balloon method’ for enteroscopy and, recently, a specialized system for the ‘double balloon method’ has been commercialized by Fujinon. The double balloon endoscopy enables visualization of the entire small bowel and also allows for interventional therapy in the small intestine. This method could be used either from the oral or anal approach. Observation of an affected area with controlled movement of the endoscope enables interventions, including biopsies, hemostasis, balloon dilatation, stent placement, polypectomy, and endoscopic mucosal resection. The procedure is safe and useful, and it provides high diagnostic yields and therapeutic capabilities.     

SURVEILLANCE BY MAGNIFYING ENDOSCOPY IN PATIENTS WITH ULCERATIVE COLITIS

Background: Patients with total or left‐sided ulcerative colitis (UC) for more than 10 years have an increased risk of colon cancer. We studied usefulness of magnifying chromoendoscopy for the surveillance of dysplasia and colitic cancer associated with UC. Methods: From April 2003 through February 2004, 39 patients who had total or left‐sided UC for at least 7 years were prospectively enrolled in an endoscopic surveillance program, including target biopsy. All patients were examined by chromoendoscopy and magnifying endoscopy. Sites showing abnormal mucosal surface patterns or pit patterns suggestive of dysplasia underwent biopsy. Results: Of the 39 patients, 26 had total UC and 13 left‐sided UC. The mean time elapsed since the onset of UC was 16.2 ± 5.9 years. Disease activity at examination was remission in 22 patients, mild in 15, and moderate in two. Dysplasia was diagnosed in two patients (three lesions), dysplastic changes were suspected in two (two lesions), and sporadic adenoma was diagnosed in four (five lesions). On endoscopic examination, dysplasia appeared as flat elevated lesions with types IIIl and IV pit patterns. Resected specimens showed low‐to‐high‐grade dysplasia. The four patients presenting with a type III to IV mucosal pit pattern during remission were evaluated as sporadic adenoma on pathological findings. Conclusions: A combination of chromoendoscopy and magnifying endoscopy is useful for the detection of dysplasia and colitic cancer in patients with UC.     

DIFFERENTIAL DIAGNOSIS OF GASTRIC LESIONS BY MAGNIFYING ENDOSCOPY

We performed magnifying endoscopy for patients with suspected gastric diseases. Among these patients, 67 patients with early gastric cancer and 31 benign gastric diseases were enrolled in this study. The patients with early gastric cancer included 46 differentiated tubular adenocarcinoma (33 mucosal cancer, 13 submucosal cancer) and 21 non‐differentiated tubular adenocarcinoma (12 mucosal cancer, 9 submucosal cancer). The benign gastric lesions included 23 gastric ulcer or gastric ulcer scars, three gastritis, and five gastric adenomas. Small regular patterns were observed; 39% in differentiated adenocarcinoma, 5% in undifferentiated adenocarcinoma, and 19% in benign gastric diseases. Irregular patterns were observed 37%, 52%, and 6%. Lack of visible structure was observed 18%, 90%, and 10%. Abnormal vessels were observed 26%, 81%, and 16%. Small regular patterns were observed significantly more frequently in differentiated adenocarcinoma than in undifferentiated adenocarcinoma (P < 0.001). Lack of visible structure and Irregular patterns were observed significantly more frequently in undifferentiated adenocarcinoma than in differentiated adenocarcinoma (P < 0.001). In order to spread this useful endoscopy widely easy recognition of abnormality, histological backbone, and further technical developments in hardware and software should be required.     

ENDOSCOPIC SUBMUCOSAL DISSECTION FOR EARLY GASTRIC CANCER USING MAGNIFYING ENDOSCOPY WITH A COMBINATION OF NARROW BAND IMAGING AND ACETIC ACID INSTILLATION

Demarcation of early gastric cancers is sometimes unclear. Enhanced‐magnification endoscopy with acetic acid instillation and magnifying endoscopy with a narrow band imaging (NBI) system have been useful for recognition of demarcation of early gastric cancers. We report a patient with early gastric cancer who underwent a successful endoscopic submucosal dissection (ESD) by magnifying endoscopy with the combined use of NBI and acetic acid instillation. A 72‐year‐old man with early gastric cancer underwent ESD. Demarcation of the lesion was not clear, but magnifying endoscopy using the combination of NBI and acetic acid clearly revealed the demarcation. ESD was carried out after spots were marked circumferentially. We identified the positional relation between the demarcation and all markings. Resection of the lesion was on the outside of the markings. Histopathologically, the lesion was diagnosed as a well‐differentiated adenocarcinoma limited to the mucosa. The margins were carcinoma free. Magnifying endoscopy combining the use of NBI with acetic acid instillation is simple and helpful for identifying the demarcation of early gastric cancer. This method may be useful in increasing the rate of complete resection by ESD for early gastric cancer.     

SURVEILLANCE OF SMALL INTESTINAL ABNORMALITIES IN PATIENTS WITH HEPATOCELLULAR CARCINOMA: A PROSPECTIVE CAPSULE ENDOSCOPY STUDY

Background: Patients with hepatocellular carcinoma (HCC) sometimes suffer from obscure gastrointestinal bleeding. Portal hypertension (PH), common in cirrhosis, induces esophagogastric varices. Because of the location, PH also may influence mucosal abnormalities in the small intestine. The objective of this study is to estimate the prevalence of small intestinal mucosal abnormalities in HCC patients using capsule endoscopy (CE). Patients and Methods: We prospectively conducted CE in HCC patients, and analyzed the findings in relation to hepatic function, the number and size of HCC tumor and findings obtained by conventional endoscopy. Results: Thirty‐six patients (aged 66.7 ± 7.5 years, 29 men) underwent CE. Abnormal findings in the small bowel were found in 16 patients (44%), angioectasias in eight patients (22%), erosions in five (14%), varices in four (11%), polyps in four (11%), and submucosal tumor in one (3%). The patients with angioectasia had a larger spleen index than the no abnormal lesions group (85.4 ± 15.8 vs 59.0 ± 24.4, P = 0.02). The former group had been more frequently treated for esophageal varices endoscopically (62% vs 15%, P = 0.02). Large HCC nodules seemed more common in the patients with angioectasia than subjects without abnormal lesions (38% vs 5%, P = 0.06). Small intestinal varices also seemed to have a positive association with large HCC. During the follow up after CE, one patient with small intestinal polyps suffered from obscure gastrointestinal bleeding. Conclusions: CE revealed that HCC patients frequently have small intestinal mucosal lesions. In particular, small intestinal angioectasia, which may cause obscure gastrointestinal bleeding, seems to be associated with portal hypertension.     

A REVIEW OF CURRENT CLINICAL APPLICATIONS OF UPPER GASTROINTESTINAL ZOOM ENDOSCOPY

Current clinical applications of upper gastrointestinal (GI) zoom endoscopy were reviewed. The objective of upper GI zoom endoscopy has been the diagnosis of neoplastic lesions as well as the diagnosis of minute inflammatory mucosal change. The target organ and pathology of the neoplastic lesions have been squamous cell carcinoma in the oro‐ and hypo‐pharynx and in the esophagus; intestinal metaplasia, dysplasia, and adenocarcinoma in Barrett's esophagus; and adenocarcinoma in the stomach. For analyzing the magnified endoscopic findings, there were two different basic principles (mucosal microstructural change and subepithelial microvascular changes). Overall diagnostic accuracy for diagnosing a neoplastic lesion was above 80% throughout the upper GI tract. Although the diagnostic accuracy of the zoom endoscopy technique seems to be superior to that of the ordinary endoscopy technique alone, the continuous efforts to establish standardized guidelines and procedures are mandatory in order to lead to the routine use of upper GI zoom endoscopy in clinical practice.     

MAGNIFYING ENDOSCOPY WITH NARROW BAND IMAGING FOR EARLY DIFFERENTIATED GASTRIC ADENOCARCINOMA

We have been using magnifying endoscopy with narrow band imaging (NBI) to study early differentiated gastric adenocarcinomas and to assess the relationship between microvessel pattern, pit pattern and histological pattern. The magnified view of the cancerous area showed three types of pattern: (i) a mesh pattern, consisting of mesh‐like connected microvessels; (ii) a loop pattern, consisting of loop‐like microvessels that were not connected and had tubule‐like or villus‐like mucosal structures along them; and (iii) an interrupted pattern, consisting of interrupted thick or thin vessels without mucosal structures. The mesh type of microvascular pattern showed a round pit pattern in 88.9% of cases (32/36) and the loop type of microvascular pattern showed a non‐round pit pattern in 100% of cases. Among lesions that showed a mesh pattern or a loop pattern, 94.9% (56/59) were mucosal cancer and 5.1% (3/59) were submucosal cancer. However, 92.3% (12/13) of lesions that showed an interrupted pattern were submucosal differentiated adenocarcinoma and 7.7% (1/13) were mucosal differentiated adenocarcinoma. The present findings provide basic data on the characteristics of mucosal differentiated gastric adenocarcinoma revealed by magnifying endoscopy with NBI, as well as invasive changes such as submucosal invasion.     

SUBTLE VILLOUS CHANGES DETECTED AT ENDOSCOPY IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Dysplastic areas in flat mucosa in patients with inflammatory bowel disease (IBD) are difficult to detect at endoscopic examination. We describe the endoscopic and clinicopathological characteristics of colorectal mucosa with subtle villous changes (SVC) detected by endoscopy and chromoscopy in patients with IBD. The present study consists of 18 IBD patients. The age at onset of the disease, duration and extent of disease, endoscopic features, and clinical follow up were noted. Of the 18 patients, 12 had ulcerative colitis and six had Crohn's colitis. The mean duration from onset of disease to the detection of SVC was 25.4 years (range 4–50 years). All patients had extensive colitis. All SVC areas were present in colorectal segments having absent vascular pattern and decrease or loss of normal folds. Mucosal redness was frequently observed. Following indigo carmine dye spraying the SVC were characterized by a subtle villous surface resembling small intestinal mucosa. Biopsies taken from SVC areas showed dysplasia in nine of the 18 patients (50.0%): LGD in seven and HGD in two. SVC can be identified with endoscopy and chromoscopy. The endoscopic identification of SVC areas may increase the accuracy in detecting epithelial dysplasia in biopsies from patients with IBD.     

FLAT AND SMALL SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS DETECTED AND DIAGNOSED BY ENDOSCOPY WITH NARROW‐BAND IMAGING SYSTEM

Reported herein is the case of a 65‐year‐old man who had completely flat and small squamous cell carcinoma in the esophagus. The subtle lesion was initially detected as a brownish area depicted by non‐magnified endoscopy with the narrow‐band imaging system (NBI). The lesion was predicted to be type 0‐IIb mucosal cancer due to assessment of morphologic change of intrapapillary capillary loop under magnified NBI observation. Endoscopic mucosal resection was performed for the lesion. The histological finding of the removed specimen indicated mucosal squamous cell carcinoma. Endoscopic observation with the NBI system was useful for detecting obscure squamous cell carcinoma and predicting the histological finding.     

MICROVASCULAR PATTERNS OF ESOPHAGEAL MICRO SQUAMOUS CELL CARCINOMA ON MAGNIFYING ENDOSCOPY

Background: Recently, esophageal microcancers have been frequently diagnosed and are receiving increasing attention as initial findings of cancer. We examined whether the clinicopathological features and microvascular patterns of esophageal microcancers on magnifying endoscopy are useful for diagnosis. Methods: Magnifying endoscopy was performed to examine the histopathological features of 55 esophageal cancers measuring ≤10 mm in diameter (34 small cancers, 16 microcancers, and five supermicrocancers). Results: Although some lesions were detected only on iodine staining, most were detected on conventional endoscopic examination. Most small cancers and microcancers were m1 or m2; some were m3 or sm2. Supermicrocancers were dysplasia or m1 cancer. As for the microvascular pattern, most m1 and m2 cancers showed type 3 vessels, while most submucosal cancers showed type 4 vessels. Conclusions: Microvascular patterns on magnifying endoscopy are useful for the differential diagnosis of benign and malignant esophageal cancers and for estimating the depth of tumor invasion. The shape of small lesions is often altered considerably by biopsy. Residual tumor may persist unless the basal layer of the lesion is included in biopsy specimens, even in microcancers. Consequently, endoscopic mucosal resection, without biopsy, is being performed in increasing numbers of patients with lesions suspected to be cancer on the basis of their microvascular patterns.     

USEFULNESS OF MAGNIFYING ENDOSCOPY IN UPPER GASTROINTESTINAL TRACT: HISTORY AND RECENT STUDIES

Although clinical trials using magnifying optical endoscopy have been reported, magnifying endoscopies have been remarkably developed in the period of electronic endoscopy. Magnifying electronic endoscopies with 80 or 100‐fold magnification are used for routine endoscopic examination of upper gastrointestinal tract in Japan. Magnifying endoscopy is used to visualize the microstructure and microvascular architecture of gastrointestinal surface mucosa. Microsurface structure of the mucosa includes normal structure, changed structure by inflammation and biological response, and tumor‐specific structure. Microvascular architecture includes normal vascular system and tumor microvessels. Magnifying endoscopy is starting to play an important role in diagnosis of any upper gastrointestinal diseases by assessment of magnified observation. Magnifying endoscopy holds a great deal of promise in the near future because magnifying endoscopic observation is approaching optical biopsy.     

CONTROVERSY ON THE MANAGEMENT OF ANTICOAGULANTS AND ANTIPLATELET AGENTS FOR SCHEDULED ENDOSCOPY

Guidelines on the management of anticoagulants and antiplatelet agents for endoscopy were established by Japan Gastroenterological Endoscopy Society (JGES) in 2005. However, the permeation of the JGES guideline is reported to possibly be low. One of the important causes of this problem is the confusing situation of gaps between the guidelines of various societies. Additionally, our ongoing investigation has revealed another important cause, which is the current daily clinical practice that cessation periods before endoscopy were determined by non‐gastroenterological specialists who might be unfamiliar with the JGES guidelines. Considering the low permeation of the guidelines for non‐gastroenterological specialists prescribing these agents, we propose that close coordination between various specialists is mandatory to fill the gap between endoscopists and non‐gastroenterological specialists.     

NARROW‐BAND IMAGING COMBINED WITH MAGNIFIED ENDOSCOPY FOR CANCER AT THE HEAD AND NECK REGION

While detection of lesions at an earlier stage in head and neck mucosal sites would obviously be of great merit to patients, there has been no modality to discover such lesions. Herein, we investigate a possibility of clinical application of narrow‐band imaging (NBI) endoscopy, which is a brand new optical technique that allows non‐invasive visualization of the microvessels at the organ surface. We found that NBI technology could be a promising and powerful tool for identifying carcinomas at an earlier stage in head and neck mucosal sites. This may open a new door in the field of head and neck oncology.     

LONG INTESTINAL TUBE INSERTION WITH THE ROPEWAY METHOD FACILITATED BY A GUIDEWIRE PLACED BY TRANSNASAL ULTRATHIN ENDOSCOPY FOR BOWEL OBSTRUCTION

Aim: For patients with bowel obstruction, intestinal decompression by a long tube is recommended. We assessed the usefulness of a new technique for insertion of a long tube with a guidewire placed by transnasal ultrathin endoscopy. Methods: Nineteen patients who had been diagnosed as suffering from bowel obstruction underwent long‐tube insertion with the ropeway technique using a guidewire placed by transnasal endoscopy. Thirty‐three patients who had undergone conventional insertion of a long tube were included as controls. The success rate of intubation of the small bowel and the time required for the procedure were compared between the subjects and controls. Results: The success rate of intubation was 94.7% (18/19) in subjects and 84.8% (28/33) in controls (P = 0.53). The time required for insertion in the subjects and controls was 24.1 ± 8.1 min and 48.7 ± 25.3 min, respectively, with a statistically significant difference (P < 0.001). No complications relevant to the procedure were encountered in either of the groups. Conclusion: Long‐tube insertion facilitated by transnasal endoscopy reduces the time required for insertion in comparison with the conventional technique without endoscopy. Endoscopy‐assisted long‐tube insertion with the ropeway method is a safe and useful procedure for decompression in patients with bowel obstruction.     

QUANTITATIVE ANALYSIS OF LOW‐DOSE ASPIRIN‐ASSOCIATED SMALL BOWEL INJURY USING A CAPSULE ENDOSCOPY SCORING INDEX

Aim: The major limitation of capsule endoscopy (CE) has been the lack of a standardized and validated severity scale for mucosal injury. The aim of the present study was to verify the usefulness of quantifying small bowel mucosal changes associated with giving low‐dose aspirin (LDA) using a CE scoring index. Methods: The CE score for small bowel mucosal injury was investigated to evaluate the severity of mucosal injury. Healthy volunteers and patients suspected of having small bowel disease were recruited for this study. The short‐term LDA group (V + S‐LDA group) consisted of volunteers who took low‐dose aspirin for 14 days; this group was then compared with healthy volunteers who did not receive LDA treatment (V‐Control group). The long‐term LDA group (L‐LDA group) consisted of patients with at least a 3‐month history of daily LDA use; this group was compared with non‐users of LDA (P‐Control group). Results: The CE score was significantly higher in the V + S‐LDA group than in the V‐Control group. In the V‐Control group, almost all the subjects were categorized as exhibiting a ‘normal’ change. ‘Mild’ changes were observed significantly more frequently in the V + S‐LDA group than in the V‐Control group. The CE score was significantly higher in the L‐LDA group than in the P‐Control group. ‘Mild’ or ‘moderate or severe’ changes were observed significantly more frequently in the L‐LDA group than in the P‐Control group. Conclusion: The CE scoring system was useful for evaluating LDA‐associated small bowel mucosal disease activity and for objectively scoring the small bowel inflammatory disease state.     

ENDOSCOPY IS ONE OF THE VALUABLE DIAGNOSTIC METHODS FOR PRIMARY AORTO‐ENTERIC FISTULA

The present report describes a case of primary aorto‐enteric ?stula (PAEF) in an 81‐year‐old man with no previous abdominal surgery. The patient was admitted to Teraoka Memorial Hospital in shock with repeated episodes of melena and hematemesis. We performed emergency endoscopy to establish a diagnosis and identi?ed a ruptured aortic aneurysm visualized through a ?stula in the second portion of the duodenum. As most PAEF cause massive gastrointestinal hemorrhage, prompt diagnosis is critical to ensure a successful outcome. Although the patient and his family refused surgery and the patient died, we were able to make the diagnosis at an early stage by endoscopy. While PAEF is usually very dif?cult to diagnose by a single modality, endoscopy can be one of the modalities to identify the source of gastrointestinal hemorrhages, even in cases of PAEF.     

ENDOSCOPIC DIAGNOSIS OF MUCOSAL ADENOCARCINOMAS AND INTESTINAL METAPLASIA OF COLUMNAR‐LINED ESOPHAGUS USING ENHANCED‐MAGNIFICATION ENDOSCOPY

The present study assessed whether or not acetic acid‐enhanced‐magnification endoscopy was practical for the detection of mucosal cancer as well as intestinal metaplasia. Fifty‐three patients (40 men, 13 women; median age 60.8 years) with columnar‐lined esophagus were enrolled in a prospective trial of enhanced‐magnification endoscopy after instillation of 1.5% acetic acid. Each enhanced‐magnification endoscopic mucosal pattern was classified as one of six types: type I, small round pits of uniform size and shape; II, slit‐reticular pattern; IIIa, gyrus pattern; IIIb, villous pattern; IV, irregular granular pattern and V, minute grain‐like pattern. Two adenocarcinomas were found in two patients and intestinal metaplasia was found in 26 of the 52 patients (50.0%); 12 of 25 (48.0%) were < 1 cm, seven of 18 (38.9%) were 1–2 cm, three of five (60.0%) were 2–3 cm and four of four (100%) were > 3 cm. A total of 115 biopsy specimens were obtained from enhanced‐magnified areas. Three of three areas (100%) showing type V and two of two areas (100%) showing type IV were adenocarcinoma. Twenty‐four (71%) of 34 areas indicating type IIIa were intestinal metaplasias and 10 (29%) showed cardiac mucosa. Nine of 10 (90%) of type IIIb were intestinal metaplasias; 45 (82%) of 55 type II specimens showed cardiac mucosa and eight (15%) were intestinal metaplasias. Eleven of 11 (100%) type I specimens showed fundic mucosa. Acetic acid‐enhanced‐magnification endoscopy was effective for the diagnosis of adenocarcinomas as well as intestinal metaplasia in Barrett’s esophagus.     

PREDICTIVE VALUE OF ENDOSCOPY AND ENDOSCOPIC ULTRASONOGRAPHY FOR REGRESSION OF GASTRIC DIFFUSE LARGE B‐CELL LYMPHOMAS AFTER HELICOBACTER PYLORI ERADICATION

Background: Some gastric diffuse large B‐cell lymphomas have been reported to regress completely after the successful eradication of Helicobacter pylori. The aim of this study was to investigate the clinical characteristics of gastric diffuse large B‐cell lymphomas without any detectable mucosa‐associated lymphoid tissue (MALT) lymphoma that went into complete remission after successful H. pylori eradication. Patients and Methods: We examined the effect of H. pylori eradication in 15 H. pylori‐positive gastric diffuse large B‐cell lymphoma patients without any evidence of an associated MALT lymphoma (clinical stage I by the Lugano classification) by endoscopic examination including biopsies, endoscopic ultrasonography, computed tomography, and bone marrow aspiration. Results: H. pylori eradication was successful in all the patients and complete remission was achieved in four patients whose clinical stage was I. By endoscopic examination, these gastric lesions appeared to be superficial. The depth by endoscopic ultrasonography was restricted to the mucosa in two patients and to the shallow portion of the submucosa in the other two patients. All four patients remained in complete remission for 7–100 months. Conclusion: In gastric diffuse large B‐cell lymphomas without a concomitant MALT lymphoma but associated with H. pylori infection, only superficial cases and lesions limited to the shallow portion of the submucosa regressed completely after successful H. pylori eradication. The endoscopic appearance and the rating of the depth of invasion by endosonography are both valuable for predicting the efficacy of H. pylori eradication in treating gastric diffuse large B‐cell lymphomas.     

ADVANTAGES OF USING THIN ENDOSCOPE‐ASSISTED ENDOSCOPIC SUBMUCOSAL DISSECTION TECHNIQUE FOR LARGE COLORECTAL TUMORS

Background: Our purpose was to evaluate the effectiveness of a newly developed non‐invasive traction technique known as thin endoscope‐assisted endoscopic submucosal dissection (TEA‐ESD) procedure for the removal of colorectal laterally spreading tumors (LST). Patients and Methods: A total of 37 LST located in the rectum and distal sigmoid colons of 37 patients were eligible for outcome analysis. Twenty‐one LST were treated with TEA‐ESD and were then retrospectively compared to 16 LST that had previously been treated with standard ESD. Tumor size, en bloc resection rate, procedure time, combined number of different electrical surgical knives used during each procedure and associated complications were evaluated in this case–control study. Results: There was no statistically significant difference in tumor size between the TEA‐ESD group and the ESD control group (43.6 ± 16 mm and 42.4 ± 14 mm, respectively). All LST were successfully resected en bloc in both groups. Procedure duration was shorter for the TEA‐ESD group than the ESD control group, although the difference was not statistically significant (96 ± 53 minutes vs 116 ± 74 minutes; P = 0.18). The percentage of cases in which only one electrical surgical knife was used during the entire procedure was significantly higher in the TEA‐ESD group compared to the ESD control group (85.7% vs 31.3%; P = 0.0005). There were no perforations in the TEA‐ESD group while the ESD control group experienced one perforation. At the present time, TEA‐ESD is limited to the rectum and distal sigmoid colon. Conclusion: It was technically easier, safer and more cost‐effective to perform ESD for LST in the rectum and the distal sigmoid colon using the newly developed TEA‐ESD traction technique.