Sedation in gastroenterological endoscopy has become an important medical option in routine clinical care. Here, the Japan Gastroenterological Endoscopy Society and the Japanese Society of Anesthesiologists together provide the revised "Guidelines for sedation in gastroenterological endoscopy" as a second edition to address on-site clinical questions and issues raised for safe examination and treatment using sedated endoscopy. Twenty clinical questions were determined and the strength of recommendation and evidence quality (strength) were expressed according to the "MINDS Manual for Guideline Development 2017." We were able to release upto-date statements related to clinical questions and current issues relevant to sedation in gastroenterological endoscopy (henceforth, "endoscopy"). There are few reports from Japan in this field (e.g., meta-analyses), and many aspects have been based only on a specialist consensus. In the current scenario, benzodiazepine drugs primarily used for sedation during gastroenterological endoscopy are not approved by national health insurance in Japan, and investigations regarding expense-related disadvantages have not been conducted. Furthermore, including the perspective of beneficiaries (i.e., patients and citizens) during the creation of clinical guidelines should be considered. These guidelines are standardized based on up-to-date evidence quality (strength) and supports on-site clinical decision-making by patients and medical staff. Therefore, these guidelines need to be flexible with regard to the wishes, age, complications, and social conditions of the patient, as well as the conditions of the facility and discretion of the physician.

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Background and study aims The pocket-creation method (PCM) is a novel strategy for endoscopic submucosal dissection (ESD). The aim of this study is to determine the efficacy of the PCM for colorectal laterally spreading tumors, non-granular type (LST-NG). Patients and methods The records of 126 consecutive patients with colorectal LST-NG who underwent ESD between April 2012 and July 2015 were retrospectively reviewed. Patients were divided into PCM (n = 73) and conventional method (CM) (n = 53) groups. Results The en bloc resection rate in the PCM group was significantly higher than in the CM group (100 % [73/73] vs. 92 % [49/53], P = 0.03). The en bloc resection rate with severe fibrosis was higher in the PCM group than in the CM group (100 % [3/3] vs. 60 % [3/5]). The R0 resection rate for the two groups was not statistically significantly different (93 % [68/73] vs. 91 % [48/53], P = 0.74). The perforation rate in the PCM group was lower than in the CM group although not statistically significantly less (0 % 0/73 vs. 4 % 2/53, P = 0.18). For lesions resected en bloc, dissection speed for the PCM group was significantly faster than for the CM group (median [IQR], 19 [13 –24] vs. 14 [10 – 22] mm2/min, P = 0.03). Conclusion ESD using PCM achieves a reliable and safe resection of colorectal LST-NG.

Duodenal endoscopic submucosal dissection (ESD) requires sophisticated endoscopic techniques because of a high rate of perforation. We introduced the pocket-creation method (PCM) of duodenal ESD to overcome difficulties. The aim of this study was to evaluate the safety and usefulness of ESD using the PCM for superficial tumors of the duodenum. We performed ESD of 17 non-ampullary duodenal lesions using the conventional method and of 28 lesions using the PCM from 2006 to 2015 and retrospectively reviewed the results, comparing the PCM and the conventional method. The median follow-up period was 35 months (range 2 - 97). There were more lesions at the duodenal angles in the PCM group compared with the conventional method group (54 % [15/28] vs. 22 % [4/17]; = 0.048), and the resected specimen diameter was larger in the PCM than the conventional method group (median 37 mm [range 25 - 101] vs. 25 mm [15 - 55]; = 0.007). Dissection speed was faster in the PCM than the conventional method group (9.4 mm/min [3.0 - 15.7] vs. 6.5 mm/min [1.5 - 19.7]; = 0.09). En bloc resection was more frequent in the PCM (100 % [28/28]) than the conventional method group (88 % [15/17]) ( = 0.07). Perforation was significantly less frequent in the PCM (7 % [2/28]) than the conventional method group (29 % [5/17]; = 0.046). The one delayed perforation in the conventional method group required surgical repair, while other intraprocedural perforations were treated by clipping. There were no recurrences. ESD of duodenal lesions can be safely performed using the PCM, which stabilizes the tip of the endoscope even in difficult locations.