Search

Competing Interests: The authors declare that they have no conflict of interest.

Objectives: There have been significant advances in the management of large (≥20 mm) laterally spreading tumors (LSTs) or nonpedunculated colorectal polyps; however, there is a lack of clear consensus on the management of these lesions with significant geographic variability especially between Eastern and Western paradigms. We aimed to provide an international consensus to better guide management and attempt to homogenize practices., Methods: Two experts in interventional endoscopy spearheaded an evidence-based Delphi study on behalf of the World Endoscopy Organization Colorectal Cancer Screening Committee. A steering committee comprising six members devised 51 statements, and 43 experts from 18 countries on six continents participated in a three-round voting process. The Grading of Recommendations, Assessment, Development and Evaluations tool was used to assess evidence quality and recommendation strength. Consensus was defined as ≥80% agreement (strongly agree or agree) on a 5-point Likert scale., Results: Forty-two statements reached consensus after three rounds of voting. Recommendations included: three statements on training and competency; 10 statements on preresection evaluation, including optical diagnosis, classification, and staging of LSTs; 14 statements on endoscopic resection indications and technique, including statements on en bloc and piecemeal resection decision-making; seven statements on postresection evaluation; and eight statements on postresection care., Conclusions: An international expert consensus based on the current available evidence has been developed to guide the evaluation, resection, and follow-up of LSTs. This may provide guiding principles for the global management of these lesions and standardize current practices., (© 2024 The Authors. Digestive Endoscopy published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Colonic diverticulosis is prevalent, affecting approximately 70% of the western population by 80 years of age. Incidence is rapidly increasing in younger age groups. Between 10% and 25% of those with diverticular disease (DD) will experience acute diverticulitis. A further 15% will develop complications including abscess, bleeding and perforation. Such complications are associated with significant morbidity and mortality and constitute a worldwide health burden. Furthermore, chronic symptoms associated with DD are difficult to manage and present a further significant healthcare burden. The pathophysiology of DD is complex due to multifactorial contributing factors. These include diet, colonic wall structure, intestinal motility and genetic predispositions. Thus, targeted preventative measures have proved difficult to establish. Recently, commonly held conceptions on DD have been challenged. This review explores the latest understanding on pathophysiology, risk factors, classification and treatment options., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

This ENETS guidance paper, developed by a multidisciplinary working group, provides an update on the previous colorectal guidance paper in a different format. Guided by key clinical questions practical advice on the diagnosis and management of neuroendocrine tumours (NET) of the caecum, colon, and rectum is provided. Although covered in one guidance paper colorectal NET comprises a heterogeneous group of neoplasms. The most common rectal NET are often small G1 tumours that can be treated by adequate endoscopic resection techniques. Evidence from prospective clinical trials on the treatment of metastatic colorectal NET is limited and discussion of patients in experienced multidisciplinary tumour boards strongly recommended. Neuroendocrine carcinomas (NEC) and mixed neuroendocrine non-neuroendocrine neoplasms (MiNEN) are discussed in a separate guidance paper., (© 2023 The Authors. Journal of Neuroendocrinology published by John Wiley & Sons Ltd on behalf of British Society for Neuroendocrinology.)

Multimodal assessment of colorectal polyps is needed before decision-making for endoscopic mucosal resection or endoscopic submucosal dissection (ESD). Assessment should include morphology according to Paris classification, magnification endoscopy for vascular pattern, and Kudo pit pattern analysis. ESD should be offered to patients that have Vi pit pattern, lateral spreading tumors (LST) granular multinodular and LST nongranular, lesions with fibrosis and those in patients with inflammatory bowel disease. A defined strategy for resection and planning is crucial for successful and efficient resection with a clear audit of outcomes aiming for a perforation and bleeding rate of less than 1% and R0 resection greater than 90%., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Background and Aims: OverStitch devices (OverStitch and OverStitch Sx; Apollo Endosurgery, Inc, Austin, Tex, USA) are used for a wide range of applications. A European registry was created to prospectively collect technical and clinical data regarding both systems to provide procedural outcomes and to find correlation between procedural characteristics and outcomes. This study shows the initial results of the first 3 years of the registry., Methods: Patients who underwent endoscopic suturing from January 2018 to January 2021 at 9 centers were enrolled. Data regarding the disease treated,suturing pattern and outcomes were registered. Technical feasibility (success reaching the target area), technical success (success placing sutures), and clinical success (complete resolution of the clinical issue) were recorded and analyzed., Results: During the study period, 137 patients (57.7% men) were enrolled with 100% technical feasibility rate. Endoscopic suturing was successfully performed in 136 cases (16.7% with OverStitch Sx), obtaining a technical success rate of 99.3%. No adverse events were recorded. Overall clinical success was 89%. Mucosal defects were sutured in 32 patients (100% clinical success). Leaks/fistulas were treated in 23 patients (64.7% clinical success). The clinical success of stent fixations (n = 38) was 85%. Perforations (n = 22) were repaired with a clinical success of 94.7%. No significant correlation between location, suture pattern or number, and the success was found, except in case of fistulas where fistulas <1 cm treated by a continuous suture were more likely to achieve clinical success in the follow-up (P < .001)., Conclusions: OverStitch-based suturing is technically feasible regardless of site and method of suturing, with no cases of failure. The overall technical success rate of 99.3% and the clinical outcome success rate of 89% demonstrate that OverStitch technology provides reliable suturing with clinical advantages, especially with fistulas <1 cm., (Copyright © 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Objective: Endoscopic resection (ER) often involves referral to tertiary centres with high volume practices. Lesions can be subject to prior manipulation and mischaracterisation of features required for accurate planning, leading to prolonged or cancelled procedures. As potential solutions, repeating diagnostic procedures is burdensome for services and patients, while even enriched written reports and still images provide insufficient information to plan ER. This project sought to determine the frequency and implications of polyp mischaracterisation and whether the use of telestration might prevent it., Design/method: A retrospective data analysis of ER referrals to four tertiary centres was conducted for the period July-December 2019. Prospective telestration with a novel digital platform was then performed between centres to achieve consensus on polyp features and ER planning., Results: 163 lesions (163 patients; mean age 67.9±12.2 y; F=62) referred from regional hospitals, were included. Lesion site was mismatched in 11 (6.7%). Size was not mentioned in the referral in 27/163 (16.6%) and incorrect in 81/136 (51.5%), more commonly underestimated by the referring centre (<0.0001), by a mean factor of 1.85±0.79. Incurred procedure time (in units of 20 min) was significantly greater than that allocated (p=0.0085). For 10 cases discussed prospectively, rapid consensus on lesion features was achieved, with agreement between experts on time required for ER., Conclusions: Polyp mischaracterisation is a frequent feature of ER referrals, but could be corrected by the use of telestration between centres. Our study involved expert-to-expert consensus, so extending to 'real-world' referring centres would offer additional learning for a digital pathway., Competing Interests: Competing interests: BH and PB are minority shareholders in Surgease Innovations Ltd., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

BACKGROUND: Artificial intelligence using computer-aided diagnosis (CADx) in real time with images acquired during colonoscopy may help colonoscopists distinguish between neoplastic polyps requiring removal and nonneoplastic polyps not requiring removal. In this study, we tested whether CADx analyzed images helped in this decision-making process. METHODS: We performed a multicenter clinical study comparing a novel CADx-system that uses real-time ultra-magnifying polyp visualization during colonoscopy with standard visual inspection of small (≤5 mm in diameter) polyps in the sigmoid colon and the rectum for optical diagnosis of neoplastic histology. After committing to a diagnosis (i.e., neoplastic, uncertain, or nonneoplastic), all imaged polyps were removed. The primary end point was sensitivity for neoplastic polyps by CADx and visual inspection, compared with histopathology. Secondary end points were specificity and colonoscopist confidence level in unaided optical diagnosis. RESULTS: We assessed 1289 individuals for eligibility at colonoscopy centers in Norway, the United Kingdom, and Japan. We detected 892 eligible polyps in 518 patients and included them in analyses: 359 were neoplastic and 533 were nonneoplastic. Sensitivity for the diagnosis of neoplastic polyps with standard visual inspection was 88.4% (95% confidence interval [CI], 84.3 to 91.5) compared with 90.4% (95% CI, 86.8 to 93.1) with CADx (P=0.33). Specificity was 83.1% (95% CI, 79.2 to 86.4) with standard visual inspection and 85.9% (95% CI, 82.3 to 88.8) with CADx. The proportion of polyp assessment with high confidence was 74.2% (95% CI, 70.9 to 77.3) with standard visual inspection versus 92.6% (95% CI, 90.6 to 94.3) with CADx. CONCLUSIONS: Real-time polyp assessment with CADx did not significantly increase the diagnostic sensitivity of neoplastic polyps during a colonoscopy compared with optical evaluation without CADx. (Funded by the Research Council of Norway [Norges Forskningsråd], the Norwegian Cancer Society [Kreftforeningen], and the Japan Society for the Promotion of Science; UMIN number, UMIN000035213.)

Objective: Hydrothermal duodenal mucosal resurfacing (DMR) is a safe, outpatient endoscopic procedure. REVITA-2, a double-blind, superiority randomised controlled trial, investigates safety and efficacy of DMR using the single catheter Revita system (Revita DMR (catheter and system)), on glycaemic control and liver fat content in type 2 diabetes (T2D)., Design: Eligible patients (haemoglobin A1c (HbA1c) 59-86 mmol/mol, body mass index≥24 and ≤40 kg/m 2 , fasting insulin >48.6 pmol/L, ≥1 oral antidiabetic medication) enrolled in Europe and Brazil. Primary endpoints were safety, change from baseline in HbA1c at 24 weeks, and liver MRI proton-density fat fraction (MRI-PDFF) at 12 weeks., Results: Overall mITT (DMR n=56; sham n=52), 24 weeks post DMR, median (IQR) HbA1c change was -10.4 (18.6) mmol/mol in DMR group versus -7.1 (16.4) mmol/mol in sham group (p=0.147). In patients with baseline liver MRI-PDFF >5% (DMR n=48; sham n=43), 12-week post-DMR liver-fat change was -5.4 (5.6)% in DMR group versus -2.9 (6.2)% in sham group (p=0.096). Results from prespecified interaction testing and clinical parameter assessment showed heterogeneity between European (DMR n=39; sham n=37) and Brazilian (DMR n=17; sham n=16) populations (p=0.063); therefore, results were stratified by region. In European mITT, 24 weeks post DMR, median (IQR) HbA1c change was -6.6 mmol/mol (17.5 mmol/mol) versus -3.3 mmol/mol (10.9 mmol/mol) post-sham (p=0.033); 12-week post-DMR liver-fat change was -5.4% (6.1%) versus -2.2% (4.3%) post-sham (p=0.035). Brazilian mITT results trended towards DMR benefit in HbA1c, but not liver fat, in context of a large sham effect. In overall PP, patients with high baseline fasting plasma glucose ((FPG)≥10 mmol/L) had significantly greater reductions in HbA1c post-DMR versus sham (p=0.002). Most adverse events were mild and transient., Conclusions: DMR is safe and exerts beneficial disease-modifying metabolic effects in T2D with or without non-alcoholic liver disease, particularly in patients with high FPG., Trial Registration Number: NCT02879383., Competing Interests: Competing interests: GM has received funding/grant support from Novo Nordisk, Fractyl Laboratories, Metacure, Keyron, and honorarium for consultancy from Johnson & Johnson, Novo Nordisk, and Fractyl Laboratories. JD has received research support from Fractyl Laboratories Inc for IRB-approved studies. DH has received honorarium for consultancy and/or speaker fees from Novo Nordisk, Sanofi, Astra Zeneca, Roche, Sunovion, and Fractyl Laboratories. EM has received honorarium for consultancy from Olympus do Brasil and Boston Scientific. CC has received funding/grant support from Novo Nordisk and honorarium for consultancy from Novo Nordisk and Eurofarma. DLB reports that he serves or has served on advisory boards for Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, Level Ex, Medscape Cardiology, PhaseBio, PLx Pharma and Regado Biosciences. He is or was a member of the board of directors for Boston VA Research Institute, Society of Cardiovascular Patient Care, and TobeSoft. He is or was chair for the American Heart Association Quality Oversight Committee, and is or was on data monitoring committees for Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo), and the Population Health Research Institute. He reports honoraria from the American College of Cardiology (senior associate editor, Clinical Trials and News, ACC.org; vice-chair, ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (editor in chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (editor in chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (guest editor and associate editor), K2P (cochair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national coleader, funded by Bayer), Slack Publications (chief medical editor, Cardiology Today–Intervention), Society of Cardiovascular Patient Care (secretary/treasurer), WebMD (CME steering committees). He reports other relationships with Clinical Cardiology (deputy editor), NCDR-ACTION Registry Steering Committee (chair), and VA CART Research and Publications Committee (chair). He reports research funding from Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Idorsia, Ironwood, Ischemix, Lexicon, Lilly, Medtronic, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi Aventis, Synaptic, and The Medicines Company. He reports royalties from Elsevier (editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease). He is or was a site coinvestigator for Biotronik, Boston Scientific, CSI, St. Jude Medical (now Abbott), and Svelte. He is or was a trustee for the American College of Cardiology. He reports unfunded research for FlowCo, Merck, Novo Nordisk, and Takeda. HR, JCL-T, KW, and VB are full-time employees of Fractyl Laboratories and may hold Fractyl stock and/or stock options. GC has received research grant support from Boston Scientific and Apollo and is on the advisory board for Cook Medical, Olympus, and Ethicon. RH has received funding/grant support/honorarium for consultancy from Cook Endoscopy, Pentax Europe, Medtronic, C2 Therapeutics, and Fractyl Laboratories to support research infrastructure. EG has received consulting fees from Fractyl Laboratories Inc, Apollo Endosurgery, and Medtronic. MGN has received honorarium for consultancy from Fractyl Laboratories, GI Windows, GI Dynamics, Apollo, and for speaker bureaus for Ethicon, Medtronic, and Olympus. GPA has been a consultant and advisory board member for Agios Pharmaceuticals, Amryt Pharma, AstraZeneca, GlaxoSmithKline and Pfizer. AR has received grant support from Norgine, Fujifilm, Boston Scientific and ERBE, and served as a member of advisory boards for Medtronic, Boston Scientific, EndoStart, EndoKey, Alfasigma and FujiFilm. AJM has received honorarium for consultancy from Fractyl Laboratories and Cook Medical. ACGvB, BH, RB, AH, MDC and NSS have nothing to disclose. AJS has been a consultant for Conatus, Gilead, Elsevier, Echosens, Malinckrodt, Immuron, Intercept, Pfizer, Salix, Uptodate, Boehringer, Ingelhiem, Novartis, Nimbus, Nitto Denko, Hemoshear, Lilly, Novo Nordisk, Fractyl Laboratories, Allergan, Chemomab, Affimmune, Teva, Ardelyx, Terns, ENYO, Birdrock, Albireo, Sanofi, Jannsen, Takeda, Zydus, BASF, Amra, Perspectum, OWL, Poxel, Servier, Second Genome, General Electric, and 89Bio. He is a stock/shareholder at Exhalenz Stock, Akarna, Durect, Indalo and Tiziana. He has received grant/research support from Novartis, Merck, Galectin, Bristol Myers, Merck, Sequana, Boehringer Ingelheim, Echosense, Salix, Malinckrodt, Cumberland, and Gilead.JJGHMB has received research support from Fractyl Laboratories for IRB-based studies and has received a consultancy fee for a single advisory board meeting for Fractyl Laboratories in September 2019., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Endoscopic submucosal dissection (ESD) in a curative intent for submucosa-invasive early (T1) colorectal cancers (T1-CRCs) often leads to subsequent surgical resection in case of histologic parameters indicating higher risk of nodal involvement. In some cases, however, the expected benefit may be offset by the surgical risks, suggesting a more conservative approach., Design: Retrospective analysis of consecutive patients with T1-CRC who underwent ESD at 13 centres ending inclusion in 2019 (n=3373). Cases with high risk of nodal involvement (non-curative ESD: G3, submucosal invasion>1000 µm, lymphovascular involvement, budding or incomplete resection/R1) were analysed if follow-up data (endoscopy/imaging) were available, regardless of the postendoscopic management (follow-up vs surgery) selected by the multidisciplinary teams in these institutions. Comorbidities were classified according to Charlson Comorbidity Index (CCI). Outcomes were disease recurrence, death and disease-related death rates in the two groups. Rate of residual disease (RD) at both the previous resection site and regional lymph nodes was assessed in the surgical cases as well as from follow-up in the follow-up group., Results: Of 604 patients treated by colorectal ESD for submucosally invasive cancer, 207 non-curative resections (34.3%) were included (138 male; mean age 67.6±10.9 years); in 65.2% of cases, no complete resection was achieved (R1). Of the 207 cases, 60.9% (n=126; median CCI: 3; IQR: 2-4) underwent surgical treatment with RD in 19.8% (25/126), while 39.1% (n=81, median CCI: 5; IQR: 4-6) were followed up by endoscopy in all cases. Patients in the follow-up group had a higher overall mortality (HR=3.95) due to non-CRC causes (n=9, mean survival after ESD 23.7±13.7 months). During this follow-up time, tumour recurrence and disease-specific survival rates were not different between the groups (median follow-up 30 months; range: 6-105)., Conclusion: Following ESD for a lesion at high risk of RD, follow-up only may be a reasonable choice in patients at high risk for surgery. Also, endoscopic resection quality should be improved., Trial Registration Number: NCT03987828., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: Rectal neuroendocrine tumours (NETs) are the most common type of gastrointestinal NET. European Neuroendocrine Tumour Society guidelines suggest that rectal NETs measuring ≤10 mm are indolent with low risk of spread. In practice, many patients with lesions ≤1 cm do not undergo complete tumour staging. However, the size of the lesion may not be the only risk factor for nodal involvement/metastases. The aim of this study was to determine if MRI ± nuclear medicine imaging alters tumour stage in patients with rectal NETs ≤10 mm., Methods: Patients referred to a tertiary NET centre between 2005 and 2020 who met the inclusion criteria of a rectal NET ≤10 mm, full cross-sectional imaging, primarily an MRI scan and, if abnormal findings were identified, a subsequent 68 Ga-DOTATATE positron emission tomography scan were included. All patients were followed up at our institution., Results: In all, 32 patients with rectal NETs 10 mm or less were included in the study: 16 women; median age 58 years (range 33-71); 47% (n = 15) were referred from bowel cancer screening procedures. The median size of the lesions was 5 mm (range 2-10 mm). 81% (n = 26) were World Health Organization Grade 1 tumours with Ki67 <3%. Radiological staging confirmed nodal involvement in 25% (8/32); two cases had distant metastatic disease. Lymphovascular invasion was present in 3% (1/32) of patients but none demonstrated peri-neural invasion., Conclusion: This study demonstrates that small rectal NETs can develop nodal metastases; therefore it is important to stage these tumours accurately with MRI at baseline and, if there are concerns regarding potential lymph node metastases, to consider 68 Ga-DOTATATE positron emission tomography imaging., (© 2021 The Association of Coloproctology of Great Britain and Ireland.)

Background and Aims: There are no agreed-on endoscopic signs for the diagnosis of villous atrophy (VA) in celiac disease (CD), necessitating biopsy sampling for diagnosis. Here we evaluated the role of near-focus narrow-band imaging (NF-NBI) for the assessment of villous architecture in suspected CD with the development and further validation of a novel NF-NBI classification., Methods: Patients with a clinical indication for duodenal biopsy sampling were prospectively recruited. Six paired NF white-light endoscopy (NF-WLE) and NF-NBI images with matched duodenal biopsy sampling including the bulb were obtained from each patient. Histopathology grading used the Marsh-Oberhuber classification. A modified Delphi process was performed on 498 images and video recordings by 3 endoscopists to define NF-NBI classifiers, resulting in a 3-descriptor classification: villous shape, vascularity, and crypt phenotype. Thirteen blinded endoscopists (5 expert, 8 nonexpert) then undertook a short training module on the proposed classification and evaluated paired NF-WLE-NF-NBI images., Results: One hundred consecutive patients were enrolled (97 completed the study; 66 women; mean age, 51.2 ± 17.3 years). Thirteen endoscopists evaluated 50 paired NF-WLE and NF-NBI images each (24 biopsy-proven VAs). Interobserver agreement among all validators for the diagnosis of villous morphology using the NF-NBI classification was substantial (κ = .71) and moderate (κ = .46) with NF-WLE. Substantial agreement was observed between all 3 NF-NBI classification descriptors and histology (weighted κ = 0.72-.75) compared with NF-WLE to histology (κ = .34). A higher degree of confidence using NF-NBI was observed when assessing the duodenal bulb., Conclusions: We developed and validated a novel NF-NBI classification to reliably diagnose VA in suspected CD. There was utility for expert and nonexpert endoscopists alike, using readily available equipment and requiring minimal training. (Clinical trial registration number: NCT04349904.)., (Copyright © 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Introduction: Haemorrhage remains a major cause of morbidity and death in all surgical specialties. The aim of this study was to analyse the feasibility of PuraStat ® , a new synthetic haemostatic device, made of self-assembling peptides in laparoscopic colorectal surgery., Material and Methods: This was a prospective observational non-randomised study. Consecutive patients undergoing laparoscopic colorectal surgery were enrolled. Inclusion criterion was the need employ a secondary method of haemostasis when traditional methods such as conventional pressure or utilization of energy devices to control the bleeding were either insufficient or not recommended., Results: Twenty patients were enrolled. The mean time to apply the product was 40 secs (±17 secs), whereas the mean time to achieve haemostasis was 17.5 secs (±3.5 secs). There were no post-operative complications in this cohort of 20 patients. Mean operative time overall was 185 mins (±45.2 mins). None of the patients experienced delayed post-operative bleeding and the mean hospital stay was five days (±3,4)., Conclusions: We demonstrated that PuraStat ® can be easily used in laparoscopic surgery and it is a safe, effective haemostatic agent. This is a feasibility study and additional controlled studies would be useful in the future.

Background: Although peroral endoscopic myotomy (POEM) is highly effective for the management of achalasia, clinical failures may occur. The optimal management of patients who fail POEM is not well known. This study aimed to compare the outcomes of different management strategies in patients who had failed POEM., Methods: This was an international multicenter retrospective study at 16 tertiary centers between January 2012 and November 2019. All patients who underwent POEM and experienced persistent or recurrent symptoms (Eckardt score > 3) were included. The primary outcome was to compare the rates of clinical success (Eckardt score ≤ 3) between different management strategies. RESULTS : 99 patients (50 men [50.5 %]; mean age 51.4 [standard deviation (SD) 16.2]) experienced clinical failure during the study period, with a mean (SD) Eckardt score of 5.4 (0.3). A total of 29 patients (32.2 %) were managed conservatively and 70 (71 %) underwent retreatment (repeat POEM 33 [33 %], pneumatic dilation 30 [30 %], and laparoscopic Heller myotomy (LHM) 7 [7.1 %]). During a median follow-up of 10 (interquartile range 3 - 20) months, clinical success was highest in patients who underwent repeat POEM (25 /33 [76 %]; mean [SD] Eckardt score 2.1 [2.1]), followed by pneumatic dilation (18/30 [60 %]; Eckardt score 2.8 [2.3]), and LHM (2/7 [29 %]; Eckardt score 4 [1.8]; P  = 0.12). A total of 11 patients in the conservative group (37.9 %; mean Eckardt score 4 [1.8]) achieved clinical success. CONCLUSION : This study comprehensively assessed an international cohort of patients who underwent management of failed POEM. Repeat POEM and pneumatic dilation achieved acceptable clinical success, with excellent safety profiles., Competing Interests: Dr. Costamagna is a consultant for Cook Medical, Boston Scientific, and Olympus, and has an Olympus research grant. Dr. Ujiki has received grants and personal fees from Boston Scientific and Gore, and personal fees from Olympus and Medtronic, outside of the the submitted work. Dr. Draganov is a consultant for Olympus, BSC, Cook, Lumendi, and Microtech. Dr. Velanovich receives payment for speakers’ bureau service from A-Cell, Inc. Dr. Marks is a consultant for Boston Scientific and Olympus. Dr. Sedarat is a consultant for Boston Scientific. Dr. Kumta is a consultant for Boston Scientific, Olympus, and Apollo Endosurgery. Dr. Khashab is a consultant for Boston Scientific, Medtronic, and Olympus., (Thieme. All rights reserved.)

Background and Aims: EMR of large (≥2 cm) nonpedunculated colorectal polyps (LNPCPs) is associated with high rates of recurrent/residual adenoma, possibly because of microadenoma left at the margin of resection. Data supporting this mechanism are required. We aimed to determine the incidence of residual microadenoma at the defect margin and base after EMR., Methods: We performed a retrospective observational study of patients undergoing EMR of large LNPCPs with the lateral defect margin further resected using the EndoRotor device (Interscope Medical, Inc, Worcester, Mass, USA) after confirming no visible residual adenomatous tissue. Aspects of the defect base were also resected in selected patients. Patients underwent surveillance at 3 to 6 months., Results: Resection of the normal defect margin was performed in 41 patients and of aspects of the base in 21 patients. Mean lesion size was 43.0 mm (range, 20-130). Microscopic residual lesion was detected in the margin of apparently normal mucosa in 8 cases (19%). In 7 cases this was an adenoma, and in 1 case a serrated lesion was found at the margin of a resected tubular adenoma. Microscopic residual lesion was detected at the base in 5 of 21 cases. Residual/recurrent adenoma was detected in 2 patients. Neither had residual microadenoma at the lateral margin or base detected after the primary resection., Conclusions: Microscopic residual adenoma after wide-field EMR was detected in 19% of cases at the apparently normal defect margin and at the resection base in 5 of 21 cases. This study confirms the presence of residual microadenoma after resection of LNPCPs, providing evidence for the mechanism of recurrence., (Copyright © 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: There is growing interest in developing impedance planimetry as a tool to enhance the clinical outcomes for endoscopic and surgical management of achalasia. The primary aim of this study was to determine whether impedance planimetry measurements can predict clinical response and reflux following peroral endoscopic myotomy (POEM)., Methods: A multicenter cohort study of patients with achalasia undergoing POEM was established from prospective databases and retrospective chart reviews. Patients who underwent impedance planimetry before and after POEM were included. Clinical response was defined as an Eckardt score of ≤ 3. Tenfold cross-validated area under curve (AUC) values were established for the different impedance planimetry measurements associated with clinical response and reflux development., Results: Of the 290 patients included, 91.7 % (266/290) had a clinical response and 39.4 % (108/274) developed reflux following POEM. The most predictive impedance planimetry measurements for a clinical response were: percent change in cross-sectional area (%ΔCSA) and percent change in distensibility index (%ΔDI), with AUCs of 0.75 and 0.73, respectively. Optimal cutoff values for %ΔCSA and %ΔDI to determine a clinical response were a change of 360 % and 272 %, respectively. Impedance planimetry values were much poorer at predicting post-POEM reflux, with AUCs ranging from 0.40 to 0.62., Conclusion: Percent change in CSA and distensibility index were the most predictive measures of a clinical response, with a moderate predictive ability. Impedance planimetry values for predicting reflux following POEM showed weak predictive capacity., Competing Interests: B. Joseph Elmunzer is a consultant for Takeda Pharmaceuticals. Mouen A. Khashab is a consultant for Boston Scientific, Olympus, and Medtronic, and is also on the medical advisory board for Boston Scientific and Olympus. Vivek Kumbhari is a consultant for Apollo Endosurgery, Boston Scientific, Medtronic, and ReShape Life Science. Bu Hayee is a consultant for Apollo Endosurgery, Boston Scientific, Fuji, Medtronic, Obalon, Pentax Medical, and ReShape Life Sciences. All other authors declare that they have no conflicts of interest., (Thieme. All rights reserved.)

Objectives: Recently, several studies have demonstrated the usefulness of endoscopic submucosal dissection (ESD) for residual or locally recurrent colorectal lesions after endoscopic treatment. However, the feasibility of ESD for recurrent rectal lesions after transanal endoscopic microsurgery (TEM) has not been fully investigated. In this study, we evaluated the feasibility and safety of ESD for recurrent rectal lesions after TEM., Methods: The treatment outcomes of 10 lesions in 9 patients, who underwent ESD between January 2006 and March 2018 for recurrent rectal lesions after transanal endoscopic microsurgery, were evaluated., Results: All lesions were successfully resected en bloc, and the R0 resection rate was 90%. The median size of the resected specimens and lesions (range) was 44 mm (21-70) and 27.5 mm (5-60), respectively. The pathological diagnoses included 4 adenomas and 6 cancerous lesions. The cancerous lesions included 5 cases of mucosal cancer and 1 case of superficial submucosal invasive cancer (depth of submucosal invasion <1,000 μm from the muscularis mucosae). No adverse events occurred. There was no recurrence during the follow-up period., Conclusions: ESD for recurrent rectal lesions after TEM by expert's hands appears to be safe and feasible., (© 2020 S. Karger AG, Basel.)

Background: The technical evolution of hernia repair has brought to the introduction of laparoscopy in this field. The most common laparoscopic techniques are transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair. Indirect comparisons between TAPP and TEP have raised questions as to which is the superior approach in improving patient outcomes; however, there is still a scarcity of data directly comparing these laparoscopic approaches. The aim of this report is to offer a retrospective comparison between the two techniques with a long-term follow-up., Methods: This study is a retrospective comparative study, comparing TEP and TAPP in the treatment of groin hernias. All patients undergoing laparoscopic hernia repair from 2015 and 2020 at a large UK Hospital Trust with tertiary referral center, were considered as eligible for inclusion. The primary endpoint was rate of successful surgery defined as absence of recurrence and chronic pain at the end of the follow-up. Secondary endpoints were conversion rate (the switch from TEP to TAPP was considered as a conversion for the index procedure), need for admission, readmission rate, serious adverse events (including visceral injuries and vascular injuries), rate of persisting pain at the end of follow-up, operative time and overall complications rate (hematoma, seroma, wound/superficial infection, mesh/deep infection, port site hernia)., Results: Of the patients included in the study who underwent laparoscopic repair of inguinal hernia between 2015 and 2020, 140 (55.1%) underwent TEP and 114 (44.9%) had TAPP repair. The mean operative time did not differ between the two groups (P=0.202). The conversion rate was nil. The two procedures did not differ for intraoperative and postoperative complications. The length of hospital stay was significantly longer in the TAPP group (P<0.0001). The overall recurrence rate was 2.4%. and did not differ between the two groups. Costs were acquired from the clinical coding department. Mean costs were measured in pounds sterling and a significant difference was noted between the two groups (P=0.083). In the short term, the most common complication was seroma formation and was significantly more frequent in the TAPP group (P<0.001). In the long term, chronic pain was the most frequent complication in both groups and significant correlated when the operation performed for recurrent hernia, whereas the hernia Type 3 was a factor that which influenced recurrence., Conclusions: In conclusion, TAPP and TEP have similar, overall complication risks, postoperative acute and chronic pain incidence and recurrence rates. Since TAPP and TEP have comparable outcomes it is recommended that the choice of the technique should be based on the surgeon's skills, education, and experience.

Artificial intelligence is a strong focus of interest for global health development. Diagnostic endoscopy is an attractive substrate for artificial intelligence with a real potential to improve patient care through standardisation of endoscopic diagnosis and to serve as an adjunct to enhanced imaging diagnosis. The possibility to amass large data to refine algorithms makes adoption of artificial intelligence into global practice a potential reality. Initial studies in luminal endoscopy involve machine learning and are retrospective. Improvement in diagnostic performance is appreciable through the adoption of deep learning. Research foci in the upper gastrointestinal tract include the diagnosis of neoplasia, including Barrett's, squamous cell and gastric where prospective and real-time artificial intelligence studies have been completed demonstrating a benefit of artificial intelligence-augmented endoscopy. Deep learning applied to small bowel capsule endoscopy also appears to enhance pathology detection and reduce capsule reading time. Prospective evaluation including the first randomised trial has been performed in the colon, demonstrating improved polyp and adenoma detection rates; however, these appear to be relevant to small polyps. There are potential additional roles of artificial intelligence relevant to improving the quality of endoscopic examinations, training and triaging of referrals. Further large-scale, multicentre and cross-platform validation studies are required for the robust incorporation of artificial intelligence-augmented diagnostic luminal endoscopy into our routine clinical practice., Competing Interests: Conflict of interest statement: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s), 2020.)

The latest state of the art technological innovations have led to a palpable progression in endoscopic imaging and may facilitate standardisation of practice. One of the most rapidly evolving modalities is artificial intelligence with recent studies providing real-time diagnoses and encouraging results in the first randomised trials to conventional endoscopic imaging. Advances in functional hypoxia imaging offer novel opportunities to be used to detect neoplasia and the assessment of colitis. Three-dimensional volumetric imaging provides spatial information and has shown promise in the increased detection of small polyps. Studies to date of self-propelling colonoscopes demonstrate an increased caecal intubation rate and possibly offer patients a more comfortable procedure. Further development in robotic technology has introduced ex vivo automated locomotor upper gastrointestinal and small bowel capsule devices. Eye-tracking has the potential to revolutionise endoscopic training through the identification of differences in experts and non-expert endoscopist as trainable parameters. In this review, we discuss the latest innovations of all these technologies and provide perspective into the exciting future of diagnostic luminal endoscopy., (© 2019 Japan Gastroenterological Endoscopy Society.)

Background and study aims  Per-oral endoscopic myotomy (POEM) is associated with a short-term clinical response of 82 % to 100 % in treatment of patients with achalasia. Data are limited on the long-term durability of the clinical response in these patients. The aim of this study was to determine the long-term outcomes of patients undergoing POEM for management of achalasia. Methods  This was a retrospective multicenter cohort study of consecutive patients who underwent POEM for management of achalasia. Patients had a minimum of 4 years follow-up. Clinical response was defined by an Eckardt score ≤ 3. Results  A total of 146 patients were included from 11 academic medical centers. Mean (± SD) age was 49.8 (± 16) years and 79 (54 %) were female. The most common type of achalasia was type II, seen in 70 (47.9 %) patients, followed by type I seen in 41 (28.1 %) patients. Prior treatments included: pneumatic dilation in 29 (19.9 %), botulinum toxin injection in 13 (8.9 %) and Heller myotomy in seven patients (4.8 %). Eight adverse events occurred (6 mucosotomies, 2 pneumothorax) in eight patients (5.5 %). Median follow-up duration was 55 months (IQR 49.9-60.6). Clinical response was observed in 139 (95.2 %) patients at follow-up of ≥ 48 months. Symptomatic reflux after POEM was seen in 45 (32.1 %) patients, while 35.3 % of patients were using daily PPI at 48 months post POEM. Reflux esophagitis was noted in 16.8 % of patients who underwent endoscopy. Conclusion  POEM is a durable and safe procedure with an acceptably low adverse event rate and an excellent long-term clinical response., Competing Interests: Competing interests Vivek Kumbhari is a consultant for Boston Scientific, Apollo Endosurgery, Medtronic, ReShape Medical. Mouen A. Khashab is a consultant and advisory board for Boston Scientific and consultant for Olympus.

Background: There is a trend toward organ conservation in the management of rectal tumors. However, there is no consensus on standardized investigations to guide treatment., Objective: We report the value of multimodal endoscopic assessment (white light, magnification chromoendoscopy and narrow band imaging, selected colonoscopic ultrasound) for rectal early neoplastic tumors to inform treatment decisions., Design: This was a retrospective study., Setting: The study was conducted in a tertiary referral unit for interventional endoscopy and early colorectal cancer., Patients: A total of 296 patients referred with rectal early neoplastic tumors were assessed using standardized multimodal endoscopic assessment and classified according to risk of harboring invasive cancer., Main Outcome Measures: Sensitivity, specificity, positive and negative predictive values of multimodal endoscopic assessment, and previous biopsy to predict invasive cancer were calculated and treatment outcomes reported., Results: After multimodal endoscopic assessment, lesions were classified as invasive cancer, at least deep submucosal invasion (n = 65); invasive cancer, superficial submucosal invasion or high risk of covert cancer (n = 119); or low risk of covert cancer (n = 112). Sensitivity, specificity, positive predictive values, and negative predictive values of multimodal endoscopic assessment for diagnosing invasive cancer, deep submucosal invasion, were 77%, 98%, 93%, and 93%. The combined classification of all lesions with invasive cancer or high risk of covert cancer had a negative predictive value of 96% for invasive cancer on final histopathology. Sensitivity of previous biopsy was 37%. A total of 47 patients underwent radical surgery and 33 transanal endoscopic microsurgery. No patients without invasive cancer were subjected to radical surgery; 222 patients initially underwent endoscopic resection. Of the 203 without deep submucosal invasion, 95% avoided surgery and were free from recurrence at last follow-up., Limitations: This was a retrospective study from a tertiary referral unit., Conclusions: Standardized multimodal endoscopic assessment guides rational treatment decisions for rectal tumors resulting in organ-conserving treatment for all patients without deep submucosal invasive cancer. See Video Abstract at http://links.lww.com/DCR/B133. LA EVALUACIÓN ENDOSCÓPICA MULTIMODAL COMO GUÍA DE DECISIONES EN EL TRATAMIENTO DE TUMORES RECTALES NEOPLÁSICOS PRECOCES: La tendencia actual es la preservación del órgano en el manejo de los tumores de rectao. Sin embargo, no hay consenso sobre las investigaciones estandar para guiar dicho tratamiento.Presentamos los valores de la evaluación endoscópica multimodal (luz blanca, cromoendoscopia de aumento, imagen de banda estrecha y ecografía colonoscópica seleccionada) para tumores rectales neoplásicos tempranos y así notificar las decisiones sobre el tratamiento.Estudio retrospectivo.El estudio se realizó en una unidad de referencia terciaria para endoscopia intervencionista y cáncer colorrectal temprano.Se evaluaron 296 pacientes referidos con tumores neoplásicos precoces de recto mediante una evaluación endoscópica multimodal estandarizada y se clasificaron de acuerdo al riesgo de albergar un cáncer invasivo.Se calcularon la sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal y la biopsia previa para predecir el cáncer invasivo y se notificaron los resultados para el tratamiento.Después de la evaluación endoscópica multimodal, las lesiones se clasificaron como: cáncer invasive (al menos invasión submucosa profunda n = 65); cáncer invasive (invasión submucosa superficial o alto riesgo de cáncer encubierto n = 119) y finalmente aquellos de bajo riesgo de cáncer encubierto (n = 112). La sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluación endoscópica multimodal para el diagnóstico de cáncer invasivo, la invasión submucosa profunda fueron 77%, 98%, 93% y 93% respectivamente. La clasificación combinada de todas las lesiones con cáncer invasivo o de alto riesgo de cáncer encubierto tuvo un VPN del 96% para el cáncer invasivo en la histopatología final. La sensibilidad fué de 37% en todas las biopsias previas. 47 pacientes fueron sometidos a cirugía radical, 33 por microcirugía endoscópica transanal. Ningún paciente sin cáncer invasivo fue sometido a cirugía radical. Inicialmente, 222 pacientes fueron sometidos a resección endoscópica. De los 203 sin invasión submucosa profunda, el 95% evitó la cirugía y no tuvieron recurrencia en el último seguimiento.Estudio retrospectivo de una unidad de referencia terciaria.La evaluación endoscópica multimodal estandarizada guía las decisiones racionales de tratamiento para los tumores rectales que resultan en un tratamiento conservador de órganos para todos los pacientes sin cáncer invasivo submucoso profundo. Consulte Video Resumen en http://links.lww.com/DCR/B133.

There is a need for well-organized comprehensive strategies to achieve good training in ESD. In this context, the European Society of Gastrointestinal Endoscopy (ESGE) have developed a European core curriculum for ESD practice across Europe with the aim of high quality ESD training.Advanced endoscopy diagnostic practice is advised before initiating ESD training. Proficiency in endoscopic mucosal resection (EMR) and adverse event management is recommended before starting ESD trainingESGE discourages the starting of initial ESD training in humans. Practice on animal and/or ex vivo models is useful to gain the basic ESD skills. ESGE recommends performing at least 20 ESD procedures in these models before human practice, with the goal of at least eight en bloc complete resections in the last 10 training cases, with no perforation. ESGE recommends observation of experts performing ESD in tertiary referral centers. Performance of ESD in humans should start on carefully selected lesions, ideally small ( < 30 mm), located in the antrum or in the rectum for the first 20 procedures. Beginning human practice in the colon is not recommended. ESGE recommends that at least the first 10 human ESD procedures should be done under the supervision of an ESD-proficient endoscopist.Endoscopists performing ESD should be able to correctly estimate the probability of performing a curative resection based on the characteristics of the lesion and should know the benefit/risk relationship of ESD when compared with other therapeutic alternatives. Endoscopists performing ESD should know how to interpret the histopathology findings of the ESD specimen, namely the criteria for low risk resection ("curative"), local risk resection, and high risk resection ("non-curative"), as well as their implications. ESD should be performed only in a setting where early and delayed complications can be managed adequately, namely with the possibility of admitting patients to a ward, and access to appropriate emergency surgical teams for the organ being treated with ESD., Competing Interests: F. Berr has received financial support from Ethical MedTech (Olympus, Fujifilm, ERBE, and others) to organize medical education courses and live endoscopy events (2009 – 2019), and speaker’s fees from Olympus (2015 – 2018). R. Bisschops has received research support from Cook and Medtronic, and financial support for symposium organization from Cook, Boston Scientific, Olympus, and Erbe (2009 – 2019), and speaker's fees from Boston Scientific and Medtronic (2009 – 2019). E. Dekker has received speaker’s fees from Olympus, Roche, and GI Supply, has provided consultancy to FujiFilm, Olympus, Tillots, GI Supply, and CPP-FAP, and is a member of the supervisory board of eNose; she receives a research grant from FujiFilm (2017 to present). P. Deprez has provided consultancy to Olympus, Erbe, and Boston Scientific (2015 – 2019). M. Dinis-Ribeiro is co-editor in-chief of Endoscopy. J. E. East received speaker’s fees from Olympus and Falk (2018) and is on the clinical advisory boards of Boston Scientific and Lumendi (2016 to present). G. Johnson has served on advisory boards for Boston Scientific and Olympus (2017) and Medtronic (2018), and has been a faculty member for annual training courses supported by Olympus (2014 to present) and Boston Scientific (2017 to present). B. L. A. M. Weusten received financial support for clinical and preclinical research from Pentax Medical Nature (2018 to 2019). E. Albéniz, M. Arvanitakis, P. Dewint, A. Ebigbo, A Haji, A. Panarese, P. Pimentel-Nunes, M. Pioche, T. Ponchon, and D. S. Sanders have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Aims: Few large Western series examine risk factors for recurrence after endoscopic resection (ER) of large (≥20 mm) colorectal laterally spreading tumors. Recurrence beyond initial surveillance is seldom reported, and differences between residual/recurrent adenoma and late recurrence are not scrutinized. We report the incidence of recurrence at successive surveillance intervals, identify risk factors for recurrent/residual adenoma and late recurrence, and describe the outcomes of ER of recurrent adenomas., Methods: Recurrence was calculated for successive surveillance periods after colorectal ER. Multiple logistic regression was used to identify independent risk factors for recurrent/residual adenoma and late recurrence (≥12 months)., Results: Six hundred twenty colorectal ERs were performed, and 456 eligible patients (98%) had completed 3- to 6-month surveillance. Residual/recurrent adenoma (3-6 months) was detected in 8.3%, at 12 months in 6.1%, between 24 and 36 months in 6.4%, and after 36 months in 13.5%. Independent risk factors for residual/recurrent adenoma were piecemeal resection (odds ratio [OR], 13.0; P = .01), adjunctive argon plasma coagulation (OR, 2.4; P = .01), and lesion occupying ≥75% of the luminal circumference (OR, 5.6; P < .001) and for late recurrence were lesion size >60 mm (OR, 6.3; P < .001) and piecemeal resection (OR, 4.4; P = .04). Of 66 patients with recurrence, 5 required surgery, 8 left the treatment pathway, 20 are still receiving ER or surveillance, and 33 had ER with normal subsequent surveillance., Conclusions: Recurrence occurs at successive periods of surveillance after ER even beyond 3 years. Aside from piecemeal resection, risk factors for residual/recurrent adenoma and late recurrence are different. Recurrence can be challenging to treat, but surgery is rarely required., (Copyright © 2019 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Purpose: Injudicious attempts at resection and extensive sampling of large colorectal adenomas prior to referral for endoscopic resection (ER) are common. This has deleterious effects, but little is known about the outcomes following ER. We retrospectively analysed the outcomes of ER of large adenomas previously subjected to substantial manipulation., Method: ER of large (≥ 2 cm) colorectal adenomas were grouped according to level of manipulation: prior attempted resection, heavy manipulation (≥ six biopsies or tattoo under lesion) or minimal manipulation (< six biopsies). Outcomes were compared between groups. Independent predictors of outcomes were identified using multiple logistic regression., Results: Five hundred forty-two lesions (mean size 53.7 mm) were included. Two hundred sixty-five (49%) had been subjected to prior attempted resection or heavy manipulation, 151 (28%) to minimal manipulation, and 126 (23%) were not previously manipulated. ESD techniques were used more frequently than EMR after substantial manipulation. There were no differences in initial success of ER (99%, 98%, 98%, p = 0.71). Prior attempted resection was independently associated with recurrence (OR 2.2, 95% CI 1.1-4.5, p = 0.03) and negatively associated with en bloc resection (OR 0.29, 95% CI 0.1-0.7, p = 0.004). Regardless of level of prior manipulation, there were no differences in sustained endoscopic cure with > 95% of patients overall free from recurrence and avoiding surgery at last follow-up., Conclusion: There is a substantial burden of injudicious lesion manipulation before referral, which makes recurrence more likely and en bloc resection less likely. However, with appropriate expertise, sustained successful endoscopic treatment is achievable for the vast majority of patients treated in a specialist unit.

Background: Chromoendoscopy (CE) is the recommended surveillance technique for colitis, but uptake has been limited and the literature provides scant information on patient experience (PE); imperative to adherence to surveillance programmes. Virtual CE (VCE) by Fujinon Intelligent Colour Enhancement digitally reconstructs mucosal images in real time, without the technical challenges of CE. We performed a multifaceted randomized crossover trial (RCT) to evaluate study feasibility and obtain preliminary comparative procedural and PE data., Methods: Patients were randomized to undergo either CE with indigo carmine or VCE as the first procedure. After 3-8 weeks, participants underwent colonoscopy with the second technique. Patient recruitment/retention, missed dysplasia, prediction of dysplasia, and contamination (memory/sampling of the first procedure) were recorded. PE was assessed by validated questionnaires, and pain was assessed using a visual analog scale (mm)., Results: Sixty patients were recruited, and 48 patients (first procedure: 23 VCE, 25 CE) completed the trial (retention 80%) with no episodes of contamination. Eleven dysplastic lesions were detected in n = 7/48 (14.5%). VCE missed 1 lesion, and CE missed 2 lesions in n = 2 (data of VCE vs CE, respectively, for dysplasia diagnostic accuracy: 93.94% [85.2%-98.32%] vs 76.9% [66.9%-98.2%]; examination time [minutes]: 14 +/- 4 vs 20 +/- 7 (95% confidence interval, 3.5 to 8; P < 0.001); pain (mm): 27.4 +/- 17.5 vs 34.7 +/- 18; patient preference: 67% [n = 31] vs 33% [n = 15] in n = 46; P < 0.001)., Conclusions: This is the first RCT to include validated PE in a colitis surveillance program. VCE is safe, technically easier, quicker, and more comfortable test, with dysplasia detection at least as good as that of CE, overcoming many barriers to the wider adoption of CE. This trial may serve as a successful foundation for a a multicenter trial to confirm the value of VCE for colitis surveillance., (© 2018 Crohn’s & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Almost any colorectal superficial neoplastic lesion can be treated by endoscopic resection (ER) but very little is known about outcomes of ER leaving circumferential or near-circumferential mucosal defects. We report the outcomes of ER leaving ≥ 75% circumferential mucosal defects performed in a western expert centre., Methods: Five hundred eighty-seven ERs of large colorectal lesions ≥ 20 mm were grouped according to the extent of the mucosal defect and comparisons made between those with < 75% and ≥ 75% defects. Independent predictors of stenosis were identified., Results: Forty-seven patients had ER leaving ≥ 75% circumference defect, most located at or distal to the rectosigmoid, with ≥ 90% defects in 5 and 100% in 11. There were no significant colonic muscle injuries in patients with ≥ 75% defect and no differences in post-procedure bleeding (OR 1.6, 95% CI 0.2-13.7, p = 0.64) between patients with ≥ 75% and < 75% defects. Stenosis developed in 9 patients. ≥ 90% circumference defect was the only independent risk factor for stenosis (OR 286, p < 0.001). Three of 4 patients with asymptomatic stenosis had successful expectant management. The remainder were treated with dilatation. Recurrence was more likely in those with ≥ 75% defect (OR 7.9, 95% CI 3.8-16.4, p < 0.001) but was managed with further ER in all but 2 cases., Conclusion: ER of colorectal lesions resulting in defects ≥ 75% of the luminal circumference is challenging but safe and effective when performed in an expert centre. The only independent predictor of stenosis is ≥ 90% circumference defect but some patients improve with expectant management; therefore, pre-emptive intervention may not be warranted.

Background: Studies suggest that defunctioning stomas reduce the rate of anastomotic leakage and urgent reoperations after anterior resection. Although the magnitude of benefit appears to be limited, there has been a trend in recent years towards routinely creating defunctioning stomas. However, little is known about post-operative complication rates in patients with and without a defunctioning stoma. We compared overall short-term post-operative complications after low anterior resection in patients managed with a defunctioning stoma to those managed without a stoma., Methods: A retrospective cohort study of patients undergoing elective low anterior resection of the rectum for rectal cancer. The primary outcome was overall 90-day post-operative complications., Results: Two hundred and three patients met the inclusion criteria for low anterior resection. One hundred and forty (69%) had a primary defunctioning stoma created. 45% received neoadjuvant radiotherapy. Patients with a defunctioning stoma had significantly more complications (57.1 vs 34.9%, p = 0.003), were more likely to suffer multiple complications (17.9 vs 3.2%, p < 0.004) and had longer hospital stays (13.0 vs 6.9 days, p = 0.005) than those without a stoma. 19% experienced a stoma-related complication, 56% still had a stoma 1 year after their surgery, and 26% were left with a stoma at their last follow-up. Anastomotic leak rates were similar but there was a significantly higher reoperation rate among patients managed without a defunctioning stoma., Conclusion: Patients selected to have a defunctioning stoma had an absolute increase of 22% in overall post-operative complications compared to those managed without a stoma. These findings support the more selective use of defunctioning stomas., Study Registration: Registered at www.researchregistry.com (UIN: researchregistry3412).

Background and Study Aims: The efficacy of per oral endoscopic myotomy (POEM) in non-achalasia esophageal motility disorders such as esophagogastric junction outflow obstruction (EGJOO), diffuse esophageal spasm (DES), and jackhammer esophagus (JE) has not been well demonstrated. The aim of this international multicenter study was to assess clinical outcomes of POEM in patients with non-achalasia disorders, namely DES, JE, and EGJOO, in a large cohort of patients., Patients and Methods: This was a retrospective study at 11 centers. Consecutive patients who underwent POEM for EGJOO, DES, or JE between 1/2014 and 9/2016 were included. Rates of technical success (completion of myotomy), clinical response (symptom improvement/Eckardt score ≤ 3), and adverse events (AEs, severity per ASGE lexicon) were ascertained ., Results: Fifty patients (56 % female; mean age 61.7 years) underwent POEM for EGJOO (n = 15), DES (n = 17), and JE (n = 18). The majority of patients (68 %) were treatment-naïve. Technical success was achieved in all patients with a mean procedural time of 88.4 ± 44.7 min. Mean total myotomy length was 15.1 ± 4.7 cm. Chest pain improved in 88.9 % of EGJOO and 87.0 % of DES/JE ( P  = 0.88). Clinical success was achieved in 93.3 % of EGJOO and in 84.9 % of DES/JE ( P  = 0.41) with a median follow-up of 195 and 272 days, respectively. Mean Eckardt score decreased from 6.2 to 1.0 in EGJOO ( P  < 0.001) and from 6.9 to 1.9 in DES/JE ( P  < 0.001). A total of 9 (18 %) AEs occurred and were rated as mild in 55.6 % and moderate in 44.4 %., Conclusion: POEM is effective and safe in management of non-achalasia esophageal motility disorders, which include DES, JE, and EGJOO.

Background: Endoscopic resection of large colorectal lesions is well reported and is the first line of treatment for all noninvasive colorectal neoplasms in many centers, but little is known about the outcomes of endoscopic resection of truly massive colorectal lesions ≥8 cm., Objective: We report on the outcomes of endoscopic resection for massive (≥8 cm) colorectal adenomas and compare the outcomes with resection of large (2.0-7.9 cm) lesions., Design: This was a retrospective study., Settings: The study was conducted in a tertiary referral unit for interventional endoscopy., Patients: A total of 435 endoscopic resections of large colorectal polyps (≥2 cm) were included, of which 96 were ≥8 cm., Main Outcome Measures: Outcomes included initial successful resection, complications, recurrence, surgery, and hospital admission., Results: Endoscopic resection was successful for 91 of 96 massive lesions (≥8 cm). Mean size was 10.1 cm (range, 8-16 cm). A total of 75% had previous attempts at resection or heavy manipulation before referral. Thirty two were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection and the rest using piecemeal endoscopic mucosal resection. No patients required surgery for a perforation. Five patients had postprocedural bleeding. There were 25 recurrences: 2 were treated with transanal endoscopic microsurgery, 2 with right hemicolectomy, and the rest with endoscopic resection. Compared with patients with large lesions, more patients with massive adenomas had complications (19.8% versus 3.3%), required admission (39.6% versus 11.0%), developed recurrence (30.8% versus 9.9%), or required surgery for recurrence (5.0% versus 0.8%)., Limitations: This was a retrospective study., Conclusions: Endoscopic resection of massive colorectal adenomas ≥8 cm is achievable with few significant complications, and the majority of patients avoid surgery. Systematic assessment is required to appropriately select patients for endoscopic resection, which should be performed in specialist units. See Video Abstract at http://links.lww.com/DCR/A653.

Background: Colorectal endoscopic submucosal dissection results in high rates of en bloc resection, few recurrences, and accurate diagnosis, and it is useful in lesions with significant fibrosis. However, endoscopic submucosal dissection has not been widely adopted by Western endoscopists and the published experience from Western centers is very limited., Objectives: This study aims to report the outcomes from a UK tertiary center using colorectal endoscopic submucosal dissection as part of a standard lesion specific treatment approach., Design: This was a retrospective study., Setting: The study was conducted in a tertiary referral unit for interventional endoscopy in the United Kingdom., Patients: A total of 116 colorectal lesions were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection in 107 patients., Main Outcome Measures: Outcomes included complications, recurrence, requirement for surgery, en bloc and R0 resection., Results: One hundred sixteen lesions (mean size 58.8mm) were resected using endoscopic submucosal dissection (n = 58) and hybrid endoscopic submucosal dissection (n = 58). Eighty-two (70.7%) had failed attempts at resection (n = 58) or extensive sampling before referral. Twelve contained invasive adenocarcinoma; endoscopic resection was curative in 6. Only 2 of 6 patients with noncurative endoscopic resection agreed to surgery, and none had lymph node metastases. Six of 7 perforations were successfully treated with endoscopic clips. Where endoscopic submucosal dissection was used alone, en bloc resection was achieved in 93% and R0 resection was achieved in 91%. Two patients experienced recurrence; both were managed with endoscopic resection., Limitations: This was a retrospective study. Procedures were planned as endoscopic submucosal dissection, but some may have been converted to hybrid endoscopic submucosal dissection and not recorded., Conclusion: Colorectal endoscopic submucosal dissection can be used in a Western center as part of a standard lesion-specific approach to deliver effective organ-conserving treatment to patients with large challenging lesions. Lesion assessment in Western practice should be improved to reduce the incidence of prior heavy manipulation and to guide appropriate referral. See Video Abstract at http://links.lww.com/DCR/A601.

Background: The SCENIC consensus statement recommends endoscopic resection of all visible dysplasia in inflammatory bowel disease, but patients with large or complex lesions may still be advised to have colectomy. This article presents outcomes for large nonpolypoid resections associated with colitis at our institution., Methods: Data including demographics, clinical history, lesion characteristics, method of resection, and postresection surveillance were collected prospectively in patients with visible lesions within colitic mucosa from January 2011 to November 2016. Resection techniques included endoscopic mucosal resection , endoscopic submucosal dissection (ESD), and hybrid ESD. Surveillance with magnification chromoendoscopy was performed at 3 months, 1-year postresection, and annually thereafter., Results: Fifteen lesions satisfied the inclusion criteria in 15 patients. Mean lesion size was 48.3+/-21.7 (20-90) mm. All lesions were non-polypoid with distinct margins and no ulceration. 73% lesions were scarred of which 64% had undergone prior instrumentation. En bloc resection was achieved in n=6. Presumed endoscopic diagnosis was confirmed histopathologically in all resected lesions. One case of perforation and another with bleeding were both managed endoscopically. Median follow-up was 28 months (12-35) with no recurrence., Conclusion: This cohort series demonstrates that endoscopic resection of large non-polypoid lesions associated with colitis is feasible and safe using an array of resection methods supporting the role of advanced endoscopic therapeutics for the management of colitis associated dysplasia in a western tertiary endoscopic center.

Background: Endoscopic resection of large colorectal polyps is well established. However, significant differences in technique exist between eastern and western interventional endoscopists. We report the results of endoscopic resection of large complex colorectal lesions from a specialist unit that combines eastern and western techniques for assessment and resection., Patients and Methods: Endoscopic resections of colorectal lesions of at least 2 cm were included. Lesions were assessed using magnification chromoendoscopy supplemented by colonoscopic ultrasound in selected cases. A lesion-specific approach to resection with endoscopic mucosal resection or endoscopic submucosal dissection (ESD) was used. Surveillance endoscopy was performed at 3 (SC1) and 12 (SC2) months., Results: Four hundred and sixty-six large (≥20 mm) colorectal lesions (mean size 54.8 mm) were resected. Three hundread and fifty-six were resected using endoscopic mucosal resection and 110 by ESD or hybrid ESD. Fifty-one percent of lesions had been subjected to previous failed attempts at resection or heavy manipulation (≥6 biopsies). Nevertheless, endoscopic resection was deemed successful after an initial attempt in 98%. Recurrence occurred in 15% and could be treated with endoscopic resection in most. Only two patients required surgery for perforation. Nine patients had postprocedure bleeding; only two required endoscopic clips. Ninety-six percent of patients without invasive cancer were free from recurrence and had avoided surgery at last follow-up., Conclusion: Combining eastern and western practices for assessment and resection results in safe and effective organ-conserving treatment of complex colorectal lesions. Accurate assessment before and after resection using magnification chromoendoscopy and a lesion-specific approach to resection, incorporating ESD where appropriate, are important factors in achieving these results.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted due to overlapping/duplicate material. Data from some patients from this study have previously been published in other journals without cross-referencing. Twenty patients overlap with a paper by Kumbhari et al. 1 Thirty-five patients overlap with the study by Ngamruengphong et al. 2 ., (Copyright © 2018.)

Competing Interests: Dr. Despott has received research and education grants from Fujifilm, Aquilant Medical, Pentax, and Olympus.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Neoadjuvant chemoradiotherapy (CRT) is considered the standard approach before any surgical intervention for locally advanced rectal tumors and has been proven to significantly improve the local recurrence rates of rectal cancer. However, the optimal timing of surgical resection after neoadjuvant CRT remains debatable., Objective and Methods: We conducted a retrospective review of 65 consecutive patients with locally advanced rectal cancer who underwent preoperative CRT followed by surgical resection in order to evaluate the optimal time for surgical treatment. We used two alternative groups for analysis: patients who underwent surgery up to 6 weeks after CRT ( n = 28) and those who underwent surgery 6 weeks or more after CRT ( n = 27). Also, we compared patients who were operated on within 3 months ( n = 39) with those who underwent surgical resection after more than 3 months ( n = 16). Nonresponders to CRT were excluded from the analysis., Results: There was no statistically significant association between waiting period post CRT and radiological downstaging for any group ( p > 0.05 for any association). Also, there was no association between recurrence of disease, cancer-related deaths, perineural invasion, or positive lymph node ratio and any waiting period up to 3 months ( p > 0.05 for all associations)., Conclusion: In this small exploratory study there was no evident difference in outcome according to timing of surgery, which suggests that further research in larger cohorts is warranted.

Background & Aims: In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM., Methods: We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non-HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months., Results: POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non-HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non-HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non-HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups., Conclusions: POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups., (Copyright © 2017 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objectives: The safety of peroral endoscopic myotomy (POEM) is still debated since comprehensive analysis of adverse events (AEs) associated with the procedure in large multicenter cohort studies has not been performed. To study (1) the prevalence of AEs and (2) factors associated with occurrence of AEs in patients undergoing POEM., Methods: Patients who underwent POEM at 12 tertiary-care centers between 2009 and 2015 were included in this case-control study. Cases were defined by the occurrence of any AE related to the POEM procedure. Control patients were selected for each AE case by matching for age, gender, and disease classification (achalasia type I and II vs. type III/spastic esophageal disorders)., Results: A total of 1,826 patients underwent POEM. Overall, 156 AEs occurred in 137 patients (7.5%). A total of 51 (2.8%) inadvertent mucosotomies occurred. Mild, moderate, and severe AEs had a frequency of 116 (6.4%), 31 (1.7%), and 9 (0.5%), respectively. Multivariate analysis demonstrated that sigmoid-type esophagus (odds ratio (OR) 2.28, P=0.05), endoscopist experience <20 cases (OR 1.98, P=0.04), use of a triangular tip knife (OR 3.22, P=0.05), and use of an electrosurgical current different than spray coagulation (OR 3.09, P=0.02) were significantly associated with the occurrence of AEs., Conclusions: This large study comprehensively assessed the safety of POEM and highly suggests POEM as a relatively safe procedure when performed by experts at tertiary centers with an overall 7.5% prevalence of AEs. Severe AEs are rare. Sigmoid-type esophagus, endoscopist experience, type of knife, and current used can be considered as predictive factors of AE occurrence.

Endoscopic submucosal dissection (ESD) enables en bloc resection of large complex colorectal superficial neoplastic lesions, resulting in very low rates of local recurrence, high-quality pathologic specimens for accurate histopathologic diagnosis and potentially curative treatment of early adenocarcinoma without resorting to major surgical resection. The safety and efficacy of the technique, which was pioneered in the upper gastrointestinal tract, has been established by the consistently impressive outcomes from expert centers in Japan and some other eastern countries. However, ESD is challenging to perform in the colorectum and there is a significant risk of complications, particularly in the early stages of the learning curve. Early studies from western centers raised concerns about the high complication rates, and the impressive results from Japanese centers were not replicated. As a result, many western endoscopists are skeptical about the role of ESD and few centers have incorporated the technique into their practice. Nevertheless, although the distribution of expertise, referral centers and modes of practice may differ in Japan and western countries, ESD has an important role and can be safely and effectively incorporated into western practice. Key to achieving this is meticulous lesion assessment and selection, appropriate referral to centers with the necessary expertise and experience and application of the appropriate technique individualized to the patient. This review discusses the advantages, risks and benefits of ESD to treat colorectal lesions and the importance of preprocedure lesion assessment and in vivo diagnosis and outlines a pragmatic rationale for appropriate lesion selection as well as the patient, technical and institutional factors that should be considered., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background and study aims  The variables associated with gastroesophageal reflux (GER) after peroral endoscopic myotomy (POEM) are largely unknown. This study aimed to: 1) identify the prevalence of reflux esophagitis and asymptomatic GER in patients who underwent POEM, and 2) evaluate patient and intraprocedural variables associated with post-POEM GER. Patients and methods  All patients who underwent POEM and subsequent objective testing for GER (pH study with or without upper gastrointestinal [GI] endoscopy) at seven tertiary academic centers (one Asian, two US, four European) were included. Patients were divided into two groups: 1) DeMeester score ≥ 14.72 (cases) and 2) DeMeester score of < 14.72 (controls). Asymptomatic GER was defined as a patient with a DeMeester score ≥ 14.72 who was not consuming proton pump inhibitor (PPI). Results  A total of 282 patients (female 48.2 %, Caucasian 84.8 %; mean body mass index 24.1 kg/m 2 ) were included. Clinical success was achieved in 94.3 % of patients. GER evaluation was completed after a median follow-up of 12 months (interquartile range 10 - 24 months). A DeMeester score of ≥ 14.72 was seen in 57.8 % of patients. Multivariable analysis revealed female sex to be the only independent association (odds ratio 1.69, 95 % confidence interval 1.04 - 2.74) with post-POEM GER. No intraprocedural variables were associated with GER. Upper GI endoscopy was available in 233 patients, 54 (23.2 %) of whom were noted to have reflux esophagitis (majority Los Angeles Grade A or B). GER was asymptomatic in 60.1 %. Conclusion  Post-POEM GER was seen in the majority of patients. No intraprocedural variables were identified to allow for potential alteration in procedural technique., Competing Interests: Competing interests: Dr. Khashab is a consultant for Boston Scientific and Olympus America, and has received research support from Cook Medical. Dr Kumbhari is a consultant for Boston Scientific and Apollo Endosurgery., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Aims: Per-oral endoscopic myotomy (POEM) has shown promising safety and efficacy in short-term studies. However, long-term follow-up data are very limited. The aims of this study were to assess (1) clinical outcome of patients with a minimum post-POEM follow-up of 2 years and (2) factors associated with long-term clinical failure after POEM., Methods: A retrospective chart review was performed that included all consecutive patients with achalasia who underwent POEM with a minimum follow-up of 2 years at 10 tertiary-care centers. Clinical response was defined by a decrease in Eckardt score to 3 or lower., Results: A total of 205 patients (45.8% men; mean age, 49 years) were followed for a median of 31 months (interquartile range, 26-38 months). Of these, 81 patients (39.5%) had received previous treatment for achalasia before POEM. Clinical success was achieved in 98% (185/189), 98% (142/144), and 91% (187/205) of patients with follow-up within 6 months, at 12 months, and ≥24 months, respectively. Of 185 patients with clinical response at 6 months, 11 (6%) experienced recurrent symptoms at 2 years. History of previous pneumatic dilation was associated with long-term treatment failure (odds ratio, 3.41; 95% confidence interval, 1.25-9.23). Procedure-related adverse events occurred in 8.2% of patients and only 1 patient required surgical intervention. Abnormal esophageal acid exposure and reflux esophagitis were documented in 37.5% and 18% of patients, respectively. However, these rates are simply a reference number among a very selective group of patients., Conclusions: POEM is safe and provides high initial clinical success and excellent long-term outcomes. Among patients with confirmed clinical response within 6 months, 6% had recurrent symptoms by 2 years., (Copyright © 2017 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background/aim: Total mesorectal excision combined with neo-adjuvant chemoradiotherary (CRT) and adjuvant chemotherapy, has been the standard treatment of locally advanced rectal cancer (LARC). Although TNM (Tumor, Node, Metastasis) classification for malignant Tumors is still the cornerstone in rectal cancer staging, there has been an effort to identify molecular biomarkers with additional prognostic or predictive value., Materials and Methods: We retrospectively analyzed molecular biomarkers on prospectively collected histological specimens and clinical data from a cohort of 135 consecutive rectal cancer cases who underwent radical excision in a tertiary center between 2011-2014 (males=87, females=48, age range=22-89 years, mean=64,67 years, SD=13.40). Radiological, histopathological, molecular staging, treatment stratification by the multidisciplinary team (MDT), as well as prognostic outcome data were compared with various biomarkers including KRAS, BRAF, p16, b-catenin, MSI, MMR and MGMT., Results: The mean follow-up was 39.21 months (range=5-83 months, SD=21.34). Twenty-eight cases were Stage I (20.9%), n=30 Stage II (22.4%), n=45 Stage III (33.6%) and n=31 Stage IV (23.1%). Forty specimens were KRAS-mutant (mt) (37.4%) while n=67 (62.6%) wild type (wt). KRAS mt status was associated with female sex (n=20, p=0.021) and older age (69.62 vs. 62.27, p=0.005). Stage I Early Cancer Subgroup analysis showed that KRAS mt status is associated with distant recurrence of disease (n=4, p=0.045)., Conclusion: KRAS mt status may affect the prognosis of early rectal cancer, as this is linked with distant recurrence., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Peroral endoscopic myotomy (POEM) is an established treatment for primary achalasia. It has gained endorsement from the American Society for Gastrointestinal Endoscopy with increasing clinical acceptance since the first procedure, performed in Japan in 2008. The first successful POEM in the UK was performed in November 2013 at King's College Hospital and this article presents the first UK case series. Prospective data were collected at 3 and 12-24 months for consecutive patients undergoing POEM. Post-POEM gastro-oesophageal reflux health-related quality of life scale (GORD-HRQoL) score was recorded. Statistical comparisons were made using paired non-parametric testing. In an initial series of 33 consecutive prospectively followed patients (12 female; 49.5±13 years; median follow-up 9 (3-28) months; 58% having had previous intervention), a 91% success rate has been achieved at 3 months. To date, 16 patients have reached the 12-month time point, with 13 (81%) sustaining response. This case series compares well with international cohorts and demonstrates excellent long-term safety and favourable efficacy., (© Royal College of Physicians 2017. All rights reserved.)

Background/aim: Transanal endoscopic microsurgery (TEMS) is emerging as an alternative treatment for rectal cancer Stage I. There remains a risk of local recurrence. The Aim of the study was to study the effect of biomarkers in local recurrence for Stage I rectal cancer following TEMS plus or minus radiotherapy., Materials and Methods: This is a case control study where we compared 10 early rectal cancers that had recurred, against 19 cases with no recurrence, total 29 patients (age=28.25-86.87, mean age=67.92 years, SD=14.91, Male, N=18, Female, N=11). All patients underwent TEMS for radiological Stage I rectal cancer (yT1N0M0 or yT2N0M0) established with combination of magnetic resonance imaging (MRI) and endorectal ultrasound. We prospectively collected all data on tumour histology, morphological features, as well as follow-up parameters. Molecular analysis was performed to identify their status on BRAF, KRAS, p16 O 6 -methylguanine-DNA methyltransferase (MGMT) and β-catenin., Results: Out of 29 specimens analyzed, 19 were KRAS wild type (65.9%) and 10 mutant (34.5%). Recurrence of the tumour was noted in 10 cases (34.5%) from which 60% were pT1 (N=6) and 40% pT2 (N=4). There was a statistically significant association between KRAS mutant status and local recurrence (N=6, p=0.037). P16 expression greater than 5% (mean=10.8%, min=0, max=95) is linked with earlier recurrence within 11.70 months (N=7, p=0.004). Membranous β-catenin expression (N=12, 48%) was also related with KRAS mutant status (p=0.006) but not with survival (p>0.05). BRAF gene was found to be wild type in all cases tested (N=23)., Conclusion: KRAS/p16/β-catenin could be used as a combined biomarker for prediction of local recurrence and stratification of the risk for further surgery., (Copyright© 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)