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Endoscopic mucosal resection (EMR) is standard therapy for nonpedunculated colorectal polyps ≥20 mm. It has been suggested recently that polyp resection without current (cold resection) may be superior to the standard technique using cutting/coagulation current (hot resection) by reducing adverse events (AEs), but evidence from a randomized trial is missing. In this randomized controlled multicentric trial involving 19 centers, nonpedunculated colorectal polyps ≥20 mm were randomly assigned to cold or hot EMR. The primary outcome was major AE (eg, perforation or postendoscopic bleeding). Among secondary outcomes, major AE subcategories, postpolypectomy syndrome, and residual adenoma were most relevant. Between 2021 and 2023, there were 396 polyps in 363 patients (48.2% were female) enrolled for the intention-to-treat analysis. Major AEs occurred in 1.0% of the cold group and in 7.9% of the hot group (P =.001; odds ratio [OR], 0.12; 95% CI, 0.03–0.54). Rates for perforation and postendoscopic bleeding were significantly lower in the cold group, with 0% vs 3.9% (P =.007) and 1.0% vs 4.4% (P =.040). Postpolypectomy syndrome occurred with similar frequency (3.1% vs 4.4%; P =.490). After cold resection, residual adenoma was found more frequently, with 23.7% vs 13.8% (P =.020; OR, 1.94; 95% CI, 1.12–3.38). In multivariable analysis, lesion diameter of ≥4 cm was an independent predictor both for major AEs (OR, 3.37) and residual adenoma (OR, 2.47) and high-grade dysplasia/cancer for residual adenoma (OR, 2.92). Cold resection of large, nonpedunculated colorectal polyps appears to be considerably safer than hot EMR; however, at the cost of a higher residual adenoma rate. Further studies have to confirm to what extent polyp size and histology can determine an individualized approach. German Clinical Trials Registry (Deutsches Register Klinischer Studien), Number DRKS00025170. [Display omitted] Cold resection of large nonpedunculated colorectal polyps appears to be safer than the hot technique with almost complete elimination of major AE, however, at the cost of a higher rate of residual neoplasia. [ABSTRACT FROM AUTHOR]

Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Endoscopic eradication therapy (EET) can be effective in eradicating BE and related neoplasia and has greater risk of harms and resource use than surveillance endoscopy. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for the use of EET in BE and related neoplasia. The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients, conducted an evidence review, and used the Evidence-to-Decision Framework to develop recommendations regarding the use of EET in patients with BE under the following scenarios: presence of (1) high-grade dysplasia, (2) low-grade dysplasia, (3) no dysplasia, and (4) choice of stepwise endoscopic mucosal resection (EMR) or focal EMR plus ablation, and (5) endoscopic submucosal dissection vs EMR. Clinical recommendations were based on the balance between desirable and undesirable effects, patient values, costs, and health equity considerations. The panel agreed on 5 recommendations for the use of EET in BE and related neoplasia. Based on the available evidence, the panel made a strong recommendation in favor of EET in patients with BE high-grade dysplasia and conditional recommendation against EET in BE without dysplasia. The panel made a conditional recommendation in favor of EET in BE low-grade dysplasia; patients with BE low-grade dysplasia who place a higher value on the potential harms and lower value on the benefits (which are uncertain) regarding reduction of esophageal cancer mortality could reasonably select surveillance endoscopy. In patients with visible lesions, a conditional recommendation was made in favor of focal EMR plus ablation over stepwise EMR. In patients with visible neoplastic lesions undergoing resection, the use of either endoscopic mucosal resection or endoscopic submucosal dissection was suggested based on lesion characteristics. This document provides a comprehensive outline of the indications for EET in the management of BE and related neoplasia. Guidance is also provided regarding the considerations surrounding implementation of EET. Providers should engage in shared decision making based on patient preferences. Limitations and gaps in the evidence are highlighted to guide future research opportunities. [ABSTRACT FROM AUTHOR]

The novel AGREE classification for adverse events (AEs) in gastrointestinal (GI) endoscopy has not yet been validated in a real-world setting. Our study aims to evaluate the correlation between the grades of AEs in the ASGE and AGREE classifications and to assess the interobserver agreement of the two classification systems. The correlation and association between the AE grades of the ASGE and AGREE classifications were analyzed using the Spearman rank correlation test and the chi-squared analysis, respectively. A weighted Cohen's kappa coefficient analysis was performed to determine the interobserver agreement of both classification systems. We prospectively collected the AEs that occurred in our endoscopy unit over the past five years. A total of 226 AEs (226/84,863, 0.3%) occurred. There was a correlation between the ASGE and AGREE classifications (ρ = 0.61) and a moderately significant association (p < 0.01, Cramer's V = 0.7). The interobserver agreement for the ASGE classification was fair (kappa 0.60, 95% confidence interval [CI]: 0.54, 0.67), whereas it was good for the AGREE classification (kappa 0.80, 95% CI: 0.62, 0.87). The AGREE classification was validated for the first time in a real-world setting and showed a positive correlation and higher interobserver agreement than the ASGE classification. [ABSTRACT FROM AUTHOR]

Underwater endoscopic mucosal resection (UEMR) is an emerging technique for endoscopic resection of superficial non-ampullary duodenal epithelial tumors (SNADETs). However, compared to conventional EMR, its efficacy and safety has not been widely explored. We conducted a comprehensive search using the Pubmed, Embase, and Cochrane Library databases to identify studies comparing the efficacy and safety of UEMR versus EMR for SNADETs. The main outcomes examined included en bloc resection rate, R0 resection rate, recurrence rate, procedure time, and adverse events. A total of 5 studies comprising 635 patients were included. All the literature included duodenal lesions smaller than 20 mm. The pooled analysis showed that UEMR could achieve a higher en bloc resection rate (OR 1.78, 95%CI: 1.17 to 2.71, P = 0.007) and shorter procedure time (MD -4.08, 95%CI: -6.44 to -1.73, P = 0.0007) than EMR. However, the pooled results did not support a superiority of UEMR over EMR for R0 resection rate (OR 1.27; 95% CI: 0.90 to 1.81, P = 0.18) or recurrence rate (OR 0.49; 95% CI: 0.15 to 1.67, P = 0.26). The occurrence of adverse events, including postoperative bleeding, intraoperative perforation, and delayed perforation, was very low in included studies. Compared to EMR, UEMR is an effective and safe technique for SNADETs ≤20 mm. [ABSTRACT FROM AUTHOR]

After resecting colonic polyps, retrieval through the scope channel may lead to polyp fragmentation, making pathologic evaluation challenging. An easy and reliable method for complete polyp retrieval is needed. We developed the water-slider method (WSM), in which the resected polyp is surrounded by water from an auxiliary water channel during suctioning. We prospectively randomized patients who underwent endoscopic resection for colonic polyps in our institute into WSM and non-WSM groups, and evaluated the polyp fragmentation rate. Analysis of the data regarding small polyps (≤10 mm in size) revealed that the WSM group had a significantly lower polyp fragmentation rate (8.2%) than the non-WSM group (23.8%, p < 0.001). Polyp retrieval time did not differ significantly between groups. The rate of a clear-cut end on neoplastic polyps was significantly higher in the WSM group (63.8%) than in the non-WSM group (50.0%; p = 0.029). The WSM achieved a significantly lower polyp fragmentation rate, allowing for more accurate histologic evaluation than the conventional method. The WSM did not influence the polyp retrieval time. [ABSTRACT FROM AUTHOR]

With respect to rectal neuroendocrine tumor (NET) resection, it remains unclear which of the following methods is the most effective: conventional endoscopic mucosal resection (cEMR), EMR using a fitted cap (EMR-C), EMR with a ligation band device (EMR-L), or endoscopic submucosal dissection (ESD). Thus, in this study, we aim to retrospectively evaluate the most effective endoscopic resection for rectal NETs < 10 mm. In total, 61 consecutive patients with primary rectal NETs < 10 mm in diameter were included in this study; they were then divided into three groups: those with cEMR; those with modified EMR (mEMR) involving EMR-C and EMR-L; and those with ESD. The primary endpoint was to evaluate the difference in the complete en bloc resection rate. The secondary endpoint was to investigate differences in procedure time and complications. Among the three groups, a significant difference was found in procedure time (cEMR vs ESD, P <.01; mEMR vs ESD, P <.01), en bloc resection rate (cEMR vs mEMR, P =.015), tumor size (mEMR vs ESD, P <.01), percentage of tumor diameter ≥ 5 mm (mEMR vs ESD, P <.01), and complete en bloc resection rate (cEMR vs mEMR, P =.014). Meanwhile, no significant difference was noted in terms of complication rate among the three groups. The mEMR was the most suitable resection method for rectal NETs < 10 mm with respect to the risks and benefits from procedure-related factors, such as complete en bloc resection rate, procedure time, and complication rate. [ABSTRACT FROM AUTHOR]

Thermal treatment of the defect margin after endoscopic mucosal resection (EMR) of large nonpedunculated colorectal lesions reduces the recurrence rate. Both snare tip soft coagulation (STSC) and argon plasma coagulation (APC) have been used for thermal margin treatment, but there are few data directly comparing STSC with APC for this indication. We performed a randomized 3-arm trial in 9 US centers comparing STSC with APC with no margin treatment (control) of defects after EMR of colorectal nonpedunculated lesions ≥15 mm. The primary end point was the presence of residual lesion at first follow-up. There were 384 patients and 414 lesions randomized, and 308 patients (80.2%) with 328 lesions completed ≥1 follow-up. The proportion of lesions with residual polyp at first follow-up was 4.6% with STSC, 9.3% with APC, and 21.4% with control subjects (no margin treatment). The odds of residual polyp at first follow-up were lower for STSC and APC when compared with control subjects (P =.001 and P =.01, respectively). The difference in odds was not significant between STSC and APC. STSC took less time to apply than APC (median, 3.35 vs 4.08 minutes; P =.019). Adverse event rates were low, with no difference between arms. In a randomized trial STSC and APC were each superior to no thermal margin treatment after EMR. STSC was faster to apply than APC. Because STSC also results in lower cost and plastic waste than APC (APC requires an additional device), our study supports STSC as the preferred thermal margin treatment after colorectal EMR. (Clinicaltrials.gov , Number NCT03654209.) [Display omitted] [ABSTRACT FROM AUTHOR]

Fibroepithelial polyps (FEP) of the lower urinary tract are relatively common in adults but rare in children, with fewer than 250 cases reported in the literature to date. The aim of this study was to address the experience of FEP management in children. A retrospective multicenter review was undertaken in children with defined FEP of the lower urinary tract managed between 2008 and 2018. The data at 18 pediatric surgery centers were collected. Their demographic, radiological, surgical, and pathological information were reviewed. A total of 33 children (26 boys; 7 girls) were treated for FEP of the lower urinary tract at 13 centers. The most common presentation was urinary outflow as hematuria (41%), acute urinary retention (25%), dysuria (19%), or urinary infections (28%). A prenatal diagnosis was made for three patients with hydronephrosis. Almost all of the children (94%) underwent ultrasound imaging of the urinary tract as the first diagnostic examination, 23 (70%) of them also either had an MRI (15%), cystourethrography (25%), computerized tomography (6%), or cystoscopy (45%). Two of these children (6%) had a biopsy prior to the surgery. The median preoperative delay was 7.52 (range: 1–48) months. Most of the patients were treated endoscopically, although four (12.1%) had open surgery and two (6.1%) had an additional incision for specimen extraction. The median hospital stay was 1.5 (range: 1–10) days. There were no recurrences and no complications after a median follow-up of 13 (range: 1–34) months. The main limitation of our study is the retrospective design, although it is the largest one for this pathology. This series supports sonography as the most suitable diagnosis tool before endoscopy to confirm the diagnosis and to perform the resection for most FEP in children. This report confirms the recognized benign nature in the absence of recurrences. Level V. Unlabelled Image [ABSTRACT FROM AUTHOR]

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Endoscopic mucosal resection (EMR) is a technique developed for the removal of sessile or flat neoplastic lesions confined to the superficial layers (mucosa and submucosa) of the gastrointestinal tract. Bleeding and perforation are well-known complications of EMR. Here we report the first case of paralytic ileus after EMR of a caecal polyp. A 66-year-old man was scheduled for elective EMR of a 3.5-cm caecal polyp under general anaesthesia after a screening colonoscopy. The procedure was performed by an expert endoscopist, and air was insufflated during the procedure because of the unavailability of CO 2. The polyp was successfully removed; the procedure duration was 81 min. After the procedure, the patient complained of abdominal pain and dyspnoea. He developed tachypnoea and tachycardia as well as oxygen desaturation with SpO 2 84%. He was administered oxygen therapy via a non-rebreather mask, following which his oxygenation improved. His abdominal X-ray findings were consistent with ileus. Therefore, a nasogastric tube was placed, and the patient was admitted to our hospital. He was managed conservatively and underwent serial abdominal X-rays that showed improvement of the ileus. On the fourth day of admission, he was started on an oral diet; on the sixth day of admission, he was discharged with resolving ileus. Computed tomography enterography performed 1 week after discharge showed complete resolution of the ileus. Factors that may have contributed to the occurrence of ileus in our patient include the use of air during the procedure, location of the polyp (caecal), duration of the procedure, effect of electrocautery, use of general anaesthesia and possibility of aspiration pneumonitis. This case report will make endoscopists aware of the abovementioned factors while performing EMR as this procedure can lead to the complication of paralytic ileus with significant patient morbidity. Conservative treatment should be attempted first before any other intervention. [ABSTRACT FROM AUTHOR]

Endoscopic resections (ERs) are performed for early (T1) cancers mostly of the esophagus, stomach and colorectum, offering a minimally invasive and tissue-preserving alternative to traditional surgical resection. Proper preparation and handling of these specimens is key to allow accurate histological assessment of parameters which will dictate the curative, or non-curative, nature of the procedure. Many histological features have been identified which correlate with risk of recurrence and/or nodal metastases, thereby dictating the need for further management. These include histological subtype of the lesion, grade, depth of invasion, margin status, tumor size, lymphovascular invasion and tumor budding [at least in the colon]. This review article will discuss the ideal specimen preparation and discuss each of these histological parameters in turn, as they pertain to the esophagus, stomach and colorectum, highlighting potential caveats and pitfalls to be aware of when reporting these specimens. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: The purpose of this study was to explore nationwide trends in treatment and outcomes of T1N0 esophageal cancer. Background: Endoscopic treatment has become an accepted option for early-stage esophageal cancer, but nationwide utilization rates and outcomes are unknown. Methods: T1N0 esophageal cancers were identified in the National Cancer Database from 2004 to 2014. We assessed trends in treatment; compared endoscopic therapy, esophagectomy, chemoradiation, and no treatment; and performed a subgroup analysis of T1a and T1b patients from 2010 to 2014 (AJCC 7). Results: A total of 12,383 patients with clinical T1N0 esophageal cancer were analyzed. Over a decade, use of endoscopic therapy increased from 12.7% to 33.6%, whereas chemoradiation and esophagectomy decreased, P < 0.01. The rise in endoscopic treatment of T1a disease from 42.7% to 50.6% was accompanied by a decrease in esophagectomies from 21.7% to 12.8% (P < 0.01). For T1b disease, the rise in endoscopic treatment from 16.9% to 25.1% (P = 0.03) was accompanied by decreases in no treatment and chemoradiation, whereas the rate of esophagectomies remained approximately 50%. Unadjusted median survival was longer for patients undergoing resection: esophagectomy, 98.6 months; endoscopic therapy, 77.7 months; chemoradiation, 17.3 months; no treatment, 8.2 months; P < 0.01. Risk-adjusted Cox modeling showed esophagectomy was associated with improved survival [hazard ratio (HR): 0.85], and chemoradiation (HR: 1.79) and no treatment (HR: 3.57) with decreased survival, compared to endoscopic therapy (P < 0.01). Conclusions: Use of endoscopic therapy for T1 esophageal cancer has increased significantly: for T1a, as an alternative to esophagectomy; and for T1b, as an alternative to no treatment or chemoradiation. Despite upfront risks, long-term survival is highest for patients who can undergo esophagectomy. [ABSTRACT FROM AUTHOR]

• Important to rule out other tumors, such as GIST and malignancy. • Pre-operative imaging including EUS is critical in choosing the appropriate surgery. • Multiple modalities exist for excision of lipoma in setting of bariatric surgery. Gastric submucosal lipoma is an uncommon finding in the stomach. A benign fatty tumor that is asymptomatic majority of the time. However, symptomatic and bigger tumors can be difficult to manage surgically and require detailed surgical planning prior to proceeding with bariatric surgery. 58 year old female who presented for weight loss consultation. Underwent an esophagogastroduodenoscopy (EGD) that demonstrated a 3 cm mass near the incisura. Endoscopic ultrasound (EUS) and biopsy demonstrated a submucosal lipoma. Due to the lipoma's location, resection was critical, as it would have led to obstructive symptoms following sleeve gastrectomy. The patient underwent a simultaneous laparoscopic vertical gastrectomy, gastric lipoma excision, EGD, and laparoscopic cholecystectomy Gastric lipomas are benign gastric submucosal tumors, representing less than 3% of all benign gastric neoplasms. Computer tomography and endoscopic ultrasound are important in establishing diagnosis. In current literature, excision with negative margins is standard of care, but small asymptomatic lesions can be followed without intervention. Gastric lipoma are a rare type of gastric submucosal tumors. Size is highly variable. Observation is a reasonable approach when small and asymptomatic, but multiple surgical modalities can be utilized to remove the tumor. Careful utilization of pre-operative imaging including EUS is critical in choosing the appropriate surgery if simultaneous bariatric management is undertaken [ABSTRACT FROM AUTHOR]

The last decade of the 20th century and the first 2 decades of the 21st century dramatically changes in the flexible endoscopy world. New endoscopic procedures were introduced into clinical practice, stimulating development of new endoscopic devices and techniques and significantly expanding the armamentarium of surgeons and gastroenterologists specializing in therapeutic flexible endoscopy. Through-the-scope endoscopic clips have become an important tissue-approximating instrument, often in combination with PolyLoops. Over-the-scope endoscopic clips demonstrate effectiveness in the closure of gastrointestinal (GI) tract fistulas and small iatrogenic perforations. The Overstitch endoscopic suturing system is a versatile tissue-approximating device, which produces effective, reliable, surgical-quality closure of GI tract defects. This device, and other developing endoscopic suturing systems may, eventually become the universal tool for endoscopic correction of fistulas, closure of submucosal tunnels, iatrogenic perforations, mucosal and full-thickness defects postendoscopic resection of GI tract lesions. [ABSTRACT FROM AUTHOR]

Abstract We describe a patient with a giant Brunner's gland hamartoma in the duodenum who was safely treated by endoscopic mucosal resection (EMR). A 64-year-old woman visited our hospital for a workup of severe anaemia (haemoglobin level: 5 g/dL). Oesophagogastroduodenoscopy revealed a large pedunculated and elongated polypoid lesion measuring approximately 70 mm in longitudinal diameter, located at the anterior wall of the duodenal bulb. We diagnosed her as having gastrointestinal bleeding originating from this lesion. Although we considered surgical intervention initially, en bloc EMR, a less invasive treatment, was finally accomplished safely by placing endoclips before resection. The histological examination of the specimen revealed a hamartomatous lesion consisting of Brunner's glands with cystic change and adipose tissue separated by the septa of smooth muscle fibers. Ultimately, we diagnosed her as having Brunner's gland hamartoma. Notably, there were tiny foci of heterotopic pancreatic tissue containing islets and duct epithelium. Although this type of lesion is benign, a larger one may cause clinical symptoms such as obstruction or bleeding, and thus, local resection is preferable. [ABSTRACT FROM AUTHOR]

Endoscopic resection has become an invaluable diagnostic and therapeutic tool in the evaluation and management of early Barrett esophagus (BE) neoplasia. While endoscopic mucosal resection (EMR) is the current standard of care for the resection of nodular early BE neoplasia, endoscopic submucosal dissection (ESD) has been recently introduced as part of the armamentarium in the treatment of these lesions. The potential advantages of ESD compared to EMR include higher en-bloc and R0 resection rates, decreased local recurrence, and the procurement of large en-bloc specimens that may facilitate pathologic staging. On the other hand, EMR is less time-consuming and has been traditionally associated with a lower incidence of serious adverse events when compared to ESD. At present, the choice of the endoscopic resection technique hinges on operator’s preferences, patient and lesions characteristics and available local expertise. Future high-quality studies comparing clinical outcomes between ESD and EMR are needed to better define their roles in the management of early BE neoplasia. [ABSTRACT FROM AUTHOR]

Background and aims Development of high-performance submucosal injection materials (SIMs) contribute to the advancement of endoscopic therapy for early-stage gastrointestinal neoplasms. This study aimed to develop a new ex vivo model that mimics the human gastrointestinal tract to evaluate the performance (the height and duration of the submucosal elevation) of various SIMs in detail. Methods A new ex vivo model that applies a constant tension to the tested specimen (the porcine gastric specimen) was developed. SIMs were injected into the submucosa at the center or edge of the tested specimen, and submucosal elevation heights (SEHs) were measured over time. Results The average value and standard deviation of SEH determined using the conventional model (the tested specimen was fixed with pins) were higher than those obtained using the new model, which showed that the new model could precisely measure the SEH of a given SIM. In addition, the performance (SEH) of SIMs decreased with increasing tension applied to the specimen, suggesting that the performance of SIMs deteriorates with the over-expansion of the gastrointestinal tract. The submucosal elevation formed at the specimen edge disappeared faster than that formed at the specimen's center. Conclusions The proposed new ex vivo model allows accurate SEH measurement under uniform conditions and detailed comparison of the performances of various types of SIMs and can contribute to the development of high-performance materials. [ABSTRACT FROM AUTHOR]

Esophageal neuroendocrine tumors are rare and often found incidentally on endoscopy. We present a unique case of an esophageal neuroendocrine tumor found in the setting of dysplasia associated with Barrett's esophagus. The tumor was removed endoscopically. This case highlights the incidence, prognosis, and management of esophageal neuroendocrine tumors. [ABSTRACT FROM AUTHOR]

The development of and adherence to quality indicators in gastroenterology, as in all of medicine, is increasing in importance to ensure that patients receive consistent high-quality care. In addition, government-based and private insurers will be expecting documentation of the parameters by which we measure quality, which will likely affect reimbursements. Barrett’s esophagus remains a particularly important disease entity for which we should maintain up-to-date guidelines, given its commonality, potentially lethal outcomes, and controversies regarding screening and surveillance. To achieve this goal, a relatively large group of international experts was assembled and, using the modified Delphi method, evaluated the validity of multiple candidate quality indicators for the diagnosis and management of Barrett’s esophagus. Several candidate quality indicators achieved >80% agreement. These statements are intended to serve as a consensus on candidate quality indicators for those who treat patients with Barrett’s esophagus. [ABSTRACT FROM AUTHOR]

Colonoscopy is the most frequently performed endoscopic procedure in the United States. It is the mainstay of diagnostic and therapeutic options for the practicing gastroenterologist. It plays a fundamental role in colorectal cancer (CRC) prevention, with a dominant position among the screening options for CRC and precancerous lesions. Over the past decade, there have been significant advances in the field of CRC and colonoscopy, including a better understanding of the importance of right-sided lesions, the sessile serrated pathway, and recognition of the significance of operator dependence in colonoscopy. This has been paralleled by an array of technological and technical advances that has transformed the field of colonoscopy and improved patient care. This article addresses the diverse and expanding field of advanced colonoscopy techniques and technologies. It is intended to be a primer on recent and effective developments in advanced technologies for screening or imaging, mucosal resection techniques, and endoscopic management of CRC. [ABSTRACT FROM AUTHOR]

Serrated polyps are important colorectal cancer precursors and are most commonly located in the proximal colon, where post-polypectomy bleeding rates are higher. There is limited clinical trial evidence to guide best practices for resection of large serrated polyps (LSPs). In a multicenter trial, patients with large (≥20 mm) non-pedunculated polyps undergoing endoscopic mucosal resection (EMR) were randomized to clipping of the resection base or no clipping. This analysis is stratified by histologic subtype of study polyp(s), categorized as serrated [sessile serrated lesions (SSLs) or hyperplastic polyps (HPs)] or adenomatous, comparing clip vs control groups. The primary outcome was severe post-procedure bleeding within 30 days of colonoscopy. A total of 179 participants with 199 LSPs (191 SSLs and 8 HPs) and 730 participants with 771 adenomatous polyps were included in the study. Overall, 5 patients with LSPs (2.8%) experienced post-procedure bleeding compared with 42 (5.8%) of those with adenomas. There was no difference in post-procedure bleeding rates between patients in the clip vs control group among those with LSPs (2.3% vs 3.3%, respectively, difference 1.0%; P = NS). However, among those with adenomatous polyps, clipping was associated with a lower risk of post-procedure bleeding (3.9% vs 7.6%, difference 3.7%; P =.03) and overall serious adverse events (5.5% vs 10.6%, difference 5.1%; P =.01). The post-procedure bleeding risk for LSPs removed via EMR is low, and there is no discernable benefit of prophylactic clipping of the resection base in this group. This study indicates that the benefit of endoscopic clipping following EMR may be specific for >2 cm adenomatous polyps located in the proximal colon. ClinicalTrials.gov , Number: NCT01936948. [ABSTRACT FROM AUTHOR]

Recent technological advances in the field of gastroenterology have revolutionized the way endoscopy is used to manage both premalignant and malignant lesions throughout the gastrointestinal tract. For many decades, endoscopic treatment was limited to superficial mucosal lesions. However, with the advent of endoscopic mucosal resection in 1992, the armamentarium of the endoscopist started to expand. More recently, endoscopic submucosal dissection and endoscopic muscularis dissection have emerged as therapeutic methods for overcoming the limitations of endoscopic mucosal resection. For deep submucosal lesions that may be challenging or technically impossible to remove with these latter methods, is there a role for taking dissection even 1 step (ie, layer) further? To help answer this question, we address the preparation and identification of lesions that may be suitable for endoscopic full-thickness resection. [ABSTRACT FROM AUTHOR]

Purpose: Several endoscopic resection therapies have been applied for the treatment of rectal carcinoid tumors. However, there is currently no consensus regarding the optimal strategy. We performed a meta-analysis to compare the efficacy and safety of endoscopic mucosal resection (EMR) or modified EMR (m-EMR) versus endoscopic submucosal dissection (ESD) for the treatment of rectal carcinoid tumors. Materials and Methods: PubMed, Web of Science, Medline, Embase and CNKI were searched up to the end of January 2014 in order to identify all studies on the effects of EMR (or m-EMR) and ESD on rectal carcinoid tumors. Results: A total of fourteen studies involving 782 patients were included. The pooled data suggested a significantly higher rate of pathological complete resection among patients treated with ESD or m-EMR than those treated with EMR [odds ratio (OR)=0.42, 95% confidence interval (CI): 0.25-0.71; OR=0.10, 95% CI: 0.03-0.33, respectively], while there was no significant difference between the m-EMR group and ESD group (OR=1.19, 95% CI: 0.49-2.86); The procedure time of ESD was longer than EMR or m-EMR groups [mean differences (MD)=-11.29, 95% CI: -14.19 - -8.38, MD=-10.90, 95% CI: -18.69 - -3.11, respectively], but it was insignificance between the EMR and m-EMR groups. No significant differences were detected among the treatment groups with regard to complications or recurrence. Conclusion: The results of this meta-analysis suggest that treatment of rectal carcinoid tumors with ESD or m-EMR is superior to EMR, and the efficacy of m-EMR is equivalence to ESD treatment. However, more well-designed studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

We present a case of Helicobacter pylori–negative rectal mucosa-associated lymphoid tissue (MALT) lymphoma found on colonoscopy done for colorectal cancer screening. The lesion was successfully removed with endoscopic mucosal resection alone, without concomitant antibacterial treatment. On surveillance exams, the patient has had a 5-year disease-free survival. While prior reports highlight use of multiple modalities, this is the only case we are aware of in which treatment with endoscopic mucosal resection alone without antimicrobial therapy led to disease-free survival at 5 years. [ABSTRACT FROM AUTHOR]

Background Outcomes on colon endoscopic mucosal resection in the very elderly patient population are unknown. Aims Aims of this study were to evaluate the outcomes and safety of colon endoscopic mucosal resection in this target population. Methods Observational, retrospective study of patients ≥80 years of age that underwent colon endoscopic mucosal resection ≥2 cm. Demographics, American Society of Anesthesiologists classification, procedural data, and surgical treatment data were collected. Results One-hundred-and-thirty-one colon endoscopic mucosal resections were performed on 99 patients ≥80 years of age with a mean age of 84. The majority of American Society of Anesthesiologists class was II. Mean lesion size was 3.3 cm (range, 2-12.5 cm), more procedures were performed in the right colon and adenoma/tubulovillous adenoma was the most common pathology. En bloc resection was performed on 26.7% of polyps (N = 35). Eight procedure-related adverse events (8/131, 6.1%) occurred. No anaesthesia related adverse events or deaths occurred. Six patients required a colonic operation, and overall, 94% of the patient cohort evaded a colon operation. Conclusions Colon endoscopic mucosal resection in very elderly patients can be performed at experienced endoscopy centres with a low rate of complications and offers these patients a non-surgical option of management of colorectal lesions. [ABSTRACT FROM AUTHOR]

Nonpedunculated colorectal polyps are normally endoscopically removed to prevent neoplastic progression. Delayed bleeding is the most common major adverse event. Clipping the resection defect has been suggested to reduce delayed bleedings. Our aim was to determine if prophylactic clipping reduces delayed bleedings and to analyze the contribution of polyp characteristics, extent of defect closure, and antithrombotic use. An individual patient data meta-analysis was performed. Studies on prophylactic clipping in nonpedunculated colorectal polyps were selected from PubMed, Embase, Web of Science, and Cochrane database (last selection, April 2020). Authors were invited to share original study data. The primary outcome was delayed bleeding ≤30 days. Multivariable mixed models were used to determine the efficacy of prophylactic clipping in various subgroups adjusted for confounders. Data of 5380 patients with 8948 resected polyps were included from 3 randomized controlled trials, 2 prospective, and 8 retrospective studies. Prophylactic clipping reduced delayed bleeding in proximal polyps ≥20 mm (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.44–0.88; number needed to treat = 32), especially with antithrombotics (OR, 0.59; 95% CI, 0.35–0.99; number needed to treat = 23; subgroup of anticoagulants/double platelet inhibitors: n = 226; OR, 0.40; 95% CI, 0.16–1.01; number needed to treat = 12). Prophylactic clipping did not benefit distal polyps ≥20 mm with antithrombotics (OR, 1.41; 95% CI, 0.79–2.52). Prophylactic clipping reduces delayed bleeding after resection of nonpedunculated, proximal colorectal polyps ≥20 mm, especially in patients using antithrombotics. No benefit was found for distal polyps. Based on this study, patients can be identified who may benefit from prophylactic clipping. (PROSPERO registration number CRD42020104317.) [ABSTRACT FROM AUTHOR]

Endoscopic resection is an important component of the endoscopic treatment of Barrett's esophagus (BE) with dysplasia and intramucosal adenocarcinoma. Endoscopic resection can be performed by cap-assisted endoscopic mucosal resection (cEMR) or endoscopic submucosal dissection (ESD). We compared the histologic outcomes of ESD vs cEMR, followed by ablation. We queried a prospectively maintained database of all patients undergoing cEMR and ESD followed by ablation at our institution from January 2006 to March 2020 and abstracted relevant demographic and clinical data. Our primary outcomes included the rate of complete remission of dysplasia (CRD): absence of dysplasia on surveillance histology, and complete remission of intestinal metaplasia (CRIM): absence of intestinal metaplasia. Our secondary outcome included complication rates. We included 537 patients in the study: 456 underwent cEMR and 81 underwent ESD. The cumulative probabilities of CRD at 2 years were 75.8% and 85.6% in the cEMR and ESD groups, respectively (P <.01). Independent predictors of CRD were as follows: ESD (hazard ratio [HR], 2.38; P <.01) and shorter BE segment length (HR, 1.11; P <.01). The cumulative probabilities of CRIM at 2 years were 59.3% and 50.6% in the cEMR and ESD groups, respectively (P >.05). The only independent predictor of CRIM was a shorter BE segment (HR, 1.16; P <.01). BE patients with dysplasia or intramucosal adenocarcinoma undergoing ESD reach CRD at higher rates than those treated with cEMR, although CRIM rates at 2 years and complication rates were similar between the 2 groups. [Display omitted] [ABSTRACT FROM AUTHOR]

Copyright of Revista Colombiana de Gastroenterología is the property of Asociacion Colombiana de Gastroenterologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The management of Barrett's esophagus (BE) and dysplastic and neoplastic changes associated with it has changed with the recent advent of techniques such as endoscopic mucosal resection and radiofrequency ablation. These two techniques have been added to the repertoire for managing this complication of gastroesophageal refl ux disease because of their high levels of safety combined with the rarity of complications resulting from them. We report a case of Barrett's esophagus and associated dysplasia which was managed fi rst with a sequence of mucosal resection of large lesions followed by radiofrequency ablation. Complete eradication of dysplasia and intestinal metaplasia was achieved. [ABSTRACT FROM AUTHOR]

Adenocarcinoma developed in Barrett's oesophagus is a tumour with an increasing incidence and still a poor prognosis. The only marker that can be used for surveillance remains dysplasia (intraepithelial neoplasia), especially when it is high-grade, that precedes intramucosal carcinoma. New forms of dysplasia have been described in complement to the classical intestinal type (foveolar dysplasia, basal crypt dysplasia). High-grade dysplasia and intramucosal carcinoma are diagnosed on biopsies taken during endoscopy. Standard endoscopy is now challenged by various techniques that represent recent major technical improvements (chromoendoscopy, virtual chromoendoscopy, optical frequency domain imaging, confocal laser endomicroscopy). In numerous cases, high-grade dysplasia and intramucosal carcinoma can be treated by procedures, allowing a precise histopathological diagnosis on the resected specimen ( mucosal resection, submucosal endoscopic. [ABSTRACT FROM AUTHOR]

Abstract: A best evidence topic was written according to a structured protocol. The question addressed was whether endoscopic mucosal resection (EMR) for early oesophageal cancer gives equivalent oncological outcomes as compared to oesophagectomy. A total of 340 papers were found using the reported searches of which 7 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Oesophagectomy with lymph node dissection for early oesophageal cancer is the standard to which every other treatment modality is compared to. However, the associated mortality and morbidity rates highlight the need for the development of effective, less invasive procedures. The evidence from the present review supports the use of EMR in this context as a first line treatment in T1a (mucosal) oesophageal cancer. The trade-off is a higher recurrence rate which can be dealt with successfully using a tight follow-up schedule and retreatment. The higher rates of lymph node involvement in T1b (submucosal) cancers preclude the use of endoscopic treatment in this setting except for patients unfit for surgery. [Copyright &y& Elsevier]

Most colonic adenomas are ≤10 mm and are routinely treated by colonoscopic polypectomy with long-term health benefits. Nonpolypoid lesions ≥20 mm, whether sessile or flat and laterally spreading, are forms of advanced mucosal neoplasia that cannot be managed by conventional polypectomy and are often referred for surgery. However, the majority of these lesions when carefully assessed are found to be noninvasive and can be safely and effectively treated by advanced endoscopic techniques including endoscopic mucosal resection or endoscopic submucosal dissection with resultant cost, morbidity, and mortality benefits. Lesion assessment is a critical component. Enhanced imaging methods provide the opportunity for accurate pathological characterization, informing treatment decisions, without the need for previous histologic confirmation. Techniques of advanced endoscopic resection are still in evolution and further improvements, including hybrid techniques, bringing less technically challenging and shorter procedures with superior safety can be reasonably expected in the next decade. Safety is a fundamental consideration. Methods of early recognition of complications, risk stratification, and management pathways are being developed and refined. Standardization, validation, and adoption of these technological developments will improve endoscopic interpretation and therapy and in combination with an increased understanding of adenoma molecular biology, will result in a progressively more individualized lesion-specific endoscopic approach. The future of advanced endoscopic resection in the colon is promising, and the next few years should see the boundaries of endoscopic resection expand well beyond the limits of what we know today. [ABSTRACT FROM AUTHOR]

Copyright of Revista Colombiana de Gastroenterología is the property of Asociacion Colombiana de Gastroenterologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Summary: Introduction: Traditionally, management of early cancer (stages 0–IIA) has comprised esophagectomy, either alone or in combination with chemotherapy and/or radiotherapy. Recent efforts to improve outcomes and minimize side-effects have focussed on minimally invasive, endoscopic treatments that remove lesions while sparing healthy tissue. This review assesses their safety and efficacy/effectiveness relative to traditional, non-endoscopic treatments for early esophageal cancer. Methods: A systematic review of peer-reviewed studies was performed using Cochrane guidelines. Bibliographic databases searched to identify relevant English language studies published in the last 3 years included: PubMed (i.e., MEDLINE and additional sources), EMBASE, CINAHL, The Cochrane Library, the UK Centre for Reviews and Dissemination (NHS EED, DARE and HTA) databases, EconLit and Web of Science. Web sites of professional associations, relevant cancer organizations, clinical practice guidelines, and clinical trials were also searched. Two independent reviewers selected, critically appraised, and extracted information from studies. Results: The review included 75 studies spanning 3124 patients and 10 forms of treatment. Most studies were of short term duration and non-comparative. Adverse events reported across studies of endoscopic techniques were similar and less significant compared to those in the studies of non-endoscopic techniques. Complete response rates were slightly lower for photodynamic therapy (PDT) relative to the other endoscopic techniques, possibly due to differences in patient populations across studies. No studies compared overall or cause-specific survival in patients who received endoscopic treatments vs. those who received non-endoscopic treatments. Discussion: Based on findings from this review, there is no single “best practice” approach to the treatment of early esophageal cancer. [ABSTRACT FROM AUTHOR]

Endoscopic mucosal resection (EMR) is a technique used to locally excise for cure of mucosal lesions and early gastrointestinal cancers that carry minimal risk of nodal metastasis. This review will describe the indications, techniques, and complications of the EMR using a cap (EMR-C) method. [ABSTRACT FROM AUTHOR]

Mastering the techniques of endoscopic hemostasis and perforation closure are critical for any endoscopist venturing into the field of endoscopic mucosal resection and dissection. These techniques could be accomplished to some extent by watching educational videos on the subject and learning from experts by participating in the hands-on courses organized by the American Society of Gastrointestinal Endoscopy. In addition, spending time in centers of excellence and learning from the experts, setting up a room fully furnished with all the necessary endoscopic accessories, and training endoscopic assistants in these procedures are critical for a successful outcome. [ABSTRACT FROM AUTHOR]

Background & Aims: Diagnosis of Barrett''s neoplasia requires collection of large numbers of random biopsy samples; the process is time consuming and can miss early-stage cancers. We evaluated the role of acetic acid chromoendoscopy in identifying Barrett''s neoplasia. Methods: Data were collected from patients with Barrett''s esophagus examined at a tertiary referral center, between July 2005 and November 2008 using Fujinon gastroscopes and EPX 4400 processor (n = 190). All procedures were performed by a single experienced endoscopist. Patients were examined with white light gastroscopy and visible abnormalities were identified. Acetic acid (2.5%) dye spray was used to identify potentially neoplastic areas and biopsy samples were collected from these, followed by quadrantic biopsies at 2 cm intervals of the remaining Barrett''s mucosa. The chromoendoscopic diagnosis was compared with the ultimate histological diagnosis to evaluate the sensitivity of acetic acid chromoendoscopy. Results: Acetic acid chromoendoscopy had a sensitivity of 95.5% and specificity of 80% for the detection of neoplasia. There was a correlation between lesions predicted to be neoplasias by acetic acid and those diagnosed by histological analysis (r = 0.98). There was a significant improvement in the detection of neoplasia using acetic acid compared with white light endoscopy (P = .001). Conclusions: Analysis of this large series showed that acetic acid-assisted evaluation of Barrett''s esophagus detects neoplasia better than white light endoscopy, with sensitivity and specificity equal to that of histological analysis. [Copyright &y& Elsevier]

Endoscopic Mucosal Resection is a well established diagnostic and therapeutic technique in the management of esophageal neoplasia arising in the background of Barrett''s esophagus. It is a valuable adjunct to ablative techniques for the treatment of dysplasia Barrett''s esophagus. This article reviews the rationale, indications, methods and outcomes of endoscopic mucosal resection in Barrett''s esophagus. [Copyright &y& Elsevier]

Abstract: Background: Submucosal injection of normal saline (NS) is commonly used during endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) but is quickly absorbed. Sodium hyaluronate (SH) produces longer lasting mucosal elevation but is expensive. Aims: To evaluate the performance of novel solutions for submucosal injection in comparison with NS and SH. Methods: One ml of the following solutions was injected in the submucosa of fresh specimens of porcine stomachs: NaCl 0.9%, SH 0.4%, human albumin 25%, two artificial tears solutions, namely, hydroxypropyl methylcellulose (HPMC) 0.3%/dextran 70.1% and polyvinyl alcohol (PVA) 1.4%, hydroxyethyl starch (HES) 6% and polyethylene glycol (PEG) 50%. The time until the disappearance of the mucosal elevation was recorded in a blind manner. Results: The median duration of mucosal elevation was significantly longer with HPMC/dextran, PVA, HES, PEG and SH (29, 26, 38, 31.5, and 41.5min, respectively) compared with NS (12min) (p <0.05 for each comparison). There were no significant time differences between SH and HPMC/dextran, HES and PEG (p >0.05). Conclusions: Novel viscous or hypertonic solutions for submucosal injection, perform better than normal saline and equally well as sodium hyaluronate in porcine stomachs in vitro. [Copyright &y& Elsevier]

Digestive endoscopy has been evolving from primary diagnostic to extensive therapeutic modalities in the management of gastrointestinal diseases. The present endoscopic imaging includes (A) standard endoscopy alone and /or with adjunct technologies such as point enhancement, e.g. confocal endomicroscopy and field enhancement technologies such as chromoendoscopy, NBI and FICE and (B) endoscopic ultrasound. Other novel imaging technologies including virtual colonoscopy or CT/MR colonography, CT or MRI enterography and capsule endoscopy have also been developed. This article reviews the diagnostic and therapeutic role of digestive endoscopy and future directions of digestive endoscopy are discussed. Digestive endoscopy is also compared with emerging novel imaging techniques in gastrointestinal diseases such as capsule endoscopy and CT colonography. The fact that digestive endoscopy has become a multidisciplinary specialty combining advances in all fields (radiology, bioengineering, surgery and gastroenterology) is highlighted. [ABSTRACT FROM AUTHOR]

In the last decades, endoscopic treatment of early neoplastic lesions in the oesophagus and stomach has evolved as a valid and less invasive alternative to surgical resection. Endoscopic resection (ER) is the cornerstone of endoscopic therapy. Apart from the curative potential of ER, by removing neoplastic lesions, ER may also serve as a diagnostic tool. The relatively large tissue specimens obtained with ER enable accurate histological staging of a lesion, allowing for optimal decision making for further patient management. ER was pioneered in Japan, mainly for the resection of gastric lesions and squamous oesophageal neoplasia, and also Western countries have been increasingly implementing ER in the treatment of early gastro-oesophageal neoplasia, mostly associated with Barrett oesophagus. In this review we will give an overview of the different techniques that have been developed and modified for ER of early gastro-oesophageal neoplasia, and we will discuss the indications for ER in the oesophagus and stomach. [Copyright &y& Elsevier]

This chapter will review the endoscopic approaches to the management of Barrett''s oesophagus with high-grade dysplasia/early mucosal cancer. Factors to consider when evaluating patients for endoscopic management are detailed. Ablation and resection methods for eradication of Barrett''s oesophagus with high-grade dysplasia/early mucosal cancer are reviewed. Strategies for combining therapies to achieve safe and effective eradication are discussed. Recommendations for complete eradication of all Barrett''s mucosa and follow-up considerations are put forward. [Copyright &y& Elsevier]

Background: Early esophageal mucosal carcinoma (M1 and M2) can be treated by ablation, or by endoscopic resection such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection. Endoscopic resection enables pathologic examination of resected specimens. We hereby report our experiences with early esophageal cancer and its endoscopically observed types, chromoendoscopy with Lugol''s iodine and EMR results. Methods: Between May 2003 and July 2007, 9 patients with early esophageal carcinoma underwent EMR. The diagnosis was made by conventional endoscopy (waiting for the relaxed phase during esophageal peristalsis) followed by chro-moendoscopy using 3% Lugol''s iodine to stain suspected early lesions or in high-risks patients. Miniprobe endoscopic ultrasound examinations were performed in all cases except 1. EMRs were carried out with a cap-fitted endoscope (EMRC). Results: There were 6 male and 3 female patients, with a median age of 53 years (range, 44–83 years). Six of the 9 cases had a history of smoking, 5 had a history of drinking, and 4 had a history of betel nut chewing. The endoscopic pictures of the early cancers were type 0–IIa (1 case), type 0–IIb (2 cases), and type 0–IIc (6 cases). One patient had double 0–IIc lesions. Two 0–IIb cases were detected only by chromoendoscopy using Lugol''s iodine staining. The median size of the lesions was 0.85 cm (range, 0.7–2.0 cm). The final pathology reports of the endoscopically resected specimens were well-differentiated squamous cell carcinoma with free vertical and lateral margins, and no vascular or lymphatic invasion. The depths of tumor invasion were mucosal layer M1 in 7 cases, M2 in 1 case, and submucosal layer SM1 in the remaining case. There were no perforation or bleeding complications. The mean follow-up period was 13.1 months (range, 4–46 months). A M2 early esophageal cancer measuring 2 cm in diameter recurred 6 months after piecemeal EMRC. No additional adjuvant therapy was given to the SM1 case owing to her old age and bedridden condition. Conclusion: Early esophageal cancer can be diagnosed by meticulous examination of the esophageal mucosa with conventional endoscopy, facilitated by Lugol''s iodine staining, and can be treated by EMR, which is safe. Recurrence can occur after piecemeal EMR. [Copyright &y& Elsevier]