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BACKGROUND : The European Society of Gastrointestinal Endoscopy (ESGE) has developed a core curriculum for high quality optical diagnosis training for practice across Europe. The development of easy-to-measure competence standards for optical diagnosis can optimize clinical decision-making in endoscopy. This manuscript represents an official Position Statement of the ESGE aiming to define simple, safe, and easy-to-measure competence standards for endoscopists and artificial intelligence systems performing optical diagnosis of diminutive colorectal polyps (1 - 5 mm). METHODS : A panel of European experts in optical diagnosis participated in a modified Delphi process to reach consensus on Simple Optical Diagnosis Accuracy (SODA) competence standards for implementation of the optical diagnosis strategy for diminutive colorectal polyps. In order to assess the clinical benefits and harms of implementing optical diagnosis with different competence standards, a systematic literature search was performed. This was complemented with the results from a recently performed simulation study that provides guidance for setting alternative competence standards for optical diagnosis. Proposed competence standards were based on literature search and simulation study results. Competence standards were accepted if at least 80 % agreement was reached after a maximum of three voting rounds. RECOMMENDATION 1:  In order to implement the leave-in-situ strategy for diminutive colorectal lesions (1-5 mm), it is clinically acceptable if, during real-time colonoscopy, at least 90 % sensitivity and 80 % specificity is achieved for high confidence endoscopic characterization of colorectal neoplasia of 1-5 mm in the rectosigmoid. Histopathology is used as the gold standard.Level of agreement 95 %. RECOMMENDATION 2:  In order to implement the resect-and-discard strategy for diminutive colorectal lesions (1-5 mm), it is clinically acceptable if, during real-time colonoscopy, at least 80 % sensitivity and 80 % specificity is achieved for high confidence endoscopic characterization of colorectal neoplasia of 1-5 mm. Histopathology is used as the gold standard.Level of agreement 100 %. CONCLUSION : The developed SODA competence standards define diagnostic performance thresholds in relation to clinical consequences, for training and for use when auditing the optical diagnosis of diminutive colorectal polyps., Competing Interests: R. Bisschops has received research support from Cook and Medtronic, and financial support for symposium organization from Cook, Boston Scientific, Olympus, and Erbe (2009–2109), and speakers’ fees from Boston Scientific and Medtronic (2009–2019). E. Coron has received speakerʼs fees from Fujifilm (2018–2020). E. Dekker has received speaker’s fees from Roche (2018), Norgine (2019), Olympus and GI Supply (both 2019 to 2020), and Fujifilm (2020), and has provided consultancy to Fujifilm (2018), CPP-FAP (2019), GI Supply (2019 to 2020), Olympus (2020 to present), PAION and Ambu (both 2021); she received a research grant from Fujifilm (2017 to 2020) and her department has equipment on loan from Fujifilm (2017 to present) and Olympus (2021). M. Dinis-Ribeiro receives an educational grant from Olympus (2020 to present) and a research grant from Fujifilm (2020 to present); he is co-editor in-chief of Endoscopy. J.E. East has provided consultancy to, and holds share options in, Satisfai Health (2020 to present). C. Hassan has received research support from Fujifilm (2017 to present); his department has received support from Sonoscape. M. Iacucci receives research support from Pentax (2011 to present), Olympus (2017 to present) and Fujifilm (2018 to present). Y. Mori receives consultancy and speaker’s fees from Olympus (2018 to present) and has an ownership interest in Cybernet System Corp. (2020 to present). H. Neumann has provided consultancy to Fujifilm, Sonoscope, and Boston Scientific (all 2019 to 2020). M. Pellisé has received consultancy and speaker’s fees from Norgine Iberia (2015 to 2020), a consultancy fee from GI Supply (2019), speaker’s fees from Casen Recordati (2016 to 2019), Olympus (2018), and Jansen (2018), and research funding from Fujifilm Spain (2019), Fujifilm Europe (2020), and Casen Recordati (2020); her department has received loan material from Fujifilm Spain (2017 to present), a research grant from Olympus Europe (2005 to 2019), and loan material and a research grant from Fujifilm Europe (2020 to 2021); she is a Board member of ESGE and SEED, and is a co-editor of Endoscopy (2015 to 2021). I. Puig has provided advisory services to Fujifilm (2020 to present) and has equipment on loan from Olympus and Fujifilm (both 2019 to present). B. Saunders receives research funding from Olympus (2019 to present). D.J. Tate received an educational grant from Olympus (2018 to 2019). G. Antonelli, M. Bustamante-Balén, G. Cortas, V.M.H. Coupé, D.E. Dobru, M.J.E. Greuter, Y. Hazewinkel, B.B.S.L. Houwen, R. Jover, R. Kuvaev, G. Longcroft-Wheaton, M.D. Rutter, and J.L.A. Vleugels declare that they have no conflict of interest., (European Society of Gastrointestinal Endoscopy. All rights reserved.)

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

This manuscript represents an official Position Statement of the European Society of Gastrointestinal Endoscopy (ESGE) aiming to guide general gastroenterologists to develop and maintain skills in optical diagnosis during endoscopy. In general, this requires additional training beyond the core curriculum currently provided in each country. In this context, ESGE have developed a European core curriculum for optical diagnosis practice across Europe for high quality optical diagnosis training. 1:  ESGE suggests that every endoscopist should have achieved general competence in upper and/or lower gastrointestinal (UGI/LGI) endoscopy before commencing training in optical diagnosis of the UGI/LGI tract, meaning personal experience of at least 300 UGI and/or 300 LGI endoscopies and meeting the ESGE quality measures for UGI/LGI endoscopy. ESGE suggests that every endoscopist should be able and competent to perform UGI/LGI endoscopy with high definition white light combined with virtual and/or dye-based chromoendoscopy before commencing training in optical diagnosis. 2:  ESGE suggests competency in optical diagnosis can be learned by attending a validated optical diagnosis training course based on a validated classification, and self-learning with a minimum number of lesions. If no validated training course is available, optical diagnosis can only be learned by attending a non-validated onsite training course and self-learning with a minimum number of lesions. 3:  ESGE suggests endoscopists are competent in optical diagnosis after meeting the pre-adoption and learning criteria, and meeting competence thresholds by assessing a minimum number of lesions prospectively during real-time endoscopy. ESGE suggests ongoing in vivo practice by endoscopists to maintain competence in optical diagnosis. If a competent endoscopist does not perform in vivo optical diagnosis on a regular basis, ESGE suggests repeating the learning and competence phases to maintain competence.Key areas of interest were optical diagnosis training in Barrett's esophagus, esophageal squamous cell carcinoma, early gastric cancer, diminutive colorectal lesions, early colorectal cancer, and neoplasia in inflammatory bowel disease. Condition-specific recommendations are provided in the main document., Competing Interests: M. Arvanitakis has received lecture fees from Olympus (2019 – 2020). R. Bisschops has received research support, speaker’s and consultancy fees from Medtronic, Cook, Pentax, and Fujifilm (2009 – 2020), he has also received consultancy and speaker’s fees from Norgine, GI supply, Medivators, and Boston Scientific (2009 – 2020). E. Coron received speaker’s fees or congress invitations from Fujifilm (2016 – 2019), and speaker’s fees from Olympus (2016, 2017). E. Dekker received a research grant from Fujifilm, consulting fees for medical advice from Tillots (2018), Olympus (2019), Fujifilm (2017), GI Supply (2018 to present), and CPP-FAP (2019), and speaker’s fees from Olympus (2018), Roche (2016, 2018), and GI Supply (2019); she has received equipment on loan from Fujifilm (2017 to present). M. Dinis-Ribeiro received a research grant from Fujifilm (2019 to present) and a teaching grant from Olympus (2019 to present); he is also co-editor in-chief of Endoscopy. J. E. East is on the clinical advisory boards of Boston Scientific and Lumendi (2017 – 2019) and Satisfai Health and Paion (2020). G. Johnson has received speaker’s fees from Boston Scientific (2012 to present) and has been a faculty member for annual training courses supported by Olympus, Pentax, and Boston Scientific (2012 to present). H. Neumann has provided consultancy to Fujifilm, SonoScape, Medtronic, and Boston Scientific (2019 – 2020). T. Ponchon has received research support from Olympus (2020). I. Puig has received speaker’s fees from Fujifilm (2019) and his department has received loan equipment to conduct a study from Olympus Europe (2019 – 2021) and from Fujifilm Europe (2019). B.B.S.L. Houwen, D.E. Dobru, R. Kuvaev, P. Pimentel-Nunes, M. Bustamante-Balén, and D.S. Sanders declare that they have no conflict of interest., (Thieme. All rights reserved.)

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

1:  ESGE suggests that high definition endoscopy, and dye or virtual chromoendoscopy, as well as add-on devices, can be used in average risk patients to increase the endoscopist's adenoma detection rate. However, their routine use must be balanced against costs and practical considerations.Weak recommendation, high quality evidence. 2:  ESGE recommends the routine use of high definition systems in individuals with Lynch syndrome.Strong recommendation, high quality evidence. 3:  ESGE recommends the routine use, with targeted biopsies, of dye-based pancolonic chromoendoscopy or virtual chromoendoscopy for neoplasia surveillance in patients with long-standing colitis.Strong recommendation, moderate quality evidence. 4:  ESGE suggests that virtual chromoendoscopy and dye-based chromoendoscopy can be used, under strictly controlled conditions, for real-time optical diagnosis of diminutive (≤ 5 mm) colorectal polyps and can replace histopathological diagnosis. The optical diagnosis has to be reported using validated scales, must be adequately photodocumented, and can be performed only by experienced endoscopists who are adequately trained, as defined in the ESGE curriculum, and audited.Weak recommendation, high quality evidence. 5:  ESGE recommends the use of high definition white-light endoscopy in combination with (virtual) chromoendoscopy to predict the presence and depth of any submucosal invasion in nonpedunculated colorectal polyps prior to any treatment. Strong recommendation, moderate quality evidence. 6:  ESGE recommends the use of virtual or dye-based chromoendoscopy in addition to white-light endoscopy for the detection of residual neoplasia at a piecemeal polypectomy scar site. Strong recommendation, moderate quality evidence. 7:  ESGE suggests the possible incorporation of computer-aided diagnosis (detection and characterization of lesions) to colonoscopy, if acceptable and reproducible accuracy for colorectal neoplasia is demonstrated in high quality multicenter in vivo clinical studies. Possible significant risks with implementation, specifically endoscopist deskilling and over-reliance on artificial intelligence, unrepresentative training datasets, and hacking, need to be considered. Weak recommendation, low quality evidence., Competing Interests: R. Bisschops has provided consultancy to and received research grants and speaker’s fees from Pentax (2008 to present) and Fujifilm (2015 to present); his department has received research grants and equipment from Pentax and Fujifilm (2015 to present). E. Coron received speaker’s fees or congress invitations from Fujifilm (2016 – 2019), and speaker’s fees from Olympus (2016, 2017). J. East received a speaker’s fee from Falk (January 2018); he has served on a Clinical Advisory Board of Boston Scientific (March 2018 to March 2019). C. Hassan has received research support from Fujifilm (2017 to present); his department has received support from Sonoscape. J. E. van Hooft has received lecture fees from Medtronics (2014 – 2015) and Cook Medical (2019), and consultancy fees from Boston Scientific (2014 – 2017); her department has received research grants from Cook Medical (2014 – 2018) and Abbott (2014 – 2017). M. Iacucci has received a research grant and consultancy fee from Pentax (2013 – 2019), and a research grant from Fujifilm (2018 – 2019); her department has received a research grant from Olympus (2017 – 2019). M.F. Kaminski has received speaker’s, teaching, and consultancy fees from Olympus (2017 to present) and speaker’s and teaching fees, and a loan of equipment from Fujifilm (2019). H. Neumann has provided consultancy to Fujifilm, Pentax, Motus GI, Boston Scientific, and Cook (2012 to present). M. Pellisé has received speaker’s fees from Casen Recordati (2016 – 2019), Olympus (2018), and Jansen (2018), consultancy and speaker’s fees from Norgine Iberia (2015 – 2019), a consultancy fee from GI Apply (2019), and research funding from Fujifilm Spain (2019); her department has received material on loan from Fujifilm Spain (2017 to present) and research grants from Olympus Europe (2005 to present); she is a board member of ESGE and SEED (2016 to present). I. Puig’s department has received loans of equipment to conduct a study from Olympus Europe (2019 – 2021) and Fujifilm Europe (January 2019 – December 2019). Y. Mori has provided consultancy to and received a Speaker’s honorarium from Olympus (2017 – 2019). G. Antonelli, M. Bustamente Balén, G. Cortas, E. Dekker, Y. Hazewinkel, G. Longcroft-Wheaton, and N. Pilonis have no competing interests., (© Georg Thieme Verlag KG Stuttgart · New York.)