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This article discusses the use of texture and color enhancement imaging (TXI) in the detection of small gastric adenocarcinomas of fundic-gland type (GA-FGs). The study focuses on a man in his 60s who underwent endoscopic resection for multiple superficial GA-FGs. During a follow-up gastroscopy, new suspicious lesions were detected using TXI that were not visible on previous endoscopies. The study concludes that TXI can improve the detection of subtle gastric lesions like GA-FGs, which may be missed using conventional imaging techniques. [Extracted from the article]

Background:Many micro-RNAs (miRNAs) are differentially expressed in Helicobacter pylori-infected gastric mucosa and in gastric cancer tissue and previous reports have suggested the possibility of serum miRNAs as complementary tumour markers. The aim of the study was to investigate serum miRNAs and pepsinogen levels in individuals at high risk for gastric cancer both before and after H. pylori eradication.Methods:Patients with recent history of endoscopic resection for early gastric cancer and the sex- and age-matched controls were enrolled. Serum was collected from subjects before or after eradication and total RNA was extracted to analyse serum levels of 24 miRNAs. Serum pepsinogen (PG) I and II levels were measured using enzyme-linked immunosorbent assay kits.Results:Using miR-16 as an endogenous control, the relative levels of miR-106 and let-7d before and after H. pylori eradication and miR-21 after eradication were significantly higher in the high-risk group than in the controls. H. pylori eradication significantly decreased miR-106b levels and increased let-7d only in the control group. After eradication, the combination MiR-106b with miR-21 was superior to serum pepsinogen and the most valuable biomarker for the differentiating high-risk group from controls.Conclusion:Serum miR-106b and miR-21 may provide a novel and stable marker of increased risk for early gastric cancer after H. pylori eradication. [ABSTRACT FROM AUTHOR]

Background and study aims: The frequency of stricture after endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma with a mucosal defect involving more than three-quarters of the circumference is 70%-90%. Stricture decreases quality of life and requires multiple endoscopic balloon dilation (EBD) sessions. We investigated the efficacy and safety of a single session of intralesional steroid injections to prevent post-ESD stricture. Patients and methods: We conducted a prospective study on 30 patients with esophageal squamous cell carcinoma treated by ESD, who had a more than three-quarter but less than whole circumferential defect. A single session of intralesional steroid injections was undertaken immediately after ESD. Esophagogastroduodenoscopy was performed whenever patients reported dysphagia and 2 months after ESD in patients without dysphagia. Results were compared with a historical control group of 29 patients who underwent ESD without intralesional steroid injection. The primary endpoint was the post-ESD stricture rate. Secondary endpoints were the number of EBD sessions and the complication rate. Results: Compared with the historical control group, the study group had a significantly lower stricture rate (10 %, 3/30 patients vs. 66%, 19/29 patients; P<0.0001) and a lower number of EBD sessions (median 0, range 0-2 vs. median 2, range 0-15; P<0.0001). The study group had a complication rate of 7% (2/30 patients), comprising a submucosal tear in one patient and bleeding in another, which were not a direct result of EBD. Conclusions: A single session of intralesional steroid injections showed promising results for the prevention of stricture after ESD for esophageal cancer. [ABSTRACT FROM AUTHOR]

Background: After endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), delayed bleeding occurs in 1.7% to 38% of cases. Routine coagulation of all nonbleeding visible vessels (NBVVs) in post-ESD ulcers is currently performed as standard practice, but it cannot eliminate bleeding. An endoscopic Doppler US (DOP-US) probe system has possible benefits for the prediction of recurrent bleeding in peptic ulcer hemorrhage. Objective: To establish optimum use and evaluate feasibility of DOP-US for post-ESD ulcers. Design: Case series study. Setting: Cancer referral center. Patients: Eight patients with mucosal EGC larger than 2 cm without ulceration or scarring and 2 patients with EGC less than 3 cm with scarring. Interventions: We searched for a positive DOP-US signal (DOP-US+), which was defined as pulsatile sound at a depth of 1.5 mm, and NBVVs or areas with DOP-US+ were coagulated with hemostatic forceps. A multibending, double-channel videoendoscope that was fitted with a transparent hood was used. Main Outcome Measurements: Detectability of DOP-US signals in post-ESD ulcers. Results: One of 13 oozing bleeding sites, 24 (18%) of 136 NBVVs, and 7 areas without any bleeding stigmata had DOP-US+ and were coagulated until the signal became silent. One hundred twelve NBVVs (82%) and 8 adherent clots without DOP-US signals were left untreated. No delayed bleeding was experienced at 30 days. Median time required for Doppler examination was 34 minutes, but it improved to 18 and 19 minutes in patients 9 and 10, respectively. Conclusions: DOP-US might be helpful in the endoscopic management of post-ESD ulcers in EGC. Our setting and maneuver warrant further investigation to clarify whether DOP-US can reduce delayed bleeding and avoid unnecessary coagulation for NBVVs in post-ESD ulcers. [ABSTRACT FROM AUTHOR]

BACKGROUND: Infrared endoscopy is used to visualize vessels in the GI tract. By applying this system, we developed a new method to visualize a bleeding point during endoscopic resection. OBJECTIVE: This study aimed to evaluate the ability of infrared endoscopy to detect a bleeding point during endoscopic resection and to elucidate the mechanism required for clear visualization of a bleeding point by in vitro color analysis. DESIGN: Observational case series. SETTING: A cancer-referral center. PATIENTS AND INTERVENTIONS: A total of 10 bleeding sites were observed during endoscopic resection of upper-GI cancers by infrared endoscopy after flushing with indocyanine green (ICG) solution (0.125 mg/mL water). MAIN OUTCOME MEASUREMENTS: Detection of bleeding points. RESULTS: Bleeding points were identified in all bleeding sites by infrared endoscopic viewing. Bleeding points were displayed in white, whereas, an ulcer bed was in blue and pooled blood was a blue-to-gray color. By in vitro color analysis, blood was white, blood twice diluted with ICG solution was dark blue, and blood 4-times diluted with ICG solution was light blue on infrared endoscopic views. Color differences with blood dilution were more obvious in an infrared endoscopic view compared with a conventional endoscopic view. Blood thickness, movement, and clotting did not influence the color differences. LIMITATIONS: Uncontrolled study. CONCLUSIONS: We reported a flushing method by which we could detect all bleeding points during endoscopic resection. Clear visualization of bleeding points comes from differences in blood and ICG concentration between spurting and pooled blood. [ABSTRACT FROM AUTHOR]

BACKGROUND: According to clinicopathologic studies, differentiated-type mucosal early gastric cancers without ulcer or ulcer scar have little risk of lymph-node metastasis, irrespective of tumor size. However, patients with large mucosal early gastric cancer have been subjected to surgery because conventional EMR methods could not resect large tumors en bloc. OBJECTIVE: To evaluate the feasibility and the efficacy of endoscopic submucosal dissection for treatment of early gastric cancers larger than 3 cm in diameter. DESIGN: Case series study. SETTING: Referral cancer center. PATIENTS: A total of 30 consecutive patients were enrolled with the following characteristics: diagnosis of differentiated-type early gastric cancer larger than 3 cm, lack of ulcerative change, no endoscopic evidence for submucosal invasion, and no evidence of lymph-node or distant metastasis (22 men and 8 women; median age, 69 years; median tumor size, 40 mm). INTERVENTIONS: Tumors were resected by endoscopic submucosal dissection with an insulated-tip knife. MAIN OUTCOME MEASUREMENTS: Complete resection, complication rate, and operation time. RESULTS: Complete resection was obtained in 23 of 30 cases (77%). Complications included hemorrhage (n = 4), perforation (n = 1), and pyloric stenosis (n = 1), but no severe complications occurred that required surgery or that led to major morbidity. Complete resection and complication rates improved in the last 10 cases (90% and 0%, respectively), though operation time was not shortened. LIMITATIONS: Small sample size and lack of controls. CONCLUSIONS: Endoscopic submucosal dissection when using the insulated-tip knife is feasible and efficacious for selected patients with mucosal early gastric cancer larger than 3 cm. [ABSTRACT FROM AUTHOR]

The article presents a case study of a woman that has undergone esophagogastroduodenoscopy (EGD) and was detected diagnosed with infiltrating gastric cancer. Topics mentioned include the detection of the gastric fundus lesion, the patients has undergone endoscopic ultrasound (EUS), white-light endoscopy (WLE), and narrow-band imaging (NBI), and the sytemic chemotherapy received.

Objective: During the last decade, the management of gastric intestinal metaplasia (GIM) has been addressed by several distinct international evidence-based guidelines. In this review, we aimed to synthesise these guidelines and provide clinicians with a global perspective of the current recommendations for managing patients with GIM, as well as highlight evidence gaps that need to be addressed with future research., Design: We conducted a systematic review of the literature for guidelines and consensus statements published between January 2010 and February 2023 that address the diagnosis and management of GIM., Results: From 426 manuscripts identified, 16 guidelines were assessed. There was consistency across guidelines regarding the purpose of endoscopic surveillance of GIM, which is to identify prevalent neoplastic lesions and stage gastric preneoplastic conditions. The guidelines also agreed that only patients with high-risk GIM phenotypes (eg, corpus-extended GIM, OLGIM stages III/IV, incomplete GIM subtype), persistent refractory Helicobacter pylori infection or first-degree family history of gastric cancer should undergo regular-interval endoscopic surveillance. In contrast, low-risk phenotypes, which comprise most patients with GIM, do not require surveillance. Not all guidelines are aligned on histological staging systems. If surveillance is indicated, most guidelines recommend a 3-year interval, but there is some variability. All guidelines recommend H. pylori eradication as the only non-endoscopic intervention for gastric cancer prevention, while some offer additional recommendations regarding lifestyle modifications. While most guidelines allude to the importance of high-quality endoscopy for endoscopic surveillance, few detail important metrics apart from stating that a systematic gastric biopsy protocol should be followed. Notably, most guidelines comment on the role of endoscopy for gastric cancer screening and detection of gastric precancerous conditions, but with high heterogeneity, limited guidance regarding implementation, and lack of robust evidence., Conclusion: Despite heterogeneous populations and practices, international guidelines are generally aligned on the importance of GIM as a precancerous condition and the need for a risk-stratified approach to endoscopic surveillance, as well as H. pylori eradication when present. There is room for harmonisation of guidelines regarding (1) which populations merit index endoscopic screening for gastric cancer and GIM detection/staging; (2) objective metrics for high-quality endoscopy; (3) consensus on the need for histological staging and (4) non-endoscopic interventions for gastric cancer prevention apart from H. pylori eradication alone. Robust studies, ideally in the form of randomised trials, are needed to bridge the ample evidence gaps that exist., Competing Interests: Competing interests: No conflicts of interest are declared by MD-R, SS, HE-S, MB, NU, HT, LGC, DL, EL, AR, J-YF, LM, JB, EJK, EME-O. PM is a member of advisory board/lecturer of Aboca, Alfasigma, Allergosan, Bayer, Biocodex, Menarini advisory boards/lectures., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In familial adenomatous polyposis (FAP) patients, fundic gland polyps (FGPs) have been considered a risk factor for gastric neoplasms. We speculated that FGPs in FAP patients spread directionally from the greater to the lesser curvature of the gastric body and investigated the relationship between the distribution of FGPs and gastric neoplasm development., Methods: We extracted 195 FAP patients from two institutions and reviewed their medical records. Gastric polyposis was classified based on the FGP distribution (P0, no FGPs; P1, localized in the fundus or greater curvature of the gastric body; P2, spreading to the anterior or posterior wall; P3, involving the proximal half of the lesser curvature; and P4, spreading from P3 to the anal side of the lesser curvature)., Results: The 195 eligible patients were divided into the neoplasm group (n = 54, 28%) and the non-neoplasm group (n = 141, 72%). Overall, 24% of the patients were Helicobacter pylori (H. pylori)-positive. In the FGP distribution, the rate of patients with gastric neoplasm tended to increase significantly with each step towards an increasingly wide distribution from P0 to P4 in H. pylori-negative patients, but not in H. pylori-positive ones. In addition, in H. pylori-negative patients, the likelihood of neoplasm increased consistently from P0 to P4, with the highest odds ratio (95% confidence interval) at P4 of 14.1 (2.5-154.4). Furthermore, multivariate analysis showed P4 and Spigelman stage ≥III were significantly associated with gastric neoplasm development., Conclusion: FGP distribution was correlated with gastric neoplasm development in FAP patients., (© 2024. The Author(s) under exclusive licence to The International Gastric Cancer Association and The Japanese Gastric Cancer Association.)

Background and Aims: There is a high incidence of stricture after endoscopic submucosal dissection (ESD) for cervical esophageal cancer. We aimed to elucidate the risk factors for stricture and evaluate the efficacy of steroid injection for stricture prevention in the cervical esophagus., Methods: We retrospectively analyzed 100 patients who underwent ESD for cervical esophageal cancer to: (1) identify the factors associated with stricture among patients who did not receive steroid injection; (2) compare the incidence of stricture between patients with and without steroid injection., Results: Among 48 patients who did not receive steroid injection, there were significant differences in tumor size (P = .026), resection time (P = .028), and circumferential extent of the mucosal defect (P = .005) between patients with stricture (n = 5) and without stricture (n = 43). Compared with patients without steroid injection, patients with steroid injection had a significantly lower incidence of stricture when the post-ESD mucosal defect was < 3/4 and ≥ 1/2 (40% versus 8%, P = .039). As for the patients with a post-ESD mucosal defect of ≥ 3/4 (n = 13), local steroid injection was performed for all the patients, and 6 patients (46%) developed stricture., Conclusions: Patients who underwent ≥ 1/2 circumferential resection were at high risk of cervical esophageal stricture. Steroid injection had a stricture-prevention effect in patients with < 3/4 and ≥ 1/2 circumferential resection, but seemed to be insufficient in preventing stricture in patients with ≥ 3/4 circumferential resection., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: The use of antifoaming and mucolytic agents prior to upper gastrointestinal (GI) endoscopy and a thorough systematic review are essential to optimize lesion detection. This study evaluated the effect of simethicone and N-acetylcysteine on the adequate mucosal visibility (AMV) of the upper GI tract by an innovative systematic method., Methods: This randomized, double-blind controlled trial included consecutive patients who underwent diagnostic upper GI endoscopy for screening for early neoplasms between August 2019 and December 2019. The upper GI tract was systematically assessed by systematic alphanumeric-coded endoscopy. Patients were divided into 4 groups: 1) water; 2) only simethicone; 3) N-acetylcysteine + simethicone; and 4) only N-acetylcysteine. The following parameters were assessed in each group: age, sex, body mass index, level of adequate mucosal visibility, and side-effects., Results: A total of 4564 images from upper GI areas were obtained for evaluation. The mean AMV in the 4 groups was 93.98±7.36%. The N-acetylcysteine + simethicone group had a higher cleaning percentage compared with the other groups (P=0.001). There was no significant difference among the remaining groups, but several areas had better cleaning when a mucolytic or antifoam alone was used. No side-effects were found in any group., Conclusion: The combination of N-acetylcysteine plus simethicone optimizes the visibility of the mucosa of the upper GI tract, which could potentially increase diagnostic yield., Competing Interests: Conflict of Interest: None, (Copyright: © 2024 Hellenic Society of Gastroenterology.)

Objectives: Early gastric cancer endoscopic resection (ER) is prominent in Japan. However, evidence regarding ER of gastric submucosal tumors (SMT) is limited. This prospective multicenter phase II study investigated the efficacy and safety of endoscopic full-thickness resection (EFTR) for gastric SMT., Methods: Endoscopic full-thickness resection indication for gastric SMT was 11-30 mm, histologically proven or clinically suspicious (irregular margin, increasing size, or internal heterogeneity) gastrointestinal stromal tumors (GIST), with no ulceration and intraluminal growth type. The primary end-point was the complete ER (ER0) rate, with a sample size of 42., Results: We enrolled 46 patients with 46 lesions between September 2020 and May 2023 at seven Japanese institutions. The mean ± SD (range) endoscopic tumor size was 18.8 ± 4.5 (11-28) mm. The tumor resection and defect closure times were 54 ± 26 (22-125) min and 33 ± 28 (12-186) min, respectively. A 100% ER0 was achieved in all 46 patients. The EFTR procedure was accomplished in all patients without surgical intervention. One patient had delayed perforation and was managed endoscopically. GIST accounted for 76% (n = 35) of the cases. R0, R1, and RX rates were 33 (77%), 3 (6.5%), and 7 (15%), respectively., Conclusion: Endoscopic full-thickness resection for gastric SMT of 11-30 mm is efficacious. It warrants further validation in a large-scale cohort study to determine the long-term outcome of this treatment for patients with gastric GIST., (© 2023 Japan Gastroenterological Endoscopy Society.)

Competing Interests: S. Shichijo has received honoraria from Fujifilm Medical, Olympus, EA Pharma, Astra Zeneca, AI Medical Service, and Janssen Pharmaceutical. N. Uedo has received honoraria from Olympus, Fujifilm Medical, Boston Scientific, Daiichi-Sankyo, Takeda Pharmaceutical, EA Pharma, Otsuka Pharmaceutical, AstraZeneca, Miyarisan Pharmaceutical, and AI Medical Service. H. Mori, K. Higashino, and T. Michida declare that they have no conflict of interest.

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

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

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

Introduction: The early detection of gastric neoplasms (GNs) leads to favorable treatment outcomes. The latest endoscopic system, EVIS X1, includes third-generation narrow-band imaging (3G-NBI), texture and color enhancement imaging (TXI), and high-definition white-light imaging (WLI). Therefore, this randomized phase II trial aimed to identify the most promising imaging modality for GN detection using 3G-NBI and TXI., Methods: Patients with scheduled surveillance endoscopy after a history of esophageal cancer or GN or preoperative endoscopy for known esophageal cancer or GN were randomly assigned to the 3G-NBI, TXI, or WLI groups. Endoscopic observations were performed to detect new GN lesions, and all suspected lesions were biopsied. The primary endpoint was the GN detection rate during primary observation. Secondary endpoints were the rate of missed GNs, early gastric cancer detection rate, and positive predictive value for a GN diagnosis. The decision rule had a higher GN detection rate between 3G-NBI and TXI, outperforming WLI by >1.0%., Results: Finally, 901 patients were enrolled and assigned to the 3G-NBI, TXI, and WLI groups (300, 300, and 301 patients, respectively). GN detection rates in the 3G-NBI, TXI, and WLI groups were 7.3, 5.0, and 5.6%, respectively. The rates of missed GNs were 1.0, 0.7, and 1.0%, the detection rates of early gastric cancer were 5.7, 4.0, and 5.6%, and the positive predictive values for the diagnosis of GN were 36.5, 21.3, and 36.8% in the 3G-NBI, TXI, and WLI groups, respectively., Discussion: Compared with TXI and WLI, 3G-NBI is a more promising modality for GN detection., (Copyright © 2024 by The American College of Gastroenterology.)

Background and Aim: Intestinal metaplasia (IM) of the gastric mucosa is strongly associated with the risk of gastric cancer (GC). This study was performed to investigate the usefulness of endoscopic and histological risk stratification for GC using IM., Methods: This was a post-hoc analysis of a multicenter prospective study involving 10 Japanese facilities (UMINCTR000027023). The ridge/tubulovillous pattern, light blue crest (LBC), white opaque substance (WOS), endoscopic grading of gastric IM (EGGIM) score using non-magnifying image-enhanced endoscopy, and operative link on gastric IM assessment (OLGIM) were evaluated for their associations with GC risk in all patients., Results: In total, 380 patients (115 with GC and 265 without GC) were analyzed. The presence of an LBC (limited to antrum: odds ratio [OR] 2.4 [95% confidence interval 1.1-5.0], extended to corpus: OR 3.6 [2.1-6.3]), the presence of WOS (limited to antrum: OR 3.0 [1.7-5.3], extended to corpus: OR 4.2 [2.1-8.2]), and histological IM (limited to antrum: OR 3.2 [1.4-7.4], extended to corpus: OR 8.5 [4.5-16.0]) were significantly associated with GC risk. Additionally, the EGGIM score (5-8 points: OR 8.8 [4.4-16.0]) and OLGIM (stage III/IV: OR 12.5 [6.1-25.8]) were useful for stratification of GC risk. The area under the receiver operating characteristic curve value for GC risk was 0.740 for OLGIM and 0.706 for EGGIM., Conclusions: The LBC, WOS, EGGIM, and OLGIM were strongly associated with GC risk in Japanese patients. This finding can be useful for GC risk assessment in daily clinical practice., (© 2024 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

We developed three e-learning systems for endoscopists to acquire the necessary skills to improve the diagnosis of early gastric cancer (EGC) and demonstrated their usefulness using randomized controlled trials. The subjects of the three e-learning systems were "detec-tion", "characterization", and "preoperative assessment". The contents of each e-learning system included "technique", "knowledge", and "obtaining experience". All e-learning systems proved useful for endoscopists to learn how to diagnose EGC. Lecture videos describing "the technique" and "the knowledge" can be beneficial. In addition, repeating 100 self-study cases allows learners to gain "experience" and improve their diagnostic skills further. Web-based e-learning systems have more advantages than other teaching methods because the number of participants is unlimited. Histopathological diagnosis is the gold standard for the diagnosis of gastric cancer. Therefore, we developed a comprehensive diagnostic algorithm to standardize the histopathological diagnosis of gastric cancer. Once we have successfully shown that this algorithm is helpful for the accurate histopathological diagnosis of cancer, we will complete a series of e-learning systems designed to assess EGC accurately.

Objectives: Prediction of the risk of esophageal squamous cell carcinoma (SCC) by endoscopic findings without iodine staining, which is irritating to the esophagus, would be beneficial. In a previous retrospective study, we found that multiple foci of dilated vascular areas (MDV) of the esophageal mucosa, seen in narrow-band imaging (NBI)/blue laser imaging (BLI), are associated with iodine-unstained lesions and, thus, may be a predictor of esophageal SCC. This prospective study aimed to investigate the association between MDV and metachronous esophageal SCC., Methods: Patients with a history of endoscopic resection for esophageal SCC were included in the study. First, evaluation of the MDV using NBI or BLI was conducted during the initial endoscopy. The patients were then monitored for metachronous esophageal SCC by endoscopic surveillance. The association between the number of MDV and incidence of metachronous esophageal SCC was investigated., Results: From February 2018 to May 2019, 206 patients were enrolled and 201 patients were included in the analysis. Patients were followed up until October 2022. The median (interquartile range) endoscopic follow-up period was 1260 (1105-1348) days. The incidence of metachronous esophageal SCC at 2 years was 7.1% in patients with MDV ≤4 and 13.9% in patients with MDV ≥5 (P < 0.01). In the multivariate analysis, MDV was an independent predictor of metachronous esophageal SCC, with an odds ratio (95% confidence interval) of 2.37 (1.06-5.31)., Conclusion: Multiple foci of dilated vascular area is a useful predictor for stratifying the risk of metachronous esophageal SCC., (© 2023 Japan Gastroenterological Endoscopy Society.)

The foregut, which includes the esophagus, stomach and duodenum, represents one of the most common sites for neuroendocrine neoplasms. These are highly heterogenous with different risk of progression depending on location, cell-type of origin, size, grade and other factors. Various endoscopic and imaging modalities exist to inform therapeutic decision-making, which may be in the form of surgical or endoscopic resection and medical therapy depending on the extent of the disease after diagnostic evaluation. This narrative review aims to explore the literature on the multimodal management of such foregut neuroendocrine neoplasms., Competing Interests: Declaration of competing interest The authors declare no conflict of interest related to this article., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Global warming caused by increased greenhouse gas (GHG) emissions has a direct impact on human health. Gastrointestinal (GI) endoscopy contributes significantly to GHG emissions due to energy consumption, reprocessing of endoscopes and accessories, production of equipment, safe disposal of biohazardous waste, and travel by patients. Moreover, GHGs are also generated in histopathology through tissue processing and the production of biopsy specimen bottles. The reduction in unnecessary surveillance endoscopies and biopsies is a practical approach to decrease GHG emissions without affecting disease outcomes. This narrative review explores the role of precision medicine in GI endoscopy, such as image-enhanced endoscopy and artificial intelligence, with a focus on decreasing unnecessary endoscopic procedures and biopsies in the surveillance and diagnosis of premalignant lesions in the esophagus, stomach, and colon. This review offers strategies to minimize unnecessary endoscopic procedures and biopsies, decrease GHG emissions, and maintain high-quality patient care, thereby contributing to sustainable healthcare practices., (© 2023 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Esophageal endoscopic submucosal dissection (ESD) is technically challenging, especially for trainees, and requires a safe training system. This study aimed to identify predictors of technical difficulty facing trainees performing esophageal ESD to establish such system., Methods: This was a single-center retrospective study of patients with esophageal cancer who underwent ESD performed by trainees between January 2010 and August 2022. Technical difficulties were defined as muscularis propria exposure and long procedure time (≥ 90 min). Factors associated with these technical difficulties were investigated., Results: A total of 798 lesions in 721 patients were evaluated. Muscularis propria exposure occurred in 298 lesions (37.3%), including 10 perforations (1.3%). The procedure time was ≥ 90 min in 134 lesions (16.8%). In the multivariate analysis, tumor size ≥ 20 mm, tumors ≥ 1/2 of the circumference, and those close to previous treatment scars significantly increased the incidence of both difficulties, whereas tumors in the upper esophagus significantly decreased this incidence. Furthermore, female sex and tumors in the left wall were independent predictors of muscularis propria exposure, and elevated morphology was an independent predictor of long procedure time. Muscularis propria exposure and long procedure time occurred in more than half of the cases with three or more predictors of each difficulty., Conclusions: Large tumors and tumors close to previous treatment scars increase technical difficulties for trainees in esophageal ESD. Conversely, tumors in the upper esophagus reduce these difficulties. These results enable us to predict the difficulty level preoperatively and select appropriate cases in stepwise training., (© 2023. The Author(s) under exclusive licence to The Japan Esophageal Society.)

Competing Interests: T. K. has received honoraria for lectures from Olympus. N. U. has received honoraria for lectures from Olympus, FUJIFILM Medical, and Boston Scientific Japan. R. I. has received honoraria for lectures from Olympus and FUJIFILM medical. The other author declares no conflict of interest for this article.

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

Competing Interests: S. Shichijo has received honoraria for lectures from Olympus, EA Pharma, AstraZeneca, AI Medical Service, and Janssen Pharmaceutical.J. W. Li has received honoraria for lectures from Fujifilm and Boston Scientific.N. Uedo has received honoraria for lectures from Olympus, Fujifilm, Boston Scientific Japan, Daiichi-Sankyo, Takeda Pharmaceutical, EA Pharma, Otsuka Pharmaceutical, AstraZeneca, Miyarisan Pharmaceutical, and AI Medical Service.

Competing Interests: Satoki Shichijo has received honoraria for lectures from Olympus, Boston Scientific Japan, EA Pharma, AstraZeneca, AI Medical Service, and Janssen Pharmaceutical. Yoji Takeuchi has received honoraria for lectures from Olympus, Boston Scientific Japan, Takeda Pharmaceutical, EA Pharma, Zeria Pharmaceutical, and Viatris. Noriya Uedo has received honoraria for lectures from Olympus, FUJIFILM, Boston Scientific Japan, Daiichi-Sankyo, Takeda Pharmaceutical, EA Pharma, Otsuka Pharmaceutical, AstraZeneca, Miyarisan Pharmaceutical, and AI Medical Service.

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

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

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

Objectives: Although countries like Japan and South Korea have implemented nationwide endoscopic screening programs, there is limited evidence on the effectiveness of endoscopy for diagnosing early gastric cancer (EGC) in developing countries such as India. In the present study, we aimed to determine the feasibility of endoscopic detection of EGC from India., Methods: The data was prospectively collected for all patients ≥40 years who underwent a diagnostic upper endoscopy from April to September 2021. A single endoscopist who performed the endoscopic procedures completed 1-month training in advanced endoscopy in Japan. Following the training, the endoscopist continued to engage in internet-based discussions regarding his cases encountered. Prior to this training, the endoscopist had not detected any EGC cases during his 12-year gastroenterology practice., Results: A total of 1033 patients were included in the study, with males accounting for 65.4% and a mean age 52 years. The average procedural time was 7.13 ± 4.8 min. A total of 25 patients (2.4%) were found to have GC, including 6 patients (0.6%) with EGC. Two patients had synchronous EGC lesions. All EGC patients were males, with an average age of 66 years. All EGCs were detected in the distal stomach in the presence of Helicobacter pylori infection and severe atrophic gastritis., Conclusion: Our findings showed that the endoscopic detection of EGC is feasible in India. Optimal training on endoscopic diagnosis of EGC can improve the detection of such lesion. Further studies are warranted to assess the optimization and implementation of an endoscopic screening program for EGC in India., Competing Interests: None., (© 2023 The Authors. DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Background and Aims: GI stromal tumors (GISTs) represent the most common mesenchymal tumors of the GI tract. Guidelines recommend the removal of histologically proven gastric GISTs >2 cm. While the conventional treatment of a gastric GIST involves surgical excision, endoscopic full-thickness resection (EFTR) has been described as an acceptable alternative. We aim to outline how the key steps used in endoscopic submucosal dissection (ESD) can be adapted to the performance of exposed EFTR and discuss the variations in technical aspects between the 2 procedures., Methods: We use a video case illustration with a comprehensive narrative to highlight the similarities and differences in equipment used and techniques in EFTR and ESD. Images and graphical illustrations are also used to describe these techniques., Results: ESD techniques and equipment can be adapted for use in EFTR of gastric GISTs. Principles such as deep mucosal incision, the appropriate use of traction, and identification of vessels for prophylactic coagulation help to ensure a safe and efficient procedure. The main difference in EFTR is the need for general anesthesia, starting the mucosal incision as close to the tumor margin as possible, submucosal dissection around the surface of the tumor capsule, and a strong closure method for the muscle defect., Conclusions: The equipment and techniques in ESD can be adapted to EFTR for gastric GISTs by endoscopists who are familiar with ESD techniques., Competing Interests: Dr Uedo has received honoraria for lecturing from Fujifilm Co Ltd, Boston Scientific Japan, Daiichi-Sankyo Co Ltd, Takeda Pharmaceutical Co Ltd, EA Pharma Co Ltd, Otsuka Pharmaceutical Co Ltd, AstraZeneca Co Ltd, Miyarisan Pharmaceutical Co Ltd, and AI Medical Service Inc. Dr Li has received honoraria for lecturing from Fujifilm Co Ltd and Boston Scientific. Dr Shichijo has received honoraria for lecturing from Olympus Co Ltd, EA Pharma Co Ltd, AstraZeneca Co Ltd, AI Medical Service Inc, and Janssen Pharmaceutical. Funding for this work was provided by the 10.13039/501100005150Osaka Foundation for the Prevention of Cancer and Lifestyle-related Diseases., (© 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Video 1Underwater endoscopic mucosal resection for a large polyp at the terminal ileum., (© 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Background and Aim: The endoscopic features of gastric neuroendocrine carcinoma (G-NEC) have not been clarified; therefore, they were investigated in relation to clinicopathological findings., Methods: Consecutive patients with G-NECs who had undergone endoscopic or surgical resection at our institution between January 2005 and March 2022 were included in this retrospective study. The endoscopic and clinicopathological findings of the lesions were analyzed to provide information of diagnostic value. In addition, cases of gastric neuroendocrine tumor (G-NET) and common-type gastric adenocarcinoma treated in the same study period were identified to compare the endoscopic findings between each G-NEC versus G-NET, and G-NEC versus common-type gastric adenocarcinoma. Patients with common-type gastric adenocarcinoma were matched for age, sex, tumor size, and depth of tumor invasion in 1:3 ratio., Results: Among 15 patients with 15 G-NECs, submucosal tumor-like marginal elevation (87%), adherent white coat (67%), and ulceration with a distinct border (60%) were characteristic endoscopic findings in white-light images. Magnifying narrow-band imaging endoscopy revealed an absent microsurface (MS) pattern plus disrupted irregular microvessel (MV) in five (71%) of seven cases with evaluable MS and MV patterns. The area with an absent MS pattern plus disrupted irregular MV corresponded to the histological finding of NEC component in all five cases. These endoscopic features were all significantly more frequent in G-NECs than G-NETs (n = 22) or common-type gastric adenocarcinomas (n = 45)., Conclusions: These endoscopic features should be taken into consideration to increase the index of suspicion and to improve the accuracy of target biopsies for G-NEC., (© 2023 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Underwater endoscopic mucosal resection (UEMR) has been developed as an effective endoscopic intervention for colon, rectum, and duodenum neoplasms. However, there are no comprehensive reports regarding the stomach, and its safety and efficacy are unknown. We aimed to examine the feasibility of UEMR for gastric neoplasms in patients with familial adenomatous polyposis (FAP)., Methods: We retrospectively extracted data of patients with FAP who underwent endoscopic resection (ER) for gastric neoplasms at Osaka International Cancer Institute from February 2009 to December 2018. Elevated gastric neoplasms of ≤ 20 mm in diameter were extracted, and conventional endoscopic mucosal resection (CEMR) and UEMR were compared. Furthermore, outcomes after ER until March 2020 were examined., Results: 91 endoscopically resected gastric neoplasms were extracted from 31 patients with 26 pedigrees, and 12 neoplasms underwent CEMR and 25 neoplasms underwent UEMR was compared. The procedure time was shorter for UEMR than for CEMR. There was no significant difference between en bloc resection and R0 resection rates by EMR methods. CEMR and UEMR showed postoperative hemorrhage rates of 8% and 0%, respectively. Residual/local recurrent neoplasms were identified in four lesions (4%), but additional endoscopic intervention (three UEMR and one cauterization) resulted in a local cure., Conclusion: UEMR was feasible in gastric neoplasms of FAP patients, especially in elevated lesions and those of ≤ 20 mm in diameter., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Endoscopic submucosal dissection enables en bloc resection of large superficial colorectal neoplasms. However, it is sometimes challenging to retrieve a large resected specimen via the anus without sample fragmentation. A novel "bag-type" retrieval device has been developed to accomplish complete isolation and non-destructive delivery of oversized specimens. This single-center retrospective study was performed to demonstrate the efficacy of this device for large colorectal resected specimens. Among 17 patients, we identified 18 superficial colorectal lesions for which the use of a novel retrieval device (Endo Carry Large Type) was indicated at specimen delivery at a referral cancer institute from March 2021 to July 2022. The median (interquartile range) tumor size was 62.5 (52.0-79.5) mm. Retrieval of 17 (94%) of 18 resected specimens was performed using the Endo Carry Large Type, and 16 (89%) were successfully retrieved without sample fragmentation. The median (interquartile range) retrieval time was 4 (4-8) minutes, and no apparent adverse events were observed. The novel Endo Carry Large Type device can accomplish colorectal specimen retrieval safely and quickly without specimen damage and therefore may contribute to accurate pathological diagnosis., Competing Interests: Conflict of Interest Satoki Shichijo has received personal fees from Olympus Corporation, Daiichi-Sankyo, EA Pharma, AstraZeneca, AI Medical Service Inc., and Jannsen Pharmaceutical. Takashi Kanesaka has received personal fees from Olympus Corporation. Yoji Takeuchi received honoraria for his lectures from Olympus, Boston Scientific (Japan), Daiichi-Sankyo, Miyarisan Pharmaceutical, Asuka Pharmaceutical, AstraZeneca, EA Pharma, Zeria Pharmaceutical, Fujifilm, Kaneka Medix, Kyorin Pharmaceutical, and the Japan Gastroenterological Endoscopy Society. Noriya Uedo has received personal fees from Olympus Corporation, Boston Scientific Japan, FUJIFILM Medical Co., Ltd., Daiichi-Sankyo, Takeda Pharmaceutical, EA Pharma, Otsuka Pharmaceutical, AstraZeneca, AI Medical Service Inc., and Miyarisan Pharmaceutical. Ryu Ishihara has received personal fees from Olympus Corporation, FUJIFILM Medical Co., Ltd., Daiichi-Sankyo, Ono Pharmaceutical, EA Pharma, and AstraZeneca. The other authors have no financial relationships to disclose., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)