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Endoscopic submucosal dissection (ESD) is effective in treating early gastric cancer (EGC). Its role in patients with comorbidities along with more advanced disease is unknown. We sought to evaluate this in a large Western cohort. Consecutive patients who underwent ESD for EGC in a single tertiary Western endoscopy center over 10 years were prospectively analyzed. The primary outcomes were long-term overall survival (OS) and disease-free survival (DFS) up to 5 years. Secondary outcomes were efficacy and serious adverse events (SAEs). ESD for 157 cases of EGC in 149 patients was performed in an elderly and comorbid cohort with a mean age of 73.7 years and age-adjusted Charlson Comorbidity Index of 4.2. Over a median follow-up of 51.6 months, no significant differences were found in 5-year OS (88.9% vs 77.9%, P =.290) and DFS (83.2% vs 75.1%, P =.593) between absolute indication EGC and relative indication (RI) EGC. The absolute indication EGC cohort achieved higher en bloc (96.3% vs 87.5%, P =.069) and R0 resection rates (93.6% vs 62.5%, P <.001) when compared with RI EGC. No significant differences were found in SAEs (7.3% vs 12.5%, P =.363). No mortality or surgical resection ensued from adverse events from ESD. ESD safely confers DFS in poor surgical candidates with RI EGC in a large Western cohort. Patients who are elderly and/or with comorbidities or who decline surgical resection may benefit from ESD and avoid the risks of surgery and its long-term sequelae. (Clinical trial registration number: NCT02306707.) [ABSTRACT FROM AUTHOR]

Residual or recurrent adenoma (RRA) detected during surveillance is the major limitation of EMR. The pathogenesis of RRA is unknown, although thermal ablation of the post–endoscopic resection defect (PED) margin reduces RRA. We aimed to identify a feature within the PED that could be associated with RRA. Between January 2017 and July 2020, detailed prospective procedural data on all EMR procedures performed at a single center were retrospectively analyzed. At the completion of EMR, the PED was systematically examined for features of incomplete mucosal layer excision (IME). This was defined as a demarcated area within the PED bordered by a white electrocautery ring and containing endoscopically identifiable features suggesting incomplete resection of the mucosa including lacy capillaries and/or visible fibers of the muscularis mucosae. Areas of IME were reinjected and re-excised by snare and submitted separately for blinded specialist GI pathologist review. EMR was performed for 508 large nonpedunculated colorectal polyps (LNPCPs) (median size, 35 mm). In 10 PEDs (2.0%), an area of IME was identified and excised. Histopathologic examination of areas of suspected IME demonstrated muscularis mucosae in 9 of 10 (90%), residual lamina propria in 9 of 10 (90.0%), and residual adenoma in 5 of 10 (50.0%). No RRA was detected during follow-up after re-excision of IME. We report the novel finding of IME within the PED after EMR of LNPCPs. IME may contain microscopic residual adenoma and therefore is a risk for RRA during follow-up. After completion of EMR, the PED should be carefully evaluated. If IME is found, it should be excised. (Clinical trial registration number: NCT01368289 and NCT02000141.) [Display omitted] [ABSTRACT FROM AUTHOR]

Although conventional hot snare resection (CR) of laterally spreading lesions of the major papilla (LSL-Ps) is effective, it can be associated with delayed bleeding in upward of 25% of cases. Given the excellent safety profile of cold snare polypectomy in the colorectum, we investigated the efficacy and safety of a novel hybrid resection (HR) technique for LSL-P management, consisting of hot snare papillectomy plus cold snare resection of the laterally spreading component. A prospective cohort of patients underwent HR in a tertiary referral center over 60 months until December 2022. This cohort was compared with a historical cohort of patients who underwent CR at the same institution over 120 months until August 2017. The primary outcomes were recurrence and bleeding. Twenty patients underwent HR (14 female; mean age 65.2 ± 12.2 years). Median lesion size was 30 mm (interquartile range, 25.0-47.5 mm). Recurrent or residual adenoma (RRA) was greater with HR (58.8% [n = 10] vs 29.8% [n = 14]; P =.034). The odds ratio for recurrence was 3.6 times (95% CI, 1.2-11.0) higher with HR (P =.027). RRA was multifocal in 4 (40%) and had a composite RRA volume >10 mm in 7 (70%). The median number of procedures required to treat RRA was higher with HR (4 vs 1, P =.002). There was no difference between CR and HR for intraprocedural bleeding (41.1% [n = 23] vs 25% [n = 5]; P =.587) or delayed bleeding (25.0% vs 10.0%, P =.211). There were no perforations. The novel HR technique for LSL-P management is associated with a high rate of RRA that is recalcitrant to treatment, without mitigating the risk of intraprocedural or delayed bleeding. Therefore, CR should remain the mainstay management option for treating patients with an LSL-P. (Clinical trial registration number: NCT02306603.) [Display omitted] [ABSTRACT FROM AUTHOR]

Large (≥15 mm) duodenal adenomas (DAs) are premalignant and require removal. Existing endoscopic resection techniques are compromised by serious adverse events (SAEs), most notably postprocedural bleeding (PPB) and perforation. To ameliorate these problems, we sought to evaluate the novel technique of cold snare EMR (CS-EMR) against the emerging standard of conventional EMR with thermal ablation of the postresection margin (EMR-T) for the safe and effective removal of DAs. Consecutive patients were enrolled in a single tertiary center for CS-EMR and prospectively analyzed against a previously reported cohort of EMR-T from the same center. The primary outcome was rate of SAEs. Secondary outcomes were residual or recurrent adenoma at first surveillance endoscopy (SE1) at 6 months and technical success per lesion. Between October 2019 and July 2022, a total of 50 DAs ≥15 mm were removed via CS-EMR (median size, 30 mm [interquartile range (IQR), 19-40 mm]; mean ± standard deviation [SD] patient age, 70 ± 9.2 years) compared with 54 DAs via EMR-T (median size, 30 mm [IQR, 19-40 mm]; mean patient age, 68 ± 12.2 years). CS-EMR had a significantly lower rate of intraprocedural bleeding (2.0% vs 37%, P <.001) and PPB (4.0% vs 16.7%, P =.036). Two cases (4.0%) of immediate perforation occurred in CS-EMR; these were recognized immediately and closed with clips without sequelae. Total SAEs (16.0% vs 16.7%, P = 1) and technical success (100% vs 100%, P = 1) were identical. Recurrence at SE1 was significantly higher with CS-EMR (24.4% vs 2.3%, P =.002). CS-EMR reduces intraprocedural bleeding and PPB. However, it may increase the risk of immediate perforation and is associated with a significantly higher rate of recurrence at SE1. Further technical refinements are required to optimize endoscopic resection techniques for DAs. (Clinical trial registration number: NCT02306603.) [Display omitted] [ABSTRACT FROM AUTHOR]

Owing to its simplicity, effectiveness, and safety, EMR is the preferred treatment for the majority of large (≥20 mm) nonpedunculated colonic polyps (LNPCPs); however, residual and recurrent adenomas (RRAs) encountered during surveillance constitute a major limitation. Thermal ablation of the post-EMR mucosal defect margin has been shown to be highly efficacious in reducing RRA in a randomized trial setting, but data on effectiveness in clinical practice are scarce. We aimed to determine the effectiveness of this technique for reducing RRAs in routine clinical practice. We analyzed data collected in 3 hospitals in Israel: Prospective data were available in 2 hospitals where margin thermal ablation with snare-tip soft coagulation (STSC) is routinely performed after EMR of LNPCP (TA-EMR). Only retrospective data were available from the third center, which exclusively did not perform STSC (standard EMR] [S-EMR]), during the study period. Surveillance was performed 4 to 6 months after resection. RRA was assessed endoscopically with high-definition white light and optical chromoendoscopy. The primary endpoint was RRA at first surveillance colonoscopy. Data from 764 patients with 824 LNPCPs were analyzed. The patient and lesion characteristics were similar between the groups. Four hundred sixty-four LNPCPs were treated by TA-EMR and 360 LNPCPs by S-EMR. RRA at first surveillance colonoscopy was detected in 14 (3.6%) of lesions in the TA-EMR group compared with 96 (31.6%) in the S-EMR group (P <.001; RR =.14; 95% CI,.07-.29). Adverse events were comparable between the 2 groups. TA-EMR leads to a significant reduction in post-EMR recurrence in routine clinical practice. [ABSTRACT FROM AUTHOR]

Resection of colorectal polyps has been shown to decrease the incidence and mortality of colorectal cancer. Large nonpedunculated colorectal polyps are often referred to expert centers for endoscopic resection, which requires relevant information to be conveyed to the therapeutic endoscopist to allow for triage and planning of resection technique. The primary objective of this study was to establish minimum expected standards for the referral of large nonpedunculated colonic polyps for potential endoscopic resection. A Delphi method was used to establish consensus on minimum expected standards for the referral of large colorectal polyps among a panel of international endoscopy experts. The expert panel was recruited through purposive sampling, and 3 rounds of surveys were conducted to achieve consensus. Quantitative and qualitative data were analyzed for each round. A total of 24 international experts from diverse continents participated in the Delphi study, resulting in consensus on 19 statements related to the referral of large colorectal polyps. The identified factors, including patient demographic characteristics, relevant medications, lesion factors, photodocumentation, and the presence of a tattoo, were deemed important for conveying the necessary information to therapeutic endoscopists. The mean scores for the statements, which were scored on a scale of 1 to 10, ranged from 7.04 to 9.29, with high percentages of experts considering most statements as a very high priority. Subgroup analysis according to continent revealed some variations in consensus rates among experts from different regions. The identified consensus statements can aid in improving the triage and planning of resection techniques for large colorectal polyps, ultimately contributing to the reduction of colorectal cancer incidence and mortality. [ABSTRACT FROM AUTHOR]

The risk of cancer in large nonpedunculated colorectal polyps ≥20 mm (LNPCPs) in the rectum relative to the remainder of the colon is unknown. We aimed to describe differences between rectal and colonic LNPCPs to better inform treatment decisions. Patients with LNPCPs referred to tertiary centers for endoscopic resection within a prospective, multicenter, observational cohort were evaluated. Data recorded were participant demographics, LNPCP location, morphology, resection modality, and histopathologic data. Multiple logistic regression analysis was used to identify those variables independently associated with rectal versus nonrectal location in the colon. Patients with LNPCPs referred for endoscopic resection between July 2008 and July 2021 were included. Rectal LNPCPs (n = 618) were larger (median size, 40 mm vs 30 mm; P <.001) and more likely to be granular (79% vs 50%, P <.001) with a nodular component (53% vs 17%, P <.001) compared with nonrectal LNPCPs (n = 2787). Rectal LNPCPs were more likely to have tubulovillous histopathology (72% vs 47%, P <.001) and contain cancer (15% vs 6%, P <.001). After adjusting for the other features independently associated with location, cancer was more common in the rectum compared with the colon (odds ratio, 1.77; 95% confidence interval, 1.25-2.53). This study suggests that compared with LNPCPs in the rest of the colon, rectal LNPCPs are more likely to be larger and contain more advanced pathology. These findings have implications for curative endoscopic resection techniques particularly where early cancer is present. (Clinical trial registration numbers: NCT01368289 and NCT02000141.) [ABSTRACT FROM AUTHOR]

Although perforation is the most feared adverse event associated with endoscopic mucosal resection (EMR), limited data exists concerning its management. Therefore, we sought to evaluate the short- and long-term outcomes of intra-procedural deep mural injury (DMI) in an international multi-center observational cohort of large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs). Consecutive patients who underwent EMR for a LNPCP ≥20 mm were evaluated. Significant DMI (S-DMI) was defined as Sydney DMI Classification type III (muscularis propria injury, target sign) or type IV/V (perforation without or with contamination, respectively). The primary outcome was successful S-DMI defect closure. Secondary outcomes included technical success (removal of all visible polypoid tissue during index EMR), surgical referral and recurrence at first surveillance colonscopy (SC1). Between July 2008 to May 2020, 3717 LNPCPs underwent EMR. Median lesion size was 35mm (interquartile range (IQR) 25 to 45mm). Significant DMI was identified in 101 cases (2.7%), with successful defect closure in 98 (97.0%) using a median of 4 through-the-scope clips (TTSCs; IQR 3 to 6 TTSCs). Three (3.0%) patients underwent S-DMI-related urgent surgery. Technical success was achieved in 94 (93.1%) patients, with 46 (45.5%) admitted to hospital (median duration 1 day; IQR 1 to 2 days). Comparing LNPCPs with and without S-DMI, no differences in technical success (94 (93.1%) vs 3316 (91.7%); P =.62) or SC1 recurrence (12 (20.0%) vs 363 (13.6%); P =.15) were identified. Significant DMI is readily managed endoscopically and does not appear to affect technical success or recurrence. [Display omitted] [ABSTRACT FROM AUTHOR]

The reported progression rate from low-grade dysplasia (LGD) in Barrett's esophagus (BE) to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) ranges from.4% to 13.4% per year. We hypothesize that some reported progression rates may be overestimated because of prevalent HGD or EAC that was not identified during endoscopic assessments performed in the community. Our aim is to determine the proportion of prevalent HGD or EAC detected by BE referral units (BERUs) in patients referred from the community with a recent diagnosis of LGD. All patients referred from the community to 6 BERUs with a diagnosis of BE with LGD were identified. Patients with an assessment endoscopy performed at BERUs more than 6 months from their referral endoscopy in the community were excluded. Visible lesions and histology outcomes were compared between the community referral endoscopy and the assessment endoscopy performed at BERUs. The median time between BERU assessment and referral endoscopy was 79 days (interquartile range, 54-114). Of the 75 patients referred from the community with LGD, BERU assessment identified HGD or EAC in 20 patients (27%). BERU assessment identified more visible lesions than referral endoscopy performed in the community (39 [52%] vs 9 [12%], respectively; P =.029). BERU assessment endoscopy identified more visible lesions than community referral endoscopy and identified HGD or EAC in 27% of patients referred from the community with a recent diagnosis of LGD. Reported progression rates from LGD to HGD or EAC may be overestimated. [ABSTRACT FROM AUTHOR]

Laterally spreading lesions (LSLs) in the duodenum are conventionally treated by EMR. Recurrence is commonly encountered and can be difficult to treat safely due to the unique anatomic characteristics of the duodenum. Auxiliary techniques designed to prevent recurrence have not been described. We sought to evaluate the effectiveness of thermal ablation of the defect margin after EMR (EMR-T) in reducing recurrence at first surveillance endoscopy (SE1, scheduled at 6 months) in a single tertiary referral center. All duodenal LSLs ≥10 mm referred for EMR were eligible. After successful EMR, thermal ablation was performed using snare-tip soft coagulation around the entire circumference of the resection defect. The primary outcome was the frequency of recurrence at SE1. A previous, well-characterized, prospective cohort of duodenal LSLs ≥10 mm treated by conventional EMR was the comparator. Over 43 months up to October 2019, 54 LSLs underwent EMR-T. One hundred twenty-five LSLs underwent conventional EMR in the comparator group. Patient and lesion characteristics were similar between the groups. Recurrence was significantly lower in the EMR-T group compared with the conventional EMR group (1 of 49 [2.3%] vs 19 of 108 [17.6%]; P =.01). No difference in technical success, EMR-related adverse outcomes, or referral to surgery were identified between the groups. EMR-T significantly reduces the frequency of recurrence for duodenal LSLs. This technique is safe in the duodenum and has the potential to significantly improve the effectiveness of duodenal EMR. (Clinical trial registration number: NCT02306603.) [ABSTRACT FROM AUTHOR]

There is a lack of clinical studies to establish indications and methodology for tattooing, therefore technique and practice of tattooing is very variable. We aimed to establish a consensus on the indications and appropriate techniques for colonic tattoo through a modified Delphi process. The baseline questionnaire was classified into 3 areas: where tattooing should not be used (1 domain, 6 questions), where tattooing should be used (4 domains, 20 questions), and how to perform tattooing (1 domain 20 questions). A total of 29 experts participated in the 3 rounds of the Delphi process. A total of 15 statements were approved. The statements that achieved the highest agreement were as follows: tattooing should always be used after endoscopic resection of a lesion with suspicion of submucosal invasion (agreement score, 4.59; degree of consensus, 97%). For a colorectal lesion that is left in situ but considered suitable for endoscopic resection, tattooing may be used if the lesion is considered difficult to detect at a subsequent endoscopy (agreement score, 4.62; degree of consensus, 100%). A tattoo should never be injected directly into or underneath a lesion that might be removed endoscopically at a later point in time (agreement score, 4.79; degree of consensus, 97%). Details of the tattoo injection should be stated clearly in the endoscopy report (agreement score, 4.76; degree of consensus, 100%). This expert consensus has developed different statements about where tattooing should not be used, when it should be used, and how that should be done. [ABSTRACT FROM AUTHOR]

Circumferential endoscopic submucosal dissection (cESD) in the esophagus has been reported to be feasible in small Eastern case series. We assessed the outcomes of cESD in the treatment of early esophageal squamous cell carcinoma (ESCC) in Western countries. We conducted an international study at 25 referral centers in Europe and Australia using prospective databases. We included all patients with ESCC treated with cESD before November 2022. Our main outcomes were curative resection according to European guidelines and adverse events. A total of 171 cESDs were performed on 165 patients. En bloc and R0 resections rates were 98.2% (95% confidence interval [CI], 95.0-99.4) and 69.6% (95% CI, 62.3-76.0), respectively. Curative resection was achieved in 49.1% (95% CI, 41.7-56.6) of the lesions. The most common reason for noncurative resection was deep submucosal invasion (21.6%). The risk of stricture requiring 6 or more dilations or additional techniques (incisional therapy/stent) was high (71%), despite the use of prophylactic measures in 93% of the procedures. The rates of intraprocedural perforation, delayed bleeding, and adverse cardiorespiratory events were 4.1%, 0.6%, and 4.7%, respectively. Two patients died (1.2%) of a cESD-related adverse event. Overall and disease-free survival rates at 2 years were 91% and 79%. In Western referral centers, cESD for ESCC is curative in approximately half of the lesions. It can be considered a feasible treatment in selected patients. Our results suggest the need to improve patient selection and to develop more effective therapies to prevent esophageal strictures. [ABSTRACT FROM AUTHOR]

Although sporadic duodenal and/or ampullary adenomas (DAs) are uncommon, they are increasingly diagnosed during upper endoscopy. These patients have a 3- to 7-fold increased risk of colonic neoplasia compared with the normal population. It is unknown, however, whether they also have an increased risk of additional small-bowel (SB) polyps. Our aim was to establish the prevalence of SB polyps in patients with DA. In a single-center, prospective study, we used video capsule endoscopy (VCE) to investigate the prevalence of SB polyps in patients with a DA compared with patients undergoing VCE for obscure GI bleeding or iron deficiency anemia. Over 25 months, 201 patients were enrolled in the study; the mean age was 65 years and 47% were male. There were 101 control patients and 100 cases of DA cases (mean size, 30 mm (range, 10-80 mm)). We did not identify any SB polyps in either group. Colonic polyps were found more frequently in the DA group compared with controls (61% versus 37%, respectively (P =.002)). Advanced colonic adenoma (high-grade dysplasia, >10 mm, villous histology) were found in 18% of the DA group and 5% of the control group (P =.018). Our data suggest that patients with a DA are not at risk for additional SB polyps and hence do not support screening with VCE. However, colonoscopy is mandatory due to the significantly higher risk of colonic polyps including advanced adenomas. (Clinical trial registration number: NCT02470416.) [ABSTRACT FROM AUTHOR]

In response to the coronavirus disease 2019 (COVID-19) pandemic, many jurisdictions and gastroenterological societies around the world have suspended nonurgent endoscopy. Subject to country-specific variability, it is projected that with current mitigation measures in place, the peak incidence of active COVID-19 infections may be delayed by over 6 months. Although this aims to prevent the overburdening of healthcare systems, prolonged deferral of elective endoscopy will become unsustainable. Herein, we propose that by incorporating readily available point-of-care tests and conducting accurate clinical risk assessments, a safe and timely return to elective endoscopy is feasible. Our algorithm not only focuses on the safety of patients and healthcare workers, but also assists in rationalizing the use of invaluable resources such as personal protective equipment. [ABSTRACT FROM AUTHOR]

Background and Aims Clinically significant post-EMR bleeding (CSPEB) is the most-frequent serious adverse event after EMR of large laterally spreading colonic lesions (LSLs). There is no proven prophylactic therapy, and it remains a significant drawback of EMR. We aimed to systematically describe and evaluate the features of the post-EMR mucosal defect (PED) and their relationship to CSPEB. Methods A prospective study of LSLs referred for EMR at a tertiary center was performed. PEDs without visible features were recorded as bland blue. Nonbland blue (NBB) PED features included size, number, and herniation of submucosal vessels and presence of submucosal hemorrhage, fibrosis, fat, and exposed muscle. NBB PEDs were analyzed for association with CSPEB, defined as bleeding occurring after completion of the procedure necessitating readmission or reintervention. Results From April 2012 to May 2017, 501 lesions in 501 patients were eligible for analysis. The frequency of CSPEB was 30 of 501 (6.0%). More than or equal to 3 visible vessels was a significant predictor of CSPEB (P =.016). None of the following showed a significant correlation with CSPEB: presence of visible vessels, their diameter, herniation, or other nonvascular PED features. Submucosal vessels were more common in the left-sided colon segment (88.6% vs 78.3%, P =.004) and were significantly larger (20.8% vs 12.1% ≥1 mm, P =.037), more numerous (median 4 vessels [interquartile range, 2-7] vs 2 vessels [interquartile range, 1-4], P <.001), and more often herniated (32% vs 22.2%, P =.022). Conclusions More than or equal to 3 visible vessels within the PED may be predictive for CSPEB and may define a target group for real-time prophylactic intervention. No other endoscopically visible features of the PEDs were predictive of CSPEB. (Clinical trial registration number: NCT03117400.) Graphical abstract [ABSTRACT FROM AUTHOR]

Large (≥20 mm) nonpedunculated colorectal polyps (LNPCPs) may have synchronous LNPCPs in up to 18% of cases. The nature of this relationship has not been investigated. We aimed to examine the relationship between individual LNPCP characteristics and synchronous colonic LNPCPs. Consecutive patients referred for resection of LNPCPs over 130 months until March 2022 were enrolled. Serrated lesions and mixed granularity LNPCPs were excluded from analysis. Patients with multiple LNPCPs resected were identified, and the largest was labelled as dominant. The primary outcome was the identification of individual lesion characteristics associated with the presence of synchronous LNPCPs. There were 3149 of 3381 patients (93.1%) who had a single LNPCP. In 232 (6.9%) a synchronous lesion was detected. Solitary lesions had a median size of 35 mm with a predominant Paris 0-IIa morphology (42.9%) and right colon location (59.5%). In patients with ≥2 LNPCPs, the dominant lesion had a median size of 40 mm, Paris 0-IIa (47.6%) morphology, and right colon location (65.9%). In this group, 35.8% of dominant LNPCPs were non-granular compared with 18.7% in the solitary LNPCP cohort. Non-granular (NG)-LNPCPs were more likely to demonstrate synchronous disease, with left colon NG-LNPCPs demonstrating greater risk (odds ratio, 4.78; 95% confidence interval, 2.95–7.73) than right colon NG-LNPCPs (odds ratio, 1.99; 95% confidence interval, 1.39–2.86). We found that 6.9% of LNPCPs have synchronous disease, with NG-LNPCPs demonstrating a greater than 4-fold increased risk. With post-colonoscopy interval cancers exceeding 5%, endoscopists must be cognizant of an individual's LNPCP phenotype when examining the colon at both index procedure and surveillance. ClinicalTrials.gov , NCT01368289; NCT02000141; NCT02198729. [ABSTRACT FROM AUTHOR]

Background and Aims Wire-guided biliary cannulation has been demonstrated to improve cannulation rates and reduce post-ERCP pancreatitis (PEP), but the impact of wire caliber has not been studied. This study compares successful cannulation rates and ERCP adverse events by using a 0.025-inch and 0.035-inch guidewire. Methods A randomized, single blinded, prospective, multicenter trial at 9 high-volume tertiary-care referral centers in the Asia-Pacific region was performed. Patients with an intact papilla and conventional anatomy who did not have malignancy in the head of the pancreas or ampulla and were undergoing ERCP were recruited. ERCP was performed by using a standardized cannulation algorithm, and patients were randomized to either a 0.025-inch or 0.035-inch guidewire. The primary outcomes of the study were successful wire-guided cannulation and the incidence of PEP. Overall successful cannulation and ERCP adverse events also were studied. Results A total of 710 patients were enrolled in the study. The primary wire-guided biliary cannulation rate was similar in 0.025-inch and 0.035-inch wire groups (80.7% vs 80.3%; P = .90). The rate of PEP between the 0.025-inch and the 0.035-inch wire groups did not differ significantly (7.8% vs 9.3%; P = .51). No differences were noted in secondary outcomes. Conclusion Similar rates of successful cannulation and PEP were demonstrated in the use of 0.025-inch and 0.035-inch guidewires. (Clinical trial registration number: NCT01408264.) [ABSTRACT FROM AUTHOR]

Endoscopic mucosal resection (EMR) should be the preferred method of removal for colonic laterally spreading lesions ≥2 cm in size since it is safer, more efficient, and more cost-effective than endoscopic submucosal dissection or surgery. Although competent endoscopists should be comfortable in removing colonic lesions up to 2 cm in size, removal of larger laterally spreading lesions by modern EMR requires advanced skills and meticulous execution of systematic technique to minimize incomplete resection and subsequent interval cancer. Determinations of competency in EMR are important to minimize patient risks and maximize patient outcomes. Assessments of competency may include procedural volumes, direct observational tools, simulators, and other metrics. Advanced training in EMR should be systematic, competency-based; learner- and patient-centered; and must include continual assessment, feedback, reflection, analysis ,and application of identified strategies for improvement. Two models for EMR training, in both the postgraduate and continuing education settings, are proposed along with resources for learning. [ABSTRACT FROM AUTHOR]

Background and Aims EMR of large laterally spreading lesions (LSL) in the colon is a safe and effective alternative to surgery. Post-EMR scar assessment currently involves taking biopsy specimens of the scar to detect residual or recurrent adenoma (RRA). The accuracy of endoscopic imaging of the post-EMR scar is unknown. We aimed to determine the accuracy of a standardized imaging protocol in post-EMR scar assessment. Methods Prospective, single-center data from the Australian Colonic EMR study were analyzed. Consecutive patients undergoing first surveillance colonoscopy (SC1) after EMR of a large LSL were eligible. All scars were sequentially examined with high-definition white light (HD-WL) and narrow-band imaging (NBI) in a standardized fashion and then biopsies were performed. Endoscopic recurrence (recurrence at the post-EMR scar detected by systematic endoscopic assessment) was compared with the histologic findings. Results One hundred eighty-three post-EMR scars were included. Thirty of 183 (16.4%) were confirmed to have RRA histologically at SC1. Thirty-seven of 183 (20.2%) post-EMR scars demonstrated RRA endoscopically. The sensitivity and specificity of endoscopic RRA detection were 93.3% (95% confidence interval [CI], 77.9%-99.2%) and 94.1% (95% CI, 89.1%-97.3%), respectively. The positive predictive value was 75.7% (95% CI, 58.8%-88.2%) and the negative predictive value was 98.6% (95% CI, 95.1%-99.8%). The diagnostic accuracy was 94.0%. Sensitivity was higher for the combination of HD-WL and NBI as opposed to HD-WL alone (93.3% vs 66.7%). The specificity was high for both HD-WL and HD-WL + NBI (96.1% and 94.1%, respectively). Flat morphology of RRA was better seen with NBI ( P = .002). Conclusions Endoscopic detection of RRA in the post-EMR scar is highly accurate using a standardized imaging protocol with HD-WL and NBI. This allows real-time, accurate detection of recurrence and its concurrent treatment, and raises the possibility that routine biopsy of the post-EMR scar may not be necessary. [ABSTRACT FROM AUTHOR]

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are complementary techniques for large (≥20 mm) nonpedunculated rectal polyps (LNPRPs). A mechanism for appropriate technique selection has not been described. We evaluated the performance of a selective resection algorithm (SRA) (August 2017 to April 2021) compared with a universal EMR algorithm (UEA) (July 2008 to July 2017) for LNPRPs within a prospective observational study. In the SRA, LNPRPs with features of superficial submucosal invasive cancer (SMIC) (<1000 μm; Kudo pit pattern Vi), or with an increased risk of SMIC (Paris 0-Is or 0-IIa+Is nongranular, 0-IIa+Is granular with a dominant nodule ≥10 mm) underwent ESD. The remaining LNPRPs underwent EMR. Algorithm performance was evaluated by SMIC identified after EMR, curative oncologic resection (R0 resection, superficial SMIC, absence of negative histologic features), technical success, adverse events, and recurrence at first surveillance colonoscopy. A total of 480 LNPRPs were evaluated (290 UEA, 190 SRA). Median lesion size was 40 (interquartile range, 30–60) mm. SMIC was identified in 56 (11.7%) LNPRPs. Significant differences in SMIC after EMR (SRA 1 [1.0%] vs UEA 35 [12.1%]; P =.001) and curative oncologic resection (SRA n = 7 [33.3%] vs UEA n = 2 [5.7%]; P =.010) were identified. No significant differences in technical success or adverse events were identified (all P >.137). Among LNPRPs with SMIC amenable to curative oncologic resection and which underwent ESD, 100% (n = 7 of 7) were cured. A rectum-specific SRA optimizes oncologic outcomes for LNPRPs and mitigates the risk of piecemeal resection of cancers. [Display omitted] [ABSTRACT FROM AUTHOR]

After EMR, prophylactic clipping is often performed to prevent clinically significant post-EMR bleeding (CSPEB) and other adverse events (AEs). Prior evidence syntheses have lacked sufficient power to assess clipping in relevant subgroups or in nonbleeding AEs. We performed a meta-analysis of individual patient data (IPD) from randomized trials assessing the efficacy of clipping to prevent AEs after EMR of proximal large nonpedunculated colorectal polyps (LNPCPs) ≥20 mm. We searched EMBASE, MEDLINE, Cochrane Central Registry of Controlled Trials, and PubMed from inception to May 19, 2021. Two reviewers screened citations in duplicate. Corresponding authors of eligible studies were invited to contribute IPD. A random-effects 1-stage model was specified for estimating pooled effects, adjusting for patient sex and age and for lesion location and size, whereas a fixed-effects model was used for traditional meta-analyses. From 3145 citations, 4 trials were included, representing 1248 patients with proximal LNPCPs. The overall rate of CSPEB was 3.5% and 9.0% in clipped and unclipped patients, respectively. IPD were available for 1150 patients, in which prophylactic clipping prevented CSPEB with an odds ratio (OR) of.31 (95% confidence interval [CI],.17-.54). Clipping was not associated with perforation or abdominal pain, with ORs of.78 (95% CI,.17-3.54) and.67 (95% CI,.20-2.22), respectively. Prophylactic clipping is efficacious in preventing CSPEB after EMR of proximal LNPCPs. Therefore, clip closure should be considered a standard component of EMR of LNPCPs in the proximal colon. [Display omitted] [ABSTRACT FROM AUTHOR]

Background and Aims Large sporadic duodenal adenomas are uncommon but they harbor malignant potential, which requires consideration of definitive treatment. EMR is gaining acceptance as an effective and safe alternative to high-risk surgical procedures, but data on long-term outcomes are limited. Herein we describe the short- and long-term outcomes of these lesions in a tertiary referral center. Methods Prospectively collected data were analyzed to identify risk factors for adverse events and outcomes. Patient demographics, lesion characteristics, and procedural technical data were collected. Results From 2007 to 2015, 106 adenomas ≥10 mm were resected (mean patient age, 69 years; 54% male; median size, 25 mm; interquartile range [IQR], 19–40). Complete endoscopic resection was achieved in 96%. Intraprocedural bleeding occurred in 43% of cases and was associated with lesion size ( P < .001), number of resected specimens ( P = .003), and longer procedures ( P = .001). Delayed bleeding occurred in 15% (56% did not require active intervention) and was associated with lesion size ( P = .03). Perforation occurred in 3 patients. The 30-day mortality was 0%. Median follow-up was 22 months (IQR, 7–45). Histologically proven adenoma recurrence was identified and treated in 12 of 83 patients (14.4%) on first surveillance endoscopy. For the 53 patients for whom follow-up ≥12 months was available (median follow-up, 36 months; IQR, 24–51), 48 patients (90.6%) were free of adenoma and considered cured. Conclusions In a tertiary referral center, endoscopic resection of duodenal adenomas is a safe and effective alternative to surgery. Lesion size is strongly associated with adverse events, particularly intraprocedural bleeding and delayed bleeding. Good long-term outcomes are demonstrated. [ABSTRACT FROM AUTHOR]

Background and Aims Laterally spreading lesions ≥20 mm are conventionally removed by EMR. Endoscopic clips are increasingly used to mitigate the risk of delayed bleeding. Clips may alter the endoscopic appearance of the scar after EMR, interfering with the assessment of adenoma recurrence. We aimed to evaluate this. Methods Prospective, single-center data from the Australian Colonic Endoscopic resection study (January 2011-May 2015) were analyzed. Patients undergoing EMR of laterally spreading lesions with endoscopic clips used at the EMR defect were eligible. Data included patient and lesion characteristics and procedural, clinical, and histologic outcomes. Results Clips were used in 111 of 885 lesions (12.5%). A total of 62 of 111 clipped lesions had standardized, high-definition, white light, and narrow-band images of the scars after EMR at first surveillance colonoscopy, and the patients were enrolled. Analysis of the images showed 4 situations: a bland scar (N = 27), residual adenoma (N = 6), mucosal elevation with normal pit pattern (N = 14), or granulation tissue related to the presence of residual clips (N = 15). The latter 2 entities were termed post-EMR scar clip artifact (ESCA). Overall, 29 of 62 previously clipped EMR sites (46.8%) had ESCA at a median follow-up of 5.2 months. Twenty scars had residual clips, and 15 of 20 (75.0%) showed ESCA ( P = .002). Lesions clipped for prophylaxis of bleeding were more likely to show ESCA than those clipped for deep mural injury or intraprocedural bleeding (65.5% vs 41.7%; P = .006). ESCA was associated with female sex ( P = .010) and greater age ( P = .011). Conclusions ESCA is characterized by a nodular elevation of the mucosa with a normal pit pattern and can occur with or without residual clips. Prophylactic clip closure and the presence of residual clips are associated with ESCA. (Clinical trial registration number: NCT01368289 .) [ABSTRACT FROM AUTHOR]

Background and Aims Complete endoscopic resection (CER) of Barrett’s esophagus (BE) with high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EEA) is a comprehensive and precise staging tool and may produce a sustained treatment response, preventing metachronous disease. There are limited data on long-term clinical outcomes and the sustainability of dysplasia eradication after CER. We aimed to describe long-term outcomes of a primary CER strategy of BE with HGD/EEA. Methods Patients with biopsy-proven HGD and EEA in short-segment BE (≤3 cm in circumferential length and ≤5 cm in maximal length) underwent staged CER by multiband mucosectomy or the cap method. The primary endpoint was remission of HGD or EEA (complete resection of HGD/EEA), dysplasia (complete resection of any dysplasia), and complete resection of intestinal metaplasia. Results Of 153 patients (126 HGD, 27 EEA; 83.7% male, median age of 66 years) considered suitable for CER, 138 met all inclusion criteria. CER was technically successful in all patients and was established after a median of 2 sessions. Covert synchronous EEA was found in 1 patient. At a mean follow-up of 40.7 months by intention-to-treat analysis, complete remission of HGD/EEA, dysplasia, and intestinal metaplasia was achieved in 98.5%, 89.1%, and 71.0%, respectively. In 47.1% of patients, CER changed the histological grade compared with pretreatment biopsies (28.1% downstaged and 19.0% upstaged). Esophageal dilation was performed in 36.8% in a mean of 2.5 sessions. At the end of follow-up, 96.4% of patients had no or minimal dysphagia and 90.6% of patients found CER an acceptable treatment. Conclusions On long-term follow-up, a primary CER strategy was a highly effective, safe, and durable treatment for HGD and EEA. Despite the need for post-CER dilation in one-third of patients, the majority found it an acceptable treatment on long-term follow-up. [ABSTRACT FROM AUTHOR]

Background Cold snare polypectomy (CSP) is widely practiced; however, the endoscopic features of the CSP mucosal defect have not been studied. In particular, protrusions within the cold snare defect (CSDPs) may create concern for residual polyp. The frequency and constituents of this phenomenon are unknown. Objective To describe the frequency, predictors, and histologic constituents of CSDPs. Design Prospective observational study. Setting Tertiary-care hospital endoscopy unit. Patients Eighty-eight consecutive patients undergoing CSP for a polyp ≤ 10 mm in size. Intervention Inspection of the cold snare mucosal defect with high-definition white light and biopsy sampling of CSDPs for separate histologic assessment, when present. Main Outcome Measurement Frequency and constituents of CSDPs. Results Two hundred fifty-seven consecutive polyps ≤ 10 mm in size were removed in 88 patients (50 men [57%], mean age 63 years). Polyps were predominately adenomatous (162, 63%), located in the proximal colon (159, 62%) and flat (200, 78%). Mean lesion size was 5.5 mm (range, 2-10 mm). High-grade dysplasia was present in a single polyp for which the defect was bland. CSDPs occurred in 36 polypectomies (14%). CSDPs were associated with polyp size ≥ 6 mm (odds ratio, 3.7; P < .001 multivariable analysis) but not age, sex, lesion, histopathology, morphology, or location. Histopathologic examination of CSDPs revealed submucosa in 34 (94%) and muscularis mucosa in 29 (80%). No residual adenomatous or serrated polyp tissue was detected. Limitations Single-center study. Small number of polyps with high-grade dysplasia. Conclusion Protrusions are common within the CSP mucosal defect and are associated with polyp size ≥ 6 mm. CSDPs do not represent vascular structures, do not contain residual polyp, and are not associated with adverse outcomes in short-term follow-up. However, CSDPs represent incomplete mucosal layer resection. [ABSTRACT FROM AUTHOR]

Background Barrett’s esophagus with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC) can be effectively treated by single-session EMR, resulting in complete Barrett’s excision (CBE). CBE provides accurate histology for staging and clinical confirmation of neoplasia eradication but is limited by a high risk of esophageal stricture formation. Objective To evaluate the effectiveness of prophylactic temporary esophageal stenting to prevent post-CBE stricture formation. Design and Setting Single-center, investigator-initiated feasibility study. Patients Circumferential, short-segment Barrett’s esophagus (≤C3≤M5) with HGD or IMC. Intervention Single-stage CBE and insertion of a fully covered metal esophageal stent at 10 days that was removed at 8 weeks. Patients were followed for a minimum of 2 surveillance endoscopies. Main Outcome Measurement Symptomatic esophageal stricture formation. Results At the end of the follow-up period, 8 patients (57.1%) required esophageal dilation for symptomatic CBE-related (n = 7) or stent-related (n = 4) strictures. A median of 3 surveillance endoscopies were performed over a median endoscopic follow-up of 17 months (range 4-25 months). Single-stage CBE successfully eliminated Barrett’s intestinal metaplasia and neoplasia in 71.4% and 92.9% of patients, respectively. Four patients were admitted to the hospital, and 4 patients had early stent removal because of pain or dysphagia. Limitations Single-center feasibility study. Conclusions In a prospective study evaluating prophylactic esophageal stent insertion after single-stage CBE, esophageal strictures formed in more than of half the study cohort, and stents were associated with significant morbidity. An alternative method to reduce stricture formation is required. (Clinical trial registration number: NCT01554280 .) [ABSTRACT FROM AUTHOR]

Despite the significant advances made in the diagnosis and treatment of Barrett's esophagus (BE), there is still a need for standardized definitions, appropriate recognition of endoscopic landmarks, and consistent use of classification systems. Current controversies in basic definitions of BE and the relative lack of anatomic knowledge are significant barriers to uniform documentation. We aimed to provide consensus-driven recommendations for uniform reporting and global application. The World Endoscopy Organization Barrett's Esophagus Committee appointed leaders to develop an evidence-based Delphi study. A working group of 6 members identified and formulated 23 statements, and 30 internationally recognized experts from 18 countries participated in 3 rounds of voting. We defined consensus as agreement by ≥80% of experts for each statement and used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to assess the quality of evidence and the strength of recommendations. After 3 rounds of voting, experts achieved consensus on 6 endoscopic landmarks (palisade vessels, gastroesophageal junction, squamocolumnar junction, lesion location, extraluminal compressions, and quadrant orientation), 13 definitions (BE, hiatus hernia, squamous islands, columnar islands, Barrett's endoscopic therapy, endoscopic resection, endoscopic ablation, systematic inspection, complete eradication of intestinal metaplasia, complete eradication of dysplasia, residual disease, recurrent disease, and failure of endoscopic therapy), and 4 classification systems (Prague, Los Angeles, Paris, and Barrett's International NBI Group). In round 1, 18 statements (78%) reached consensus, with 12 (67%) receiving strong agreement from more than half of the experts. In round 2, 4 of the remaining statements (80%) reached consensus, with 1 statement receiving strong agreement from 50% of the experts. In the third round, a consensus was reached on the remaining statement. We developed evidence-based, consensus-driven statements on endoscopic landmarks, definitions, and classifications of BE. These recommendations may facilitate global uniform reporting in BE. [ABSTRACT FROM AUTHOR]

Background EMR of advanced mucosal neoplasia (AMN) (ie, sessile or laterally spreading lesions of ≥20 mm) of the colon has become an increasingly popular alternative to surgical resection. However, data regarding safety and mortality of EMR in comparison to surgery are limited. Objective To compare actual endoscopic with predicted surgical mortality. Design Prospective, observational, multicenter cohort study. Setting Academic, high-volume, tertiary-care referral center. Patients Consecutive patients referred for EMR. Intervention EMR. Main Outcome Measurements To predict hypothetical surgical mortality, the Association of Coloproctology of Great Britain and Ireland score, composed of physiological and surgical components, was calculated for each patient. Predicted surgical mortality was then compared with actual outcomes of EMR. The results were validated by an unselected subcohort by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity. Results Among 1050 patients with AMN treated by EMR, including patients with a predicted mortality rate of greater than 5% (13.8% of cohort), no deaths occurred within 30 days after the procedure. The predicted surgical mortality rate was 3.3% with the Association of Coloproctology of Great Britain and Ireland score ( P < .0001). This suggests a significant advantage of EMR over surgery. The results were validated by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity in 390 patients predicting a surgical mortality rate of 3.2% ( P = .0003). Limitations Nonrandomized study. Conclusion In this large multicenter study of EMR for colonic AMN, the predicted surgical mortality rate was significantly higher than the actual endoscopic mortality rate. Given that endoscopic therapy is less morbid and less expensive than surgery and can be performed as an outpatient treatment, it should be considered as the first line of treatment for most patients with these lesions. [ABSTRACT FROM AUTHOR]