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Background:  Piecemeal endoscopic mucosal resection (EMR) of large (≥ 20 mm) nonpedunculated colorectal polyps (LNPCPs) is succeeded by a 6-month surveillance endoscopy to evaluate the post-EMR scar for recurrence. Data from expert centers suggest that routine tattoo placement and scar biopsies can be omitted, but data from community hospitals are lacking., Methods:  The agreement between optical assessment and histological confirmation by routine biopsies was evaluated in a post-hoc analysis of the STAR-LNPCP study (NTR7477), containing prospective data on 6-month post-EMR scar assessments in 30 Dutch community hospitals (October 2019 to May 2022). A standardized protocol was followed for documentation of optical characteristics, imaging, and biopsy of the post-EMR scar. RESULTS : In 1277 post-EMR scar assessments, identification of the scar was achieved in 1215/1277 (95 %). Tattoo placement did not influence scar identification. Scar biopsy was performed in 1050/1215 cases (86 %). Recurrences were seen in 200/1050 cases (19 %). There was good agreement between optical assessment of recurrence and histological confirmation (Cohen's kappa 0.78 [95 %CI 0.73-0.83]). The negative and positive predictive values were 98 % (95 %CI 97 %-99 %) and 74 % (95 %CI 68 %-80 %), respectively. A higher false-positive rate was seen after prior use of clips (11 % vs. 5 %; P  = 0.02). Dedicated endoscopists identified the scar more often (96 % vs. 88 %; P  < 0.001), and showed a lower optical recurrence miss rate (1 % vs. 3 %; P  = 0.11) compared with nondedicated endoscopists. CONCLUSION : Based on this multicenter community hospital study, routine tattoo placement and scar biopsies of the post-EMR scar can be omitted. Assessment of post-EMR scars by dedicated endoscopists is advised., Competing Interests: P. Siersema received grants or speaker’s fees from Pentax Japan, The E-Nose Company The Netherlands, Microtech China, Lucid Diagnostics USA, Magentiq Eye Israel, Norgine UK/The Netherlands, and Motus GI USA. M. Pellisé has received speaker’s fees from Norgine Iberia (2018–2023), Casen Recordati (2016 – 2019), Olympus (2018, 2022), Jansen (2018), Medtronic (2022), Fujifilm (2022); a consultancy fee GI Supply (2019), Fujifilm Europe (2022) and research funding from Fujifilm (2019–2021), Casen Recordati (2020); Ziuz (2021); 3-DMatrix (2021); her department has received loan material from Fujifilm (2017– ongoing), a consultancy service with Olympus (2022-ongoing); She is Board member of ESGE and AEG; and has received a fee from Thieme as an Endoscopy Co-Editor (2015–2021). She has shared actions of MiWendo. M. Bourke received research support for ethics-approved studies from Boston Scientific, Cook Medical, and Olympus Medical. A. Masclee received research grants from the Dutch Cancer Society (KWF) and the Dutch Organization for Health Research and Innovation (ZonMW). L. Moons acts as a consultant for Boston Scientific.The other authors disclose no competing interests., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Background:  Recognition of submucosal invasive colorectal cancer (T1 CRC) is difficult, with sensitivities of 35 %-60 % in Western countries. We evaluated the real-life effects of training in the OPTICAL model, a recently developed structured and validated prediction model, in Dutch community hospitals., Methods:  In this prospective multicenter study (OPTICAL II), 383 endoscopists from 40 hospitals were invited to follow an e-learning program on the OPTICAL model, to increase sensitivity in detecting T1 CRC in nonpedunculated polyps. Real-life recognition of T1 CRC was then evaluated in 25 hospitals. Endoscopic and pathologic reports of T1 CRCs detected during the next year were collected retrospectively, with endoscopists unaware of this evaluation. Sensitivity for T1 CRC recognition, R0 resection rate, and treatment modality were compared for trained vs. untrained endoscopists., Results:  1 year after e-learning, 528 nonpedunculated T1 CRCs were recorded for endoscopies performed by 251 endoscopists (118 [47 %] trained). Median T1 CRC size was 20 mm. Lesions were mainly located in the distal colorectum (66 %). Trained endoscopists recognized T1 CRCs more frequently than untrained endoscopists (sensitivity 74 % vs. 62 %; mixed model analysis odds ratio [OR] 2.90, 95 %CI 1.54-5.45). R0 resection rate was higher for T1 CRCs detected by trained endoscopists (69 % vs. 56 %; OR 1.73, 95 %CI 1.03-2.91)., Conclusion:  Training in optical recognition of T1 CRCs in community hospitals was associated with increased recognition of T1 CRCs, leading to higher en bloc and R0 resection rates. This may be an important step toward more organ-preserving strategies., Competing Interests: The authors declare that P. Siersema received grants or speaker's fees from Pentax Japan, The E-Nose Company The Netherlands, Microtech China, Lucid Diagnostics USA, Magentiq Eye Israel, Norgine UK/The Netherlands, and Motus GI USA; A. Masclee received research grants from the Dutch Cancer Society (KWF) and the Dutch Organization for Health Research and Innovation (ZonMW); L. Moons acts as a consultant for Boston Scientific. The other authors declare that no conflicts of interest exist., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Background: Complete endoscopic resection and accurate histological evaluation for T1 colorectal cancer (CRC) are critical in determining subsequent treatment. Endoscopic full-thickness resection (eFTR) is a new treatment option for T1 CRC < 2 cm. We aimed to report clinical outcomes and short-term results., Methods: Consecutive eFTR procedures for T1 CRC, prospectively recorded in our national registry between November 2015 and April 2020, were retrospectively analyzed. Primary outcomes were technical success and R0 resection. Secondary outcomes were histological risk assessment, curative resection, adverse events, and short-term outcomes., Results: We included 330 procedures: 132 primary resections and 198 secondary scar resections after incomplete T1 CRC resection. Overall technical success, R0 resection, and curative resection rates were 87.0 % (95 % confidence interval [CI] 82.7 %-90.3 %), 85.6 % (95 %CI 81.2 %-89.2 %), and 60.3 % (95 %CI 54.7 %-65.7 %). Curative resection rate was 23.7 % (95 %CI 15.9 %-33.6 %) for primary resection of T1 CRC and 60.8 % (95 %CI 50.4 %-70.4 %) after excluding deep submucosal invasion as a risk factor. Risk stratification was possible in 99.3 %. The severe adverse event rate was 2.2 %. Additional oncological surgery was performed in 49/320 (15.3 %), with residual cancer in 11/49 (22.4 %). Endoscopic follow-up was available in 200/242 (82.6 %), with a median of 4 months and residual cancer in 1 (0.5 %) following an incomplete resection., Conclusions: eFTR is relatively safe and effective for resection of small T1 CRC, both as primary and secondary treatment. eFTR can expand endoscopic treatment options for T1 CRC and could help to reduce surgical overtreatment. Future studies should focus on long-term outcomes., Competing Interests: Prof. dr. Fockens reports personal fees from Cook, Ethicon and Olympus, research support from Boston Scientific, outside the submitted work. Prof. dr. Dekker has endoscopic equipment on loan of FujiFilm, received a research grant from FujiFilm, received a honorarium for consultancy from FujiFilm, Olympus, Tillots, GI Supply and CPP-FAP and a speakers' fee from Olympus, Roche and GI Supply. Prof. dr. Weusten received research support from Pentax Medical Inc and Aqua Medical, outside the submitted work. Dr. Bastiaansen received a speakers’ fee from Olympus, Tillotts Pharma AG and Ovesco Endoscopy AG. All other authors have nothing to disclose., (Thieme. All rights reserved.)

Background: Endoscopic full-thickness resection (eFTR) is a minimally invasive resection technique that allows definite diagnosis and treatment for complex colorectal lesions ≤ 30 mm unsuitable for conventional endoscopic resection. This study reports clinical outcomes from the Dutch colorectal eFTR registry., Methods: Consecutive patients undergoing eFTR in 20 hospitals were prospectively included. The primary outcome was technical success, defined as macroscopic complete en bloc resection. Secondary outcomes were: clinical success, defined as tumor-free resection margins (R0 resection); full-thickness resection rate; and adverse events. RESULTS : Between July 2015 and October 2018, 367 procedures were included. Indications were difficult polyps (non-lifting sign and/or difficult location; n = 133), primary resection of suspected T1 colorectal cancer (CRC; n = 71), re-resection after incomplete resection of T1 CRC (n = 150), and subepithelial tumors (n = 13). Technical success was achieved in 308 procedures (83.9 %). In 21 procedures (5.7 %), eFTR was not performed because the lesion could not be reached or retracted into the cap. In the remaining 346 procedures, R0 resection was achieved in 285 (82.4 %) and full-thickness resection in 288 (83.2 %). The median diameter of resected specimens was 23 mm. Overall adverse event rate was 9.3 % (n = 34/367): 10 patients (2.7 %) required emergency surgery for five delayed and two immediate perforations and three cases of appendicitis. CONCLUSION : eFTR is an effective and relatively safe en bloc resection technique for complex colorectal lesions with the potential to avoid surgery. Further studies assessing the role of eFTR in early CRC treatment with long-term outcomes are needed., Competing Interests: P. Fockens receives personal fees from Cook, Ethicon, and Olympus, and research support from Boston Scientific outside the submitted work. E. Dekker has endoscopic equipment on loan from FujiFilm, and has received a research grant from FujiFilm, consultancy fees from FujiFilm, Olympus, Tillotts, GI Supply, and CPP-FAP, and speaker’s fees from Olympus, Roche, and GI Supply. B. Bastiaansen has received speaker’s fees from Olympus, Tillotts Pharma AG, and Ovesco Endoscopy AG. The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background and Study Aims: Endoscopic optical diagnosis can potentially replace histopathological evaluation of small colorectal lesions. The aim of this study was to evaluate diagnostic performance of WavSTAT, a novel system for automatic optical diagnosis based on laser-induced autofluorescence spectroscopy., Patients and Methods: Consecutive patients who were scheduled for colonoscopy were included in the study. Each detected lesion with a size of ≤ 9 mm was differentiated using high resolution endoscopy (HRE) by the endoscopist, who then reported this as a low or high confidence call. Thereafter, all lesions were analyzed using WavSTAT. Histopathology was used as the reference standard. The primary outcome measures were the accuracy of WavSTAT to differentiate between adenomatous and nonadenomatous lesions, and the accuracy of an algorithm combining HRE (lesions differentiated with high confidence) and WavSTAT (all remaining lesions). The secondary outcome measure was the accuracy of on-site recommended surveillance intervals., Results: At total of 87 patients with 207 small colorectal lesions were evaluated. Accuracy and negative predictive value of WavSTAT were 74.4 % and 73.5 %, respectively. The corresponding figures for the algorithm were 79.2 % and 73.9 %, respectively. Accuracy of on-site recommended surveillance interval was 73.7 % for WavSTAT alone and 77.2 % for the algorithm of HRE and WavSTAT., Conclusions: Both accuracy of WavSTAT alone and the algorithm combining HRE with WavSTAT proved to be insufficient for the in vivo differentiation of small colorectal lesions, and do not fulfill American Society for Gastrointestinal Endoscopy performance thresholds for assessment of diminutive lesions. Future studies should assess whether combining WavSTAT with more advanced imaging techniques could result in a higher accuracy.Netherlands Trial Registry (NTR 3235)., (© Georg Thieme Verlag KG Stuttgart · New York.)