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Background This study evaluated the safety and efficacy of salvage endoscopic submucosal dissection (ESD) for Barrett's neoplasia recurrence after radiofrequency ablation (RFA). Methods Data from patients at 16 centers were collected for a multicenter retrospective study. Patients who underwent at least one RFA treatment for Barrett's esophagus and thereafter underwent further esophageal ESD for neoplasia recurrence were included. Results Data from 56 patients who underwent salvage ESD between April 2014 and November 2022 were collected. Immediate complications included one muscular tear (1.8%) treated with stent (Agree classification: grade IIIa). Two transmural perforations (3.6%; treated with clips) and five muscular tears (8.9%; two treated with clips) had no clinical impact and were not considered as adverse events. Seven patients (12.5%) developed strictures (grade IIIa), which were treated with balloon dilation. Histological analysis showed 36 adenocarcinoma, 17 high grade dysplasia, and 3 low grade dysplasia. En bloc and R0 resection rates were 89.3% and 66.1%, respectively. Resections were curative in 33 patients (58.9%), and noncurative in 22 patients (39.3%), including 11 "local risk" (19.6%) and 11 "high risk" (19.6%) resections. At the end of follow-up with a median time of 14 (0–75) months after salvage ESD, and with further endoscopic treatment if necessary (RFA, argon plasma coagulation, endoscopic mucosal resection, ESD), neoplasia remission ratio was 37/53 (69.8%) and the median remission time was 13 (1–75) months. Conclusion In expert hands, salvage ESD was a safe and effective treatment for recurrence of Barrett's neoplasia after RFA treatment. [ABSTRACT FROM AUTHOR]

Background Recognition of submucosal invasive cancer (SMIC) in large (≥20 mm) nonpedunculated colonic polyps (LNPCPs) informs selection of the optimal resection strategy. LNPCP location, morphology, and size influence the risk of SMIC; however, currently no meaningful application of this information has simplified the process to make it accessible and broadly applicable. We developed a decision-making algorithm to simplify the identification of LNPCP subtypes with increased risk of potential SMIC. Methods Patients referred for LNPCP resection from September 2008 to November 2022 were enrolled. LNPCPs with SMIC were identified from endoscopic resection specimens, lesion biopsies, or surgical outcomes. Decision tree analysis of lesion characteristics identified in multivariable analysis was used to create a hierarchical classification of SMIC prevalence. Results 2451 LNPCPs were analyzed: 1289 (52.6%) were flat, 1043 (42.6%) nodular, and 118 (4.8%) depressed. SMIC was confirmed in 273 of the LNPCPs (11.1%). It was associated with depressed and nodular vs. flat morphology (odds ratios [ORs] 35.7 [95%CI 22.6–56.5] and 3.5 [95%CI 2.6–4.9], respectively; P <0.001); rectosigmoid vs. proximal location (OR 3.2 [95%CI 2.5–4.1]; P <0.001); nongranular vs. granular appearance (OR 2.4 [95%CI 1.9–3.1]; P <0.001); and size (OR 1.12 per 10-mm increase [95%CI 1.05–1.19]; P <0.001). Decision tree analysis targeting SMIC identified eight terminal nodes: SMIC prevalence was 62% in depressed LNPCPs, 19% in nodular rectosigmoid LNPCPs, and 20% in nodular proximal colon nongranular LNPCPs. Conclusions This decision-making algorithm simplifies identification of LNPCPs with an increased risk of potential SMIC. When combined with surface optical evaluation, it facilitates accurate lesion characterization and resection choices. [ABSTRACT FROM AUTHOR]

Background Non-achalasia esophageal motility disorders (NAEMDs), encompassing distal esophageal spasm (DES) and hypercontractile esophagus (HCE), are rare conditions. Peroral endoscopic myotomy (POEM) is a promising treatment option. In NAEMDs, unlike with achalasia, the lower esophageal sphincter (LES) functions normally, suggesting the potential of LES preservation during POEM. Methods This retrospective two-center observational study focused on patients undergoing LES-preserving POEM (LES-POEM) for NAEMD. Eckardt scores were assessed pre-POEM and at 6, 12, and 24 months post-POEM, with follow-up endoscopy at 6 months to evaluate for reflux esophagitis. Clinical success, defined as an Eckardt score ≤3, served as the primary outcome. Results 227 patients were recruited over 84 months until May 2021. Of these, 16 underwent LES-POEM for an NAEMD (9 with HCE and 7 with DES). The median pre-POEM Eckardt score was 6.0 (interquartile range [IQR] 5.0–7.0), which decreased to 1.0 (IQR 0.0–1.8; P <0.001) 6 months post-POEM. This was sustained at 24 months, with an Eckardt score of 1.0 (IQR 0.0–1.8; P<0.001). Two patients (12.5%) developed Los Angeles grade A or B esophagitis. Conclusions LES-POEM for NAEMD demonstrates favorable clinical outcomes, with infrequent esophagitis and reintervention for LES dysfunction rarely required. [ABSTRACT FROM AUTHOR]

Background Cold snare polypectomy (CSP) is safer than and equally efficacious as hot snare polypectomy (HSP) for the removal of small (<10mm) colorectal polyps. The maximum polyp size that can be effectively managed by piecemeal CSP (p-CSP) without an excessive burden of recurrence is unknown. Methods Resection error risks (RERs), defined as the estimated likelihood of incomplete removal of adenomatous tissue for a single snare resection pass, for CSP and HSP were calculated, based on an incomplete resection rate. Polyp area, snare size, estimated number of resections, and optimal resection defect area were modeled. Overall risk of incomplete resection (RIR) was defined as RIR=1 – (1 – p)n, where p is the RER and n the number of resections. Results A 40-mm polyp has a four times greater area than a 20-mm polyp (314.16mm2 vs. 1256.64mm2), and requires three times more resections (11 vs. 33, respectively, assuming 8-mm piecemeal resection pieces for p-CSP). RIRs for a 40-mm polyp by HSP and p-CSP were 15.1%–23% and 40.74%–60.60% respectively. Conclusion RER is more important with p-CSP than with HSP. The number of resections, n, and consequently RIR increases with increasing polyp size. Given the overwhelming safety of CSP, specific techniques to minimize the RER should be studied and developed. [ABSTRACT FROM AUTHOR]

Background Large (≥20mm) adenomatous anastomotic polyps (LAAPs) are uncommon. Data pertaining to their prevalence, characteristics, and the efficacy of endoscopic resection (ER) are absent. A safe and effective strategy for ER would reduce morbidity and healthcare costs. Methods Large nonpedunculated colorectal polyps of ≥20mm (LNPCPs) referred for ER were prospectively studied. Multiple data points were recorded including anastomotic location, polyp morphology, resection modality, complications, and technical success. Results Over 7 years until November 2022, 2629 lesions were referred. Of these, 10 (0.4%) were LAAPs (median size 35 mm [interquartile range (IQR) 30–40mm]). All LAAPs were removed by piecemeal endoscopic mucosal resection (EMR), most (n=9; 90%) in combination with cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST). On comparison of the LAAP group with the conventional LNPCP group, CAST was more commonly used (90% vs. 9%; P <0.001) and deep mural injury (DMI) type II was more frequent (40% vs. 11%, P =0.003); however, significant DMI (III–V) did not occur. At 6 month (IQR 5.25–6 months) surveillance, there was no recurrence in any of the 10 cases. There were no serious adverse events. Conclusions LAAPs present unique challenges owing to their location overlying an anastomosis. Despite these challenges they can be safely and effectively managed endoscopically without recurrence at endoscopic follow-up. [ABSTRACT FROM AUTHOR]

This article explores a new technique called DD-POEM for treating symptomatic thoracic esophageal diverticula. These diverticula are rare but can cause significant symptoms. The traditional treatment involves surgery, which carries risks. DD-POEM offers a less invasive option by dissecting the muscular septum while preserving the mucosa. The article presents the procedure and shares positive outcomes from a study of 10 patients who underwent DD-POEM, with no recurrence of symptoms or adverse events. The authors suggest that DD-POEM could become a standard treatment for symptomatic thoracic diverticula. [Extracted from the article]

The article presents the development of a case selection score (CSS) called the Endoscopic Mucosal Resection Case Selection Score (EMR-CSS) for endoscopists undergoing training in conventional colonic EMR. The CSS incorporates factors such as lesion size, morphology, and challenging location to predict the risk of technical failure or adverse events during the procedure. The study found that the EMR-CSS accurately identified high-risk lesions in the validation cohort, suggesting that it can be used to guide case selection and improve the accuracy of competency markers for EMR trainees. [Extracted from the article]

Severe strictures only occurred in patients with an ER defect >= 90 % (22.6 %, 7/31), with none occurring in patients with an ER defect of < 90 %. In patients underdoing colorectal ESD, Hayashi et al. reported stricture formation in 0.49 % of all patients, and in 11.1 % of those with an ER defect >= 90 % [32]. Stricture prevalence and severity In the final cohort of 916 patients, the circumferential extent of the ER defect was >= 90 % in 31/916 patients (3.4 %), 60 %-89 % in 88/916 (9.6 %), and < 60 % in 797/916 (87.0 %). Graph Introduction Large (>= 20 mm) nonpedunculated colorectal polyps (LNPCPs) are effectively and safely managed by endoscopic resection (ER). [Extracted from the article]

Main recommendations: Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3 A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4 Trained EMR practitioners should be familiar with the patient consent process for EMR. 5 The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6 Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7 A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8 A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9 A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10 Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11 Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document. [ABSTRACT FROM AUTHOR]

Baseline characteristics of included patients and their lesions The mean age of all patients at the time of the EMR procedure was 68.9 years (SD 10.4) and 176 patients (52.4 %) were men (Table 1). In this study of consecutive patients undergoing EMR at a tertiary endoscopy center, pain after colonic EMR (VAS > 0 for longer than 5 minutes) was reported in 20 % of patients. Endoscopic mucosal resection (EMR) is accepted as the first-line technique to remove large (>= 20 mm) laterally spreading lesions (LSLs) of the colorectum [1][2][3][4]. This information offers the practicing EMR clinician and their patient an insight into the post-EMR situation as regards pain after colonic EMR, a clear guide for how to treat pain after colonic EMR, and when to be concerned about it. [Extracted from the article]

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection. [ABSTRACT FROM AUTHOR]

Background Pre-resection biopsy (PRB) of large nonpedunculated colorectal polyps (LNPCPs, ≥ 20 mm) is often performed before referral for endoscopic mucosal resection (EMR). How this affects the EMR procedure is unknown. Methods This was a retrospective analysis of a prospectively collected cohort of patients with LNPCPs referred for EMR between 2013 to 2016 at an Australian tertiary center. Outcomes were differences between PRB and EMR histology, and effects of PRB on the EMR procedure. Results Among 586 LNPCPs, lesions that underwent PRB were larger (median 35 vs. 30 mm; P < 0.007), and more commonly morphologically flat or slightly elevated (P = 0.01) compared with lesions without PRB. PRB histology was upstaged in 26.1 %, downstaged in 13.8 %, and unchanged in 60.1 % after EMR. Sensitivity of PRB was 77.2 % (95 %CI 71.1–82.4) for low grade dysplasia (LGD) and 21.2 % (95 %CI 11.5–35.1) for high grade dysplasia (HGD). Where EMR specimen showed HGD, PRB had detected LGD in 76.9 %. Where EMR specimen showed cancer, PRB had detected dysplasia only. PRB was associated with more submucosal fibrosis (P = 0.001) and intraprocedural bleeding (P = 0.03). EMR success or recurrence was not affected. Conclusions Routine PRB of LNPCP did not reliably detect advanced histology and may have affected EMR complexity. PRB should be utilized with caution in guiding endoscopic management of LNPCPs. [ABSTRACT FROM AUTHOR]

A prospective single-center study of 183 post-EMR scars in the pre-MTA era showed that for lesions >= 20 mm in size, scars were easy to detect and the absence of RRA was highly predictable [6]. 2016, 83: 608 - 616 10 João, M. Areia, M. Pinto Pais, T. Can white-light endoscopy or narrow-band imaging avoid biopsy of colorectal endoscopic mucosal resection scars?. [Extracted from the article]

ESGE recommends that the evaluation of superficial gastrointestinal (GI) lesions should be made by an experienced endoscopist, using high definition white-light and chromoendoscopy (virtual or dye-based).ESGE does not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection.ESGE recommends endoscopic submucosal dissection (ESD) as the treatment of choice for most superficial esophageal squamous cell and superficial gastric lesions.For Barrett's esophagus (BE)-associated lesions, ESGE suggests the use of ESD for lesions suspicious of submucosal invasion (Paris type 0-Is, 0-IIc), for malignant lesions > 20 mm, and for lesions in scarred/fibrotic areas.ESGE does not recommend routine use of ESD for duodenal or small-bowel lesions.ESGE suggests that ESD should be considered for en bloc resection of colorectal (but particularly rectal) lesions with suspicion of limited submucosal invasion (demarcated depressed area with irregular surface pattern or a large protruding or bulky component, particularly if the lesions are larger than 20 mm) or for lesions that otherwise cannot be completely removed by snare-based techniques.ESGE recommends that an en bloc R0 resection of a superficial GI lesion with histology no more advanced than intramucosal cancer (no more than m2 in esophageal squamous cell carcinoma), well to moderately differentiated, with no lymphovascular invasion or ulceration, should be considered a very low risk (curative) resection, and no further staging procedure or treatment is generally recommended.ESGE recommends that the following should be considered to be a low risk (curative) resection and no further treatment is generally recommended: an en bloc R0 resection of a superficial GI lesion with superficial submucosal invasion (sm1), that is well to moderately differentiated, with no lymphovascular invasion, of size ≤ 20 mm for an esophageal squamous cell carcinoma or ≤ 30 mm for a stomach lesion or of any size for a BE-related or colorectal lesion, and with no lymphovascular invasion, and no budding grade 2 or 3 for colorectal lesions.ESGE recommends that, after an endoscopically complete resection, if there is a positive horizontal margin or if resection is piecemeal, but there is no submucosal invasion and no other high risk criteria are met, this should be considered a local-risk resection and endoscopic surveillance or re-treatment is recommended rather than surgery or other additional treatment.ESGE recommends that when there is a diagnosis of lymphovascular invasion, or deeper infiltration than sm1, or positive vertical margins, or undifferentiated tumor, or, for colorectal lesions, budding grade 2 or 3, this should be considered a high risk (noncurative) resection, and complete staging and strong consideration for additional treatments should be considered on an individual basis in a multidisciplinary discussion.ESGE recommends scheduled endoscopic surveillance with high definition white-light and chromoendoscopy (virtual or dye-based) with biopsies of only the suspicious areas after a curative ESD. [ABSTRACT FROM AUTHOR]

10.1055/a-2239-7371In the above-mentioned article the title has been corrected. Correct is: When less is more: lower esophageal sphincter-preserving peroral endoscopic myotomy is effective for non-achalasia esophageal motility disorders. This was corrected in the online version on March 11, 2024.By Varan Perananthan; Sunil Gupta; Anthony Whitfield; Ana Craciun; Oliver Cronin; Timothy O'Sullivan; Karen Byth; Mayenaaz Sidhu; Luke F. Hourigan; Spiro Raftopoulos; Nicholas G. Burgess and Michael J. BourkeReported by Author; Author; Author; Author; Author; Author; Author; Author; Author; Author; Author; Author [Extracted from the article]

Background: Recognition of the post-endoscopic mucosal resection (EMR) scar is critical for large (≥ 20 mm) non-pedunculated colorectal polyp (LNPCP) management. The utility of intraluminal tattooing to facilitate scar identification is unknown.Methods: We evaluated the ability of simple easy-to-use optical evaluation criteria to detect the post-EMR scar, with or without tattoo placement, in a prospective observational cohort of LNPCPs referred for endoscopic resection. The primary outcome was scar identification, further stratified by lesion size (20-39 mm, ≥ 40 mm) and histopathology (adenomatous, serrated).Results: 1023 LNPCPs underwent both successful EMR and first surveillance colonoscopy (median size 35 mm, IQR 30-50 mm); 124 (12.1 %) had an existing tattoo or a tattoo placed at the index EMR. The post-EMR scar was identified in 1020 patients (99.7 %). The presence of a tattoo did not affect scar identification (100.0 % vs. 99.7 %; P > 0.99). There was no difference for LNPCPs 20-39 mm, LNPCPs ≥ 40 mm, adenomatous LNPCPs, and serrated LNPCPs (all P > 0.99).Conclusions: The post-EMR scar can be reliably identified with simple easy-to-use optical evaluation criteria, without the need for universal tattoo placement. [ABSTRACT FROM AUTHOR]

BACKGROUND : Clinically significant post-endoscopic bleeding (CSPEB) is a common complication following colonic endoscopic mucosal resection (EMR). Current prediction tools are clinical and do not use the appearance of the post-EMR mucosal defect. We aimed to predict CSPEB by analyzing blood vessel morphology within the post-EMR mucosal defect. METHODS : 43 patients with CSPEB were matched to 43 non-bleeders for clinical variables associated with CSPEB. Computerized image analysis quantified the morphologic characteristics of the blood vessels in the defect. Variables were measured in relation to the mucosal defect area. Multivariate analysis and a neural network (NNET) were used as prediction models. RESULTS : The CSPEB group vessels had larger maximum diameter (113.07 vs. 69.03; P < 0.001), larger minimum radius (5.09 vs. 3.28; P = 0.002), larger perimeter value (337.82 vs. 193.86; P < 0.001), larger vessel length-of-outline (351.83 vs. 220.68; P = 0.002), and larger fractal dimension (1.11 vs. 1.10; P = 0.005) compared with non-bleeders. Discriminant analysis yielded 86 % sensitivity and 76.7 % specificity and an NNET classifier yielded 100 % sensitivity and 76.9 % specificity for identifying patients at risk. CONCLUSIONS : Blood vessel morphology in the post-EMR defect can be used to predict bleeding following colonic EMR. [ABSTRACT FROM AUTHOR]

Background: Large prolapse-related lesions (LPRL) of the sigmoid colon have been documented histologically but may not be readily recognized endoscopically.Methods: Colonic lesions referred for endoscopic mucosal resection (EMR) were enrolled prospectively. Endoscopic features were carefully documented prior to resection. Final diagnosis was made based on established histologic criteria, including vascular congestion, hemosiderin deposition, fibromuscular hyperplasia, and crypt distortion.Results: Of 134 large ( ≥ 20 mm) sigmoid lesions, 12 (9.0 %) had histologic features consistent with mucosal prolapse. Distinct endoscopic features were: broad-based morphology; vascular pattern obscured by dusky hyperemia; blurred crypts of varying size and shape; and irregular spacing of sparse crypts. Focal histologic dysplasia was identified in 6 of 12 lesions (50.0 %).Conclusions: LPRL of the sigmoid colon exhibit a distinct endoscopic profile. Although generally non-neoplastic, dysplasia may be present, warranting consideration of EMR. [ABSTRACT FROM AUTHOR]

BACKGROUND : Intraprocedural bleeding (IPB) during multiband mucosectomy (MBM) for Barrett's neoplasia can obscure the endoscopic field. Current hemostatic devices may affect procedure continuity and technical success. Snare-tip soft coagulation (STSC) as a first-line therapy for primary hemostasis has not previously been studied in this setting.Methods: Between January 2014 and November 2019, 191 consecutive patients underwent 292 MBM procedures for Barrett's neoplasia within a prospective observational cohort in two tertiary care centers. A standard MBM technique was performed. IPB was defined as bleeding obscuring the endoscopic field that required intervention. The primary outcome was the technical success and efficacy of STSC.Results: IPB occurred in 63 MBM procedures (21.6 %; 95 % confidence interval 17.3 % - 26.7 %). STSC was attempted as first-line therapy in 51 IPBs, with the remainder requiring alternate therapies because of pooling of blood. STSC achieved hemostasis in 48 cases (94.1 % by per-protocol analysis; 76.2 % by intention-to-treat analysis). No apparatus disassembly was required to perform STSC.Conclusions: STSC is a safe, effective, and efficient first-line hemostatic modality for IPB during MBM for Barrett's neoplasia. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to report the impact of the pandemic lockdown period on the treatment and prognosis of superficial gastrointestinal neoplastic lesions.Methods: A survey was completed by 11 centers from four continents regarding postponements during the early lockdown period of the pandemic, and the same period in 2019.Results: In 2020, 55 % of the scheduled procedures were deferred, which was 11 times higher than in 2019; the main reasons were directly related to COVID-19. In countries that were highly affected, this proportion rose to 76 % vs. 26 % in those where there was less impact. Despite the absolute reduction, the relative distribution in 2019 vs. 2020 was similar, the only exception being duodenal lesions (affected by a 92 % reduction in mucosectomies). Although it is expected that the majority of postponements will not affect the stage (based on the results from biopsies and/or endoscopic appearance), 3 % of delayed procedures will probably require surgery.Conclusions: The lockdown period caused by the SARS-CoV-2 pandemic led to a substantial reduction in the number of endoscopic resections for neoplastic lesions. Nevertheless, based on clinical judgment, the planned median delay will not worsen the prognosis of the affected patients. [ABSTRACT FROM AUTHOR]

The net effect is precise and clean tissue excision, limited thermal injury to the submucosal bed beneath the lesion, and sharp crisp mucosal incision margins where the lesion has been removed, which facilitates subsequent evaluation for potential residual adenoma. I inspect the mucosal defect after every resection for adequacy of resection and DMI (Fig. 2 Endoscopic views showing: a - c a 40-mm 0-IIa granular lesion treated with wide-field endoscopic mucosal resection; d - f endoscopic mucosal resection (EMR) of a 90 % circumferential 0-IIa + Is granular lesion, with snare-tip soft coagulation applied to the margin of the post-EMR defect at completion of the procedure for the prevention of adenoma recurrence. [Extracted from the article]

Background: Sessile serrated polyps (SSPs) are important precursors of colorectal carcinoma and interval cancer. Large SSPs (≥ 20 mm) outside the definition of serrated polyposis syndrome (SPS) have not been studied in comparison with SPS. We aimed to describe the characteristics of patients with large SSPs in this context.Methods: Patients with at least one SSP (≥ 20 mm) were eligible. Data from three consecutive colonoscopies were used to compare clinical and endoscopic characteristics in three patient groups: SPS, a solitary large SSP, and patients with at least two SSPs without fulfilling the criteria for SPS (oligo-SSP). Data on the diagnostic colonoscopy were collected retrospectively, whereas the remaining data was collected prospectively.Results: 67/146 patients (45.9 %) had SPS, 53/146 (36.3 %) had a solitary SSP, and 26/146 (17.8 %) were categorized as oligo-SSP. Personal (16.4 %, 9.4 %, and 11.5 %, respectively) and family (17.9 %, 17.0 %, and 23.1 %, respectively) history of colorectal carcinoma did not differ significantly between groups. Polyp burden was greater in SPS compared with solitary SSP but was not different from oligo-SSP (advanced adenomas: SPS 32.8 % vs. solitary SSP 9.4 % [P = 0.002] vs. oligo-SSP 34.6 % [P = 0.87]; ≥ 10 conventional adenomas: 11.9 % vs. 0 % [P = 0.01] vs. 3.8 % [P = 0.44], respectively). Dysplasia in large SSPs was frequent in all groups (41.1 % overall). SPS was recognized by referring endoscopists in only 9.0 % of cases.Conclusion: Patients with oligo-SSPs have similar synchronous polyp burden and clinical characteristics as patients with SPS and may require similar surveillance. Modification of the criteria for the diagnosis of SPS to include this group seems warranted. Patients with a solitary SSP have a lower risk of synchronous polyps, including advanced adenomas. Larger studies are warranted to determine whether these patients may return to standard surveillance following complete examination and clearance of the colon. [ABSTRACT FROM AUTHOR]

Given that large nonpedunculated colorectal polyps (LNPCPs) comprise only about 5 % of all polyps, and of these, covert malignancy occurs in a small proportion [2], a multicenter study is likely needed to determine whether PRB meaningfully detects cancer in these lesions prior to endoscopic resection. References 1 Ma, M X. Tate, D J. Sidhu, M. Effect of pre-resection biopsy on detection of advanced dysplasia in large nonpedunculated colorectal polyps undergoing endoscopic mucosal resection. Overall, the EMR histology differed from PRB histology in over one in three cases, with the degree of dysplasia being upstaged in the majority of discordant cases. [Extracted from the article]

Background: Endoscopic resection of ampullary adenomas is a safe and effective alternative to surgical resection. A subgroup of patients have large laterally spreading lesions of the papilla Vateri (LSL-P), which are frequently managed surgically. Data on endoscopic resection of LSL-P are limited and long-term outcomes are unknown. The aim of this study was to compare the outcomes of endoscopic resection of LSL-P with those of standard ampullary adenomas.Methods: A retrospective analysis of a prospectively collected and maintained database was conducted. LSL-P was defined as extension of the lesion ≥ 10 mm from the edge of the ampullary mound. Piecemeal endoscopic mucosal resection of the laterally spreading component was followed by resection of the ampulla. Patient, lesion, and procedural data, as well as results of endoscopic follow-up, were collected.Results: 125 lesions were resected. Complete endoscopic resection was achieved in 97.6 % at the index procedure (median lesion size 20 mm, interquartile range [IQR] 13 - 30 mm). Compared with ampullary adenomas, LSL-Ps were significantly larger (median 35 mm vs. 15 mm), contained a higher rate of advanced pathology (38.6 % vs. 18.5 %), and had higher rates of intraprocedural bleeding (50 % vs. 24.7 %) and delayed bleeding (25.0 % vs. 12.3 %). Both groups had similar rates of histologically proven recurrence at first surveillance (16.4 % vs. 17.9 %). Median follow-up for the entire cohort was 18.5 months. For patients with at least two surveillance endoscopies (n = 68; median follow-up 29 months, IQR 18 - 48 months), 95.6 % were clear of disease and considered cured.Conclusions: LSL-P can be resected endoscopically with comparable outcomes to standard ampullectomy, albeit with a higher risk of bleeding. Endoscopic treatment should be considered as an alternative to surgical resection, even for large LSL-P. [ABSTRACT FROM AUTHOR]

BACKGROUND AND STUDY AIMS : Large series suggest endoscopic mucosal resection is safe and effective for the removal of large (≥ 10 mm) sessile serrated polyps (SSPs), but it exposes the patient to the risks of electrocautery, including delayed bleeding. We examined the feasibility and safety of piecemeal cold snare polypectomy (pCSP) for the resection of large SSPs.Methods: Sequential large SSPs (10 - 35 mm) without endoscopic evidence of dysplasia referred over 12 months to a tertiary endoscopy center were considered for pCSP. A thin-wire snare was used in all cases. Submucosal injection was not performed. High definition imaging of the defect margin was used to ensure the absence of residual serrated tissue. Adverse events were assessed at 2 weeks and surveillance was planned for between 6 and 12 months.Results: 41 SSPs were completely removed by pCSP in 34 patients. The median SSP size was 15 mm (interquartile range [IQR] 14.5 - 20 mm; range 10 - 35 mm). The median procedure duration was 4.5 minutes (IQR 1.4 - 6.3 minutes). There was no evidence of perforation or significant intraprocedural bleeding. At 2-week follow-up, there were no significant adverse events, including delayed bleeding and post polypectomy syndrome. First follow-up has been undertaken for 15 /41 lesions at a median of 6 months with no evidence of recurrence.Conclusions: There is potential for pCSP to become the standard of care for non-dysplastic large SSPs. This could reduce the burden of removing SSPs on patients and healthcare systems, particularly by avoidance of delayed bleeding. [ABSTRACT FROM AUTHOR]

Background and Aims: Non-lifting large laterally spreading colorectal lesions (LSLs) are challenging to resect endoscopically and often necessitate surgery. A safe, simple technique to treat non-lifting LSLs endoscopically with robust long-term outcomes has not been described.Methods: In this single-center prospective observational study of consecutive patients referred for endoscopic mucosal resection (EMR) of LSLs ≥ 20 mm, LSLs not completely resectable by snare because of non-lifting underwent standardized completion of resection with cold-forceps avulsion and adjuvant snare-tip soft coagulation (CAST). Scheduled surveillance colonoscopies were performed at 4 - 6 months (SC1) and 18 months (SC2). Primary outcomes were endoscopic evidence of adenoma clearance and avoidance of surgery. The secondary outcome was safety.Results: From January 2012 to October 2016, 540 lifting LSLs (82.2 %) underwent complete snare excision at EMR. CAST was required for complete removal in 101 non-lifting LSLs (17.8 %): 63 naïve non-lifting lesions (NNLs; 62.7 %) and 38 previously attempted non-lifting lesions (PANLs; 37.3 %). PANLs were smaller (P < 0.001) and more likely to be non-granular (P = 0.001) than the lifting LSLs. NNLs were of similar size (P = 0.77) and morphology (P = 0.10) to the lifting LSLs. CAST was successful in all cases and adverse events were comparable to lifting LSLs resected by complete snare excision. Recurrence at SC1 was comparable for PANLs (15.2 %) and lifting LSLs (15.3 %; P = 0.99), whereas NNLs recurred more frequently (27.5 %; P = 0.049); however, surgery was no more common for either type of non-lifting LSL than for lifting LSLs.Conclusion: CAST is a safe, effective, and surgery-sparing therapy for the majority of non-lifting LSLs. It is easy to use, inexpensive, and does not require additional equipment. [ABSTRACT FROM AUTHOR]

Can we stop routine biopsy of post-endoscopic mucosal resection scars? Endoscopy DOI: 10.1055/a-2085-5660 In the above-mentioned article, Figure 1 has been corrected. [Extracted from the article]

Background and study aims Endoscopic mucosal resection (EMR) of laterally spreading colonic lesions ≥ 20 mm (LSLs) is ideally performed in a single session (ssEMR) and avoids surgery in > 90 % of patients. We investigated whether a second attempt is safe or useful when ssEMR fails at a tertiary center. Patients and methods In a multicenter prospective observational study of patients with LSL treated by EMR at four tertiary centers over 8 years, incompletely resected LSLs were referred for surgery or underwent two-stage EMR (tsEMR). At tsEMR, the scar was located and all visible residual tissue removed by snare, with thermal treatment permitted thereafter. Scheduled surveillance was performed at 5 months (SC1) and 18 months (SC2). The primary outcome was avoidance of surgery. Results A total of 1944 LSLs (median size 35 mm) underwent EMR. ssEMR was unsuccessful in 127 lesions, 43 of which underwent tsEMR, with success in 36 (83.7 %). Compared with ssEMR, tsEMR lesions were larger (median size 50 mm vs. 30 mm; P < 0.001), exhibited more submucosal fibrosis (P < 0.001), and histology was more often tubular adenoma and less often serrated (P = 0.005). Lesions mainly required tsEMR for nonlifting (41.9 %) or poor endoscopic access (37.2 %). Failure of tsEMR was predicted by larger LSL (P = 0.03). Safety was comparable to ssEMR. Of the 33 LSLs that underwent tsEMR for benign disease and completed first surveillance, 27 (81.8 %) avoided surgery to long term follow-up. Conclusions tsEMR shows promise as a salvage therapy for LSLs that cannot be resected in a single session for patients in whom other options such as surgery are not preferred or not possible.Trial registered at ClinicalTrials.gov (NCT01368289). [ABSTRACT FROM AUTHOR]

Background and study aims Adenomas of the duodenum and ampulla are uncommon. For lesions ≤ 20 mm in size and confined to the papillary mound, endoscopic resection is well supported by systematic study. However, for large laterally spreading lesions of the duodenum or papilla (LSL-D/P), surgery is often performed despite substantial associated morbidity and mortality. We aimed to compare actual endoscopic outcomes of such lesions and costs with those predicted for surgery using validated prediction tools. Patients and methods Patients who underwent endoscopic resection of LSL-D/P were analyzed. Two surgeons assigned the hypothetical surgical management. The National Surgical Quality Improvement Program (NSQIP), and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) were used to predict morbidity, mortality, and length of hospital stay. Actual endoscopic and hypothetical surgical outcomes and costs were compared. Results A total of 102 lesions were evaluated (mean age of patients 69 years, 52 % male, mean lesion size 40 mm). Complete endoscopic resection was achieved in 93.1 % at the index procedure. Endoscopic adverse events occurred in 18.6 %. Recurrence at first surveillance endoscopy was seen in 17.7 %. For patients with ≥ 2 surveillance endoscopies (n = 55), 90 % were clear of disease and considered cured (median follow-up 27 months). Compared with hypothetical surgical resection, endoscopic resection had less morbidity (18 % vs. 31 %; P = 0.001) and shorter hospital stay (median 1 vs. 4.75 days; P < 0.001), and was less costly than surgery (mean $ 11 093 vs. $ 19 358; P < 0.001). Conclusion In experienced centers, even extensive LSL-D/P can be managed endoscopically with favorable morbidity and mortality profiles, and reduced costs, compared with surgery. [ABSTRACT FROM AUTHOR]

Background and Study Aims: Clinically significant bleeding (CSPEB) is the most common adverse event following endoscopic mucosal resection (EMR) of large sessile and laterally spreading colorectal lesions (LSLs), and is associated with morbidity and resource utilization. CSPEB occurs more frequently with proximal LSLs. Prophylactic clipping of the post-EMR defect may be beneficial in CSPEB prevention. The aim of this study was to determine the cost-effectiveness of a prophylactic clipping strategy. We hypothesized that prophylactic clipping in the proximal colon was cost-effective.Patients and Methods: An economic model was applied to outcomes from the Australian Colonic Endoscopic Mucosal Resection (ACE) Study. Clip distances of 3, 5, 8, and 10 mm were analyzed. The cost of treating CSPEB was determined from an independent costing agency. The funds needed to spend (FNS) was the cost incurred in order to prevent one episode of CSPEB. A break-even analysis was performed to determine cost equivalence of the costs of clipping and CSPEB.Results: Outcomes of 1717 LSLs (mean size 35.8 mm; 52.6 % proximal colon) that underwent EMR were analyzed. The overall rate of CSPEB was 6.4 % (proximal 8.9 %; distal 3.7 %). Endoscopic management was required in 45 % of CSPEB episodes. With a clip distance of 3 mm, the expected cost of prophylactic clipping was € 1106 per lesion compared with € 157 per lesion for the expected cost of CSPEB without clipping. At 100 % clipping efficacy, the FNS was € 14 826 (proximal and distal lesions € 9309 and € 29 540, respectively). A clip price of € 10.35 was required for the cost of clipping to offset the cost of CSPEB.Conclusions: A prophylactic clipping strategy is not cost-effective and at present cannot be justified for all lesions or selectively for lesions in the proximal colon.Trial Registration: ClinicalTrials.gov (NCT01368289). [ABSTRACT FROM AUTHOR]

Background and Study Aims: Endoscopic mucosal resection (EMR) is an established treatment for large (≥ 20 mm) laterally spreading lesions (LSLs). LSLs with complete or subtotal (> 90 %) circumferential extent (C-LSLs) are generally referred for surgery. Data on technique, efficacy, and safety of EMR for these lesions are absent. The aim of this study was to describe the technique and long-term outcomes of EMR for C-LSLs.Patients and Methods: Prospective observational study of consecutive patients referred for EMR of LSL at a tertiary care center over 63 months to April 2015. Amongst 979 patients with LSL, 12 patients with C-LSL were seen.Results: All lesions were tubulovillous adenomas with granular 0 - IIa + Is morphology. Median longitudinal extent was 95 mm (range 60 - 160), 58 % were located in the rectum, and 3 lesions (25 %) had complete circumferential involvement. EMR technical success was 100 %. There were no major adverse events. Symptomatic stricturing occurred in 2 cases (17 %) and was treated with endoscopic balloon dilation (median 4 sessions). Median follow up is 13 months. Minor residual adenoma was found in 7 (58 %) at first surveillance colonoscopy and was treated with snare excision. A total of 10 patients have completed a second surveillance colonoscopy with minor residual adenoma found in only 1 case. No patient required surgery or developed cancer in long-term follow-up.Conclusions: Endoscopic resection of C-LSL is feasible and safe. Minor residual adenoma is common but endoscopically treatable with long-term cure. Symptomatic stricturing amenable to balloon dilation may occur. Empiric surgical referral for C-LSL based on extensive circumferential involvement may be avoided.ClinicalTrials.gov NCT01368289. [ABSTRACT FROM AUTHOR]

Background and Study Aims: Stricture formation is the main limitation of endoscopic resection in the esophagus. The optimal electrosurgical current (ESC) for endoscopic resection in the esophagus and other gastrointestinal sites is unknown. There may be a relationship between the type of ESC used and the development of post-procedure esophageal stricture. Unlike the low power coagulating current (LPCC), the microprocessor-controlled current (MCC), which alternates between short pulse cutting and coagulation, avoids high peak voltages that are thought to result in deep thermal injury. The aim of this study was to determine the histopathological variables associated with these two commonly employed ESCs used for esophageal endoscopic resection.Methods: Standardized endoscopic resection of normal mucosa by band mucosectomy was performed by a single endoscopist in 12 adult pigs. The procedures were randomized 1 : 1 to either LPCC (ERBE 100 C at 25 W) or MCC (ERBE Endocut Q, Effect 3). Necropsy and esophagectomy were performed at 72 hours after the procedure. Two histopathologists, who were blinded to the ESC allocation, independently assessed the presence and depth of ulceration, necrosis and inflammation.Results: A total of 45 resections were analyzed. In the LPCC and MCC groups, ulceration extending into the muscularis propria was present in 9/24 (37.5 %) and 1/21 (4.8 %) resected specimens, respectively (P = 0.04). Necrosis extending into the muscularis propria was present in 13/24 (54.1 %) and 1/21 (4.8 %) resected specimens, respectively (P = 0.002). One case of microperforation with muscularis propria injury was noted in the LPCC group compared with none in the MCC group. The quantified mean depth of ulceration, necrosis, and acute inflammation was significantly greater in the LPCC group. Conclusions: In an in vivo porcine survival model of esophageal endoscopic mucosal resection, the use of MCC resulted in significantly less deep thermal ulceration, necrosis, and acute inflammation compared with LPCC. MCC should be used in preference over LPCC for esophageal endoscopic resection. [ABSTRACT FROM AUTHOR]

Background and Aims: Complete endoscopic resection (CER) of short-segment Barrett's esophagus with high grade dysplasia (HGD) and early esophageal adenocarcinoma (EEA) is a precise staging tool and achieves durable disease control. The major drawback is development of post-endoscopic resection esophageal stricture (PERES). No effective therapy to prevent PERES has been described. Viscous budesonide slurry (VBS) may have a role in the prevention of PERES by suppressing the post-CER inflammatory process. The study aim was to evaluate the efficacy of VBS for the prevention of PERES.Methods: Prospective data were collected on patients referred for CER of HGD or EEA. After January 2012, patients routinely received VBS (two 0.5-mg/2-mL budesonide respules mixed with sucralose) twice daily for 6 weeks following each stage of the CER schedule. All patients received high dose proton pump inhibitor therapy for the duration of CER and the following 3 months. Patients had no other intervention to prevent PERES. A validated dysphagia score was used (0 - 4, no dysphagia to aphagia). Endoscopic dilation was performed for dysphagia. Patients receiving VBS were compared with historical controls. The primary endpoint was the need for dilation.Results: Between January 2008 and January 2015, 104 of 116 eligible patients completed CER. The VBS group (n = 29) and non-VBS group (n = 75) had similar patient, disease, and procedural characteristics. Dilations were needed in 13.8 % vs. 37.3 % (P = 0.03), with a median of one vs. two procedures (P = 0.01), and median dysphagia score during CER of 0 vs. 1 (P = 0.02) in the VBS and non-VBS groups, respectively. No VBS-related adverse events were noted.Conclusion: In this pilot study VBS significantly reduced PERES and shortened the dilation program after CER. [ABSTRACT FROM AUTHOR]

Background and study aims: Endoscopic mucosal resection (EMR) of laterally spreading lesions (LSLs) involving the ileocecal valve (ICV) is technically demanding. Conventionally, these lesions are considered too challenging for endoscopic therapy and are primarily managed surgically. The aims of the study were to describe effectiveness, safety, and outcomes following EMR of LSLs at the ICV. Patients and methods: This was a single-center, prospective, observational, cohort study performed at an academic, tertiary referral center. Patients undergoing EMR for LSLs ≥20mm involving the ICV were recruited over a 5-year period. Standard or cap-assisted colonoscopy with injectand- resect EMR technique was performed with standardized post-EMR management. Procedural success, safety, and outcomes compared with non-ICV LSLs managed during the same period were analyzed. Results: A total of 53 patients with ICV LSLs were referred for EMR (median age 69 years; median lesion size 35.0 mm; 52.8% females). Six patients went directly to surgery because of an endoscopic diagnosis of malignancy (n=2) or technical failure of EMR (n=4). EMR achieved complete adenoma clearance in 44 out of 47 attempted (93.6 %). Surgery was ultimately avoided in 43/53 (81.1 %). Complications included bleeding in 6.4 %. There were no perforations or strictures. Early adenoma recurrence was detected in 7/40 patients (17.5 %), and 1/22 (4.5 %) had late recurrence. All were successfully managed endoscopically. Factors associated with failure of ICV EMR were ileal infiltration and involvement of both ICV lips. Conclusions: In the majority of cases, LSL involving the ICV can be effectively treated by EMR on an outpatient basis. In specialized centers, complications are infrequent, and>80% of patients ultimately avoid surgery. [ABSTRACT FROM AUTHOR]

An editorial is presented on a study concerning the effectiveness of endoscopic submucosal dissection (ESD) in treating patients with large nonpedunculated colorectal polyps.

The author reflects on the when and whom should colorectal endoscopic submucosal dissection (ESD) be employed. Topics discussed include curative resection as an advantage of ESD over endoscopic mucosal resection (EMR) for early cancer, effectiveness and safety of ESD, and diagnostic and therapeutic endoscopy.

The article reports on a study conducted for evaluating vascular patterns of the gastrointestinal mucosa through various methods such as High-definition endoscopes, magnification and manipulation of light wavelengths. Topics discussed include sessile serrated adenomas/polyps (SSA/Ps) as a risk factor for colorectal cancer (CRC), presence of a "skirt" around margins of colonic laterally spreading tumors (LSTs), and presence of "chicken- skin" mucosa around colonic lesions.

Background: The SMSA (size, morphology, site, access) polyp scoring system is a method of stratifying the difficulty of polypectomy through assessment of four domains. The aim of this study was to evaluate the ability of SMSA to predict critical outcomes of endoscopic mucosal resection (EMR).Methods: We retrospectively applied SMSA to a prospectively collected multicenter database of large colonic laterally spreading lesions (LSLs) ≥ 20 mm referred for EMR. Standard inject-and-resect EMR procedures were performed. The primary end points were correlation of SMSA level with technical success, adverse events, and endoscopic recurrence.Results: 2675 lesions in 2675 patients (52.6 % male) underwent EMR. Failed single-session EMR occurred in 124 LSLs (4.6 %) and was predicted by the SMSA score (P < 0.001). Intraprocedural and clinically significant postendoscopic bleeding was significantly less common for SMSA 2 LSLs (odds ratio [OR] 0.36, P < 0.001 and OR 0.23, P < 0.01) and SMSA 3 LSLs (OR 0.41, P  < 0.001 and OR 0.60, P = 0.05) compared with SMSA 4 lesions. Similarly, endoscopic recurrence at first surveillance was less likely among SMSA 2 (OR 0.19, P < 0.001) and SMSA 3 (OR 0.33, P < 0.001) lesions compared with SMSA 4 lesions. This also extended to second surveillance among SMSA 4 LSLs.Conclusion: SMSA is a simple, readily applicable, clinical score that identifies a subgroup of patients who are at increased risk of failed EMR, adverse events, and adenoma recurrence at surveillance colonoscopy. This information may be useful for improving informed consent, planning endoscopy lists, and developing quality control measures for practitioners of EMR, with potential implications for EMR benchmarking and training. [ABSTRACT FROM AUTHOR]