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Background and study aims The European Colonoscopy Quality Investigation (ECQI) Group comprises expert colonoscopists and investigators with the aim of raising colonoscopy standards. We assessed the levels of monitoring and achievement of European Society of Gastrointestinal Endoscopy (ESGE) performance measures (PMs) across Europe using responses to the ECQI questionnaires. Methods The questionnaire comprises three forms: institution and practitioner questionnaires are completed once; a procedure questionnaire is completed on multiple occasions for individual total colonoscopies. ESGE PMs were approximated as closely as possible from the data collected via the procedure questionnaire. Procedure data could provide rate of adequate bowel preparation, cecal intubation rate (CIR), withdrawal time, polyp detection rate (PDR), and tattooing resection sites. Results We evaluated ECQI questionnaire data collected between June 2016 and April 2018, comprising 91 practitioner and 52 institution questionnaires. A total of 6445 completed procedure forms were received.Institution and practitioner responses indicate that routine recording of PMs is not widespread: adenoma detection rate (ADR) is routinely recorded in 29 % of institutions and by 34 % of practitioners; PDR by 42 % and 47 %, CIR by 62 % and 64 %, bowel preparation quality by 56 % and 76 %, respectively.Procedure data showed a rate of adequate bowel preparation of 84.2 %, CIR 73.4 %, PDR 40.5 %, mean withdrawal time 7.8 minutes and 12.2 % of procedures with possible removal of a non-pedunculated lesion ≥ 20 mm reporting tattooing. Conclusions Our findings clearly show areas in need of quality improvement and the importance of promoting quality monitoring throughout the colonoscopy procedure.

Objectives: Previous meta-analysis including nonrandomized studies showed marginal benefit of underwater endoscopic mucosal resection(U-EMR) compared to conventional EMR(C-EMR) in terms of polypectomy outcomes. We evaluated U-EMR compared to C-EMR in the treatment of colorectal polyps with respect to effectiveness and safety by analyzing only randomized controlled trials(RCTs). Material and methods: PubMed and Cochrane Library databases were searched for RCTs published until 11/2020, evaluating U-EMR vs. C-EMR regarding en bloc resection, post-endoscopic resection adenoma recurrence, complete resection, adverse events rates and difference in resection time. Abstracts from Digestive Disease Week, United European Gastroenterology Week and ESGE Days meetings were also searched. Effect size on outcomes is presented as risk ratio(RR; 95% confidence interval[CI]) or mean difference(MD; 95%CI). The I2 test was used for quantifying heterogeneity, while Grading of Recommendations Assessment, Development and Evaluation(GRADE) was used to assess strength of evidence. Results: Six RCTs analyzing outcomes from 1157 colorectal polypectomies(U-EMR589;C-EMR,568) were included. U-EMR associated with significant higher rate of en bloc resection compared to C-EMR [RR(95%CI):1.26(1.01-1.58); Chi² for heterogeneity=30.43, P

Background The Endocuff Vision device (Arc Medical Design Ltd., Leeds, UK) has been shown to increase mucosal exposure, and consequently adenoma detection rate (ADR), during colonoscopy. This nationwide multicenter study assessed possible benefits and harms of using Endocuff Vision in a fecal immunochemical test (FIT)-based screening program. Methods Patients undergoing colonoscopy after a FIT-positive test were randomized 1:1 to undergo Endocuff-assisted colonoscopy or standard colonoscopy, stratified by sex, age, and screening history. Primary outcome was ADR. Secondary outcomes were ADR stratified by endoscopists’ ADR, advanced ADR (AADR), adenomas per colonoscopy (APC), withdrawal time, and adverse events. Results 1866 patients were enrolled across 13 centers. After exclusions, 1813 (mean age 60.1 years; male 53.8 %) were randomized (908 Endocuff Vision, 905 standard colonoscopy). ADR was significantly higher in the Endocuff Vision arm (47.8 % vs. 40.8 %; relative risk [RR] 1.17, 95 % confidence interval [CI] 1.06–1.30), with no differences between arms regarding size or morphology. When stratifying for endoscopists’ ADR, only low detectors (ADR Conclusion Endocuff Vision increased ADR in a FIT-based screening program by improving examination of the whole colonic mucosa. Utility was highest among endoscopists with a low ADR.

Background Estimates on miss rates for upper gastrointestinal neoplasia (UGIN) rely on registry data or old studies. Quality assurance programs for upper GI endoscopy are not fully established owing to the lack of infrastructure to measure endoscopists’ competence. We aimed to assess endoscopists’ accuracy for the recognition of UGIN exploiting the framework of artificial intelligence (AI) validation studies. Methods Literature searches of databases (PubMed/MEDLINE, EMBASE, Scopus) up to August 2020 were performed to identify articles evaluating the accuracy of individual endoscopists for the recognition of UGIN within studies validating AI against a histologically verified expert-annotated ground-truth. The main outcomes were endoscopists’ pooled sensitivity, specificity, positive and negative predictive value (PPV/NPV), and area under the curve (AUC) for all UGIN, for esophageal squamous cell neoplasia (ESCN), Barrett esophagus-related neoplasia (BERN), and gastric adenocarcinoma (GAC). Results Seven studies (2 ESCN, 3 BERN, 1 GAC, 1 UGIN overall) with 122 endoscopists were included. The pooled endoscopists’ sensitivity and specificity for UGIN were 82 % (95 % confidence interval [CI] 80 %–84 %) and 79 % (95 %CI 76 %–81 %), respectively. Endoscopists’ accuracy was higher for GAC detection (AUC 0.95 [95 %CI 0.93–0.98]) than for ESCN (AUC 0.90 [95 %CI 0.88–0.92]) and BERN detection (AUC 0.86 [95 %CI 0.84–0.88]). Sensitivity was higher for Eastern vs. Western endoscopists (87 % [95 %CI 84 %–89 %] vs. 75 % [95 %CI 72 %–78 %]), and for expert vs. non-expert endoscopists (85 % [95 %CI 83 %–87 %] vs. 71 % [95 %CI 67 %–75 %]). Conclusion We show suboptimal accuracy of endoscopists for the recognition of UGIN even within a framework that included a higher prevalence and disease awareness. Future AI validation studies represent a framework to assess endoscopist competence.

The European Society of Gastrointestinal Endoscopy (ESGE) and the Japan Gastroenterological Endoscopy Society (JGES) give no specific recommendations on the best treatment for colorectal neoplasia involving the dental line (DLCN).Aim of this study was to analyse efficacy and safety of Endoscopic Submucosal Dissection in the treatment of colorectal neoplasia involving the dentate line (DLCN) compared to non-DLCN.Retrospective study.We retrospectively evaluated all consecutive patients undergoing ESD for rectal neoplasia at two endoscopical tertiary referral centers (Italy and Japan) from January 2008 to December 2019.Anthropometric, clinical, procedural, and follow-up data was collected, analysed, and compared between patients with DLCN and patients with non-DLCN.Overall, 314 patients were enrolled (163 female, 51.9%). Mean age was 68 years (range, 32-92 years). En-bloc resection was achieved in 311/314 (99%) patients. Lesion size was higher in DLCN group than in the non-DLCN group (46.1 vs 38.9 mm;Retrospective study design.ESD seems to be safe and effective in the treatment of colorectal neoplasia involving the dentate line and can be considered the best therapeutic strategy.

Main RecommendationsThe following recommendations for post-polypectomy colonoscopic surveillance apply to all patients who had one or more polyps that were completely removed during a high quality baseline colonoscopy. 1 ESGE recommends that patients with complete removal of 1 – 4 Strong recommendation, moderate quality evidence.If organized screening is not available, repetition of colonoscopy 10 years after the index procedure is recommended.Strong recommendation, moderate quality evidence. 2 ESGE recommends surveillance colonoscopy after 3 years for patients with complete removal of at least 1 adenoma ≥ 10 mm or with high grade dysplasia, or ≥ 5 adenomas, or any serrated polyp ≥ 10 mm or with dysplasia. Strong recommendation, moderate quality evidence. 3 ESGE recommends a 3 – 6-month early repeat colonoscopy following piecemeal endoscopic resection of polyps ≥ 20 mm.Strong recommendation, moderate quality evidence. A first surveillance colonoscopy 12 months after the repeat colonoscopy is recommended to detect late recurrence.Strong recommendation, high quality evidence. 4 If no polyps requiring surveillance are detected at the first surveillance colonoscopy, ESGE suggests to perform a second surveillance colonoscopy after 5 years. Weak recommendation, low quality evidence.After that, if no polyps requiring surveillance are detected, patients can be returned to screening. 5 ESGE suggests that, if polyps requiring surveillance are detected at first or subsequent surveillance examinations, surveillance colonoscopy may be performed at 3 years. Weak recommendation, low quality evidence.A flowchart showing the recommended surveillance intervals is provided (Fig. 1).

Background Post-colonoscopy adverse events are a key quality indicator in population-based colorectal cancer screening programs, and affect safety and costs. This study aimed to assess colonoscopy-related adverse events and mortality in a screening setting. Methods We retrieved data from patients undergoing colonoscopy within a screening program (fecal immunochemical test every 2 years, 50–69-year-olds, or post-polypectomy surveillance) in Italy between 2002 and 2014, to assess the rate of post-colonoscopy adverse events and mortality. Any admission within 30 days of screening colonoscopy was reviewed to capture possible events. Mortality registries were also matched with endoscopy databases to investigate 30-day post-colonoscopy mortality. Association of each outcome with patient-/procedure-related variables was assessed using multivariable analysis. Results Overall, 117 881 screening colonoscopies (66 584, 56.5 %, with polypectomy) were included. Overall, 497 (0.42 %) post-colonoscopy adverse events occurred: 281 (0.24 %) bleedings (3.69‰/0.68‰, operative/diagnostic procedures) and 65 (0.06 %) perforations (0.75‰/0.29‰, respectively). At multivariable analysis, bleeding was associated with polyp size (≥ 20 mm: odds ratio [OR] 16.29, 95 % confidence interval [CI] 9.38–28.29), proximal location (OR 1.46, 95 %CI 1.14–1.87), and histology severity (high risk adenoma: OR 5.6, 95 %CI 2.43–12.91), while perforation was associated with endoscopic resection (OR 2.91, 95 %CI 1.62–5.22), polyp size (OR 4.34, 95 %CI 1.46–12.92), and proximal location (OR 1.94, 95 %CI 1.12–3.37). Post-colonoscopy mortality occurred in 15 /117 881 cases (1.27/10 000 colonoscopies). Conclusions In an organized screening program, post-colonoscopy adverse events were rare but not negligible. The most frequent event was post-polypectomy bleeding, especially after resection of large (≥ 20 mm) and proximal lesions.

Summary of statementsIn Europe at present, but also in 2040, 1 in 3 cancer-related deaths are expected to be caused by digestive cancers. Endoscopic technologies enable diagnosis, with relatively low invasiveness, of precancerous conditions and early cancers, thereby improving patient survival. Overall, endoscopy capacity must be adjusted to facilitate both effective screening programs and rigorous control of the quality assurance and surveillance systems required. 1 For average-risk populations, ESGE recommends the implementation of organized population-based screening programs for colorectal cancer, based on fecal immunochemical testing (FIT), targeting individuals, irrespective of gender, aged between 50 and 75 years. Depending on local factors, namely the adherence of the target population and availability of endoscopy services, primary screening by colonoscopy or sigmoidoscopy may also be recommendable. 2 In high-risk populations, endoscopic screening for gastric cancer should be considered for individuals aged more than 40 years. Its use in countries/regions with intermediate risk may be considered on the basis of local settings and availability of endoscopic resources. 3 For esophageal and pancreatic cancer, endoscopic screening may be considered only in high-risk individuals:– For squamous cell carcinoma, in those with a personal history of head/neck cancer, achalasia, or previous caustic injury; – For Barrett’s esophagus (BE)-associated adenocarcinoma, in those with long-standing gastroesophageal reflux disease symptoms (i. e., > 5 years) and multiple risk factors (age ≥ 50 years, white race, male sex, obesity, first-degree relative with BE or esophageal adenocarcinoma [EAC]). – For pancreatic cancer screening, endoscopic ultrasound may be used in selected high-risk patients such as those with a strong family history and/or genetic susceptibility.

Background. The COVID-19 pandemic has imposed radical behavioral and social changes in the general population, significantly impacting the lives of individuals affected by disabilities. The aim of this study was to investigate the impact of COVID-19 on non-institutionalized subjects with sensorineural disabilities during the first COVID-19 wave in Italy. Methods. A 39-item online national survey was disseminated from 1 April 2020 to 31 June 2020 via social media throughout Italy to communities of individuals with proven severe sensorineural disabilities, affiliated to five national patient associations. The survey collected extensive information on the socio-demographic profile, health, everyday activities, and lifestyle of individuals with hearing and visual disabilities. Results. One hundred and sixty-three respondents with hearing (66.9%) and visual (33.1%) disabilities returned a usable questionnaire. The mean age of interviewees was 38.4 ± 20.2 years and 56.3% of them were females. Despite the vast majority of respondents (77.9%) perceiving their health status as unchanged (68.8% of interviewees with hearing deficits vs. 96.3% of those with visual impairments), about half the interviewees reported sleep disorders during lock-down, more likely those with visual deficits. Remote services were seemingly more effective for business than school activities. Furthermore, although just 18.8% of respondents rated remote rehabilitation care unsatisfactory, only 12.8% of interviewees felt supported by health and social services during the COVID-19 emergency. The vast majority of respondents were concerned about the future and the risk of SARS-CoV-2 contagion, particularly individuals with hearing impairments. Among the various risk mitigation measures, facemasks caused the greatest discomfort due to communication barriers, particularly among interviewees affected by hearing disabilities (92.2% vs. 45.7%). The most common request (46.5%) of respondents to reduce the inconveniences of the COVID-19 emergency was improving the access to and delivery of health and social services for individuals with sensorineural disabilities (19.3%), followed by the use of transparent masks (17.5%). Conclusions. Although health protection measures such as face masks and social distancing play a key role in preventing and controlling the spread of SARS-CoV-2, the unmet needs of disabled individuals should be carefully considered, especially those affected by sensory disabilities. Tailored access to health and social services for individuals affected by sensorineural disabilities should be implemented. Additional actions should include the use of face shields as a valid alternative to face masks to reduce communication barriers linked to hearing-impairment, as well as the improvement of remote services, especially distance learning at school.

ObjectiveArtificial intelligence (AI) may reduce underdiagnosed or overlooked upper GI (UGI) neoplastic and preneoplastic conditions, due to subtle appearance and low disease prevalence. Only disease-specific AI performances have been reported, generating uncertainty on its clinical value.DesignWe searched PubMed, Embase and Scopus until July 2020, for studies on the diagnostic performance of AI in detection and characterisation of UGI lesions. Primary outcomes were pooled diagnostic accuracy, sensitivity and specificity of AI. Secondary outcomes were pooled positive (PPV) and negative (NPV) predictive values. We calculated pooled proportion rates (%), designed summary receiving operating characteristic curves with respective area under the curves (AUCs) and performed metaregression and sensitivity analysis.ResultsOverall, 19 studies on detection of oesophageal squamous cell neoplasia (ESCN) or Barrett's esophagus-related neoplasia (BERN) or gastric adenocarcinoma (GCA) were included with 218, 445, 453 patients and 7976, 2340, 13 562 images, respectively. AI-sensitivity/specificity/PPV/NPV/positive likelihood ratio/negative likelihood ratio for UGI neoplasia detection were 90% (CI 85% to 94%)/89% (CI 85% to 92%)/87% (CI 83% to 91%)/91% (CI 87% to 94%)/8.2 (CI 5.7 to 11.7)/0.111 (CI 0.071 to 0.175), respectively, with an overall AUC of 0.95 (CI 0.93 to 0.97). No difference in AI performance across ESCN, BERN and GCA was found, AUC being 0.94 (CI 0.52 to 0.99), 0.96 (CI 0.95 to 0.98), 0.93 (CI 0.83 to 0.99), respectively. Overall, study quality was low, with high risk of selection bias. No significant publication bias was found.ConclusionWe found a high overall AI accuracy for the diagnosis of any neoplastic lesion of the UGI tract that was independent of the underlying condition. This may be expected to substantially reduce the miss rate of precancerous lesions and early cancer when implemented in clinical practice.

We retrospectively collected a series of 82 endoscopically removed early colorectal cancers. Histological specimens were revised by two gastrointestinal pathologists, performing a re-evaluation of all risk factors for lymph node metastasis. The comparison between second opinion and first pathological report revealed that lymphovascular invasion and tumor grading showed a lower level of concordance than other parameters. Our results demonstrated that second opinion modified risk assessment in about 10% of cases. It was mainly due to a lack in reporting of some parameters at the first diagnosis and a different evaluation in second opinion for updated guidelines. Considering the subgroup of patients with modified risk assessment, clinical data revealed that tumors, re-classified as low risk, did not develop lymph node metastasis that, conversely, occurred in patients identified as high risk by second opinion. In conclusion, second opinion significantly alters risk perception of endoscopically removed early colorectal carcinomas representing a valuable tool for their appropriate clinical management.

Background and study aims Correct optical diagnosis of colorectal polyps is crucial to implement a resect and discard strategy. Training methods have been proposed to reach recommended optical diagnosis thresholds. The aim of our study was to present a systematic review and meta-analysis on optical diagnosis training. Methods PubMed/Medline and Cochrane databases were searched between 1980 and October 2019 for studies reporting outcomes on optical diagnosis training of colorectal polyps. The primary outcome was optical diagnosis accuracy compared to histological analysis pre-training and post-training intervention. Subgroup analyses of experienced/trainee endoscopists, training methods, and small/diminutive polyps were included. Results Overall, 16 studies met inclusion criteria, analyzing the impact of training on 179 endoscopists. Pre-training accuracy was 70.3 % (6416/9131 correct diagnoses) whereas post-training accuracy was 81.6 % (7416/9213 correct diagnoses) (risk ratio [RR] 1.17; 95 % confidence interval [CI]: 1.09–1.24, P Conclusions Optical diagnosis training is effective in improving accuracy of histology prediction in colorectal polyps. Didactic and computer-based training show comparable effectiveness in improving diagnostic accuracy.

Aims An outbreak of coronavirus disease 19 (COVID-19) has altered the dynamic of endoscopic practices. Many guidelines, questionnaires have been published addressing service resumption during the pandemic. Curious about the situation indifferent endoscopic units across the globe, the study was designed to evaluate different aspects of practice resumptionworldwide and their adherence to guidelines. Methods An online questionnaire was created and distributed by national/regional representatives and societies. Redcapplatform was used as the interface;afterwards, Microsoft Excel 2016 and Prism 5 were utilized for data analysis. Results From a total of 307 responses from 47 countries/regions was collected, 290 valid answers were analyzed. Almosthalf (47 %) were in post-peak period by August, 2020. Many units were not designated to be COVID-oriented facility. About15.5 % of centers remained unrecovered, mainly in North and South America;those were recovered, training was still withheld significantly. Nevertheless, opened centers kept safety measurements strictly. Patient load was decreased by 37 %,but waiting list was increased 0-25 %. Among many surveillance methods, body temperature, PCR and chest CT were themost common. 74.8 % increased post-procedural disinfection time and 68.2 % increase in per-case inspection were noted.PPE usage was implemented highly and shortage of these posed as one of the resumption barriers. Post-procedural patientsurveillance was not reinforced. Conclusions The study represented real-time global endoscopic service's adaptation to COVID-19 pandemic. Previouslypublished barriers upon practice resumption remained. Despite Delphi consensus' emphasis on post-procedural surveillance, application was not widely reinforced, raising concerns in disease control.

Purpose: To evaluate the effects of the COVID-19 pandemic on the Ophthalmic Emergency Department (OED) activity of the tertiary eye centre of Verona. Methods: OED reports of patients visited during lockdown (COVID-period) and in the corresponding period of 2017, 2018 and 2019 (COVID-free period) have been retrieved to draw a comparison. Patients’ demographic and clinical data recorded and analysed are the following: age, gender, previous ocular history, aetiology, symptoms onset, type of symptoms, discharge diagnosis, urgency and severity of diagnosis. Results: OED consultations dropped from 20.6 ± 7.3 visits/day of the COVID-free period to 8.6 ± 4.6 visits/day of the COVID-period. In the COVID-period patients waited longer before physically going to the OED, lamented more vision loss and less redness and reported a higher percentage of traumatic events when compared to the COVID-free period. A significant reduction of ocular surface conditions occurred, while vitreo-retinal disorders increased. Overall, both urgency and severity of diagnosed diseases raised significantly in the COVID-period. Conclusion: The COVID-19 pandemic drove a significant reduction of the overall OED activity. People with less urgent and milder conditions preferred to wait and endure their ocular discomfort for a few days rather than leaving home and risking to contract the infection. Our analysis highlights how several times the OED is used improperly by patients diagnosed with non-urgent disorders. A more accurate use of the OED would allow a reduction of management costs and the avoidance of overcrowding, which can lead to delays in the care of patients that really need assistance.

Received 28th January 2021. Accepted 23rd February 2021. Published online 17th March 2021. Issue published 1st April 2021.

Background and aimsArtificial intelligence has been shown to increase adenoma detection rate (ADR) as the main surrogate outcome parameter of colonoscopy quality. To which extent this effect may be related to physician experience is not known. We performed a randomised trial with colonoscopists in their qualification period (AID-2) and compared these data with a previously published randomised trial in expert endoscopists (AID-1).MethodsIn this prospective, randomised controlled non-inferiority trial (AID-2), 10 non-expert endoscopists (ResultsIn 660 patients (62.3±10 years; men/women: 330/330) with equal distribution of study parameters, overall ADR was higher in the CADe than in the control group (53.3% vs 44.5%; relative risk (RR): 1.22; 95% CI: 1.04 to 1.40; pConclusionsIn less experienced examiners, CADe assistance during colonoscopy increased ADR and a number of related polyp parameters as compared with the control group. Experience appears to play a minor role as determining factor for ADR.Trial registration numberNCT:04260321.

Contains fulltext : 235679.pdf (Publisher’s version ) (Closed access) BACKGROUND: One of the aims of the European Society of Gastrointestinal Endoscopy (ESGE) is to encourage high quality endoscopic research at a European level. In 2016, the ESGE research committee published a set of research priorities. As endoscopic research is flourishing, we aimed to review the literature and determine whether endoscopic research over the last 4 years had managed to address any of our previously published priorities. METHODS: As the previously published priorities were grouped under seven different domains, a working party with at least two European experts was created for each domain to review all the priorities under that domain. A structured review form was developed to standardize the review process. The group conducted an extensive literature search relevant to each of the priorities and then graded the priorities into three categories: (1) no longer a priority (well-designed trial, incorporated in national/international guidelines or adopted in routine clinical practice); (2) remains a priority (i. e. the above criterion was not met); (3) redefine the existing priority (i. e. the priority was too vague with the research question not clearly defined). RESULTS: The previous ESGE research priorities document published in 2016 had 26 research priorities under seven domains. Our review of these priorities has resulted in seven priorities being removed from the list, one priority being partially removed, another seven being redefined to make them more precise, with eleven priorities remaining unchanged. This is a reflection of a rapid surge in endoscopic research, resulting in 27 % of research questions having already been answered and another 27 % requiring redefinition. CONCLUSIONS: Our extensive review process has led to the removal of seven research priorities from the previous (2016) list, leaving 19 research priorities that have been redefined to make them more precise and relevant for researchers and funding bodies to target.

Background Endoscopic submucosal dissection (ESD) is the treatment of choice for colorectal superficial neoplasia, but certain anatomical locations are challenging even for skilled endoscopists. Ileocecal valve (ICV) is considered a technically challenging site for ESD. Objective Aim of this study was to analyze efficacy and safety of Endoscopic Submucosal Dissection in the treatment of colorectal neoplasia involving the ileocecal valve (ICV) Design Retrospective study. Patients We retrospectively evaluated 1507 consecutive patients undergoing ESD at two tertiary referral centres for ESD (Italy and Japan) from January 2008 to March 2020. Main Outcome Measures Demographic, clinical, procedural, and follow-up data was collected, analysed, and compared between patients with ileocecal valve lesions (ICVL) and patients with non-ICVL. Results Overall, 1507 patients were enrolled (872 M, 57.8%), of these 53 patients had lesions involving the ICV. Mean age was 70.2 years (range, 53–83 years). En-bloc resection was achieved in 52 (98%) patients. The median specimen size of ICVL was 36.4 mm (range, 8–80 mm), significantly smaller than non-ICVL (p = 0.005). Procedure time was significantly longer in the ICVL group, (71.3 vs. 58.9 min; p = 0.03). Non Granular Type Laterally Spreading Tumors (LST-NG) were significantly more frequent in the ICVL group compared to rectum (52.8% vs. 25.7; p = 0.0001). En-bloc resection rate in the ileocecal region did not differ significantly between groups (p = 0.20). Complications such as perforation and postoperative occurred respectively in 3/53 (5.7%) and 1/53 (2%) patient, and were treated conservatively. At first surveillance colonoscopy performed at 6 months, recurrent adenoma was detected in 2/53 patients (3.9%). Conclusions ESD is safe and effective for the treatment of colorectal neoplasia involving the ileocecal valve if performed by expert endoscopist in referral centres.

Background and Objectives: Pancreatic cystic lesions (PCLs) are frequent incidental findings on cross-sectional imaging and represent a diagnostic challenge as different kinds of PCLs harbor a dissimilar risk of malignancy. Two diagnostic tools have recently been developed and introduced: through-the-needle biopsy (TTNB) and needle-based confocal laser endomicroscopy (nCLE). The aim of this meta-analysis was to compare the diagnostic yield and performance, as well as the safety profile of the two methods. Methods: This meta-analysis was performed in accordance with the PRISMA statement. Medline, Embase, Web of Science, and Cochrane Library databases were searched for studies with five or more patients undergoing either endoscopic ultrasound (EUS)-TTNB or EUS-nCLE for a PCL. Reviews, case reports, editorials, conference abstracts, and studies on exclusively solid pancreatic lesions were excluded. Outcomes of interest were diagnostic yield and performance, safety, and technical success. Results: Twenty studies with 1023 patients were included in the meta-analysis. Pooled diagnostic yield of EUS-nCLE was higher compared to EUS-TTNB (85% vs. 74%, P < 0.0001), while diagnostic performance was high and comparable for both methods (pooled sensitivity: 80% vs. 86% and pooled specificity: 80% vs. 83% for TTNB and nCLE, respectively, P > 0.05). Pooled estimate of total adverse event (AE) rate was 5% in the TTNB group and 3% in the nCLE group, P = 0.302. Technical success rates were high and comparable (94% and 99% for EUS-TTNB and nCLE, respectively; P = 0.07). Conclusion: EUS-TTNB and EUS-nCLE have a similar safety profile with a relatively low number of AEs. Technical success, sensitivity, and specificity are comparable; however, EUS-nCLE seems to have a slightly higher diagnostic yield.

Background and aims: Adequate bowel cleansing is critical to ensure quality and safety of a colonoscopy. A novel 1-L polyethylene glycol plus ascorbate (1L-PEG+ASC) regimen was previously validated against low-volume regimens but was never compared with high-volume regimens. Methods: In a phase IV study, patients undergoing colonoscopy were randomized 1:1 to receive split-dose 1L PEG+ASC or a split-dose 4-L PEG-based regimen (4L-PEG) in 5 Italian centers. Preparation was assessed with the Boston Bowel Preparation Scale (BBPS) by local endoscopists and centralized reading, both blinded to the randomization arm. The primary endpoint was noninferiority of 1L-PEG+ASC in colon cleansing. Secondary endpoints were superiority of 1L-PEG+ASC, patient compliance, segmental colon cleansing, adenoma detection rate, tolerability, and safety. Results: Three hundred eighty-eight patients (median age, 59.8 years) were randomized between January 2019 and October 2019: 195 to 1L-PEG+ASC and 193 to 4L-PEG. Noninferiority of 1L-PEG+ASC was demonstrated for cleansing in both the entire colon (BBPS≥ 6: 97.9% vs 93%; relative risk [RR], 1.03; 95% confidence interval [CI], 1.001-1.04; P superiority= .027) and in the right-sided colon segment (98.4% vs 96.0%; RR, 1.02; 95% CI, .99-1.02; P noninferiority= .013). Compliance was higher with 1L-PEG+ASC than with 4L-PEG (178/192 [92.7%] vs 154/190 patients [81.1%]; RR, 1.10; 95% CI, 1.05-1.12), whereas no difference was found regarding safety (moderate/severe side effects: 20.8% vs 25.8%; P= .253). No difference in adenoma detection rate (38.8% vs 43.0%) was found. Conclusions: One-liter PEG+ASC showed noninferiority compared with 4L-PEG in achieving adequate colon cleansing and provided a higher patient compliance. No differences in tolerability and safety were detected. (Clinical trial registration number: NCT03742232.).

Artificial intelligence (AI) systems, especially after the successful application of Convolutional Neural Networks, are revolutionizing modern medicine. Gastrointestinal Endoscopy has shown to be a fertile terrain for the development of AI systems aiming to aid endoscopists in various aspects of their daily activity. Lesion detection can be one of the two main aspects in which AI can increase diagnostic yield and abilities of endoscopists. In colonoscopy, it is well known that a substantial rate of missed neoplasia is still present, representing the major cause of interval cancer. In addition, an extremely high variability in adenoma detection rate, the main key quality indicator in colonoscopy, has been extensively reported. The other domain in which AI is believed to have a considerable impact on everyday clinical practice is lesion characterization and aid in "optical diagnosis". By predicting in vivo histology, such pathology costs may be averted by the implementation of two separate but synergistic strategies, namely the "leave-in-situ" strategy for < 5 mm hyperplastic lesions in the rectosigmoid tract, and "resect and discard" for the other diminutive lesions. In this opinion review we present current available evidence regarding the role of AI in improving lesions' detection and characterization during colonoscopy.

Background Ischemic colitis (IC) is caused by a transient hypo-perfusion of the colon leading to mucosal ulcerations, inflammation, and hemorrhage. The primary aim was to identify predictive factors of endoscopic severity of IC. Secondary endpoints were to show epidemiology, clinical presentation, endoscopic findings, and outcomes of IC. Methods In this single-center retrospective analysis, IC was scored according to endoscopy as: grade 1 (hyperemia, 1 cm superficial, partially confluent ulcers); and grade 3 (deep or diffuse ulcers or necrosis). Then, IC was grouped into low- (grade 1) and high-grade (grades 2 and 3). Significant (P≤0.1) independent factor of severe IC at univariate analysis were entered into multivariate analysis and considered significant at P

Background Use of artificial intelligence may increase detection of colorectal neoplasia at colonoscopy by improving lesion recognition (CADe) and reduce pathology costs by improving optical diagnosis (CADx). Methods A multicenter library of ≥ 200 000 images from 1572 polyps was used to train a combined CADe/CADx system. System testing was performed on two independent image sets (CADe: 446 with polyps, 234 without; CADx: 267) from 234 polyps, which were also evaluated by six endoscopists (three experts, three non-experts). Results CADe showed sensitivity, specificity, and accuracy of 92.9 %, 90.6 %, and 91.7 %, respectively. Experts showed significantly higher accuracy and specificity, and similar sensitivity, while non-experts + CADe showed comparable sensitivity but lower specificity and accuracy than CADe and experts. CADx showed sensitivity, specificity, and accuracy of 85.0 %, 79.4 %, and 83.6 %, respectively. Experts showed comparable performance, whereas non-experts + CADx showed comparable accuracy but lower specificity than CADx and experts. Conclusions The high accuracy shown by CADe and CADx was similar to that of experts, supporting further evaluation in a clinical setting. When using CAD, non-experts achieved a similar performance to experts, with suboptimal specificity.

Background and study aims Few reports exist about long-term outcomes of transoral incisionless fundoplication (TIF) for treating refractory gastro-esophageal reflux disease (GERD). Methods A literature search of four major scientific databases was performed up to May 2020 for studies reporting on more than 3-year outcomes of TIF. Data on atient satisfaction, proton pump inhibitor (PPI) daily consumption, PPI use reduction, GERD health-related quality-of-life (GERD-HRQL) score, and normalization of heartburn and regurgitation scores were pooled and summarized with forest plots. Publication bias and heterogeneity were explored. Results Overall, eight studies (418 patients, 232 men; 55.5 %) with a mean follow-up of 5.3 years (range: 3–10 years) were included. The pooled proportion of patient-reported satisfaction before and after TIF was 12.3 % (95 % CI:12.3–35.1 %, I2 = 87.4 %) and 70.6 % (95 % CI:51.2–84.6, I2 = 80 %), respectively, corresponding to an odds ratio of 21.4 (95 % CI:3.27–140.5). Pooled rates of patients completely off PPIs and on occasional PPIs were 53.8 % (95 %CI: 42.0 %-65.1 %) and 75.8 % (95 %CI: 67.6–82.6), respectively. The pooled estimated mean GERD-HRQL scores off PPI before and after TIF werey 26.1 (95 %CI: 21.5–30.7; range: 20.0–35.5) and 5.9, respectively (95 %CI:0.35.1–11.4; range: 5.3–9.8; P Conclusion Our study shows that TIF appears to offer a long-term safe therapeutic option for selected patients with GERD who refuse life-long medical therapy or surgery, are intolerant to PPIs, or are at increased surgical risk.

IMPORTANCE: Previous retrospective studies have shown that sarcopenia substantially alters the postoperative and oncological outcomes after liver resection for malignant tumors. However, the evidence is limited to small retrospective studies with heterogeneous results and the lack of standardized measurements of sarcopenia. OBJECTIVE: To investigate the role of sarcopenia as a risk factor associated with 90-day morbidity after liver resection for malignant tumors. DESIGN, SETTING, AND PARTICIPANTS: This cohort study included 234 consecutive patients undergoing liver resection for malignant tumors at San Camillo Forlanini Hospital, Rome, Italy, between June 1, 2018, and December 15, 2019. Muscle mass and strength were assessed using the skeletal muscle index (SMI) on preoperative computed tomographic scans and the handgrip strength test, respectively. Patients were then divided into the following 4 groups: group A (normal muscle mass and strength), group B (reduced muscle strength), group C (reduced muscle mass), and group D (reduced muscle mass and strength). MAIN OUTCOMES AND MEASURES: The primary outcome of the study was 90-day morbidity. The following secondary outcomes were investigated: 90-day mortality, hospital stay, and readmission rate. RESULTS: Sixty-four major and 170 minor hepatectomies were performed in 234 patients (median age, 66.50 [interquartile range, 58.00-74.25] years; 158 men [67.5%]). The median SMI of the entire population was 46.22 (interquartile range, 38.60-58.20) cm/m(2). The median handgrip strength was 30.80 (interquartile range, 22.30-36.90) kg. Patients in group D had a statistically significantly higher rate of 90-day morbidity than patients in the other groups (51.5% [35 of 68] vs 38.7% [29 of 75] in group C, 23.1% [3 of 13] in group B, and 6.4% [5 of 78] in group A; P

Summary box #### What is already known about this subject? #### What are the new findings? #### How might it impact on clinical practice in the foreseeable future? In this prospective multicentre …

Background and Aims One-fourth of colorectal neoplasia are missed at screening colonoscopy, representing the main cause of interval colorectal cancer. Deep learning systems with real-time computer-aided polyp detection (CADe) showed high accuracy in artificial settings, and preliminary randomized controlled trials (RCTs) reported favorable outcomes in the clinical setting. The aim of this meta-analysis was to summarize available RCTs on the performance of CADe systems in colorectal neoplasia detection. Methods We searched MEDLINE, EMBASE, and Cochrane Central databases until March 2020 for RCTs reporting diagnostic accuracy of CADe systems in the detection of colorectal neoplasia. The primary outcome was pooled adenoma detection rate (ADR), and secondary outcomes were adenoma per colonoscopy (APC) according to size, morphology, and location; advanced APC; polyp detection rate; polyps per colonoscopy; and sessile serrated lesions per colonoscopy. We calculated risk ratios (RRs), performed subgroup and sensitivity analyses, and assessed heterogeneity and publication bias. Results Overall, 5 randomized controlled trials (4354 patients) were included in the final analysis. Pooled ADR was significantly higher in the CADe group than in the control group (791/2163 [36.6%] vs 558/2191 [25.2%]; RR, 1.44; 95% confidence interval [CI], 1.27-1.62; P Conclusions According to available evidence, the incorporation of artificial intelligence as aid for detection of colorectal neoplasia results in a significant increase in the detection of colorectal neoplasia, and such effect is independent from main adenoma characteristics.

Background Colorectal cancer (CRC) screening programs based on fecal immunochemical testing (FIT) generate substantial pressure on colonoscopy capacity in Europe. Thus, a relevant proportion of FIT-positive patients undergo colonoscopy after the recommended 30-day interval, which may be associated with an excess CRC risk. Methods In a cohort of 50–69-year-old patients undergoing biennial rounds of FIT (OC-Hemodia latex agglutination test; cutoff 20 µg hemoglobin/g feces) between 2004 and 2017, we assessed the outcome at colonoscopy (low/high risk adenoma/CRC/advanced stage CRC) among FIT-positive patients, according to different time intervals. The association of each outcome with waiting time, and demographic and clinical factors, was analyzed through multivariable analysis. Results 123 138/154 213 FIT-positive patients (79.8 %) underwent post-FIT colonoscopy. Time to colonoscopy was ≤ 30 days, 31–180 days, and ≥ 181 days in 50 406 (40.9 %), 71 724 (58.3 %), and 1008 (0.8 %) patients, respectively. At colonoscopy, CRC, high risk adenoma, and low risk adenoma were diagnosed in 4813 (3.9 %), 30 500 (24.8 %), and 22 986 (18.7 %) patients, respectively. An increased CRC prevalence at colonoscopy was observed for a time to colonoscopy of ≥ 270 days (odds ratio [OR] 1.75, 95 % confidence interval [CI] 1.15–2.67), whereas it was stable for waiting times of Conclusion In a European FIT-based screening program, post-FIT colonoscopy after 9 months was associated with an increased risk of CRC and CRC progression.

SUMMARY This is an official guidance statement of The International Society of the Diseases of the Esophagus (ISDE) to address all the operators involved in management of patients affected by upper gastrointestinal diseases during COVID-19 pandemic. This guidance is based on the best available evidence to date and will be updated as new evidence becomes available.

Contains fulltext : 220063.pdf (Publisher’s version ) (Closed access) We are currently living in the throes of the COVID-19 pandemic that imposes a significant stress on health care providers and facilities. Europe is severely affected with an exponential increase in incident infections and deaths. The clinical manifestations of COVID-19 can be subtle, encompassing a broad spectrum from asymptomatic mild disease to severe respiratory illness. Health care professionals in endoscopy units are at increased risk of infection from COVID-19. Infection prevention and control has been shown to be dramatically effective in assuring the safety of both health care professionals and patients. The European Society of Gastrointestinal Endoscopy (www.esge.com) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (www.esgena.org) are joining forces to provide guidance during this pandemic to help assure the highest level of endoscopy care and protection against COVID-19 for both patients and endoscopy unit personnel. This guidance is based upon the best available evidence regarding assessment of risk during the current status of the pandemic and a consensus on which procedures to perform and the priorities on resumption. We appreciate the gaps in knowledge and evidence, especially on the proper strategy(ies) for the resumption of normal endoscopy practice during the upcoming phases and end of the pandemic and therefore a list of potential research questions is presented. New evidence may result in an updated statement.

Background & Aims The risk of metachronous colorectal cancer (CRC) among patients with no adenomas, low-risk adenomas (LRAs), or high-risk adenomas (HRAs), detected at index colonoscopy, is unclear. We performed a systematic review and meta-analysis to compare incidence rates of metachronous CRC and CRC-related mortality after a baseline colonoscopy for each group. Methods We searched the PubMed, Embase, Google Scholar, and Cochrane databases for studies that reported the incidence of CRC and adenoma characteristics after colonoscopy. The primary outcome was odds of metachronous CRC and CRC-related mortality per 10,000 person-years of follow-up after baseline colonoscopy for all the groups. Results Our final analysis included 12 studies with 510,019 patients (mean age, 59.2 ± 2.6 years; 55% male; mean duration of follow up, 8.5 ± 3.3 years). The incidence of CRC per 10,000 person-years was marginally higher for patients with LRAs compared to those with no adenomas (4.5 vs 3.4; odds ratio [OR], 1.26; 95% CI, 1.06–1.51; I2=0), but significantly higher for patients with HRAs compared to those with no adenoma ( 13.8 vs 3.4; odds ratio [OR], 2.92; 95% CI, 2.31–3.69; I2=0 ) and patients with HRAs compared to LRAs (13.81 vs 4.5; OR, 2.35; 95% CI, 1.72–3.20; I2=55%). However, the CRC-related mortality per 10,000 person-years did not differ significantly for patients with LRAs compared to no adenomas (OR, 1.15; 95% CI, 0.76–1.74; I2=0) but was significantly higher in persons with HRAs compared with LRAs (OR, 2.48; 95% CI, 1.30–4.75; I2=38%) and no adenomas (OR, 2.69; 95% CI, 1.87–3.87; I2=0). Conclusions The results of this systematic review and meta-analysis demonstrate that the risk of metachronous CRC and mortality is significantly higher for patients with HRAs, but this risk is very low in patients with LRAs, comparable to patients with no adenomas. Follow-up of patients with LRAs detected at index colonoscopy should be the same as for persons with no adenomas.

Background and aims Endoscopic ultrasound-guided gastro-enteric anastomosis (EUS-GEA) using lumen-apposing metal stents (LAMS) is emerging as a minimally invasive alternative to surgery across several indications. Literature on this subject is heterogeneous, with variable reporting of techniques and outcomes. Our aim was to perform a meta-analysis of published data on EUS-GEA, providing a pooled estimate of technical and clinical outcomes. Methods The protocol was registered in PROSPERO (Reg. no. CRD42018111110). PubMed, Embase, Scopus, and Web of Science databases were searched until February 2019 for studies describing patients undergoing EUS guided enteric anastomosis. PRISMA methodology was used. Pooled technical and clinical success rates as well as pooled adverse events rates were calculated. Study quality, publication bias, and heterogeneity were explored. Results Twelve studies including 290 patients were included, published between 2016 and 2019. All studies but one were retrospective. Main procedure indication was gastric outlet obstruction (62.4%), followed by ERCP access (27.9%) in patients with gastric bypass surgery. Direct puncture technique was the most frequently adopted (68.2%). Pooled technical success rate (12 studies, 290 patients) was 93.5% [95% confidence interval (CI) 89.7–6.0%; I2:0%], while clinical success rate (11 studies, 260 patients) was 90.1% [95%CI 85.5–93.4%; I2:0%]. Pooled total adverse events rate (11 cohorts, 261 patients) was 11.7% [95%CI 8.2–16.6%; I2:0%], mainly mild/moderate: 10.6% [95%CI 7 – 15.6%]. No publication bias or significant heterogeneity was found. Conclusions EUS-GEA has a high rate of technical and clinical success when performed in expert centers. The procedure appears to be relatively safe, and might represent a non-inferior minimally invasive alternative to surgery. The paucity of long-term clinical outcomes suggests prudency and need for further research, especially regarding non-malignant indications.

Introduction: An outbreak of coronavirus disease 19 (COVID-19) has altered the dynamic of world’s healthcare system, including endoscopic practices. Curious about the situation in different endoscopic units across the globe, the study was designed to evaluate different aspects of practice resumption worldwide. Methods: An online questionnaire was created and distributed by national/regional representatives. Redcap® platform was used as the interface; afterwards, Microsoft Excel 2016 and Prism 5 were utilized for data analysis. Results: A total of 307 responses from 47 countries/regions was collected, from which 290 valid answers were inducted and further analyzed. Almost half (47%) were in post-peak period by August, 2020. Many units were not designated to be COVID-oriented facility. About 15.5% of centers remained unrecovered, mainly in North and South America; those were recovered, training was still withheld significantly. Nevertheless, opened centers kept safety measurement strictly. Though patient load was decreased by 37% in most centers, waiting list was increased 0-25%. Among many surveillance methods, body temperature, PCR and chest CT prevailed the be the most commonly used. 74.8% claimed to have increased post-procedural disinfection time and 68.2% also observed an increased in per-case inspection. PPE usage was implemented highly and shortage of these posed as one of the resumption barriers. Post-procedural patient surveillance was not reinforced. Conclusions: The study reflected closely the global revolution of the pandemic. Shortage in staff and PPE as well as difficulty in training resumption remained barriers worldwide. Incapacity of patient post-procedural surveillance raised concerns in disease control. Funding Statement: None to declare. Declaration of Interests: None to declare. Ethics Approval Statement: The study was approved by the Institutional Review Board of the National Liver Institute, Menoufia University, Egypt (NLI IRB 00003413) in June 2020, protocol number 00203/2020.

Background and study aims As with all other fields of medical practice, gastrointestinal endoscopy has been impacted by the COVID-19 pandemic. However, data on the impact of the pandemic in Africa, especially sub-Saharan Africa are lacking. Methods A web-based survey was conducted by the International Working Group of the European Society for Gastrointestinal Endoscopy and the World Endoscopy Organization to determine the impact and effects the COVID-19 pandemic has had on endoscopists in African countries. Results Thirty-one gastroenterologists from 14 countries in north, central, and sub-Saharan Africa responded to the survey. The majority of respondents reduced their endoscopy volume considerably. Personal protective equipment including FFP-2 masks were available in almost all participating centers. Pre-endoscopy screening was performed as well. Conclusion The COVID-19 pandemic has had a substantial impact on gastrointestinal endoscopy in most African countries; however, the impact may not have been as devastating as expected.

Background and Aims Previous meta-analysis showed marginal benefit of high-definition white-light endoscopy (HD-WLE) over standard-definition colonoscopy (SDC) for adenoma detection, but with residual uncertainty due to inclusion of nonrandomized studies. We aimed to further assess the effect of HD-WLE on adenoma detection by including only randomized controlled trials (RCTs). Methods A literature search was performed for RCTs evaluating HD-WLE versus SDC in terms of adenoma, advanced adenoma, and serrated sessile adenoma detection rates as well as the mean number of adenomas per colonoscopy (MAC), the mean number of advanced adenomas per colonoscopy (MAAC), and the mean number of sessile serrated adenomas per colonoscopy (MSSAC). The effect size on study outcomes is presented as the risk ratio (RR; 95% confidence interval [CI]) or mean difference (MD; 95% CI). We assessed the strength of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results Six RCTs involving 4594 individuals (HD-WLE, 2323; SDC, 2271) were included. Clinical indications were screening (1 study), positive result for fecal occult blood test, personal/family history of colorectal cancer (1 study), and mixed indications (4 studies). Withdrawal time was similar between the 2 arms (MD, −0.06; 95% CI, −0.25 to 0.12; P = .50). The adenoma detection rate was significantly higher in the HD-WLE arm compared with the SDC arm (40% vs 35%; RR, 1.13; 95% CI, 1.05-1.22; P = .001; I2 = 0%; GRADE, low). This effect was consistent for advanced and sessile serrated adenoma detection rates (RR, 1.33; 95% CI, 1.03-1.72; P = .03; I2 = 0%; GRADE, low; and RR, 1.55; 95% CI, 1.05-2.28; P = .03; I2 = 0%; GRADE, low, respectively). In contrast, the difference was not significant for MAC, MAAC, and MSSAC. Conclusions Meta-analyses of RCT data support the use of HD-WLE in clinical practice, although the additional benefit is limited.

The miss rate of flat advanced colorectal neoplasia is still unacceptably high, especially in the Western setting, notwithstanding the widespread implementation of quality improvement programs and training. It is well known that flat morphology is associated with miss rate of colorectal neoplasia, and that this subset of lesions often shows a more aggressive biological behaviour. Artificial intelligence (AI) applied to the detection of colorectal neoplasia has been shown to increase adenoma detection rate, consistently across all lesion sizes and locations in the colon. However, there is still uncertainty whether AI can reduce the miss rate of flat advanced neoplasia, mainly because all published trials report a low number of flat colorectal lesions in their training sets, and this could reduce AI accuracy for this subset of lesions. In addition, flat lesions have different morphologies with variable prevalence and potentially different accuracy in their detection. For example, the subtle appearance and rarer frequency of a non-granular laterally spreading tumor (LST) could be much harder to identify than a granular mixed LST. In this review, we present a summary of the evidence on the role of AI in the identification of colorectal flat neoplasia, with a focus on data regarding presence of LSTs in the training/validation sets of the AI systems currently available on the market.

Background and Aims False positive (FP) results by computer-aided detection (CADe) hamper the efficiency of colonoscopy by extending examination time. Our aim was to develop a classification of the causes and clinical relevance of CADe FPs, and to assess the relative distribution of FPs in a real-life setting. Methods In a post-hoc analysis of a randomized trial comparing colonoscopy with and without CADe (NCT: 04079478), we extracted 40 CADe colonoscopy videos. Using a modified Delphi process, 4 expert endoscopists identified the main domains for the reasons and clinical relevance of FPs. Then, 2 expert endoscopists manually examined each FP and classified it according to the proposed domains. The analysis was limited to the withdrawal phase. Results The 2 main domains for the causes of CADe FPs were identified as artifacts due to either the mucosal wall or bowel content, and clinical relevance was defined as the time spent on FPs and the FP rate per minute. The mean number of FPs per colonoscopy was 27.3 ± 13.1, of which 24 ± 12 (88%) and 3.2 ± 2.6 (12%) were due to artifacts in the bowel wall and bowel content, respectively. Of the 27.3 FPs per colonoscopy, 1.6 (5.7%) required additional exploration time of 4.8 ± 6.2 seconds per FP (ie, 0.7% of the mean withdrawal time). In detail, 15 (24.2%), 33 (53.2%), and 14 (22.6%) FPs were classified as being of mild, moderate, or severe clinical relevance. The rate of FPs per minute of withdrawal time was 2.4 ± 1.2, and was higher for FPs due to artifacts from the bowel wall than for those from bowel content (2.4 ± 0.6 vs 0.3 ± 0.2, P Conclusions FPs by CADe are primarily due to artifacts from the bowel wall. Despite a high frequency, FPs result in a negligible 1% increase in the total withdrawal time because most of them are immediately discarded by the endoscopist.