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The EndoRings device is a distal attachment consisting of two layers of circular flexible rings that evert mucosal folds. The aim of this study was to investigate whether EndoRing assisted colonoscopy (ER) improves polyp and adenoma detection compared to standard colonoscopy (SC).Multicenter, parallel group, randomized controlled trial.Total of 556 patients randomized to ER (n = 275) or SC (n = 281). Colonoscopy completed in 532/556 (96%) cases. EndoRings removed in 74/275 (27%) patients. Total number of polyps in ER limb 582 vs. 515 in SC limb, P = 0.04. Total number of adenomas in ER limb 361 vs. 343 for SC limb, P = 0.49. A statistically significant difference in the mean number of polyps per patient in both the intention to treat (1.84 SC vs. 2.10 ER, P = 0.027) and per protocol (PP) (1.84 SC vs. 2.25 ER, P = 0.004).Our study shows promise for the EndoRings device to improve polyp detection.

Introduction In this study, we review long-term outcomes of gastric endoscopic submucosal dissection [ESD] in western setting in light of the latest Japanese indication criteria, and examine predictors of outcomes and complications. Methods Data was collected on consecutive patients referred for gastric ESD in four participating centres from 2009 to 2021. Retrospective analysis of data with logistic regression and survival analysis was performed. Results A total of 415 patients were included. Mean age was 71.7 years, 56.4% were males. Absolute indication criteria [2018 guidelines] were fulfilled in 75.3% of patients. Median follow-up was 52 months. Post-resection histology was adenocarcinoma, HGD and LGD in 49.9%, 22.7% and 17.1% respectively. Perforation, early bleeding and delayed bleeding occurred in 2.4%, 4.3% and 3.4% respectively. En-bloc, R0 and recurrence on first endoscopic follow-up were 94.7%, 83.4% and 2.7% respectively. Relative indication [2018 Guidelines] for ESD was associated with R1 outcome [P-value 0.002]. Distal location [P-value 0.002] and increased procedure time [P-value 0.04] were significantly associated with bleeding risk, whereas scarring [P-value 0.009] and increased procedure duration [P-value 0.003] were associated with perforation. Recurrence-free survival at 2 years and 5 years was 94% and 83% respectively. Conclusion This is the largest multicenter western cohort suggesting gastric ESD is safe and effective in the western setting. A quarter of our patients fell outside of the new absolute indications for ESD, suggesting that western practice involves more advanced lesions. We identified the predictors of adverse outcomes in western practice. This should inform future practice and research.

The COVID-19 global pandemic resulted in a radical change in the provision and delivery of endoscopy services worldwide. As we emerge from this pandemic, various strategies were advocated to resume endoscopy whilst prioritizing the safety and wellbeing of patients and staff.This review summarizes the main changes including infection control and prevention measures in endoscopy and explores the overarching impact of the pandemic on the gastrointestinal lab. Various solutions are outlined to enable the well tolerated resumption of endoscopy services including retention of certain infection control measures, use of personal protective equipment, testing and vaccination. Strategies to deal with the mounting backlog of cases are also discussed.The COVID-19 pandemic wreaked havoc on healthcare systems worldwide and affected the provision and delivery of gastrointestinal diagnostic services, such as endoscopy necessitating a new way of working and an emphasis on infection control and better use of technology that are likely to be here to stay in the post pandemic era.

Background and objectivesGastric varices (GV) bleeding is a catastrophic complication of portal hypertension and is associated with significant morbidity and mortality. There are limited effective therapeutic interventions for the management of bleeding GV. Recently, EUS-guided therapy has been shown to be effective and safe intervention for such patients. However, there are no data to describe the feasibility and safety of EUS-guided therapy for GV in Arab population. The aim of this study is to describe our initial experience of EUS-guided therapy for GV in Kuwait.MethodsA case-series of patients that underwent EUS-guided therapy for clinically significant GV. All patients underwent EUS-guided therapy including Cyanoacrylate (CYA) injection with or without coil embolization. Patients were followed post procedure to document GV obliteration and monitor for any adverse events.ResultsIn total, 15 patients were included in this study (80% male) with mean age of 58 ± 12 years. The main indication for therapy was active GV bleeding (53.3%) followed by secondary prophylaxis (33.3%). Most patients had GOV-2 (80%) with mean GV size of 24.9 ± 7.9 mm. Combined EUS coil-CYA was used in most patients (80%), mean volume of CYA injected was 1.5 ± 0.74ml and mean number coils used of 1.5 ± 1.4. The technical success rate was 100% and all patients achieved GV obliteration after a median of 1 session (range 1-2). There were no major adverse events.ConclusionAmong Arab population with portal hypertension, EUS-guided therapy is highly effective and safe option for the managements of clinically significant GV.

The aim of this study is to develop and externally validate a computer aided detection (CADe) system for detection and localization of Barrett's neoplasia and assess its performance compared to general endoscopists in a statistically powered multi-center study using real-time video sequences.In phase-1, the hybrid VGG16-SegNet model was trained using 75,198 images and videos (96 patients) of neoplastic and 1,014,973 images/videos (65 patients) of non-neoplastic Barrett's. In phase-2, image-based validation was performed on a separate dataset of 107 images (20 patients) of neoplastic and 364 images (14 patients) of non-neoplastic Barrett's. In phase-3 (video-based external validation) we designed a real-time video-based study with 32 neoplastic videos (32 patients) and 43 non-neoplastic (43 patients) Barrett's videos from four European centers to compare the performance of the CADe model to that of six non-expert endoscopists. The primary end point was the sensitivity of CADe diagnosis of Barrett's neoplasia.In phase 2, CADe detected Barrett's neoplasia with sensitivity, specificity and accuracy of 95.3%, 94.5% and 94.7% respectively. In phase 3, the CADe system detected Barrett's neoplasia with sensitivity, specificity, NPV and accuracy of 93.8%, 90.7%, 95.1% and 92.0% respectively compared to the endoscopists' performance of 63.5%, 77.9%, 74.2% and 71.8% respectively (p0.05 in all parameters). The CADe system localized neoplastic lesions with accuracy, mean precision and mean IoU of 100%, 0.62, 0.54 respectively when compared to at least one of the expert markings. The processing speed of the CADe detection and localization were 5ms/image and 33ms/image respectively.This is the first study describing external (multi-center) validation of AI algorithms for Barrett's neoplasia detection on real-time endoscopic videos. The CADe system in this study significantly outperformed non-expert endoscopists on real-time video-based assessment achieving90% sensitivity for neoplasia detection. This needs to be validated during real-time endoscopic assessment.

The recent breakthrough of technological innovation has contributed to a tangible advance in endoscopic imaging. Optical diagnosis is an indispensable diagnostic and therapeutic tool for gastrointestinal (GI) disease. Endocytoscopy opens the realm of real-time microscopic evaluation of GI tract, providing information about cellular and subcellular changes during ongoing endoscopy, therapy potentially accelerating clinical diagnosis and specific therapy. Different generations of the endocytoscopes have evolved through the years and finally the development of computer-aided diagnosis and artificial intelligence-based system has gained momentum to tackle the challenges associated with the concept of optical biopsies to facilitate the decision in management of GI diseases. The current available scientific literature of endocytoscopy in the luminal gastrointestinal tract is discussed in this systematic review.

ObjectiveEndoscopic submucosal dissection (ESD) in a curative intent for submucosa-invasive early (T1) colorectal cancers (T1-CRCs) often leads to subsequent surgical resection in case of histologic parameters indicating higher risk of nodal involvement. In some cases, however, the expected benefit may be offset by the surgical risks, suggesting a more conservative approach.DesignRetrospective analysis of consecutive patients with T1-CRC who underwent ESD at 13 centres ending inclusion in 2019 (n=3373). Cases with high risk of nodal involvement (non-curative ESD: G3, submucosal invasion>1000 µm, lymphovascular involvement, budding or incomplete resection/R1) were analysed if follow-up data (endoscopy/imaging) were available, regardless of the postendoscopic management (follow-up vs surgery) selected by the multidisciplinary teams in these institutions. Comorbidities were classified according to Charlson Comorbidity Index (CCI). Outcomes were disease recurrence, death and disease-related death rates in the two groups. Rate of residual disease (RD) at both the previous resection site and regional lymph nodes was assessed in the surgical cases as well as from follow-up in the follow-up group.ResultsOf 604 patients treated by colorectal ESD for submucosally invasive cancer, 207 non-curative resections (34.3%) were included (138 male; mean age 67.6±10.9 years); in 65.2% of cases, no complete resection was achieved (R1). Of the 207 cases, 60.9% (n=126; median CCI: 3; IQR: 2–4) underwent surgical treatment with RD in 19.8% (25/126), while 39.1% (n=81, median CCI: 5; IQR: 4–6) were followed up by endoscopy in all cases. Patients in the follow-up group had a higher overall mortality (HR=3.95) due to non-CRC causes (n=9, mean survival after ESD 23.7±13.7 months). During this follow-up time, tumour recurrence and disease-specific survival rates were not different between the groups (median follow-up 30 months; range: 6–105).ConclusionFollowing ESD for a lesion at high risk of RD, follow-up only may be a reasonable choice in patients at high risk for surgery. Also, endoscopic resection quality should be improved.Trial registration numberNCT03987828.

In the last decade, flexible endoscopic septotomy has been reported as a well-tolerated and effective treatment for Zenker's diverticulum. More recently, novel endoscopic submucosal tunneling techniques, namely Zenker-PerOral Endoscopic Myotomy (Z-POEM) and PerOral Endoscopic Septotomy (POES) have been proposed to obtain complete muscular septum exposure and deeper myotomy. The aim of this study is to provide a systematic review with a meta-analysis of the first experiences of third space approaches for Zenker's diverticulum. Electronic databases (Medline, Scopus, EMBASE) were searched up to October 2020. Studies including patients with symptomatic Zenker's diverticulum who underwent endoscopic treatment by submucosal tunneling technique were eligible. Procedural, clinical and safety outcomes were assessed by pooling data with a random-effect model to obtain a proportion with a 95% confidence interval. Nine retrospective studies were eligible for inclusion (196 patients). Five studies were performed in the USA, two in Europe and two in Asia. Endoscopic treatment was feasible in 96.9% (I2 = 0%) of patients. The mean procedure duration was 36.4 ± 14.3 minutes. Clinical success was achieved after 93.4% (I2 = 0%) of procedures. The overall adverse events rate was 4.9% (I2 = 0%). No differences between the two approaches (Z-POEM vs POES) have been shown in terms of both efficacy and safety. Submucosal tunneling techniques appear to be feasible for symptomatic Zenker's diverticulum, with promising results in terms of efficacy and safety outcomes.

Background and Aims Inflammatory bowel disease is associated with an increased risk of colorectal cancer, with estimates ranging 2–18%, depending on the duration of colitis. The management of neoplasia in colitis remains controversial. Current guidelines recommend endoscopic resection if the lesion is clearly visible with distinct margins. Colectomy is recommended if complete endoscopic resection is not guaranteed. We aimed to assess the outcomes of all neoplastic endoscopic resections in inflammatory bowel disease. Methods This was a multicentre retrospective cohort study of 119 lesions of visible dysplasia in 93 patients, resected endoscopically in inflammatory bowel disease. Results A total of 6/65 [9.2%] lesions 20 mm in size were treated by EMR vs 35/51 [68.6%] by ESD. Almost all patients [97%] without fibrosis were treated by EMR, and patients with fibrosis were treated by ESD [87%], p < 0.001. In all, 49/78 [63%] lesions treated by EMR were resected en-bloc and 27/41 [65.9%] of the ESD/KAR [knife-assisted resection] cases were resected en-bloc, compared with 15/41 [36.6%] resected piecemeal. Seven recurrences occurred in the cohort. Seven complications occurred in the cohort; six were managed endoscopically and one patient with a delayed perforation underwent surgery. Conclusions Larger lesions with fibrosis are best treated by ESD, whereas smaller lesions without fibrosis are best managed by EMR. Both EMR and ESD are feasible in the management of endoscopic resections in colitis.

BACKGROUND: Blue Light Imaging (BLI) is a new imaging technology that enhances mucosal surface and vessel patterns. A specific BLI classification was recently developed to enable better characterisation of colorectal polyps (BLI Adenoma Serrated International Classification (BASIC)). The aim of this study was to validate the diagnostic performance of BASIC in predicting polyp histology in experienced and trainee endoscopists. METHODS: Five experienced and five trainee endoscopists evaluated high-definition white light (HDWL) and BLI images from 45 small polyps to assess baseline accuracy, sensitivity, specificity, and positive and negative predictive values (NPVs) of polyp histology. Each endoscopist was trained with the BLI classification before repeating the exercise. Results were compared pre- and post-training. RESULTS: The overall pre-training accuracy improved from 87% to 94%. The sensitivity and NPV of adenoma diagnosis also improved significantly from 79% to 96% and 81% to 95% with BASIC training. This improvement was noted in both groups. The interobserver level of agreement was very good (K = 0.90) in the experienced cohort and good (K = 0.66) in the trainee group post-training. CONCLUSIONS: BLI is a useful tool for optical diagnosis, and the use of BASIC with adequate training can significantly improve the accuracy, sensitivity and NPV of adenoma diagnosis. ispartof: UNITED EUROPEAN GASTROENTEROLOGY JOURNAL vol:7 issue:2 pages:316-325 ispartof: location:England status: published

Background Endoscopic submucosal dissection (ESD) is associated with a risk of bleeding. Bleeding is usually treated with diathermy, although this does carry a risk of mucosal thermal injury. Purastat is a topical hemostat that may be effective in controlling bleeding during ESD, thereby reducing the use of heat therapy. The aim of this study was to assess the reduction in heat therapy used in the interventional group (Purastat) compared with the control group. The secondary aims were to compare the procedure length, time for hemostasis, delayed bleeding rate, adverse events, and wound healing between the groups. Methods This was a single-center randomized controlled trial of 101 patients undergoing ESD. Participants were randomized to a control group where diathermy was used to control bleeding or an interventional group where Purastat could be used. Follow-up endoscopy was performed at 4 weeks to assess wound healing. Results There was a significant reduction in the use of heat therapy for intraprocedural hemostasis in the interventional group compared with controls (49.3 % vs. 99.6 %, P Conclusions This study has demonstrated that Purastat is an effective hemostat that can reduce the need for heat therapy for bleeding during ESD. It may also have a role in improving post-resection wound healing.

COVID-19 pandemic has played havoc at various levels throughout the world but has especially impacted the Health care professionals and put them at risk of mental ill health. The morbidity, mortality, and financial impact of COVID-19 have been huge and can easily dwarf the issues about mental wellbeing of individuals during these tough times. This can potentially have a long-lasting impact resulting in delayed recovery from this pandemic on all fronts of life. In our review, we aim to explore the issue of mental health with particular emphasis on health care workers and try and understand the size of problems, the symptoms and specific causes pertaining to COVID-19 related mental ill health. Finally, we have summarized some of the measures that can be taken by institutions and individuals to minimize the impact of COVID-19 pandemic on our mental wellbeing.

Electronic (virtual) chromoendoscopy technologies have had an enormous impact on the early detection and characterization of upper and lower gastrointestinal neoplasia. This has led to an improvement in optical diagnosis of early neoplasia, and allowed more targeted biopsies and better prediction of the risk of invasive cancer. In this chapter, we review various techniques and discuss their clinical use, focusing on oesophageal neoplasia and colorectal polyps.

The COVID-19 pandemic has had a profound impact on provision of endoscopy services globally as staff and real estate were repurposed. As we begin to recover from the pandemic, a cohesive international approach is needed, and guidance on how to resume endoscopy services safely to avoid unintended harm from diagnostic delays. The aim of these guidelines is to provide consensus recommendations that clinicians can use to facilitate the swift and safe resumption of endoscopy services. An evidence-based literature review was carried out on the various strategies used globally to manage endoscopy during the COVID-19 pandemic and control infection. A modified Delphi process involving international endoscopy experts was used to agree on the consensus statements. A threshold of 80% agreement was used to establish consensus for each statement. 27 of 30 statements achieved consensus after two rounds of voting by 34 experts. The statements were categorised as pre-endoscopy, during endoscopy and postendoscopy addressing relevant areas of practice, such as screening, personal protective equipment, appropriate environments for endoscopy and infection control precautions, particularly in areas of high disease prevalence. Recommendations for testing of patients and for healthcare workers, appropriate locations of donning and doffing areas and social distancing measures before endoscopy are unique and not dealt with by any other guidelines. This international consensus using a modified Delphi method to produce a series of best practice recommendations to aid the safe resumption of endoscopy services globally in the era of COVID-19. ispartof: GUT vol:69 issue:11 pages:1915-1924 ispartof: location:England status: published

Coronavirus-19 (COVID-19) caused by SARS-CoV-2 has become a global pandemic. Risk of transmission may occur during endoscopy and the goal is to prevent infection among healthcare professionals while providing essential services to patients. Asia was the first continent to have a COVID-19 outbreak, and this position statement of the Asian Pacific Society for Digestive Endoscopy shares our successful experience in maintaining safe and high-quality endoscopy practice at a time when resources are limited. Sixteen experts from key societies of digestive endoscopy in Asia were invited to develop position statements, including patient triage and risk assessment before endoscopy, resource prioritisation and allocation, regular monitoring of personal protective equipment, infection control measures, protective device training and implementation of a strategy for stepwise resumption of endoscopy services after control of the COVID-19 outbreak.

Colonoscopy reduces the risk of colorectal cancer, by interrupting the adenoma-carcinoma sequence enabling the detection and removal of adenomas before they turn into colorectal cancer. Colonoscopy has its limitations as adenoma miss rates as high as 25% have been reported. The reasons for missed pathology are complicated and multi-factorial. The recent drive to improve adenoma detection rates has led to a plethora of new technologies. Areas covered: An increasing number of advanced endoscopes and distal attachment devices have appeared in the market. Advanced endoscopes aim to improve mucosal visualization by widening the field of view. Distal attachment devices aim to increase adenoma detection behind folds by flattening folds on withdrawal. In this review article, we discuss the three following distal attachment devices: the transparent cap, the Endocuff, and the Endoring. Expert commentary: The authors believe that the distal attachment devices will have a greater benefit for endoscopists with low baseline adenoma detection rates.

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.

BACKGROUND AND AIMS: Detecting subtle Barrett's neoplasia during surveillance endoscopy can be challenging. Blue-light imaging (BLI) is a novel advanced endoscopic technology with high-intensity contrast imaging that may improve the identification of Barrett's neoplasia. The aim of this study was to develop and validate the first classification to enable characterization of neoplastic and non-neoplastic Barrett's esophagus using BLI. METHODS: In phase 1, descriptors pertaining to neoplastic and non-neoplastic Barrett's esophagus were identified to form the classification, named the Blue Light Imaging for Barrett's Neoplasia Classification (BLINC). Phase 2 involved validation of these component criteria by 10 expert endoscopists assessing 50 BLI images. In phase 3, a web-based training module was developed to enable 15 general (nonexpert) endoscopists to use BLINC. They then validated the classification with an image assessment exercise in phase 4, and their pre- and post-training results were compared. RESULTS: In phase 1 the descriptors were grouped into color, pit, and vessel pattern categories to form the classification. In phase 2 the sensitivity of neoplasia identification was 96.0% with a very good level of agreement among the experts (κ = .83). In phase 3, 15 general endoscopists completed the training module. In phase 4 their pretraining sensitivity (85.3%) improved significantly to 95.7% post-training with a good level of agreement (κ = .67). CONCLUSIONS: We developed and validated a new classification system (BLINC) for the optical diagnosis of Barrett's neoplasia using BLI. Despite the limitations of this image-based study with a high prevalence of neoplasia, we believe it has the potential to improve the optical diagnosis of Barrett's neoplasia given the high degree of sensitivity (96%) noted. It is also a promising tool for training in Barrett's esophagus optical diagnosis using BLI. ispartof: GASTROINTESTINAL ENDOSCOPY vol:91 issue:2 pages:310-320 ispartof: location:United States status: published

Introduction The EndoringsTM is a distal attachment consisting of two layers of circular flexible rings that evert mucosal folds. Aims; to investigate if Endorings Colonoscopy (ER) improves polyp and adenoma detection compared to standard colonoscopy (SC). Methods This multi-centre, parallel group, randomized controlled trial included screening, surveillance and symptomatic patients. Primary outcome; number of polyps per patient. Secondary outcomes; number of adenomas per patient, adenoma/polyp detection rates and withdrawal times. Results Total of 556 patients (214 females, 342 males) randomized to ER (275) or SC (281). Mean age 67. Colonoscopy completed 532/556 (96%) cases. EndoRings removed in 74/275 (27%) patients. In 66/74 (89%) cases removal was performed due to difficulties with sigmoid intubation. Remainder removed to facilitate retroflexion or polyp removal/retrieval. Total number of polyps in ER limb 571 vs 444 in SC limb. Total number of adenomas in ER limb 361 vs 343 for SC limb. Our study showed a statistically significant difference in the mean number of polyps per patient in both the Intention to Treat (ITT) (1.8 SC vs 2.1 ER, p-value 0.02) and Per Protocol (PP) (1.8 SC vs 2.25 ER, p-value 0.009). There was a trend towards a greater polyp detection rate in the ER colonoscopy (67.5% SC vs 75.2% ER, p-value 0.05). Conclusions Despite the high removal rate of Endorings, there was a statistically significant increase in the mean number of polyps in the ER limb compared to the SC limb. Our study shows promise for the EndoRingsTM device to improve polyp detection.

Cancer incidence in –0mm endoscopically detected colorectal lesions Introduction Recent data has shown the risk of cancer in colorectal lesions Methods We analysed outcomes of all patients who underwent colonoscopy from January 2007 to December 2018 and were found to have colorectal polyps. Data was prospectively collected on an online endoscopy reporting system and pathology reporting system. A chart review was then carried out analysing the site, size, morphology and histological diagnoses of each polyp. Results A total of 15906 polyps were removed at colonoscopy over the specified period, size of the polyps ranging from 1 mm to 120 mm and a mean size of 7.3 mm. A histopathological diagnosis of 104 cancers was made (0.65% of all polyps), of which 94 cancers (90.25%) were associated with non pedunculated polyps [OR 1.45, 95%CI 0.7–.78]. 89 cancers were found in the left colon and rectum compared with 15 cancers in the right colon ( 85.5% vs 14.5%) [OR 4.31, 95%CI 2.–.7, p Conclusions This study demonstrates that the prevalence of covert cancer in colorectal lesions between –0mm is very low. Cancer risk, however, increased more than 20 fold in polyps greater than 1 cm (3.6%) [OR 21, 95%CI 7.8–8.15 p

Introduction Endoscopic ampullectomy is a minimally invasive technique of treating non-invasive lesions involving the ampulla of Vater, and offers an alternative to major surgical intervention. In this study, we describe the safety and outcome of this procedure from a large, tertiary centre. Methods Data were prospectively collected on an electronic database. Parameters related to ampullectomy outcome and complications were retrospectively analyzed. Results A total of 37 cases were included in this analysis, between 2009 and 2018. Average age was 66. Female represented 59.4% of patients. Mean duration of follow up was 62.3 weeks. 23 (62.1%) lesions were pure ampullary, and the remaining involved the duodenal wall as well. Lesions ranged from 5 to 80 mm in size, with average size of 21.58 mm. 5 patients (13.5%) had familial adenomatous polyposis FAP. Pre resection histology confirmed HGD in one patient (2.7%), and neuro-endocrine tumor NET in one case (2.7%). Post resection histology showed focal adenocarcinoma in 1 patient (2.7%). Prophylactic PD stenting was performed in 26 cases (70.2%), adjunctive APC used in 7 cases (18.9%), and Submucosal injection in 27 cases (72.9%). En-bloc resection was achieved in 16 (43.2%), while piecemeal in 21 cases (56.7%). Recurrence observed in 9/37 cases (24.3%). Piecemeal resection and lack of submucosal injection were significantly associated with higher risk of recurrence (P=0.0485, P=0.0471, respectively). Early bleeding (including intra-procedural and bleeding within 24 hours of procedure) happened in 5 patients (13.5%), delayed bleeding (after 24 hours) in 2 cases (5.4%), all were successfully treated endoscopically. Only 1 patient (2.7%) had Pancreatitis, and one patient developed ampullary stenosis post procedure. There was no report of perforation, need for emergency surgery or 30 day mortality in this series. Conclusion Our series demonstrate the safety of this procedure in the UK setting. Piecemeal resection, and lack of submucosal injection seems to predict risk of recurrence, while size of the lesion did not significantly affect this outcome.

Introduction Duodenal and ampullary adenomas have the potential for malignant transformation to carcinomas by an adenoma-to-carcinoma sequence as seen elsewhere in the gastrointestinal tract. Endoscopic resection of these lesions is increasingly being used in place of invasive surgery. However, endoscopic resection in the duodenum can be challenging due to its anatomy and may be associated with a higher risk of complications. This study aims to evaluate the safety and efficacy of endoscopic resection of such lesions. Methods All patients with ampullary and large non-ampullary (>10 mm) duodenal polyps who underwent endoscopic resection between February 2008 and January 2019 in a single tertiary referral centre were included in the study. A retrospective analysis on data including demographics, size, histology, location, method of resection and complications was performed. Results There were a total of 112 patients referred for endoscopic therapy. Of these 112 patients, 37 underwent ampullectomy and 85 patients were referred for resection of non-ampullary duodenal polyps > 10 mm. In patients who underwent ampullectomy, 27 (73%) had a submucosal injection, whereas pancreato-duodenal stent was placed in 26 (70%) of patients. 7 (20%) patients had adjunct tissue ablation (APC). 62% of the lesions were pure ampullary, whereas 38% polyps involved the duodenum. In the 85 patients who were referred with a non ampullary duodenal lesion, 58 (68%) underwent endoscopic mucosal resection (EMR) and 27 (32%) had knife assisted resection (KAR). Majority of the lesions (70) were found in D2 (82%). Further characteristics have been summarized in table 1 All complications were managed endoscopically The majority of the recurrences were treated successfully with subsequent endoscopic resection. No procedure related mortality was noted in this cohort. Conclusions Endoscopic resection of duodenal and ampullary lesions is a safe and effective technique for complete removal of these polyps. The risk of complications is similar in ampullary and non-ampullary resections, however, the risk of recurrence is higher in patients with ampullary adenomas. Nevertheless, we demonstrated that all complications and most recurrences were successfully managed endoscopically.

Introduction Endoscopic submucosal dissection (ESD) is a technique first developed in Japan to enable en-bloc endoscopic resection of early gastric neoplasia. The high prevalence of gastric neoplasia allowed for greater opportunity to train and refine the technique in the Far East. The same is not applicable to the West where the prevalence of gastric neoplasia is low. In this study, we aim to review the efficacy and safety of ESD for early gastric neoplasia from three large European referral centres. Methods Data was prospectively collected on an electronic database. We analysed this database and patient’s electronic record. Parameters related to ESD outcome were collected. Results A total of 175 gastric neoplasia were resected between 2009 and 2017 (152 ESD, 23 hybrid ESD), 51.4% were in proximal stomach. Mean size was 29 mm. Only 13 (7.42%) were sub-epithelial lesions. Table 1 shows outcomes and procedure-related complications. The overall en-bloc resection, R0 (deep), and R0 (deep and lateral) rates were 92.5%, 83.4%, and 61.0%, respectively. Proximal location of the lesion was a predictor for R1 outcome (p value 0.011). Size of the lesion was not significantly related to the R0 rate. The overall adverse event rate was 11.3%. There was no 30-day procedure related mortality. Recurrence at 3 months occurred in 7 patients (4%). Conclusion This is the largest western gastric ESD series, demonstrating the feasibility and safety of this technique in a European setting. Despite the low R0 rate, our recurrence rate is low and comparable to Japanese data. Reasons behind good clinical outcome (very low recurrence) despite an average technical outcome (R0) remains uncertain. This raises a possibility that in the west, R-1 should not automatically be considered as an indication for surgery.

Queen Alexandra Hospital, Portsmouth Introduction Non-ampullary duodenal adenomas (sporadic and duodenal lesions associated with familial adenomatous polyposis or FAP) are rare, with most lesions found incidentally on gastroscopy. Endoscopic resection of duodenal lesions is increasingly being used in place of invasive surgery. However, endoscopic resection in the duodenum can be challenging due to its anatomy and may be associated with a higher risk of complications. This study aims to evaluate the safety and efficacy of endoscopic resection of duodenal polyps. Methods All patients with large (>10 mm) non-ampullary duodenal polyps who underwent endoscopic resection between February 2008 and January 2019 in a single tertiary referral centre were included in the study. A retrospective analysis on data including demographics, size, histology, location, method of resection and complications was performed. Results There were a total of 85 patients with polyps >10 mm referred for endoscopic therapy (median age 64 years, [IQR] 27–87 years, 52% male). 58 (68%) underwent endoscopic mucosal resection (EMR) and 27 (32%) had knife assisted resection (KAR). Histology revealed 67 (79%) LGD and 11 (13%) HGD. Majority of the lesions (70) were found in D2 (82%). 8 patients (9.4%) had a diagnosis of FAP. The mean polyp size was 25.3 mm [IQR 10–80]. 80 polyps (94.1%) were removed in a single session with an en-bloc resection rate of 40%. The overall recurrence, bleeding and perforation rate was 7%, 8% and 2% respectively. Table 1 shows the complication and recurrence rates stratified by lesion size ( 30 mm). All complications were managed endoscopically. The median follow up period was 38 months [IQR 4–120] and a higher rate of recurrence (16%) was noted in lesions >30 mm. The majority (4/6) of the recurrences were treated successfully with subsequent endoscopic resection. The complication and recurrence rate was similar in patients undergoing EMR and KAR. No procedure related mortality was noted in this cohort. Conclusions Endoscopic resection of duodenal lesions is a safe and effective technique for complete removal of these polyps. Lesion assessment is crucial in patient selection for endoscopic removal as noted by the absence of cancers in this cohort. The risk of complications, particularly bleeding is higher in lesions greater than 3 cm. Similarly, recurrence rates are also higher in this group. Nevertheless, we demonstrated that all complications and most recurrences were successfully managed endoscopically.

Background & Aims One-fourth of colorectal neoplasias are missed during screening colonoscopies; these can develop into colorectal cancer (CRC). Deep learning systems allow for real-time computer-aided detection (CADe) of polyps with high accuracy. We performed a multicenter, randomized trial to assess the safety and efficacy of a CADe system in detection of colorectal neoplasias during real-time colonoscopy. Methods We analyzed data from 685 subjects (61.32 ± 10.2 years old; 337 men) undergoing screening colonoscopies for CRC, post-polypectomy surveillance, or workup due to positive results from a fecal immunochemical test or signs or symptoms of CRC, at 3 centers in Italy from September through November 2019. Patients were randomly assigned (1:1) to groups who underwent high-definition colonoscopies with the CADe system or without (controls). The CADe system included an artificial intelligence–based medical device (GI-Genius, Medtronic) trained to process colonoscopy images and superimpose them, in real time, on the endoscopy display a green box over suspected lesions. A minimum withdrawal time of 6 minutes was required. Lesions were collected and histopathology findings were used as the reference standard. The primary outcome was adenoma detection rate (ADR, the percentage of patients with at least 1 histologically proven adenoma or carcinoma). Secondary outcomes were adenomas detected per colonoscopy, non-neoplastic resection rate, and withdrawal time. Results The ADR was significantly higher in the CADe group (54.8%) than in the control group (40.4%) (relative risk [RR], 1.30; 95% confidence interval [CI], 1.14–1.45). Adenomas detected per colonoscopy were significantly higher in the CADe group (mean, 1.07 ±1.54) than in the control group (mean 0.71 ± 1.20) (incidence rate ratio, 1.46; 95% CI, 1.15–1.86). Adenomas 5 mm or smaller were detected in a significantly higher proportion of subjects in the CADe group (33.7%) than in the control group (26.5%; RR, 1.26; 95% CI, 1.01–1.52), as were adenomas of 6 to 9 mm (detected in 10.6% of subjects in the CADe group vs 5.8% in the control group; RR, 1.78; 95% CI, 1.09–2.86), regardless of morphology or location. There was no significant difference between groups in withdrawal time (417 ± 101 seconds for the CADe group vs 435 ± 149 for controls; P = .1) or proportion of subjects with resection of non-neoplastic lesions (26.0% in the CADe group vs 28.7% of controls; RR, 1.00; 95% CI, 0.90–1.12). Conclusions In a multicenter, randomized trial, we found that including CADe in real-time colonoscopy significantly increases ADR and adenomas detected per colonoscopy without increasing withdrawal time. ClinicalTrials.gov no: 04079478

Endoscopic treatment of colorectal lesions has seen major developments in the last decade. It is now considered curative for intramucosal and superficial submucosal cancers. Endoscopic Mucosal Resection in expert hands has very good outcomes with low complication rates but recurrence and inadequate treatment of early cancers remain an issue. This has led to a technical evolution that can lead to one piece resection of neoplasia. This includes a range of techniques from knife assisted snare resection (KAR), endoscopic submucosal dissection (ESD) to full thickness resections. This article reviews all the resection techniques and the evidence base behind them.

Introduction The advent of image enhanced endoscopic modalities have paved the way for better optical diagnosis of colorectal polyps. Blue Light Imaging (BLI) is a new technology that utilises powerful light emitting diode technology to enhance mucosal surface and vessel patterns. A specific BLI classification has recently been developed to enable better characterisation of colorectal polyps (BLI Adenoma Serrated International Classification - BASIC) The aim of our study was to investigate the diagnostic ability of BLI before and after training using this classification in experienced and non-experienced endoscopists. Methods BLI images from 45 polyps were shown to 10 endoscopists (5 with experience of advanced endoscopic imaging and 5 trainees with limited experience). They independently classified each of the images as adenoma or hyperplastic initially without any focused training on interpretation of BLI images. A training module on BASIC was developed and each endoscopist undertook a face to face training session where direct feedback was given. All endoscopists then repeated the image classification exercise. The sensitivity, specificity, accuracy, negative (NPV) and positive predictive value (PPV) for adenoma detection was calculated. Results In both groups of endoscopists, there was a significant improvement in sensitivity and NPV of adenoma detection (p Conclusions The use of a bespoke BLI classification system with adequate training can significantly improve the sensitivity and NPV of adenoma detection in both experienced and non-experienced endoscopists thereby enabling the full potential of this novel imaging technology to be realised.