PURPOSE OF REVIEW: Esophageal cancer is one of the most common cancers in the world and carries a poor prognosis. While esophagectomy poses considerable mortality and morbidity risks, endoscopic resection can provide a safer and less invasive alternative. RECENT FINDINGS: Endoscopic resection therapy has allowed a less invasive approach with comparable outcomes to esophagectomy. EMR is considered safe and requires less intensive training, yet it does not offer complete histopathological assessment due to the nature of piecemeal resection for larger lesions. Alternatively, ESD offers an R0 resection, therefore allowing precise histopathological evaluation. Training in ESD is essential; however, a uniform training model has not been agreed upon. The Japanese apprenticeship training model has proven effective, with promising training outcomes from the Eastern experience. In the West, a comprehensive training model through a combination of apprenticeship with progressive exposure, including ex-vivo and live animal hands-on training, could be the optimal approach. Different methods of ESD training are currently available, all of which aim to provide the experience needed to perform safe ESD. Despite the differences in training styles between the East and the West, a modified apprenticeship model could potentially result in more effective and better training outcomes. The currently available technologies provide the environment to enhance ESD training.

Endoscopic mucosal resection (EMR) is an established technique for the diagnosis and treatment of high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) in Barrett's esophagus. Submucosal preinjection is not universally used or generally recommended when performing routine ligation-assisted EMR. Prior studies, however, have demonstrated evidence of at least superficial muscle injury on ligation-assisted EMR without submucosal injection. There are limited published data supporting any potential benefit of submucosal preinjection. Our aim was to review this technique and determine the rate of any degree of muscle injury in patients with Barrett's HGD and EAC treated with submucosal preinjection before ligation-assisted EMR.

Patients undergoing submucosal preinjection before ligation-assisted EMR for Barrett's esophagus at a single institution between 2012 and 2016 were identified. Data were collected regarding patient demographics and medical history, endoscopy and histopathology findings, adverse events, and subsequent outcomes. All EMR specimens were reviewed by an expert gastrointestinal pathologist.

One hundred fifty consecutive EMR procedures were performed on 70 patients. Of 70 patients, 85.7% of patients were men, with a median age of 68 years. EAC was identified in 75 specimens (50%) and HGD in 44 specimens (29.3%). Deep resection margins were clear of adenocarcinoma in all specimens. Muscularis propria was not identified in any of the 150 specimens. There were no cases of post-EMR perforation.

Preinjection before ligation-assisted EMR achieved complete excision with histologically clear margins, without histological evidence of any inadvertent muscularis propria.

The endoscopic pressure study integrated system (EPSIS) measures intragastric pressure (IGP) during esophagogastroduodenoscopy. Previous research demonstrated that EPSIS correlates with the 24-h impedance-pH (MII-pH) test and shows lower maximum IGP (IGP-Max) and a flatter waveform gradient in gastroesophageal reflux disease (GERD) patients, attributed to lower esophageal sphincter dysfunction. Although endoscopic antireflux therapy (EARTh) is effective for GERD, the MII-pH monitoring, the gold standard for assessing treatment outcomes, requires hospitalization and can be a burden. EPSIS offers a noninvasive alternative for evaluating post-EARTh outcomes. This study aimed to assess EPSIS as an additional diagnostic tool in this context.

We conducted a retrospective analysis of GERD patients who underwent EARTh and were subsequently assessed using EPSIS within 6 months, from May 2018 to April 2024. Changes in IGP parameters, including IGP-Max and waveform gradient, were analyzed pre- and post-EARTh. Additionally, the study examined Hill's Classification following EARTh.

Out of 39 patients assessed with EPSIS before and after EARTh, the average age was 55 years (standard deviation [SD] 16.7), with 64.1% male. Postoperative IGP-Max increased from 15.2 mmHg to 18.0 mmHg (P = 0.004), and the pressure gradient improved from 0.16 mmHg/s to 0.28 mmHg/s (P < 0.001). Hill's Classification improved significantly from a mean of 2.2 (SD 0.7) to 1.1 (SD 0.3) (P < 0.001).

This study indicates that EPSIS is a reliable diagnostic tool for evaluating the effects of EARTh and holds potential as a supplementary tool for assessing GERD treatment outcomes.

The incidence of colorectal neuroendocrine tumors (NETs) has increased with colorectal cancer screening programs and increased colonoscopies. The management of colorectal NETs has recently shifted from radical surgery to endoscopic resection. We aimed to evaluate the short-term outcomes of various methods of endoscopic resection for colorectal NETs.

Among those registered in the C-NET STUDY, patients with colorectal NETs who underwent endoscopic treatment as the initial therapy were included. Short-term outcomes, such as the en bloc resection rate and R0 resection (en bloc resection with tumor-free margin) rate, were analyzed based on treatment modalities.

A total of 472 patients with 477 colorectal NETs received endoscopic treatment. Of these, 418 patients with 421 lesions who met the eligibility criteria were included in the analysis. The median age of the patients was 55 years, and 56.9% of them were men. The lower rectum was the most commonly affected site (88.6%), and lesions <10 mm accounted for 87% of the cases. Endoscopic submucosal resection with a ligation device (ESMR-L, 56.5%) was the most common method, followed by endoscopic submucosal dissection (ESD, 31.4%) and endoscopic mucosal resection using a cap (EMR-C, 8.5%). R0 resection rates <10 mm were 95.5%, 94.8%, and 94.3% for ESMR-L, ESD, and EMR-C, respectively. All 16 (3.8%) patients who developed treatment-related complications could be treated conservatively. Overall, 23 (5.5%) patients had incomplete resection without independent clinicopathological risk factors.

ESMR-L, ESD, and EMR-C were equally effective and safe for colorectal NETs with a diameter <10 mm.

Background and Objectives: Endoscopic resection of gastrointestinal (GI) tract lesions, originating from Japan, is becoming more frequently used in European countries. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) ensure minimally invasive removal of benign, premalignant, and early neoplastic tumors of esophagus, stomach, and intestine in selected group of patients. Aim of this study was to determine the outcomes, radical resection rate (R0), and complication rate of ESD procedures performed in our department. Methods: The data from 100 ESD procedures of esophageal, gastric, duodenal, and colorectal lesions performed in out unit between 02.01.2020 and 30.06.2023 were collected and analyzed retrospectively. Results: A total of 42 male and 58 female patients in the median age of 64 years (range, 31-89 years) underwent ESD. Mean duration of the procedure was 66 minutes (ranging 25-185 minutes). Tumors were located in the esophagus in 8 cases (8%), stomach in 25 cases (25%), duodenum in 1 case (1%), and colon in 66 cases (66%). Radical resection was achieved in 98 cases (98%); 2 patients were qualified for surgical treatment. Average size of dissection lesions was 26 × 19 mm. The biggest one was 60 × 60 mm (sigmoid adenoma), and the smallest one was 5 × 5 mm (gastrointestinal neuroectodermal tumors). Complication occurred in 10 patients (10%)-9 perforations of the wall of intestine (9%) and 1 hemorrhage, which required endoscopic intervention (1%). Conclusions: Implementation of ESD to clinical practice gives the opportunity for minimally invasive, radical treatment of benign, premalignant, and early neoplastic lesions of gastrointestinal tract in selected group of patients. Experienced endoscopists, following current guidelines and standardized process of qualification, are crucial to minimize the risk of severe complications.

Video 1XXX.

Anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA) were developed as interventions for proton pump inhibitor (PPI)-refractory/-dependent gastroesophageal reflux disease (GERD). Although ARMS and ARMA are established treatments for PPI-refractory GERD, reliance on natural healing for ulcer scar formation introduces uncertainty and bleeding risk. To address these issues, we introduced a novel approach called anti-reflux mucoplasty (ARM-P), which involves immediate closure of mucosal defects following mucosectomy. This pilot study aims to evaluate the safety, feasibility, and efficacy of ARM-P.

A retrospective single-center study was conducted using prospectively collected data from October 2022 to July 2023. Patients with PPI-refractory/-dependent GERD who underwent ARM-P were included. The study evaluated technical success of ARM-P, before and after ARM-P GERD-Health Related Quality of Life Questionnaire, GerdQ, and Frequency Scale for the Symptoms of GERD scores, along with PPI discontinuation and endoscopic esophagogastric junction morphology.

A total of 20 patients with a median age of 61.5 years underwent the ARM-P procedure. The procedure achieved 100% technical success without adverse events. After ARM-P, 55.0% discontinued PPI usage and 15.0% reduced PPI dose by half. Median GERD-Health Related Quality of Life Questionnaire score improved from 21 to 6 (P = 0.0026), median GerdQ score improved from 9 to 7 (P = 0.0022), and median Frequency Scale for the Symptoms of GERD score decreased from 16 to 7 (P = 0.0003). Median Hill's Classification significantly improved from grade III to grade I (P = 0.0001).

This study presents the first pilot report of ARM-P, demonstrating its procedural safety, technical feasibility, and short-term efficacy.

Endoscopic submucosa dissection (ESD) allows complete excision of the whole lesion, which results in a higher percentage of complete excision and an improved quality of life by minimizing the amount of excision as opposed to an endoscopic mucosal resection (EMR). Although ESD is now being carried out in the majority of hospitals, ESD's possible complications (such as trauma and perforation) have given rise to doubts about ESD practices in patients with early-stage stomach cancer when deciding on therapy and reimbursement. This study was designed to evaluate the effectiveness and safety of ESD over EMR in treating early-stage stomach cancer. Four main databases have been searched, including EMBASE and published. The ROBINS-I tool suggested in the Cochrane Handbook has been applied to evaluate the quality of the chosen trials. It may better reflect the risk of bias in the included studies. The meta-analyses were carried out with ReMan 5.3, and the results were treated with endote. Seven cohort studies have been completed. Meta analysis indicated that EMR and ESD surgery did not differ significantly from each other in terms of postoperative haemorrhage (OR, 0.76; 95%CI, 0.56,1.04 p = 0.09); EMR, however, was associated with a lower rate of postoperative perforation than ESD surgery (OR, 0.36; 95%CI, 0.24,0.54 p < 0.0001). Taking into account that ESD and EMR did not differ significantly in the risk of wound bleeding, even though the risk of perforation is not likely to result in life-threatening illness. In the analysis of these data, however, the potential advantages of EMR might be greater than ESD.

Endoscopy is mandatory to detect early gastric cancer (EGC). When considering the cost-effectiveness of the endoscopic screening of EGC, risk stratification by combining serum pepsinogen values and anti-H. pylori IgG antibody values is very promising. After the detection of suspicious lesions of EGC, a detailed observation using magnifying endoscopy with band-limited light is necessary, which reveals an irregular microsurface and/or an irregular microvascular pattern with demarcation lines in the case of cancerous lesions. Endocytoscopy enables us to make an in vivo histological diagnosis. In terms of the indications for endoscopic resection, the likelihood of lymph node metastasis and technical difficulties in en bloc resection is considered, and they are divided into absolute, expanded, and relative indications. Endoscopic mucosal resection and endoscopic submucosal dissection are the main treatment modalities nowadays. After endoscopic resection, curability is evaluated histologically as endoscopic curability (eCura) A, B, and C (C-1 and C-2). Recent evidence suggests that the outcomes of endoscopic resection for many EGCs are comparable to those of gastrectomy and that endoscopic resection is the gold standard for node-negative early gastric cancers. Personalized medicine is also being developed to overcome the unmet needs in treatments of EGC, for example the further expansion of indications and newer resection techniques, such as full-thickness resection.

In this editorial we comment on the article published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2023; 15 (11): 634-680. Gastric cancer (GC) remains the fifth most common malignancy and the fourth leading cause of cancer-related death worldwide. The overall prevalence of GC has declined, although that of proximal GC has increased over time. Thus, a significant proportion of GC cases and deaths can be avoided if preventive interventions are taken. Early GC (EGC) is defined as GC confined to the mucosa or submucosa. Endoscopic resection is considered the most appropriate treatment for precancerous gastrointestinal lesions improving patient quality of life, with reduced rates of complications, shorter hospitalization period, and lower costs when compared to surgical resection. Endoscopic mucosal resection (EMR) and endoscopic sub-mucosal dissection (ESD) are representative endoscopic treatments for EGC and precancerous gastric lesions. Standard EMR implies injection of a saline solution into the sub-mucosal space, followed by excision of the lesion using a snare. Complete resection rates vary depending on the size and severity of the lesion. When using conventional EMR methods for lesions less than 1 cm in size, the complete resection rate is approximately 60%, whereas for lesions larger than 2 cm, the complete resection rate is low (20%-30%). ESD can be used to remove tumors exceeding 2 cm in diameter and lesions associated with ulcers or submucosal fibrosis. Compared with EMR, ESD has higher en bloc resection rates (90.2% vs 51.7%), higher complete resection rates (82.1 vs 42.2%), and lower recurrence rates (0.65% vs 6.05%). Thus, innovative techniques have been introduced.

Video 1We present a new therapeutic approach called antireflux mucoplasty for proton pump inhibitor-refractory GERD.

EUS is the most accurate procedure to determine the originating mural layer and subsequently select the treatment of submucosal tumors (SMTs). However, it requires superb technical and cognitive skills. In this study, we propose a system named SMT Master to determine the originating mural layer of SMTs under EUS.

We developed 3 models: deep convolutional neural network (DCNN) 1 for lesion segmentation, DCNN2 for mural layer segmentation, and DCNN3 for the originating mural layer classification. A total of 2721 EUS images from 201 patients were used to train the 3 models. We validated our model internally and externally using 283 images from 26 patients and 172 images from 26 patients, respectively. We applied 368 images from 30 patients for the man-machine contest and used 30 video clips to test the originating mural layer classification.

In the originating mural layer classification task, DCNN3 achieved a classification accuracy of 84.43% and 80.68% at internal and external validations, respectively. In the video test, the accuracy was 80.00%. DCNN1 achieved Dice coefficients of 0.956 and 0.776 for lesion segmentation at internal and external validations, respectively, whereas DCNN2 achieved Dice coefficients of 0.820 and 0.740 at internal and external validations, respectively. The system achieved 90.00% accuracy in classification, which is comparable with that of EUS experts.

Our proposed system has the potential to solve difficulties in determining the originating mural layer of SMTs in EUS procedures, which relieves the EUS learning pressure of physicians.

Endoscopic resection (ER) is an effective treatment for early gastric cancer (EGC) without metastases. Existing endoscopic mucosal resection (EMR) is easy to perform, has few complications, and can be applied when the lesion size is small. However, en bloc and complete resection rates vary depending on the size and severity of the lesion. EMR using the cap-mounted panendoscopic method and EMR after circumferential preamputation of the lesion are useful in the treatment of EGC. However, completely oversized lesions (≥2 cm) and lesions associated with ulcers or submucosal fibrosis are more likely to fail resection. Endoscopic submucosal dissection has been widely used to resect tumors larger than 2 cm in diameter and has a higher acceptable complication rate and en bloc and complete resection rates than EMR. ER for EGC is superior to surgical resection in terms of improving patient quality of life. Additionally, compared to surgery, emergency rooms have a lower rate of treatment-related complications, shorter hospital stays, and lower costs. Accordingly, the indications for ER are expanding in the field of therapeutic endoscopy. Long-term outcomes regarding recurrence are excellent in both absolute and extended criteria for ER in EGC. Close surveillance should be performed after ER to detect early metachronous gastric cancer and precancerous lesions that can be treated with ER. Follow-up gastroscopy and abdominopelvic computed tomography scans every 6 to 12 months are recommended for patients who undergo curative ER for EGC on absolute or extended criteria.

Chemoradiotherapy (CRT) and radiotherapy (RT) are treatment options for esophageal squamous cell carcinoma (ESCC), but local residual/recurrent cancer after CRT/RT is a major problem. Endoscopic resection (ER) is an effective treatment option for local residual/recurrent cancer. To ensure the efficacy of ER, complete removal of endoscopically visible lesions with cancer-free vertical margins is desired. This study aimed to identify the endoscopic parameters associated with the complete endoscopic removal of local residual/recurrent cancer. In this single-center, retrospective study, we used a prospectively maintained database to identify esophageal lesions that were diagnosed as local residual/recurrent cancer after CRT/RT and treated by ER between January 2012 and December 2019. We evaluated the associations of endoscopic R0 resection with findings on conventional endoscopy and endoscopic ultrasonography (EUS). In total, 98 lesions (83 cases) were identified from our database. The rate of endoscopic R0 resection was higher for flat lesions (100% versus 77%, P = 0.00014). EUS was performed for 24 non-flat lesions, and endoscopic R0 resection was achieved for 94% of lesions with an uninterrupted fifth layer. Flat lesions on conventional endoscopy and lesions with an uninterrupted fifth layer on EUS are good candidates for ER.

Early gastric cancer comprises gastric malignancies that are confined to the mucosa or submucosa, irrespective of lymph node metastasis. Endoscopic resection is currently pivotal for the management of such early lesions, and it is the recommended treatment for tumors presenting a very low risk of lymph node metastasis. In general, these lesions consist of two groups of differentiated mucosal adenocarcinomas: non-ulcerated lesions (regardless of their size) and small ulcerated lesions. Endoscopic submucosal dissection is the technique of choice in most cases. This procedure has high rates of complete histological resection while maintaining gastric anatomy and its functions, resulting in fewer adverse events than surgery and having a lesser impact on patient-reported quality of life. Nonetheless, approximately 20% of resected lesions do not fulfill curative criteria and demand further treatment, highlighting the importance of patient selection. Additionally, the preservation of the stomach results in a moderate risk of metachronous lesions, which underlines the need for surveillance. We review the current evidence regarding the endoscopic treatment of early gastric cancer, including the short-and long-term results and management after resection.

Endoscopic submucosal dissection is an established method for complete resection of large and early gastrointestinal tumors. However, methods to reduce bleeding, perforation, and other adverse events after endoscopic resection (ER) have not yet been defined. Mucosal defect closure is often performed endoscopically with a clip. Recently, reopenable clips and large-teeth clips have also been developed. The over-the-scope clip enables complete defect closure by withdrawing the endoscope once and attaching the clip. Other methods involve attaching the clip-line or a ring with an anchor to appose the edges of the mucosal defect, followed by the use of an additional clip for defect closure. Since clips are limited by their grasping force and size, other methods, such as endoloop closure, endoscopic ligation with O-ring closure, and the reopenable clip over-the-line method, have been developed. In recent years, techniques often utilized for full-thickness ER of submucosal tumors have been widely used in full-thickness defect closure. Specialized devices and techniques for defect closure have also been developed, including the curved needle and line, stitches, and an endoscopic tack and suture device. These clips and suture devices are applied for defect closure in emergency endoscopy, accidental perforations, and acute and chronic fistulas. Although endoscopic defect closure with clips has a high success rate, endoscopists need to simplify and promote endoscopic closure techniques to prevent adverse events after ER.

The sixth edition of the Japanese Gastric Cancer Treatment Guidelines was completed in July 2021, incorporating new evidence that emerged after publication of the previous edition. It consists of a text-based "Treatments" part and a "Clinical Questions" part including recommendations and explanations for clinical questions. The treatments parts include a comprehensive description regarding surgery, endoscopic resection and chemotherapy for gastric cancer. The clinical question part is based on the literature search and evaluation by an independent systematic review team. Consequently, not only evidence for each therapeutic recommendation was clearly shown, but it also identified the research fields that require further evaluation to provide appropriate recommendations.

Gastric cancer is the third leading cause of cancer-related death. In Western countries, its lower prevalence and the absence of mass screening programmes contribute to late diagnosis and a slower implementation of minimally invasive treatments. A secondary prevention strategy through endoscopic surveillance of patients at high risk of intestinal-type gastric adenocarcinoma or by screening gastric cancer within colorectal screening programmes is cost-effective in intermediate-risk countries, though the identification of these patients remains challenging. Virtual chromoendoscopy with narrow-band imaging improves the accuracy of endoscopic diagnosis, significantly increasing the sensitivity for intestinal metaplasia while preserving specificity. Endoscopic grading of gastric intestinal metaplasia is feasible, correlates well with histological staging systems and also with gastric neoplasia risk and can be used to stratify risk. Endoscopic submucosal dissection (ESD) in the West achieves efficacy and safety outcomes similar to those reported for Eastern countries, and the long-term disease-specific survival is higher than 95%. A prospective comparative study with gastrectomy confirms its higher safety and its benefits concerning health-related quality of life. However, ESD is associated with a 5% risk of postprocedural bleeding and a 20% risk of non-curative resection. The knowledge of risk factors for adverse events and non-curative resection can improve patient selection. The risk of metachronous lesions after ESD is high (3-5% per year), and endoscopic surveillance is needed. The management of patients with non-curative resection can be optimized using risk scoring systems for lymph node metastasis.

Gastric cancer (GC) has a good prognosis, if detected at an early stage. The intestinal subtype of GC follows a stepwise progression to carcinoma, which is treatable with early detection and intervention using high-quality endoscopy. Premalignant lesions and gastric epithelial polyps are commonly encountered in clinical practice. Surveillance of patients with premalignant gastric lesions may aid in early diagnosis of GC, and thus improve chances of survival. An expert professional workgroup was formed to summarise the current evidence and provide recommendations on the management of patients with gastric premalignant lesions in Singapore. Twenty-five recommendations were made to address screening and surveillance, strategies for detection and management of gastric premalignant lesions, management of gastric epithelial polyps, and pathological reporting of gastric premalignant lesions.

Endoscopic resection for early gastric cancer is recommended when the risk of lymph node metastasis is negligible and should be performed through submucosal dissection due to well-established short- and long-term results. To overcome technical difficulties and decrease adverse events some techniques have been studied. This review outlines current strategies for improving patient selection and highlights innovative techniques that help minimize adverse events. Moreover, we discuss how to improve management after curative and noncurative resections.

Cap-assisted endoscopic mucosal resection (EMRC), ligation-assisted endoscopic mucosal resection (EMRL), endoscopic submucosal dissection (ESD), and multiband mucosectomy (MBM) are used for treating early esophageal cancer patients. Our aim was to compare the efficacy and safety of four different endoscopic treatments.

Electronic databases (PubMed, Cochrane, Embase, and Web of Science) were systematically searched to include relevant studies published from database inception until February 15, 2021. There were no date or language restrictions. Data related to study such as characteristics, methods, outcomes, and risks of bias were extracted by two reviewers.

A total of 11 articles with 1880 patients were included. The results of the network meta-analysis showed that ESD was a better choice considering the efficacy of en bloc resection rate (surface under the cumulative ranking curves (SUCRA) = ESD: 99.5%, EMRC: 26.5%, MBM: 24.1%) and local recurrence rate (SUCRA = EMRC: 95.6%, MBM: 42.9%, ESD: 11.6%). MBM had a lower rate of side effects compared to the other treatments: perforation rate (SUCRA = ESD: 100%, EMRC: 48.1%, MBM: 1.9%), stricture rate (SUCRA = ESD: 99.8%, MBM: 40.8%, EMRC: 9.4%), and bleeding rate (SUCRA = EMRC: 69.4%, ESD: 62.2%, EMRL: 61.6%, MBM: 6.8%). MBM also had the shortest operation time and smallest diameter of the specimens.

The MBM endoscopic treatment was recommended for early esophageal cancer patients, but considering the increase in lesion size, ESD would be better.

Endoscopic resection (ER) is a minimally invasive treatment for esophageal squamous cell carcinoma (ESCC). However, stricture may develop after ER for widespread lesions. Application of ER is justified if these cancers are pathological T1a-epithelial/lamina propria (pEP/LPM) cancers that can be cured by ER. We conducted a study to clarify the association between pathological invasion depth and lesion size or circumference in clinical (c) EP/LPM cancers.

From our database, we identified patients diagnosed with cEP/LPM ESCC via endoscopic examination who underwent endoscopic or surgical tumor resection. The accuracy of the cEP/LPM ESCC diagnosis was determined by histologically diagnosing cancer invasion depth as a reference standard.

Between January 2015 and December 2019, 1271 cancer patients were diagnosed with cEP/LPM ESCC, of which 1195 (94.0%) were correctly diagnosed with pEP/LPM cancer. The positive predictive value (PPV) classified according to lesion sizes of ≤25, 26-49, and ≥50 mm was 95.8% (981/1024 lesions), 89.7% (191/213 lesions), and 67.6% (23/34 lesions), respectively. PPV according to the circumferential extent of <3/4, ≥3/4, and <1, and whole was 94.6% (1164/1230 lesions), 75.0% (24/32 lesions), and 77.8% (7/9 lesions), respectively. In multivariate analysis, the PPV of cEP/LPM ESCC was significantly associated with lesion size (P < 0.001) and male sex.

Between January 2015 and December 2019, 1271 cancer patients were diagnosed with cEP/LPM ESCC, of which 1195 (94.0%) were correctly diagnosed with pEP/LPM cancer. The PPV of cEP/LPM ESCC was related to lesion size. Treatment should be determined considering the high risk of cancer invasion into the muscularis mucosa or deeper in cEP/LPM cancers with a lesion size of ≥50 mm.

Endoscopic resection is first-line therapy in the management of superficial neoplasms throughout the gastrointestinal tract, as well as an increasingly viable therapeutic alternative in the resection of selected small deep lesions throughout the upper and lower gastrointestinal tract. The mainstay of therapy has traditionally been endoscopic snare polypectomy and endoscopic mucosal resection. However, recent innovative advancements in therapeutic endoscopy have provided for the ability to resect large superficial lesions and selected subepithelial lesions in en bloc and margin-negative fashion. In this review, we discuss the current state of the art in advanced endoscopic resection techniques including endoscopic submucosal dissection and endoscopic full-thickness resection.

Beginning in 1955, when the saline injection was first described to prevent transmural injury during polyp fulguration, endoscopic mucosal resection (EMR) has grown exponentially, both in scope and in practice. Because EMR is an organ-preserving technique even for large polyps, this allows for comparable outcomes to surgery, but substantially improved cost savings and significantly reduced morbidity and mortality. To achieve this, however, one must master the 4 fundamental components that are critical to the success of EMR- time, team, tools, and technique. This article aims to provide a compendium of state of the art updates within the field of endoluminal resection.

In the last years, endoscopic techniques gained a crucial role in the treatment of colorectal flat lesions. At the same time, the importance of a reliable assessment of such lesions to predict the malignancy and the depth of invasion of the colonic wall emerged. The current unsolved dilemma about the endoscopic excision techniques concerns the necessity of a reliable submucosal invasive cancer assessment system that can stratify the risk of the post-procedural need for surgery. Accordingly, this narrative literature review aims to compare the available diagnostic strategies in predicting malignancy and to give a guide about the best techniques to employ. We performed a literature search using electronic databases (MEDLINE/PubMed, EMBASE, and Cochrane Library). We collected all articles about endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) registering the outcomes. Moreover, we analyzed all meta-analyses comparing EMR vs ESD outcomes for colorectal sessile or non-polypoid lesions of any size, preoperatively estimated as non-invasive. Seven meta-analysis studies, mainly Eastern, were included in the analysis comparing 124 studies and overall 22954 patients who underwent EMR and ESD procedures. Of these, eighty-two were retrospective, twenty-four perspective, nine case-control, and six cohorts, while three were randomized clinical trials. A total of 18118 EMR and 10379 ESD were completed for a whole of 28497 colorectal sessile or non-polypoid lesions > 5-10 mm in size. In conclusion, it is crucial to enhance the preoperative diagnostic workup, especially in deciding the most suitable endoscopic method for radical resection of flat colorectal lesions at risk of underlying malignancy. Additionally, the ESD necessitates further improvement because of the excessively time-consuming as well as the intraprocedural technical hindrances and related complications. We found a higher rate of en bloc resections and R0 for ESD than EMR for non-pedunculated colorectal lesions. Nevertheless, despite the lower local recurrence rates, ESD had greater perforation rates and needed lengthier procedural times. The prevailing risk for additional surgery in ESD rather than EMR for complications or oncologic reasons is still uncertain.

Previous guidelines have not described clear recommendations for performing endoscopic resection (ER) of T1a-muscularis mucosa (MM)/T1b-submucosal (SM1) cancers that have invaded ≤ 200 μm because these are considered to have a non-negligible risk of metastasis based on previous analyses of pathologically diagnosed (p)MM/SM1 cancers. Considering that the indication for ER is determined based on a clinical diagnosis, the applicability of ER should be investigated in clinical (c)MM/SM1 but not pMM/SM1 cancers. This study aimed to evaluate validity of ER for cMM/SM1 cancers.

In total, 175 cMM/SM1 esophageal squamous cell carcinoma cases that were endoscopically or surgically resected between January 2008 and December 2018 were identified from a prospectively maintained database. We histologically evaluated resected specimens and divided them into low- (n = 92) and high-risk (n = 83) cancers for metastasis.

Univariate analysis showed that longer tumor length and larger circumferential extent were significantly correlated with high-risk cancer (P < 0.001). Multivariate analysis showed that tumor circumference was an independent predictor of high-risk cancer (P = 0.036). The proportion of low-risk cancers among cases with ≤ 3/4, > 3/4 and < 1, and whole circumferential extent were 59, 17, and 14%, respectively, and the post-ER stricture rates of these groups were 12, 33, and 100%, respectively.

ER is the first-line treatment for cMM/SM1 cancers with ≤ 3/4 circumferential extent considering that 59% of cMM/SM1 cancers were low-risk cancers for which ER is mostly curative. ER is not recommended for whole circumferential cMM/SM1 cancers given the low proportion of low-risk cancers and the high risk of stricture after ER.

With improvements in the early detection of early gastric cancer (EGC) and advances in therapeutic techniques, endoscopic resection (ER) for EGC has become widely adopted in East Asian and Western countries. Endoscopic submucosal dissection has higher rates of en bloc, complete, and curative resections with lower rates of local recurrence than that of endoscopic mucosal resection. ER is a minimally invasive method with low morbidity that provides excellent outcomes. ER for EGC is a safe, effective method, preserving organ function and thus maintaining the patient's quality of life, and is recognized as the first-line treatment of EGC in selected patients.

En bloc resection is essential for accurate pathological evaluation in patients with superficial esophageal squamous cell carcinoma (SESCC). This retrospective study aimed to clarify optimal treatment selection of endoscopic resection according to lesion size. A total of 760 patients underwent endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) between January 2011 and December 2015. Among them, this retrospective study included 196 solitary index SESCC lesions ≤20 mm, with the deepest invasion to the mucosa or superficial submucosa endoscopically. The lesions were classified according to size measured via endoscopy as follows; group A: lesions ≤10 mm, group B: lesions ≥11 mm but ≤15 mm, and group C: lesions ≥16 mm but ≤20 mm. The short- and long-term outcomes were investigated for EMR and ESD subgroups. In patients undergoing EMR and ESD, en bloc resection rates for group A and B were not different (98.8 vs. 100%, 93.3 vs. 100%, respectively). However, the en bloc resection rate was significantly lower in EMR than that in ESD for group C (64.3 vs. 100%, P < 0.001). Furthermore, the use of adjunctive ablative therapy rate was significantly higher in EMR than that in ESD in group C (35.7 vs. 0%, P < 0.001). The 5-year cumulative local recurrence rate of group C was significantly higher than that of group A + B after EMR (P < 0.01). EMR was an adequate treatment for SESCC lesions ≤15 mm. On the other hand, ESD could be necessary to achieve en bloc resection for lesions ≥16 mm to avoid local recurrence.

Although esophageal squamous cell carcinoma (ESCC) is more likely to develop in patients with any risk factor (male, drinking, or smoking), it is sometimes detected in patients with very low risk factors (female, nondrinking, and nonsmoking). We examined the endoscopic features of superficial ESCC in patients with very low risk factors.

In this single-center case-control study, 666 patients with 666 superficial ESCC lesions were divided into 2 groups: those with very low risk factors (very low-risk group, n = 34) and those with any risk factors (any-risk group, n = 632). After case-control selection at a 1:5 ratio, the very low-risk group comprised 34 patients and the any-risk group comprised 170 patients. We compared the baseline characteristics, endoscopic findings, and treatment results (including pathological diagnosis) between the 2 groups.

There were no statistically significant differences between the 2 groups in age, tumor size, tumor location, tumor morphology, or treatment results (including tumor depth and lymphovascular invasion). A longitudinal lesion with an attachment of white keratinized epithelium was more likely to be detected in the very low-risk group than the any-risk group (61.8 vs. 17.6%, respectively; p < 0.001).

ESCC in patients with very low risk factors is rare but can be encountered in daily practice. A longitudinal lesion with an attachment of white keratinized epithelium is its main characteristic, which is slightly different from that of patients with any risk factors.

This study was aimed to reveal risk factors for delayed bleeding after endoscopic resection (ER) of superficial non-ampullary duodenal epithelial tumors (SNADETs) and at exploring measures to prevent this complication.

A total of 235 consecutive patients with 249 SNADETs who had undergone ER were enrolled in this study. They were divided into two groups: OTSC group, consisting of the initial 114 cases in which the defects were closed only using OTSCs; and OTSC-c group, consisting of the later 135 cases in which conventional clips were additionally used to cover the inverted submucosa after post-procedure defect closure using OTSCs. The therapeutic outcomes were then compared between the OTSC and OTSC-c groups.

All lesions were successfully resected en-bloc, and the R0 resection rate was 92.4%. The complete defect closure rate was 90.0% and no delayed perforation occurred when successful defect closure was achieved. The rate of delayed bleeding was significantly higher in the OTSC group than in OTSC-c group (11.4% vs. 1.5%, P = 0.001). Multivariate logistic regression analyses revealed that tumor location distal to the ampulla (OR 10.0; 95% CI 1.24-81.0, P = 0.03) and use of a DOAC (OR 8.83; 95% CI 1.13-68.7, P = 0.04) were significant independent predictors of delayed bleeding. Propensity score-matching analysis revealed that additional use of conventional clips was associated with a significantly reduced risk of delayed bleeding (P = 0.003).

Additional use of conventional clips after prophylactic defect closure using OTSCs appears to be useful to reduce the risk of delayed bleeding after ER of SNADETs. UMIN Clinical Trials (No. 000035478).

Some patients with gastroesophageal reflux disease (GERD) are refractory to proton pump inhibitor (PPI) therapy. Anti-reflux mucosectomy (ARMS) is a minimally invasive endoscopic procedure for treatment of GERD. In this study, we retrospectively evaluated the outcomes of ARMS performed in patients with PPI-refractory GERD at our institution.

A total of 109 patients with PPI-refractory GERD who underwent ARMS were retrospectively reviewed. Pre- and post-ARMS questionnaire scores, acid exposure time (AET), DeMeester score, proximal extent, and PPI discontinuation rate were compared.

There was a significant improvement in the symptom score (P < 0.01) and 40-50% of patients were able to discontinue PPI after ARMS. In patients who were followed up for 3 years, sustained improvement in subjective symptoms was observed. AET and DeMeester score significantly improved after ARMS (P < 0.01); however, there was no significant improvement in proximal extent (P = 0.0846).

Anti-reflux mucosectomy is an effective minimally invasive therapy for patients with PPI-refractory GERD. The therapeutic efficacy is attributable to suppression of acid backflow due to contraction of the scar tissue in cardia.

The prognosis for pharyngeal cancer is relatively poor. It is usually diagnosed in an advanced stage. Although the recent development of narrow-band imaging (NBI) and increased awareness among endoscopists have enabled detection of superficial pharyngeal cancer, these techniques are still not prevalent worldwide. Nevertheless, artificial intelligence (AI)-based deep learning has led to significant advancements in various medical fields. Here, we demonstrate the diagnostic ability of AI-based detection of pharyngeal cancer from endoscopic images in esophagogastroduodenoscopy.

We retrospectively collected 5403 training images of pharyngeal cancer from 202 superficial cancers and 45 advanced cancers from the Cancer Institute Hospital, Tokyo, Japan. Using these images, we developed an AI-based diagnostic system with convolutional neural networks. We prepared 1912 validation images from 35 patients with 40 pharyngeal cancers and 40 patients without pharyngeal cancer to evaluate our system.

Our AI-based diagnostic system correctly detected all pharyngeal cancer lesions (40/40) in the patients with cancer, including three small lesions smaller than 10 mm. For each image, the AI-based system correctly detected pharyngeal cancers in images obtained via NBI with a sensitivity of 85.6%, much higher sensitivity than that for images obtained via white light imaging (70.1%). The novel diagnostic system took only 28 s to analyze 1912 validation images.

The novel AI-based diagnostic system detected pharyngeal cancer with high sensitivity. It could facilitate early detection, thereby leading to better prognosis and quality of life for patients with pharyngeal cancers in the near future.

Multi-band mucosectomy (MBM) is effective and safe for Barrett's neoplasia. No studies have yet compared the efficacy and safety of the MBM devices commercially available: Duette™ (CookMedical) and Captivator™ (BostonScientific). Our aim is to compare the two devices.

This is a dual-center retrospective case-control study (Rozzano, Portsmouth) comparing efficacy, safety, and histology of resected specimens between Duette™ (DUE) and Captivator™ (CAPT). Efficacy was assessed by R0 and local recurrence (LR) rate. Bleedings, perforations, and strictures were recorded as safety outcomes. Moreover, the specimens were re-examined by two pathologists, blinded about the study group, to assess the maximum thickness of both the whole specimens and the resected submucosal layer.

Seventy-six patients (38 per group) were included. The two groups did not differ in terms of baseline characteristics. R0 resection was achieved in 96.7% versus 96.3% (p = ns) and LR were recorded in 4/38 (10.5%) versus 3/38 (7.9%) in DUE and CAPT group, respectively (p = ns). Considering Duette™ versus Captivator™, 2 versus 3 patients developed a symptomatic stricture. Only one post-procedural bleeding occurred (Captivator™). Maximum medium thicknesses of specimens and of resected submucosa did not differ between the groups.

MBM is safe and effective for resecting visible lesions using either of the two available devices.

Multiband mucosectomy (MBM) is a widely used technique for the treatment of Barrett's esophagus (BE). However, large multicenter studies enabling a generalizable estimation of the risk of serious adverse events, such as perforation and postprocedural bleeding, are lacking. The aim of this study was to estimate the rate of, and risk factors for, serious adverse events associated with MBM.

In this retrospective analysis, consecutive patients who underwent MBM for treatment of BE in 14 tertiary referral centers in Europe, the United States, Canada, and Australia were included. Primary outcomes were perforation and postprocedural bleeding rate. Potential risk factors were identified by logistic regression.

Between 2001 and 2016, a total of 3827 MBM procedures were performed in 2447 patients (84% male, mean age 66 years, median BE length C2M4). Perforation occurred in 17 procedures (0.4%; 95% confidence interval [CI], 0.3-0.7), of which 15 could be treated endoscopically or conservatively. Female gender was an independent risk factor for perforation (odds ratio [OR], 2.77; 95% CI, 1.02-7.57; P = .05). Postprocedural bleeding occurred after 35 procedures (0.9%; 95% CI, 0.6-1.3). The number of resections (OR, 1.15; 95% CI, 1.06-1.25; P < .001) was significantly associated with postprocedural bleeding.

The results of this study show that MBM for BE is safe with a low risk of serious adverse events. In addition, most of the adverse events could be managed endoscopically or conservatively. The number of resections was an independent risk factor for postprocedural bleeding.

Endoscopic submucosal dissection (ESD) has become the standard treatment method for early gastric cancers (EGCs) due to the negligible risk for lymph node metastasis (LNM) in Eastern Asian countries. According to the guidelines, the curability of EGC after endoscopic resection was classified into three groups: curative resection, expanded curative resection, and noncurative resection. In Eastern Asian countries, a structured follow-up schedule is needed for patients undergoing curative resection and expanded curative resection. Conversely, in Western countries, additional surgery may be recommended for some patients undergoing expanded curative resection (ulcerated, undifferentiated, or slight submucosal invasion) due to the potential risk for LNM, even though specimens of ESD and surgery may not be handled with the same methodology as that used in Japan, which may lead to this slightly higher risk. In noncurative resection, additional surgery is the standard method after ESD because of the risk for LNM. However, in elderly patients and/or those with severe underlying diseases, the advantages and disadvantages of additional surgery should be considered when selecting a post-ESD treatment strategy for patients undergoing noncurative resection. Risk-scoring systems for LNM may facilitate clinical decisions for these patients. However, it should be noted that when recurrence was detected in patients who were followed up with no additional treatment after ESD with noncurative resection, most of them had a poor prognosis. To select an appropriate treatment method, especially in elderly patients undergoing ESD with noncurative resection, a new tool for evaluating the condition of patients should be established.

Salvage endoscopic resection (ER) has been reported to be effective for patients with local failure of esophageal squamous cell carcinoma (ESCC) after definitive chemoradiotherapy (dCRT). This study aimed to evaluate the long-term outcomes of salvage ER for patients with local failure of ESCC and to identify risk factors associated with disease recurrence after salvage ER.

This study included 45 patients undergoing salvage ER after dCRT during 2000 to 2017. After ER, all patients were required to undergo surveillance esophagogastroduodenoscopy (EGD) once or twice every year, and a computed tomography (CT) examination was repeated every 3 to 6 months. We assessed short-term outcomes and long-term outcomes.

Of the 45 patients in this study, the baseline clinical T stage before dCRT was T1 in 80%, 66% of the patients did not have nodal metastasis. The median time from CRT to the detection of local failure was 11 months (range 2-130 months). The en-bloc resection rate was 46%, and the R0 resection rate was 38%, respectively. Stricture occurred after salvage ER for one case, while adverse events such as bleeding or perforation and ER-related death did not occur. After a median observation period of 57 months, recurrence free survival at 3 years was 58%, overall survival was 72%, and disease specific survival was 81%. In multivariate analysis, clinical N stage before CRT was the only independent risk factor of recurrence after salvage ER (p = 0.04).

Salvage ER might be effective local treatment in patients with local failure after dCRT. For the patients with clinical N stage, frequent surveillance should be performed.