The complete closure of mucosal defects following colorectal endoscopic submucosal dissection (ESD) is often challenging. We invented a traction band-assisted endoscopic closure (TBEC) technique using clips with an integrated traction band. We aimed to evaluate the feasibility of TBEC for closing mucosal defects following colorectal ESD.This multicenter prospective single-arm pilot study was conducted at three institutions from June 2022 to March 2023. A total of 34 patients with colorectal neoplasms measuring 20-50 mm scheduled for ESD were enrolled. TBEC was performed at each mucosal defect after ESD. The primary outcome was the complete closure rate by TBEC. Secondary outcomes included the number of clips used, procedure time, and adverse events (AEs).TBEC yielded a 100% (95%CI 89.8%-100%) complete closure rate, with a median (interquartile range [IQR]) closure time of 14.5 (12.9) minutes. The median (IQR) number of clips used was 10 (3.3). One case of delayed bleeding and one of post-ESD coagulation syndrome (both 2.9% [95%CI 0.5%-14.9%]) occurred following TBEC.This study demonstrated the feasibility of TBEC for the closure of mucosal defects following colorectal ESD. TBEC is a simple and easily applicable technique for endoscopic closure. Further studies are required to evaluate its efficacy in reducing delayed AEs.

For the treatment of advanced colorectal neoplasms, colon endoscopic submucosal dissection (ESD) is a crucial technique, although it is time-consuming. The purpose of this study was to evaluate the efficacy of a recently developed one-step knife (OSK) in colon ESD and compare its performance with that of a conventional knife (CK).

Between July 2020 and November 2021, patients scheduled to undergo colorectal ESD were randomly assigned to either the OSK group or the CK group. The primary outcome was the total submucosal injection time. Additionally, total procedure time, treatment outcomes, adverse events, and operator convenience were analyzed.

Data from 53 patients (28 in the OSK group and 25 in the CK group) were analyzed. The mean total injection time was lower in the OSK group than in the CK group (186 s [IQR, 116.8-249.5] vs. 265 s [IQR, 130.5-553.0]), but the difference was not statistically significant (P = 0.082). The total procedure time tended to be shorter in the OSK group than in the CK group (15.5 min [IQR, 11.3-22.8] vs. 20 min [IQR, 13.5-42.5], P = 0.110). Resection rates and adverse events did not differ between the two groups. A greater proportion of endoscopists expressed high satisfaction with the OSK, particularly regarding submucosal injection.

Compared to the CK, OSK use led to shorter injection and procedure times, though not statistically significant. The use of this newly developed endoscopic knife can potentially enhance the effectiveness and efficiency of colorectal ESD (Clinical Research Information Service: KCT0005123).

It is uncertain whether underwater endoscopic mucosal resection (UEMR) enables resection of the submucosal tissue with sufficient margins for T1 colorectal cancer (CRC) because UEMR forgoes submucosal injection. Therefore, we developed a novel "underwater injection EMR" (UIEMR) method that combines submucosal injection with UEMR to obtain an adequate vertical margin.We retrospectively analyzed procedure-related outcomes of 135 consecutive lesions from patients who underwent UIEMR for ≥10-mm nonpedunculated colorectal polyps (median size 15 mm). The outcomes included the en bloc, R0, RX, and R1 resection rates, and adverse events. Additionally, the vertical margin distance of seven T1 CRCs was evaluated.En bloc resection was achieved in 127 lesions (94.1%). R0 and RX resections were observed in 92 (68.1%) and 42 lesions (31.1%), respectively, while R1 resection was seen in only one lesion (0.7%). There were two cases with adverse events (1.5%), both delayed bleeding. In T1 CRCs, all seven cases had free vertical margins, and the median vertical margin distance was 1140 µm (range 731-1570 µm).UIEMR safely demonstrated high success rates for en bloc resection, and potentially ensures a sufficient vertical margin. This technique might be an option, particularly for relatively small lesions concerning for T1 CRC, and deserves further study.

Endoscopic submucosal dissection (ESD) is an advanced technique that can provide successful 'en-bloc' and R0 resection rate for large gastrointestinal lesions. To date, several ESD techniques have been proposed, but their comparative efficacy is still unclear.

Major databases were systematically searched for RCTs comparing the efficacy and safety of different ESD techniques for the resection of colonic lesions. The primary outcomes were 'en-bloc' and R0 resection rates. The secondary outcome was the incidence of procedure-related AEs.

After selection of studies, 9 RCTs were included in the systematic review. On network meta-analysis for 'en-bloc' resection, pocked with traction ESD (PT-ESD) (RR=1.02; 95%CI=0.96-1.07) and pocket ESD (P-ESD) (RR=1.02; 95%CI=0.98-1.05) showed higher efficacy, whereas hybrid ESD (H-ESD) (RR=0.94; 95%CI=0.87-1.02) lower efficacy compared to conventional ESD (C-ESD). With regard to R0 resection, PT-ESD (RR=1.05; 95%CI=0.96-1.16) showed higher efficacy, and H-ESD (RR=0.97; 95%CI=0.84-1.13) lower efficacy compared to C-ESD. Concerning safety PT-ESD (RR=0.35; 95%CI=0.05-2.48) was associated with lower incidence of AEs, and H-ESD (RR=1.22; 95%CI=0.30-5.01) with higher incidence of AEs, compared to C-ESD.

The results of this network meta-analysis show a trend towards greater effectiveness and safety of PT-ESD for the removal of colonic lesions. H-ESD was associated with worse results and should be reserved as a rescue treatment, preferring other techniques.

The effectiveness of defect closure in preventing postoperative complications in rectal lesions exceeding 30 mm in size following endoscopic submucosal dissection (ESD) remains uncertain; this study aimed to assess the effectiveness of defect closure in reducing postoperative complications after ESD in patients with large rectal neoplasms.

A retrospective review was conducted on consecutive patients with large rectal neoplasms who underwent ESD at our center from January 2013 to December 2024. Patients were divided into two groups: the closure group and the non-closure group. Propensity score matching (PSM) was used to minimize selection bias. The study compared adverse events, postoperative fever, and postoperative hospital stay between the two matched groups.

A total of 215 patients were enrolled in the study and included in the analysis. The baseline characteristics of the 83 matched patient pairs were comparable after PSM. The incidence of adverse events was significantly lower in the closure group than in the non-closure group (1.2% vs. 9.6%, P = 0.040). While no statistically significant differences were observed between the two groups in terms of postoperative fever and prolonged postoperative hospital stay, the rates were lower in the closure group compared to the non-closure group (9.6% vs. 10.8%, P = 0.798; 22.9% vs. 33.7%, P = 0.121, respectively). Moreover, defect closure was independently associated with a reduced risk of delayed bleeding (OR, 0.181; 95% CI, 0.035-0.932; P = 0.041).

Defect closure after ESD decreased the adverse events in patients with large rectal neoplasms. Moreover, defect closure was independently associated with a reduced risk of delayed bleeding. Future prospective studies with larger samples are needed to provide more definitive guidance for clinical practice.

This study explored the efficacy of a prophylactic intestinal decompression tube in reducing the incidence of post-endoscopic submucosal dissection electrocoagulation syndrome (PECS).

A total of 157 eligible patients with colorectal mucosal lesions scheduled for endoscopic submucosal dissection (ESD) were prospectively recruited; after drop out 11 patients, 146 patients were randomly assigned to an experimental group (group 1, n = 73) or control group (group 2, n = 73). Patients in the experimental group underwent placement of an intestinal decompression drainage tube after ESD, while the control group received no additional treatment after ESD. The primary outcome was the incidence of PECS. Secondary outcomes included the incidence of postoperative complications, time to removal of the intestinal decompression tube, the degree of abdominal pain as measured by the visual analog scale (VAS), and the participants' self-rated comfort level with the intestinal decompression tube.

A total of 146 patients (n = 73 per group) were finally analyzed between July 2022 and February 2023. All tumors were successfully resected en bloc. A significant difference in the incidence of PECS was found between group 1 and group 2 (5.5% vs 16.4%; P = 0.034). Precisely, 61.6% of patients felt painless for intestinal decompression tube, and no severe or unbearable pain was reported.

The placement of intestinal decompression drainage tube could reduce the incidence of PECS after colorectal ESD, which might play a preventive role in the occurrence of PECS.

Endoscopic submucosal dissection (ESD) is very effective for the treatment of digestive tract neoplasia. However, it is very demanding, with a long learning curve, and, therefore, a significant rate of non-curative resections is expected, considering lesion characteristics, location, and endoscopist experience. The management of patients after a non-curative ESD is not definitely established. It must consider patients' comorbidities and expected survival, as well as the morbidity and mortality of complementary treatments such as surgery, chemotherapy, or radiotherapy. On the other hand, there is a window of opportunity to offer those additional treatments to complete neoplastic treatment and give patients an oncological cure. This decision is sometimes difficult, since the diverse histological criteria that define a non-curative ESD do not have the same weight regarding residual risk and oncological progression. The prediction of residual lesion would be paramount to decide whether to refer patients to surgery; nowadays, this prediction is far from perfect, since most of the patients that undergo surgery due to a non-curative ESD do not have residual neoplasia in the surgical specimen. In this review, ESD curativeness and the management of non-curative ESDs performed for esophageal, gastric, and colorectal lesions will be addressed.

The MANTIS Closure Device (MCD; Boston Scientific, Marlborough, Massachusetts, USA) is a reopenable clip with a sharp claw used for closure after endoscopic submucosal dissection (ESD). We evaluated the effectiveness of the MCD for fast and complete closure after colorectal ESD.Cases involving closure with the MCD after ESD of 20-60-mm colorectal lesions between April 2023 and January 2024 were reviewed. The primary end point was complete closure of the ESD defect with the MCD. Secondary end points included closure time, delayed bleeding, delayed perforation, and post-ESD coagulation syndrome (PECS). MCD application involved: 1) grasping the mucosa on the anal-side of the defect; 2) pushing the clip toward the oral-side mucosa and deploying it; 3) adding other reopenable clips for complete closure.61 cases involving MCD were analyzed. Mean tumor size was 32.3 (SD 9.2) mm. Complete closure rate was 98.4% and mean closure time was 6.9 (SD 2.6) minutes. The mean number of MCDs and other clips used was 1.0 (SD 0.1) and 4.7 (SD 1.4), respectively. Rates of delayed bleeding, delayed perforation, and PECS were 0%, 0%, and 9.8%, respectively.Fast and complete closure after colorectal ESD was successfully achieved using the MCD.

Endoscopic submucosal dissection (ESD) is a transformative advancement in the endoscopic management of superficial gastrointestinal lesions. Initially conceived for the treatment of early gastric cancer, ESD has demonstrated proficiency in achieving en-bloc resection of superficial gastrointestinal lesions. ESD has experienced widespread acceptance in Japan and East Asia; however, its adoption in the USA remains delayed. This initial hesitancy could be attributed to procedural complexity and training demands; nonetheless, recently, ESD has been gaining popularity in the USA. This is due to the advancements in endoscopic technology, tailored training programs, and cumulative evidence regarding the efficacy and safety of ESDs. This review aimed to deliberate the historical progress, current implementation, and prospective trajectory of ESDs in the USA. With ongoing clinical research, technological integration, and educational efforts, ESD is likely to become the gold standard for managing large gastrointesitinal lesions. This progress marks an imperative step toward less invasive, more precise, and patient-centric approaches regarding advanced therapeutic endoscopy in the USA.

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection may result in complications or may be unsuitable for tumors that are difficult to treat endoscopically. We investigated the usefulness of a newly developed endoscopic resection technique-EMR with an over-the-scope clip (EMR-O)-for difficult-to-treat lesions.

We retrospectively examined patients who underwent EMR-O for colorectal tumors between September 2017 and January 2024. Patient and lesion characteristics, technical success rates, en bloc resection rates, R0 resection rates, procedure time, histopathology, and the clinical course were evaluated.

EMR-O was performed for 18 patients. Indications for EMR-O included residual or recurrent lesions (seven patients; 38.9%), diverticulum lesions (five patients; 27.8%), appendiceal orifice lesions (three patients; 16.7%), T1 cancers (two patients; 11.1%), and subepithelial tumors (one patient; 5.5%). The median lesion size was 11 mm. The rates of technical success, en bloc resection, and R0 resection were 100%, 86.7%, and 86.7%. The median procedure time was 10 min. The only adverse event was diverticulitis (one patient; 5.5%). Intraoperative and delayed perforation and bleeding were not observed. The pathological resection depths were full-thickness for three patients (16.7%), muscularis resection for four patients (22.2%), and deep submucosal resection for 11 patients (61.1%).

Although EMR-O is limited by the target lesion size, it shortens the procedure time, prevents perforation, and avoids the need for surgery. EMR-O may be a minimally invasive treatment option for small lesions that are difficult to treat endoscopically.

Pit pattern diagnosis using crystal violet staining for colorectal tumors is useful for qualitative and depth diagnosis. However, due to its reported carcinogenic potential, the use of crystal violet has been restricted. This study was aimed at investigating the efficacy of texture and color enhancement imaging (TXI) magnification in pit pattern diagnosis.

This study enrolled consecutive patients with consent obtained and with colonic tumors indicated for magnifying endoscopy in which all modalities' images (magnified observation with crystal violet staining (CV), magnified white light observation with indigo carmine (IC-WLI), and magnified TXI observation with indigo carmine (IC-TXI)) were evaluable between July 2020 and January 2023. The visibility of the pit pattern using a 5-point Likert scale and its diagnostic accuracy were compared (IC-TXI vs. IC-WLI, reference: CV, by three experts).

A total of 145 colorectal tumors from 145 patients were included. Visibility scores for the pit pattern were significantly higher with IC-TXI compared to IC-WLI (all three experts, p < 0.0001). The pit pattern match rate (Type II/III/IV/V) of IC-TXI compared to CV was also superior to IC-WLI (72.9% vs. 59.7%; p = 0.02).

IC-TXI provided reasonably good and higher visibility and diagnostic accuracy than IC-WLI for pit pattern diagnosis of colorectal tumors compared to CV, suggesting it as an alternative to CV.

A newly developed articulated through-the-scope traction device, TRACMOTION, has been used clinically for endoscopic submucosal dissection (ESD). However, there are few reports on the characteristics of this device and the lesion types for which it is most effective. Therefore, we evaluated its optimal use, efficacy, and safety clinically in animals. Subsequently, we confirmed the safety and efficacy of ESD using this device in humans. Two live swine were used; one underwent conventional ESD (C-ESD) and the other traction-assisted ESD (T-ESD). To examine the traction effect at each resection site, three ESD ulcers (greater curvature/anterior wall/posterior wall) with a diameter of approximately 40 mm were created in each swine. Based on our preliminary experiments, scissor-type and needle-type knives were used in the T-ESD and C-ESD groups, respectively. The primary endpoint was the resection speed, and the secondary endpoint was the degree of muscle layer damage. T-ESD was faster than C-ESD on the posterior wall, similar to the greater curvature, and T-ESD was slower than C-ESD on the anterior wall. There were no cases of intraoperative perforations. Obvious muscle layer damage was observed in post-C-ESD wounds on the anterior wall. The submucosal layer was retained in all post-T-ESD wounds. Although this study showed that ESD with TRACMOTION may be safe and effective, it is necessary to consider that it may be unsuitable for some lesions. This may be due to device characteristics and requires further validation.

Colorectal endoscopic submucosal dissection (ESD) for large tumors is spreading worldwide. Gastric cancer (GC) sometimes occurs after colorectal ESD. However, its status including frequency and risk factors have not been examined well. In this study, we analyzed the detailed status of GC after colorectal ESD.

This was a single-center retrospective study. Patients receiving colorectal ESD between 2010 and 2018 were reviewed. All patients were recommended to receive esophagogastroduodenoscopy (EGD) for screening. Finally, 436 patients receiving EGD, who underwent colorectal ESD for lesions of ≥20 mm were analyzed. The primary outcome was the GC rate after colorectal ESD, including intramucosal cancer. As a control, we compared it to the GC rate in matched Japanese national cancer registry data. The secondary outcome was risk factors for developing GC.

The mean age was 66.9 ± 10.6 and 55.3% were males. The GC rate was 5.96% (26/436) with a median observation period of 27 months. It was significantly higher than the mean GC rate in the diagnosed age calculated with the cancer registry (0.26%, observed value/expected value ratio [95% confidence interval]: 22.20 [14.50-32.53], p < 0.01). The comparison between cases with and without GC showed that significant risk factors were male (p = 0.02) and smokers (p < 0.01) and their GC rates were 8.3% and 10.9%. Also, in the limited cases, Helicobacter pylori infection (past and present) and atrophic gastritis were significant and their GC rates were 11.1% and 11.6%.

The GC rate was high after resecting colorectal tumors of ≥20 mm, suggesting the necessity of EGD.

To evaluate the risks of colorectal endoscopic submucosal dissection (ESD) in older adult patients, given the increasing number of ESD in an aging population.

We conducted a retrospective cohort study using the Japanese nationwide database from 2012 to 2023. Patients aged 60 years or older who underwent colorectal ESD were included. The primary outcome was overall adverse events (AEs), including in-hospital mortality, procedure-related perforation, abdominal surgery, aspiration pneumonia, and significant postoperative bleeding and thromboembolic events. We first examined the association between age and AEs using multivariable regression adjusting for patient characteristics. Next, to explore the factors associated with overall AEs in those aged 85 years or older, we fit a multivariable logistic regression.

The study included 143,925 cases. Age distribution was as follows: 60-64 (13.5%), 65-74 (44.9%), 75-84 (35.8%), and ≥85 (5.8%) years. The prevalence of overall AEs increased with age: 5.3% for ages 60-64 years, 7.9% for ages 85-89 years, and 9.2% for ages 90 years or older. Patients aged 85 years or older had a higher prevalence of overall AEs compared with patients aged 60-64 years, with an adjusted odds ratio of 1.19 (95% confidence interval: 1.07-1.33, P < 0.01) for those aged 85-89 years and an adjusted odds ratio of 1.45 (95% confidence interval: 1.16-1.80, P < 0.01) for those aged 90 years or older. Most AEs in patients aged 85 years or older were due to significant postoperative bleeding, with anticoagulant use and body mass index ≥30 identified as key risk factors.

The risks of AEs during colorectal ESD increase with age, particularly in patients aged 85 years or older.

Recent advances in endoscopic equipment have improved the diagnosis of gastrointestinal tumors. Image-enhanced endoscopy, including narrow-band imaging, blue light imaging, and linked color imaging, has unified magnifying observation classification methods and significantly improved the qualitative and quantitative diagnostic performance of gastrointestinal epithelial tumors. Endoscopic submucosal dissection (ESD), a minimally invasive treatment for early-stage gastrointestinal cancer, is widely used. The aging population in Japan has been gradually increasing. Despite this, ESD has shown good outcomes in older adults. However, long-term prognostic analyses should take into account the high mortality rate from other illnesses. Prognostic indicators such as the Charlson Comorbidity Index (CCI) and the Prognostic Nutrition Index (PNI) should be used to determine whether ESD should be performed. Even in cases of noncurative resection, follow-up without additional surgical resection is an option if there are other comorbidities that affect the prognosis.

Nowadays, gastric cancer has become a significant issue in the global cancer burden, and its impact cannot be ignored. The rapid development of artificial intelligence technology is attempting to address this situation, aiming to change the clinical management landscape of gastric cancer fundamentally. In this transformative change, machine learning and deep learning, as two core technologies, play a pivotal role, bringing unprecedented innovations and breakthroughs in the diagnosis, treatment, and prognosis evaluation of gastric cancer. This article comprehensively reviews the latest research status and application of artificial intelligence algorithms in gastric cancer, covering multiple dimensions such as image recognition, pathological analysis, personalized treatment, and prognosis risk assessment. These applications not only significantly improve the sensitivity of gastric cancer risk monitoring, the accuracy of diagnosis, and the precision of survival prognosis but also provide robust data support and a scientific basis for clinical decision-making. The integration of artificial intelligence, from optimizing the diagnosis process and enhancing diagnostic efficiency to promoting the practice of precision medicine, demonstrates its promising prospects for reshaping the treatment model of gastric cancer. Although most of the current AI-based models have not been widely used in clinical practice, with the continuous deepening and expansion of precision medicine, we have reason to believe that a new era of AI-driven gastric cancer care is approaching.

Preventing colorectal adenoma (CRA) recurrence after polypectomy is essential. However, the current evidence of Chinese herbal medicine (CHM) for CRA recurrence is still limited. This study aims to synthesize the effects of CHM as a prevention method for CRA recurrence.

Nine databases were searched up to May 2024. Randomised controlled trials identifying the preventive effects of CHM among people with CRA post-polypectomy were included. spreadsheets were used to collect and extract data. RevMan and STATA were used for data analysis. We performed subgroup and sensitivity analyses to explore potentially influencing variables.

Twenty trials (2,325 participants) were included. The commonly used botanical drugs belonged to the categories of strengthening the spleen and anti-tumour metabolites. Compared to routine care (RC) alone, oral CHM plus RC significantly reduced the CRA recurrence rate at 12 months (RR 0.51, 95% CI [0.39, 0.67], I2 = 42%), 6 months (RR 0.44, 95% CI [0.36, 0.55], I2 = 0%), and 3 months (RR 0.46, 95% CI [0.22, 0.96], I2 = 0%) post-polypectomy. Compared to CHM placebo plus RC, San zi granule combined with RC significantly reduced CRA recurrence at 12 months post-polypectomy (RR 0.39, 95% CI [0.16, 0.93], I2 = 0%) and during the 2-year follow-up (RR 0.73, 95% CI [0.58, 0.90]). There were no significant differences between groups for treatment duration and syndromes. Additional analysis showed that oral CHM containing the botanical drugs of Si jun zi decoction plus RC reduced CRA recurrence at 12 months post-polypectomy with a low heterogeneity, compared to RC alone (RR 0.26, 95% CI [0.13, 0.54], I2 = 0%). Adverse events were similar in the above two comparisons.

Oral CHM combined with RC may reduce CRA recurrence and be well-tolerated. San zi granule and Si jun zi decoction may be representative prescriptions Experimental studies of the frequent botanical drugs have found anti-cancer effects that may account for the clinical findings. Future rigorous clinical trials are needed due to low-to-moderate certainty of evidence.

PROSPERO (CRD42023324197), https://www.crd.york.ac.uk/PROSPERO/view/CRD42023324197.

Endoscopic submucosal dissection (ESD) is a standardized therapeutic approach for early carcinoma of the digestive tracts. In this regard, the process of histopathological diagnosis requires standardization. However, the uneven development of healthcare in China, especially in eastern and western China, creates challenges for sharing a standardized diagnostic process.

To optimize the process of ESD specimen sampling, embedding and slide production, and to provide complete and accurate pathological reports.

We established a practical process of specimen sampling, created standardized reporting templates, and trained pathologists from neighboring hospitals and those in the western region. A training effectiveness survey was conducted, and the collected data were assessed by the corresponding percentages.

A total of 111 valid feedback forms have been received, among which 58% of the participants obtained photographs during specimen collection, whereas the percentage increased to 79% after training. Only 58% and 62% of the respondents ensured the mucosal tissue strips were flat and their order remained unchanged; after training, these two proportions increased to 95% and 92%, respectively. Approximately half the participants measured the depth of the submucosal infiltration, which significantly increased to 95% after training. The percentage of pathologists who did not evaluate lymphovascular invasion effectively reduced. Only 22% of the participants had fixed clinic-pathological meetings before training, which increased to 49% after training. The number of participants who had a thorough understanding of endoscopic diagnosis also significantly increased.

There have been significant improvements in the process of specimen collection, section quality, and pathology reporting in trained hospitals. Therefore, our study provides valuable insights for others facing similar challenges.

Additional surgery is considered when deep submucosal (SM) invasion (≥1,000 µm) is pathologically observed following the endoscopic resection of early-stage colorectal cancer (eCRC). The Japanese Society for Cancer of the Colon and Rectum (JSCCR) states that the depth of SM invasion be measured from the lower border of the muscularis mucosae (MM) when MM can be identified/estimated and from the lesion's surface when it cannot, irrespective of macroscopic types. In MM-tangled pedunculated eCRC cases, SM invasion depth should be measured from the reference line, which is the boundary between the tumor head and stalk. In the present study, in order to validate these measuring rules compared with the Haggitt classification, 73 consecutive pedunculated eCRC cases were analyzed. Using Elastica-van Gieson and desmin immunostaining, 37, 10, 18 and eight cases were diagnosed as pTis (without SM invasion by JSCCR)/Haggitt level (HL) 0, pTis/HL1-2 (head invasion), pT1b (SM invasion ≥1,000 µm)/HL1-2 and pT1b/HL3 (stalk invasion), respectively. No lymph node metastasis was observed. Recurrence occurred in one pTis/HL1 case; however, no pT1b/HL1-3 cases experienced recurrence. These results suggest that the pedunculated eCRC may be overstaged by the JSCCR rule in terms of adverse outcomes. The Haggitt classification, which evaluates HL1-3 as a shallow SM invasion, may be more useful when considering additional surgery.

Accurate endoscopic characterization of colorectal lesions is essential to predict histology and select the best treatment strategy but remains very difficult. Instead of the recommended endoscopic characterization, many gastroenterologists routinely perform biopsies of the lesion to propose endoscopic resection with or without R0 intent. The aim of this study was to determine which of endoscopic characterization or biopsies, either targeted (TB) or non-targeted (NTB), is the most effective to determine the best treatment strategy for colorectal neoplasia > 2 cm.

We prospectively assessed the best strategy between endoscopic characterization and targeted or non-targeted biopsies, so that the proposed resection technique offered a level of quality of tumor resection adapted to the definitive histology of the lesion on R0-resected specimen.

84 patients with 88 lesions were included. "Adequate treatment" was proposed by endoscopic characterization in 52.3 to 70.5% of cases, "under treatment" in 2.3 to 9.1% and "over treatment" in 20.5 to 45.5%. Two severe events were recorded. "Adequate treatment" was proposed by TB and NTB in respectively 72.7 and 69.3% of cases, "under treatment" in respectively 27.3 and 30.7% and no case of "over treatment" was reported. TB and NTB were ineffective to evaluate the depth of invasion in the submucosa and to differentiate superficial invasive from deep invasive adenocarcinomas.

Biopsies-based strategies are unable to predict depth of cancer invasion and could be associated with a risk of under treatment of large colorectal lesions in near a third of the cases compared to only around 5% with endoscopic characterization. Endoscopic characterization could lead to over treatment, but mainly by endoscopic submucosal dissection with low morbidity. Characterization with the CONECCT classification could decrease the risk of under treatment and avoid surgeries for non-malignant colorectal lesions. Other endoscopic criteria should be determined to better characterize colorectal lesions and to improve the best adapted treatment for each lesion.

The development of the EndoMaster "Endoluminal Access Surgical Efficacy" (EASE) system aims to enhance the safety and efficacy of colonic endoscopic submucosal dissection (ESD) through two flexible robotic arms. This is the first clinical trial to evaluate the performance of colorectal ESD using EndoMaster.

Patients with early mucosal colorectal neoplasia that was not suitable for en bloc resection with snare-based techniques were recruited. The EndoMaster EASE robotic system consisted of an independently designed flexible robotic platform with two robotic arms. The primary outcome was the complete resection rate using EndoMaster. Secondary outcomes included operating time, hospital stay, procedure-related complications, and oncologic outcomes.

43 patients underwent robotic ESD, with a median robotic dissection time of 49 minutes. The technical success rate was 86.0%, while en bloc resection rate among cases with technical success was 94.6%. The complete resection rate was 83.8% and the median size of specimen was 35 mm (range 15-90 mm). The median hospital stay was 2 (range 1-7) days and there was one delayed bleed after 4 days, which was controlled endoscopically. One patient sustained perforation during the procedure, which was completely closed using clips without sequelae. Two patients were treated by salvage surgery.

This first clinical trial confirmed the safety and efficacy of performing colorectal ESD using the EndoMaster EASE robotic system.

The COVID-19 pandemic dramatically impacted endoscopy practice. Recommendations were to postpone elective cases, including procedures for removal of luminal neoplasia. This provided a natural experiment to evaluate outcomes related to these decisions and the impact of time to procedure on change in histology.

The primary aim is to examine time to endoscopy for therapy of colorectal polyps and Barrett's esophagus with dysplasia and oncologic outcomes during the COVID-19 pandemic.

This was a retrospective cohort study of individuals referred for endoscopic therapy of advanced colorectal polyps and dysplastic Barrett's esophagus (BE) between July 2019 and January 2022. Multivariable logistic regression was used to evaluate whether time to therapeutic exam was associated with a change in histology. Time from index to therapeutic exam before versus after the start of the pandemic (March 20, 2020) was compared using a Cox regression.

There were 310 patients (56% male, mean age 65) who were referred for colon polyps (n = 256) and BE-related neoplasia (n = 54). The median time to therapeutic exam was 78 days (range 4-718). Time to therapy was shorter for colon polyp cases completed after versus before the pandemic (HR: 1.49, 95% CI 1.14-1.96). The pandemic was not associated with a difference in time to exam for BE. Change in histology from index to therapeutic exam was noted in 51 cases (16.5%) and was mostly upstaging (70.6%). There was no association between time to therapeutic exam, sex, or timing related to the pandemic on the probability of being upstaged for colon polyps or BE.

Fewer than 1 in 5 cases had a change in histology from index to therapeutic exam, and there was no delay related to the COVID-19 pandemic. These findings suggest that procedures for removal of advanced colon polyps or dysplastic BE can potentially be postponed with minimal impact, helping guide triaging decisions going forward.

This study compared the diagnostic performance of standard endoscopic ultrasound (EUS) and submucosal injection of normal saline and epinephrine-enhanced EUS (SINE-EUS) in detecting early colorectal cancer (CRC), emphasizing accuracy, sensitivity, and specificity.

The self-controlled study was conducted with 115 patients diagnosed with early CRC through optical enhancement (OE) magnified endoscopy. Among them, 104 patients underwent sequential diagnostic procedures, starting with standard EUS and followed by SINE-EUS. Pathological findings were used as the reference standard. Statistical analyses assessed the diagnostic metrics and identified factors influencing accuracy.

Among 104 patients, 82 were pathologically diagnosed with early CRC (63 cases of Tis/T1a and 19 cases of T1b). Standard EUS showed a sensitivity of 68.3%, specificity of 52.6%, and overall accuracy of 64.6%. In contrast, SINE-EUS significantly improved sensitivity (85.7%), specificity (68.4%), and overall accuracy (81.7%) (P < 0.0167). Risk factors such as ulceration were identified as independent predictors of reduced diagnostic accuracy.

SINE-EUS outperforms standard EUS in diagnosing early CRC, particularly in terms of sensitivity and overall accuracy. This technique is reliable for clinical application, although limitations remain in improving specificity for deeper lesions.

Optical diagnosis of superficial nonampullary duodenal epithelial tumors using white-light imaging (WLI) and/or narrow-band imaging with magnifying endoscopy (NBI-ME) is used to guide the treatment strategy and avoid biopsy-induced fibrosis. However, the effectiveness of this approach has not been elucidated. We conducted a systematic review and meta-analysis aiming to investigate the diagnostic yield between Vienna classification category 3 (VCL C3) and categories 4 or 5 (VCL C4/C5) using biopsy, WLI, NBI-ME, and WLI + NBI-ME.

A literature search identified studies on the diagnosis of superficial nonampullary duodenal epithelial tumors using biopsy, WLI, or NBI-ME. A bivariate random-effects model was utilized to analyze the summary estimates of sensitivity and specificity, as well as the area under the summary receiver operating characteristic curves for diagnosing VCL C4/C5.

Ultimately, 13 studies were included in the meta-analysis. For the diagnosis of VCL C4/C5, summary estimates of sensitivity, specificity, and area under the curve were for biopsy 47% (95% confidence interval: 37-58), 86% (79-91), and 0.745; for WLI 80% (65-89), 80% (70-87), and 0.859; for NBI-ME were 72% (61-81), 76% (68-85), and 0.811; and for WLI + NBI-ME 88% (67-96), 87% (51-98), and 0.929, respectively.

WLI, NBI-ME, and WLI + NBI-ME showed high values for sensitivity and area under the curve. Biopsies can be replaced by WLI, NBI-ME, and WLI + NBI-ME for the preoperative diagnosis of superficial nonampullary duodenal epithelial tumors. However, further accumulation of research findings is needed.

Endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (LNPCPs) offers excellent efficacy and safety. Referral biopsies are commonly obtained prior to EMR despite their potential adverse effects. We aimed to assess the diagnostic accuracy of referral biopsy as compared with optical evaluations and the polyp's final pathology.

We analyzed a cohort from two centers that included adult patients referred for EMR of LNPCPs between 2017 and 2022. The NICE classification system was used for optical classification. We compared procedural outcomes of lesions with or without a referral biopsy and diagnostic accuracy of referral biopsy and optical evaluation to the final histopathology of the resected polyp.

Of 605 EMR procedures, 398 (65.8%) had referral biopsies. Polyp size was larger in the biopsy group. No significant differences were observed in en-bloc resection rate, adequate lifting, procedural bleeding, or surveillance recurrence rates. Optical biopsies had higher diagnostic concordance with final histology (Cohen's Kappa 0.62 vs. 0.55) and enhanced sensitivity for sessile serrated polyps/hyperplastic polyps (SSP/HP) and cancer as compared to referral biopsies (0.75 vs. 0.72, p < 0.01, and 0.19 vs. 0.0, p < 0.01, respectively). Optical evaluation was more accurate in non-biopsied lesions.

Referral biopsies do not offer additional diagnostic accuracy and may reduce the accuracy of optical evaluation for LNPCPs.

Studies evaluating endoscopic full-thickness resection (EFTR) and endoscopic submucosal dissection (ESD) for complex colorectal lesions have shown variable results. We conducted a meta-analysis of the available data.

Online databases were searched for studies comparing EFTR versus ESD for complex colorectal lesions. The outcomes of interest were resection rates, procedure time (min), and complications. Pooled odds ratios (OR) and standardized mean difference (SMD) along with 95% CI were calculated.

A total of 4 studies with 530 patients (n=215 EFTR, n=315 ESD) were included. The mean follow-up duration was 5 months. The mean age of the patients was 68 years and 64% were men. The EFTR and ESD groups had similar rates of en bloc resection (OR: 1.73, 95% CI: 0.60-4.97, P =0.31) and R0 resection (OR: 1.52, 95% CI: 0.55-4.14, P =0.42). The EFTR group had significantly reduced procedure time (SMD -1.87, 95% CI: -3.13 to -0.61, P =0.004), total complications (OR: 0.24, 95% CI: 0.13-0.44, P <0.00001), perforation (OR: 0.12, 95% CI: 0.03-0.39, P =0.0005) and postresection electrocoagulation syndrome (OR: 0.06, 95% CI: 0.01-0.48, P =0.008). Delayed bleeding was similar in the 2 groups (OR: 0.80, 95% CI: 0.30-2.12, P =0.66). Residual/recurrent lesions were significantly higher in the EFTR group (OR: 4.67, 95% CI: 1.39-15.66, P =0.01).

This meta-analysis of small studies with high heterogeneity showed that EFTR and ESD have comparable resection rates for complex colorectal lesions. EFTR is faster and has fewer complications, but it increases residual or recurrent lesions.

 The effectiveness of prophylactic clip closure in reducing the risk of delayed bleeding after colorectal endoscopic submucosal dissection (ESD) is uncertain among patients on anticoagulants. We therefore aimed to assess this effectiveness using data from a large multicenter study.

 We used the ABCD-J study database to analyze delayed bleeding among 34 455 colorectal ESD cases from 47 Japanese institutions. Delayed bleeding rates among the no/partial and complete closure groups were compared in patients on direct oral anticoagulants (DOACs) or warfarin. Propensity score matching was used for baseline characteristics to reduce the effects of selection bias.

 Overall, data from 1478 patients on anticoagulants who underwent colorectal ESD were examined. After propensity score matching, the complete and no/partial closure groups were compared in 212 patients on DOACs and 82 on warfarin. The complete closure group showed a significantly lower delayed bleeding rate in patients receiving DOACs (10.8 % vs. 5.2 %, absolute risk reduction [ARR] 5.7 %, P = 0.048) and warfarin (17.1 % vs. 6.1 %, ARR 11.0 %, P = 0.049). Additionally, complete closure significantly reduced the risk of delayed bleeding among patients taking DOACs for right-sided lesions (ARR 6.7 %, P = 0.04), whereas no risk reduction was observed for left-sided (P > 0.99) or rectal (P = 0.50) lesions. A similar trend was observed among patients on warfarin.

 Prophylactic complete clip closure after colorectal ESD significantly reduced the delayed bleeding rate in patients receiving DOACs or warfarin. It should be performed after ESD, particularly for right-sided lesions.

Optimal management of T1 colorectal cancer (CRC) remains controversial. This study compared the long-term outcomes of endoscopic resection with additional surgical resection (ER + ASR) versus primary surgical resection (PS) in patients with T1 CRC and identified risk factors for lymph node metastasis (LNM). This retrospective cohort study included 373 patients with T1 CRC who underwent ER + ASR or PS between January 2010 and December 2020 at a tertiary center in Taiwan. Surgical and oncological outcomes, including recurrence rates, LNM, 5-year overall survival (OS), and 5-year recurrence-free survival (RFS) were compared. Univariate and multivariate analyses identified risk factors for LNM. No significant differences were observed between the ER + ASR and PS groups in surgical outcomes, recurrence rates, LNM, 5-year OS (93% vs. 89%, P = 0.18), or 5-year RFS (89% vs. 88%, P = 0.47). Patients with ≥ 2 high-risk factors had significantly lower 5-year OS and RFS compared to those with ≤ 1 risk factor (p < 0.01). Poor histology grade and lymphovascular invasion were independent risk factors for LNM. ER + ASR and PS had comparable long-term outcomes in patients with T1 CRC. A multidisciplinary approach and standardized protocols are required for optimal management of early-stage CRC.

Gastrointestinal endoscopy has been widely used in the diagnosis and treatment of gastrointestinal diseases. A great many of studies on gastrointestinal endoscopy have been done.

To analyze the characteristics of top 100 cited articles on gastrointestinal endoscopy.

A bibliometric analysis was conducted. The publications and their features were extracted from the Web of Science Core Collection, Science Citation Index-Expanded database. Excel, Web of Science database and SPSS software were used to perform the statistical description and analysis. VOSviewer software and MapChart were responsible for the visualizations.

The top 100 cited articles were published between 1976 and 2022. The guidelines (52%) and clinical trials (37%) are the main article types, and average publication year of the guidelines is much later than that of the clinical trials (2015 vs 1998). Among the clinical trials, diagnostic study (27.0%), cohort study (21.6%), case series (13.5%) and cross-sectional study (10.8%) account for a large proportion. Average citations of different study types and designs of the enrolled studies are of no significant differences. Most of the 100 articles were published by European authors and recorded by the endoscopic journals (65%). Top journals in medicine, such as the Lancet, New England Journal of Medicine and JAMA, also reported studies in this field. The hot spots of involved diseases include neoplasm or cancer-related diseases, inflammatory diseases, obstructive diseases, gastrointestinal hemorrhage and ulcer. Endoscopic surgery, endoscopic therapy and stent placement are frequently studied.

Our research contributes to delineating the field and identifying the characteristics of the most highly cited articles. It is noteworthy that there is a significantly smaller number of clinical trials included compared to guidelines, indicating potential areas for future high-quality clinical trials.

Endoscopic submucosal dissection (ESD) requires an injection solution to create a submucosal cushion for safe endoscopic resection. This study evaluated the safety and feasibility of a new injection solution (PuraLift) in ESD for early-stage gastrointestinal tumors. This prospective, single-arm, single-center pilot study included 11 patients with gastrointestinal neoplasms of the stomach (n = 5) or colorectum (n = 6) who underwent ESD. All patients underwent outpatient follow-up at week 4 to confirm presence or absence of adverse events (AEs). All underwent protocol treatment and post-treatment follow-up. None of the AEs were judged to have a cause-and-effect relationship with the study. Questionnaires to the operators who performed the protocol treatment and assistants who performed submucosal injections were evaluated in comparison with saline, and maintenance of mucosal lifting was long, comparable, and short (9/2/0). En bloc and R0 resections were achieved in all patients without intraprocedural AEs. Median size of the specimens was 40 mm (range, 20-70). Median excision time was 52 minutes (range, 22-130). Median volume of PuraLift was 32 mL (range, 22-130). No postoperative bleeding or delayed perforation was observed in any patient. The novel injectable material, PuraLift, can potentially ensure safe and feasible ESD.

Background and study aims Endoscopic mucosal resection (EMR) is a safe and minimally invasive procedure to remove colorectal non-pedunculated polyps. Recurrence rates are relatively high and differ among endoscopists. We aimed to evaluate whether endoscopists are able to predict recurrence based on thorough inspection of images of mucosal defects after an assumed complete EMR. Methods We developed an online survey in which endoscopists were invited to indicate whether they expected recurrence to develop when inspecting 30 post-EMR defect images. All EMRs were considered to be complete resections by the performing endoscopist. Participating endoscopists were scored based on the number of correct answers regarding presence or absence of recurrence found at first surveillance colonoscopy. Results A total of 140 endoscopists responded to the survey (response rate 25%). A total of 124 respondents with a mean age of 46.5 years evaluated the 30 images. The overall score in the cohort was 70%, indicating that respondents were able to correctly predict recurrence in three-quarters of cases with an overall level of certainty of 53.4%. When comparing results of experienced and less experienced endoscopists based on the number of endoscopic submucosal dissections and/or EMRs performed yearly, no difference (71% versus 69%, P = 0.23) was found. Conclusions This study shows that recurrences after presumed complete EMR can reasonably well be predicted by both experienced and less experienced endoscopists when evaluating images with mucosal defects. Thorough inspection of the post-EMR defect may reduce recurrence rates by recognizing and subsequent treatment of suspect areas.

Fever is a complication after colorectal endoscopic submucosal dissection (ESD). The objective of this study was to explore the incidence and risk factors of fever after colorectal ESD and establish a predictive nomogram model. This retrospective analysis encompassed patients with colorectal lesions who underwent ESD between June 2008 and December 2021 in our center. Multivariate analyses were performed to identify the independent risk factors of fever after colorectal ESD based on univariate analysis, and derived predictive nomogram model was constructed. The performance of nomogram model was evaluated through the receiver operating characteristic curve, calibration curve, decision curve analysis (DCA) and clinical impact curve (CIC). Among the 1096 enrolled patients with colorectal lesions, fever after colorectal ESD occurred in 204 (18.6%) patients. Multivariate logistic regression revealed that tumor size (P < 0.001), ESD procedure time > 30 min (P < 0.001), injury to muscle layer (P < 0.001) and intraoperative perforation (P = 0.046) were estimated to be independent risk factors of fever after colorectal ESD. A predictive nomogram model, incorporating these four predictors, were established and performed well in both training and validation groups. Both DCA and CIC showed this nomogram model had a good potential for clinical practicability.

Background and aims Endoscopic mucosal resection (EMR) is a standard preventive method for colorectal cancer. Managing patients on anticoagulants during EMR is challenging because of balancing bleeding and thrombotic risks. Updated guidelines recommend continuing anticoagulants over heparin bridging; however, data on bleeding risks with continuing anticoagulants remain limited. This multicenter prospective study evaluated bleeding rates in patients who continued oral anticoagulants during EMR. Methods Patients on warfarin or direct oral anticoagulants (DOACs) undergoing EMR were enrolled from 12 tertiary hospitals. Warfarin was maintained on the day of EMR, while DOACs were paused on the day of EMR and resumed afterward. Post-EMR mucosal defects were closed with clips per protocol. Adverse events were monitored for 30 days. The primary endpoint was the major bleeding rate, defined as immediate bleeding requiring difficult hemostasis or delayed bleeding necessitating endoscopic intervention. The secondary endpoints were minor bleeding, other adverse events, and differences in bleeding rates between warfarin and DOACs. Results Among 107 patients (341 polyps; mean size = 6.7 mm), major bleeding occurred in five (4.7%) patients (95% confidence interval: 2.0%-10.5%), and all cases were managed endoscopically. Minor bleeding and thromboembolism events occurred in eight (7.5%) patients and one (0.9%) patient, respectively. No significant differences in bleeding rates were observed between warfarin and DOACs. Major bleeding rates were lower than those reported for heparin bridging. Conclusions Continuing anticoagulant therapy during EMR was associated with a low major bleeding rate (4.7%) and minimal thrombotic events, supporting its safety as an alternative to heparin bridging.

Reports on postoperative bleeding after esophageal endoscopic resection are limited.

This study aimed to identify the clinical characteristics and risk factors for postoperative bleeding following endoscopic resection of esophageal neoplasms.

This single-center, retrospective study included consecutive patients who underwent endoscopic resection for esophageal squamous cell carcinoma or squamous intraepithelial neoplasm between January 2018 and December 2022. We investigated the incidence, timing, severity, and risk factors for postoperative bleeding.

Of 1288 patients, 1062 (82%) underwent endoscopic submucosal dissection, and 226 (18%) underwent endoscopic mucosal resection. Postoperative bleeding occurred in seven (0.5%) patients (95% confidence interval [CI] 0.2-1.1%; median postoperative day 8 [range, 4-17 days]). In these seven patients, hemoglobin concentration decreased by a median of 3.0 g/dL (range, 1.6-6.8 g/dL). Antithrombotic agent use, resection wound circumference, and specimen size were significantly associated with postoperative bleeding (P < 0.001, P = 0.002, and P = 0.024, respectively). Among 43 patients who received direct oral anticoagulants (DOACs), postoperative bleeding occurred in four (9%) patients (95% CI 2.6-22.1%). DOACs were significantly associated with postoperative bleeding even after propensity score matching (4/40 [10%] vs. 0/80 [0%], respectively; P = 0.011).

The overall bleeding rate following esophageal endoscopic resection was 0.5%, with a delayed onset, leading to anemia. DOACs emerged as the most significant risk factor for postoperative bleeding.

Colorectal endoscopic submucosal dissection is a technically demanding procedure with a steep learning curve. In Japan, the National Cancer Center Hospital allows overseas doctors to participate in hands-on training. We aimed to assess the colorectal endoscopic submucosal dissection performance and learning curve of an endoscopist who participated in hands-on training.

In this retrospective analysis using a prospectively collected database, 100 consecutive superficial colorectal tumors from 100 patients treated with endoscopic submucosal dissection by a colorectal surgeon between January 2020 and May 2024 were included. The cases were grouped into three learning periods: phase I (the initial 30 cases under local expert supervision before training in Japan), phase II (the middle 30 cases), and phase III (the last 40 cases). The primary outcome was resection speed.

The median resection speed was 5, 11.7, and 13.2 cm2/h in phases I, II, and III, respectively. In matched data, the resection speeds in phases II and III were higher than that in phase I (P = 0.02 and P < 0.001, respectively). En bloc and R0 resection rates were 99% and 95%, respectively. The en bloc resection, R0 resection, and complication rates were not different between phases. Cumulative sum analysis of the resection speed revealed that proficiency was achieved after 36 cases.

An endoscopist who underwent a tutored approach and hands-on training in Japan achieved the proficiency benchmarks for colorectal endoscopic submucosal dissection after 36 cases. However, the endoscopist's extensive experience before training may contribute to excellent outcomes.