To investigate the influence of a micro-enema on diagnostic performance, submucosal width, reader confidence, and tumor conspicuity using MRI to stage early rectal cancers (ERC).

In this single-center study, we consecutively included 50 participants with assumed ERC who all completed MRI with (MRin) and without (MRex) a micro-enema. The diagnostic performance was recorded for two experienced radiologists using histopathology as the gold standard. In addition, the width of the submucosa in the tumor-bearing wall, reader confidence for T-staging, and tumor conspicuity were assessed. Significance levels were calculated using McNemar's test (diagnostic performance) and Wilcoxon's signed-rank test (reader confidence, submucosal width, and conspicuity). Interreader agreement was assessed using kappa statistics.

Sensitivity/specificity were for Reader1 91%/87% for both MRex and MRin and for Reader2 74%/87% and 89%/87%, both readers p > 0.05. The micro-enema induced a significant widening of the submucosa, p < 0.001, with a mean increase of 2.2/2.8 mm measured by Reader1/Reader2. Reader confidence in T-staging and tumor conspicuity increased for both readers, p < 0.005. The proportion of tumors with both correct staging and high reader confidence increased from 58% (29/50) to 80% (40/50) (p = 0.04) for Reader1 and from 42% (21/50) to 72% (36/50) (p = 0.002) for Reader2. Interreader agreement increased from moderate (kappa 0.58) to good (kappa 0.68).

The micro-enema significantly increased the submucosal width in the tumor-bearing wall, reader confidence, and tumor conspicuity and improved interreader agreement from moderate to good. Sensitivity and specificity in T-staging did not improve, but there was a significant increase in the proportion of tumors staged with both high confidence and correct T-stage.

The objective of this study was to determine independent clinicopathological factors that can predict submucosal invasion and non-curative resection (NCR) outcomes after endoscopic submucosal dissection (ESD) in patients with early gastric cancer (EGC).

Data were collected from consecutive patients who underwent gastric ESD at the First Affiliated Hospital of Ningbo University between 2016 and 2023. A retrospective analysis was conducted using the chi-squared test and logistic regression analysis. Multiple logistic regression analysis was applied to investigate factors independently predicting both submucosal invasion and NCR. These factors were used to construct predictive nomograms.

A total of 511 patients (535 EGC lesions) underwent ESD. Of these, 452 were curative (84.7%), and 83 (15.5%) were non-curative. Multivariate analysis revealed that location in the body and fundus or cardia of the stomach, larger tumor size (≥ 30 mm), and histological undifferentiated type were independent risk factors for submucosal invasion and deep submucosal invasion in patients with EGC (all P < 0.05). Multivariate analysis showed that tumor size of 20 ~ 29 mm, tumor size ≥ 30 mm, elevated lesions, depressed lesions, undifferentiated tumors and submucosal invasion were all independent predictors of NCR for EGCs (all P < 0.05). The area under the ROC curve (AUC) of the nomogram model for predicting submucosal invasion and non-curative resection was 0.821 (95% CI, 0.758 ~ 0.884) and 0.937 (95%CI, 0.889 ~ 0.985), respectively.

We developed nomograms to predict the risk of submucosal invasion and NCR prior to ESD. These predictive factors in addition to the existing ESD criteria can help provide the best treatment option for patients with EGC.

Complications of endoscopic mucosal resection (EMR) of large colorectal polyps remain a concern.

We aimed to compare safety and efficacy of cold EMR (without electrocautery) to hot EMR (with electrocautery) of large colorectal polyps.

In this multicentre randomised trial, patients with any large (≥20 mm) non-pedunculated colon polyp were assigned to cold or hot EMR (primary intervention), and to submucosal injection with a viscous or non-viscous solution (secondary intervention) following a 2×2 design. The primary outcome was the rate of severe adverse events (SAEs). The secondary outcome was polyp recurrence. In this study, we report results of the primary intervention.

660 patients were randomised and analysed. An SAE was observed in 2.1% of patients in the cold EMR group and in 4.3% in the hot EMR group (p=0.10) (per protocol analysis 1.4 vs 5.0%, p=0.017) with fewer perforations following cold EMR (0%) compared with hot EMR (1.6%, p=0.028). Postprocedure bleeding did not differ (1.5% vs 2.2%, p=0.57). The effect of cold resection was independent of the type of submucosal injection solution, polyp size or antithrombotic medications. Recurrence was detected in 27.6% and 13.6% in the cold and hot EMR groups, respectively (p<0.001). Recurrence was not significantly different for 20-29 mm polyps (18.6% vs 13.4%, p=0.24) and for sessile serrated polyps (14.1% vs 8.5%, p=0.33).

Universal application of cold EMR did not significantly lower SAEs (unless cold EMR could be completed) and doubled the recurrence rate compared with hot EMR.

ClinicalTrials.gov, number: NCT03865537.

Conventional nodular gastritis has been known to be caused by Helicobacter pylori infection. Several cases of gastric mucosa-associated lymphoid tissue (MALT) lymphoma with non-H. pylori Helicobacters (NHPH) exhibit endoscopic findings resembling nodular gastritis. Considering the differences in malignancy, distinguishing between these two conditions is crucial. This study aimed to identify the distinguishing endoscopic features of NHPH-induced gastric MALT lymphoma with nodular gastritis-like appearance (NHPHi-MNG) and H.-induced conventional nodular gastritis (HPi-NG).

Between 2011 and 2022, we analyzed 17 patients with NHPHi-MNG and 50 patients with HPi-NG at Hiroshima University Hospital and evaluated nodule morphology and distribution patterns.

Compared with the HPi-NG group, the NHPHi-MNG group exhibited significantly larger nodules (2.5 vs. 2.0 mm, P < 0.05) with protruded morphology (protruded/superficial, elevated: 14/3 vs. 8/42, P < 0.05), most prominently in the gastric angulus. The variability in nodule size was significantly higher in the NHPHi-MNG group than in the HPi-NG group (0.85 vs. 0.37 mm, P < 0.05), reflecting nodule heterogeneity. The distance from the gastric angulus to the proximal end of the nodular lesions was significantly greater in the NHPHi-MNG group than in the HPi-NG group (4.4 vs. 1.7 cm, P < 0.05). The nodules in the HPi-NG group were smaller, superficial, elevated, and most prominent in the gastric antrum compared with those in the NHPHi-MNG group. They were predominantly distributed in the gastric antrum with a homogeneous morphology.

NHPHi-MNG and HPi-NG can be endoscopically differentiated according to nodule morphology and distribution. Recognizing these distinguishing features is essential for an accurate diagnosis.

Today, endoscopy plays a crucial role not only in the detection of precancerous and malignant colorectal lesions, but also in the treatment of even widespread adenomas and T1 early cancers. In addition to classic polypectomy and endoscopic mucosal resection (EMR) using a snare, in recent years, endoscopic submucosal dissection (ESD) has become increasingly important. Marking, submucosal injection, circumferential incision of the mucosa around the lesion, tunneling, and submucosal dissection using a short diathermic knife facilitate the 'en bloc' resection of lesions larger than 3 cm, difficult to resect in one piece using a snare. Lesions with high-grade dysplasia or mucosal carcinoma are other good candidates aside from widespread adenomata with a high risk of recurrence after piecemeal resection. ESD allows R0 resection rates of more than 90% in specialized centers. Lesions of 20 cm have been removed 'en bloc' by expert endoscopists. ESD provides an optimal histopathologic yield and has a risk of recurrence as low as 3%. Endoscopic full-thickness resection using a special device (eFTRD) is another addition to the resection armamentarium. It is especially suitable for circumscribed lesions up to 2 cm in the middle and upper rectum. Endoscopic intermuscular dissection (EID) is a recent modification of ESD primarily in the rectum, including the inner, circular muscular layer into the resection specimen. In this way, it allows a histopathologic analysis of the entire submucosa beyond the mucosal and upper submucosal layer such as in ESD. This is especially important for T1 cancers invading the submucosa without any other risk factors of invasion.

Accurately identifying the status of lymph node metastasis (LNM) is crucial for determining the appropriate treatment strategy for early gastric cancer (EGC) patients.

Univariate and multivariate logistic regression analyses were used to explore the association between clinicopathological factors and LNM in EGC patients, leading to the development of a nomogram. Differential expression analysis was conducted to identify biomarkers associated with LNM, and their expression was evaluated through immunohistochemistry. The biomarker was integrated into the conventional model to create a new model, which was then assessed for reclassification and discrimination abilities.

Multivariate logistic regression analysis revealed that tumor size, histological type, and the presence of ulcers are independent risk factors for LNM in EGC patients. The nomogram demonstrated good clinical performance. Incorporating HAVCR1 immunohistochemical expression into the new model further improved its performance, reclassification, and discrimination abilities.

The novel nomogram predictive model, based on preoperative clinicopathological factors such as tumor size, histological type, presence of ulcers, and HAVCR1 expression, provides valuable guidance for selecting treatment strategies for EGC patients.

Esophageal squamous cell carcinoma (ESCC) remains a significant global health challenge, being the sixth leading cause of cancer mortality with pronounced geographic variability. The incidence rates range from 125 per 100,000 in northern China to 1-1.5 per 100,000 in the United States, driven by environmental and lifestyle factors such as tobacco and alcohol use, dietary habits, and pollution. Major modifiable risk factors include tobacco and alcohol consumption, with a synergistic risk increase when combined. Nonmodifiable risk factors include previous diagnoses of head and neck squamous cell carcinoma (H&N SCC), achalasia, and prior radiotherapy. Prevention strategies must be tailored to specific regional burdens to efficiently allocate medical and financial resources. Gastrointestinal endoscopy is crucial in reducing ESCC burden through early detection and characterization of neoplastic changes, such as high-grade dysplasia. Early diagnosis significantly improves survival rates, while endoscopic resection of noninvasive dysplasia can prevent ESCC onset, reducing treatment burden for advanced disease. Postresection surveillance can detect high-risk metachronous lesions. Despite these benefits, endoscopic prevention faces challenges, including the lack of high-level evidence supporting its efficacy, opportunity costs, the need for specialized training and techniques, and the requirement for advanced technology investments. This Position Statement from the World Endoscopy Organization (WEO) aims to address these challenges, supplying recommendations for the exploitation of endoscopic resources regarding the possible role of screening, quality, and training for the detection, characterization, resection, and surveillance of ESCC.

Endoscopic ultrasound (EUS) is important for diagnosing and staging esophageal cancer. However, substantial variability in the diagnostic and staging accuracy of EUS, especially in early-stage cancers, affects patients' treatment choices and quality of life.

To explore whether conventional endoscopic ultrasonography (EUS-C) combined with submucosal saline injection (EUS-SSI) improves diagnostic accuracy in preoperative T1a and T1b staging in superficial esophageal squamous cell carcinoma (SESCC).

Patients with SESCC first underwent EUS-C. Then, they received SSI and underwent a repeat EUS. The diagnostic accuracy of EUS-C and EUS-SSI was evaluated based on the final postoperative pathology results.

A total of 92 patients with endoscopically diagnosed SESCC were included in the study. Postoperative pathology confirmed superficial SESCC in all patients (T1a stage, n = 77; T1b stage, n = 15). EUS-C correctly identified 54 of 77 patients with T1a cancer and nine of 15 patients with T1b cancer, whereas EUS-SSI identified 68 of 77 patients with T1a cancer and 10 of 15 patients with T1b cancer. EUS-SSI was more accurate than EUS-C in diagnosing T1a and T1b stage SESCC (84.8 and 68.5%, respectively).

EUS-SSI differentiates between T1a and T1b stages of superficial SESCC with better diagnostic accuracy than EUS-C, thereby reducing the rate of over-staging.

Gastric cancer is a common malignancy characterized by an insidious onset and high mortality rate. Exosomes, a special type of extracellular vesicle, contain various bioactive molecules and have been found to play crucial roles in maintaining normal physiological functions and homeostasis in the body. Recent research has shown that the contents of exosome play a significant role in the progression and metastasis of gastric cancer through communication and regulatory functions. These mechanisms involve promoting gastric cancer cell proliferation and drug resistance. Additionally, other cells in the gastric cancer microenvironment can regulate the progression of gastric cancer through exosomes. These include exosomes derived from fibroblasts and immune cells, which modulate gastric cancer cells. Therefore, in this review, we provide a brief overview of recent advances in the contents and occurrence mechanisms of exosome. This review specifically focused on the regulatory mechanisms of exosomes derived from gastric cancer and other cellular subtypes in the tumor microenvironment. Subsequently, we summarize the latest research progress on the use of exosomes in liquid biopsy, discussing the potential of gastric cancer exosomes in clinical applications.

The use of various classifications to grade and differentiate appearances of digestive diseases has enhanced precision and provided better means for their clinical evaluation and comparison. Staging systems abound to classify erosive esophagitis, gastro-esophageal varices, upper gastrointestinal hemorrhage, histopathology of celiac disease, various types of gastrointestinal neoplasia, and colitis associated with Crohn's disease or ulcerative colitis. The present review serves to highlight how potential bias may become introduced when comparing clinical outcomes based on varying and continuously evolving staging systems of digestive diseases.

Although accurate assessment of polyp morphology helps endoscopists select the appropriate management for colorectal polyps, some studies have reported unsatisfactory accuracy in such assessment. This study aimed to clarify the usefulness of a short educational video available on the Internet for accurate polyp morphology assessment.

This was a multicenter randomized controlled trial. Participants were randomly assigned to the pre- or post-education groups after a pre-test comprising images of 42 polyps, including 12 laterally spreading tumors. Participants who scored ≥ 80% on the pre-test were excluded. Only the post-education group completed the diagnostic test after watching an online educational video. The primary outcome was the difference in diagnostic accuracy between the pre-test and diagnostic tests for each group.

Of the 296 endoscopists enrolled from 48 institutions, 34 missed the test deadline, and 29 who scored ≥ 80% in the pre-test were excluded. The primary outcome analysis sets were 117 and 116 in the pre- and post-education groups, respectively. The mean pre-test accuracies in the pre-education and post-education groups were 60.6% and 60.7%, respectively. The difference in diagnostic accuracy between the pre-test and diagnostic test was significantly higher in the post-education than the pre-education group (12.0 points, 95% confidence interval [CI] 9.9-14.1 and 2.3 points, 95% CI 0.9-3.6; p < 0.001).

This multicenter randomized controlled trial demonstrated the usefulness of a short educational video for accurate polyp morphology assessment.

The current landscape of machine learning models in GI endoscopy is fraught with considerable variability in methodologies and quality, posing challenges for validation and generalization. To ensure the effective integration of AI in clinical practice, it is crucial to develop and validate models rigorously across diverse and representative datasets. This involves standardizing reference standards, ensuring thorough external validation, using representative patient populations, and incorporating a range of image qualities. Addressing these methodological discrepancies will enhance the reliability and robustness of AI models, thereby facilitating their adoption and improving patient care in GI endoscopy.

Recently, various endoscopic treatments for colorectal polyps have been reported, including cold snare polypectomy (CSP) and underwater endoscopic mucosal resection (UEMR), in addition to EMR. However, a precise treatment strategy for sessile serrated lesions (SSL) has not been established. In this study, we analyzed the clinicopathological features of SSL resected by EMR, CSP, and UEMR to determine the most suitable treatment for SSL.

A total of 92 SSL resected via EMR (n = 11), CSP (n = 36), and UEMR (n = 45) were retrospectively enrolled between February 2021 and October 2022. To evaluate pathological findings, we examined SSL samples, which were stretched before formalin fixation and sectioned at 2-mm intervals. Primary outcomes were the R0 resection rate and thickness of submucosal (SM) tissue specimens for each treatment. In addition, we evaluated SSL with dysplasia (SSLD) and the inverted growth pattern which may affect the vertical margin.

The R0 resection rate significantly differed among the three groups (EMR, 73%; CSP, 42%; UEMR, 87%, p = 0.001). The median thickness of SM tissue resected by CSP (0 µm) was significantly less than that by EMR (362 µm) and UEMR (325 µm; p < 0.001). All four SSLDs were diagnosed endoscopically. Five SSLs with inverted growth patterns were pathologically diagnosed. Of these, two SSLs with inverted growth patterns could not be diagnosed endoscopically.

UEMR is considered to be a suitable treatment option for SSL. CSP results were pathologically insufficient. Therefore, surveillance to evaluate local recurrence is important, and the results of further multicenter prospective studies should be referred.

Endoscopic ampullectomy is the preferred treatment for selected periampullary lesions, yet up to 10.6% of patients may experience delayed bleeding post-procedure. This study aims to identify predictors for bleeding, which remain poorly understood.

This was a single-center retrospective cohort study of adult patients who underwent endoscopic ampullectomy (EA) between January 2011 and September 2023. The primary outcome was the risk factors for delayed bleeding, defined as post-procedural bleeding that necessitated either an emergency department visit, hospital admission, blood transfusion, or re-intervention. Secondary outcomes included adverse events, such as perforation and pancreatitis.

A total of 113 patients underwent EA, and 25 (22.1%) experienced delayed bleeding. Of these, 20 (80%) required repeat endoscopy, six (24%) needed blood transfusions, and three (12%) were managed conservatively. Multivariable logistic regression analysis identified international normalized ratio ≥1.2 (odds ratio [OR] 3.32, 95% confidence interval [95% CI] 1.03-10.74, p = 0.05), presence of high-grade dysplasia or intramucosal cancer (OR 3.76, 95% CI 1.20-11.81, p = 0.03), female sex (OR 3.14, 95% CI 1.11-8.93, p = 0.03), size of lesion (OR 1.04, 95% CI 1.01-1.08, p = 0.03) and procedure duration (OR 0.98, 95% CI 0.97-0.99, p = 0.04) as independent predictors of delayed bleeding.

Several factors, including features of high-grade dysplasia-intramucosal cancer, international normalized ratio ≥1.2, female sex, lesion size, and procedure duration are associated with delayed post-ampullectomy bleeding. These factors should be taken into consideration when strategizing the reduction of post-ampullectomy bleeding.

Pyloric gland adenoma (PGA) is a distinct subtype of duodenal adenoma. PGA has been increasingly recognized as a histologically and molecularly distinct entity; however, its endoscopic features have not been precisely described. This study aims to investigate the endoscopic characteristics of duodenal PGA, including the association of their putative precursors, Brunner's gland hyperplasia (BGH), and gastric epithelial heterotopia/metaplasia (GEM/H).

This study was a single-center, retrospective case series. Fourteen consecutive patients with duodenal PGA were retrieved from the pathological database. PGA was diagnosed according to the World Health Organization classification.

The median tumor size was 22.5 mm (range: 12-40 mm), and 79% of cases were located in the first part of the duodenum. Six PGAs demonstrated high-grade dysplasia. PGA could be classified into two subtypes based on their appearance: villous lobulated type and smoothly protruding type. BGH and GEM/H were identified in the background mucosa in 28% and 7% of the cases, respectively. BGH was more abundant in the background mucosa of the PGA group than in the control group (p < 0.05). Six PGAs (43%) exhibited high-grade dysplasia, and no significant difference was observed in the endoscopic findings between low- and high-grade dysplasia.

The 14 patients with PGA demonstrated characteristic endoscopic findings. BGH and GEM/H might be precursors of PGA.

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.

Cold snare polypectomy (CSP) is widely performed for small colorectal polyps. However, small colorectal polyps sometimes include high-grade adenomas or carcinomas that require endoscopic resection with electrocautery. This study aimed to evaluate the efficacy and safety of a novel resection technique, hot snare polypectomy with low-power pure-cut current (LPPC-HSP) for small colorectal polyps, compared with CSP and conventional endoscopic mucosal resection (EMR).

Records of patients who underwent CSP, EMR, or LPPC-HSP for nonpedunculated colorectal polyps less than 10 mm between April 2021 and March 2022 were retrospectively evaluated. We analyzed and compared the treatment outcomes of CSP and EMR with those of LPPC-HSP using propensity score matching.

After propensity score matching of 396 pairs, an analysis of CSP and LPPC-HSP indicated that LPPC-HSP had a significantly higher R0 resection rate (84% vs. 68%; p < 0.01). Delayed bleeding was observed in only two cases treated with CSP before matching. Perforation was not observed with either treatment. After propensity score matching of 176 pairs, an analysis of EMR and LPPC-HSP indicated that their en bloc and R0 resection rates were not significantly different (99.4% vs. 100%, p = 1.00; 79% vs. 81%, p = 0.79). Delayed bleeding and perforation were not observed with either treatment.

The safety of LPPC-HSP was comparable to that of CSP. The treatment outcomes of LPPC-HSP were comparable to those of conventional EMR for small polyps. These results suggest that this technique is a safe and effective treatment for nonpedunculated polyps less than 10 mm.

The risk of colorectal advanced adenomas (CAAs) and colorectal cancer (CRC) in siblings aged ≤ 50 of patients diagnosed with early-onset CAAs (E-CAAs), defined as having CAA at or below 50 years, is poorly understood. This study examined the risks of adenomas, CAA, and CRC in siblings aged ≤ 50 of patients diagnosed with E-CAA.

This case-control study was conducted at a tertiary hospital in Vietnam. The participants included 96 cases who were siblings aged ≤ 50 of patients diagnosed with E-CAA. Controls were randomly selected from consecutive patients aged ≤ 50 who did not have siblings diagnosed with E-CAA. Controls were matched to cases in a 2:1 ratio for age, sex, and smoking status.

The mean age was similar between cases (40.9 ± 6.0 years) and controls (41.1 ± 6.0 years). Except for indications for colonoscopy, there were no significant differences in the baseline demographics between the two groups. A heightened risk of CAA was documented in cases compared with controls (odds ratio [OR] 6.33; 95% confidence interval [CI] 1.43-43.8; P = 0.018). This increased risk was more pronounced in males (OR 13.7; 95% CI 1.23-262; P = 0.006). Cases had higher risks of colorectal adenomas (OR 2.43; 95% CI 1.27-4.67; P = 0.009) and colorectal neoplasia (OR 2.33; 95% CI 1.24-4.40; P = 0.011) than those in controls.

Siblings aged ≤ 50 of patients diagnosed with E-CAA have an increased risk of adenomas, CAA, and colorectal neoplasia. CRC screening should be initiated early in these high-risk individuals.

The diagnosis of inflammatory bowel disease (IBD) associated with high-grade dysplasia (HGD) has a significant impact on clinical management, including colectomy. However, the prognosis of HGD remains unclear due to diagnostic uncertainty and low-quality data on subsequent synchronous and metachronous neoplasia. We aimed to evaluate a diagnostic strategy with dedicated gastrointestinal (GI) pathologist consensus of revised HGD and the impact on synchronous and metachronous neoplasia rates.

In this retrospective multicenter cohort study, we used the Dutch Nationwide Pathology Databank to identify IBD patients with HGD in seven hospitals. Histopathological specimens of the initial HGD were independently revised by two dedicated GI pathologists. Definitive diagnosis was established in a consensus meeting. Synchronous and metachronous neoplasia incidences were assessed with a competing risk analysis.

We included 54 IBD patients with HGD, of whom 33 (61.1%) with ulcerative colitis and 42 (77.8%) with extensive disease. After consensus, 18 (33.3%) lesions were downgraded to indefinite/low-grade dysplasia, and 6 (11.1%) were revised to colorectal cancer (CRC). Seven patients (13.0%) had synchronous CRC. Patients with downgraded lesions showed a lower cumulative advanced neoplasia (HGD/CRC) incidence compared with confirmed HGD [(Gray's test P < 0.01), 5-year cumulative incidence 0.0% vs. 26.6%].

We demonstrated frequent downgrading of HGD, associated with lower metachronous neoplasia rates. This underlines the potential impact of dedicated GI pathologist consensus meetings. The high and synchronous and metachronous neoplasia rates after HGD underline the need for close surveillance.

Large non-pedunculated colorectal polyps ≥20 mm (LNPCPs) constitute approximately 1% of all colorectal polyps and present a spectrum of risks, including overt and covert submucosal invasive cancer (T1 colorectal cancer (CRC)). Importantly, a curative resection may be achieved for LNPCPs with superficial T1 CRC (T1a or T1b <1000 µm into submucosa), if an enbloc R0 excision (clear margins) with favourable histology is achieved (ie, absence of high-grade tumour budding, lympho-vascular invasion, and poor differentiation). Thus, while consensus recommendations advocate for endoscopic resection as the primary treatment option for LNPCPs, thorough optical assessment is imperative for selecting the most suitable ER strategy. In this review, we highlight the critical components of optical evaluation that assist in predicting the risk of T1 CRC, including morphology (Paris and LST classifications), surface pit/vascular pattern (JNET and Kudo classifications), and lesion location. Different resection modalities, including endoscopic submucosal dissection and endoscopic mucosal resection are discussed, along with important considerations that may influence the resection strategy of choice, such as access to the LNPCP and submucosal fibrosis.

Linear-array endoscopic ultrasound (EUS) and narrow-band imaging (NBI) are both used to estimate the invasion depth of nonpedunculated rectal lesions (NPRLs). However, it is unclear which procedure is more accurate. This randomized controlled trial aimed to compare the diagnostic accuracy of linear EUS and NBI for estimating the invasion depth of NPRLs.

This study is a single-center, randomized, tandem trial. Eligible patients with NPRLs were randomly assigned to A group (assessment with EUS followed by NBI) or B group (assessment with NBI followed by EUS). The invasion depth of each lesion was independently measured by each procedure and categorized as mucosal to slight submucosal (M-SM s , invasion depth <1,000 μm) or deep submucosal (SM d , invasion depth ≥1,000 μm) invasion, with postoperative pathology as the standard of measurement. The primary outcome was diagnostic accuracy, and secondary outcomes included sensitivity, specificity, and procedure time.

Eighty-six patients with NPRLs were enrolled, and 79 patients were finally analyzed, including 39 cases in the A group and 40 cases in the B group. Comparable diagnostic accuracies were observed between EUS and NBI (96.2% vs 93.7%, P = 0.625). EUS identified lesions with deep submucosal invasion with 81.8% sensitivity while that of NBI was 63.6% ( P = 0.500). The specificity of both EUS and NBI was 98.5%. The procedure time was also similar between EUS and NBI (5.90 ± 3.44 vs 6.4 ± 3.94 minutes, P = 0.450). Furthermore, the combined use of EUS and NBI did not improve diagnostic accuracy compared with EUS or NBI alone (94.9% vs 96.2% vs 93.7%, P = 0.333).

Linear EUS and NBI measure the invasion depth of NPRLs with comparable accuracy. The combination of the 2 methods does not improve the diagnostic accuracy. Single NBI should be preferred, considering its simplicity and convenience in clinical practice.

Small polyps are the most frequently detected lesions during colonoscopy, with an incomplete resection rate of 6.8% to 15.9%. This study aimed to improve small polyp cold snare resection radicality using submucosal contrast dye pre-lifting (PL+CSP).

This single-center, prospective, randomized controlled trial compared the standard cold snare polypectomy technique (PL-CSP) with PL+CSP to evaluate endoscopic and histological complete resection rates, adverse events, procedural times, and polyp retrieval failure rates.

In 143 patients consecutively enrolled, 186 small polyps were detected and randomly assigned following a 1:1 ratio to the PL-CSP (n=97, 51.6%) and PL+CSP (n=90, 48.4%) techniques. Endoscopic (p=0.97) and histologic (p=0.23) complete resection rates did not differ significantly even in univariate analysis. The intraprocedural bleeding rate was significantly higher in the PL+CSP group as confirmed by the univariate analysis (35.8% vs. 8.3%, p<0.001). The polyps retrieval failure rates were similar (p=0.83). Procedural time was significantly longer for PL+CSP (median time, 75 vs. 45 seconds; p<0.001), without impacting colonoscopy withdrawal time (p=0.215).

PL+CSP of small polyps did not improve endoscopic and histological complete resection rates and polyp sample retrieval. PL+CSP had higher rates of intraprocedural bleeding and was "time-consuming".

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.

Colorectal cancer prevention relies on surveillance colonoscopy, with the adenoma detection rate as a key factor in examination quality. Linked color imaging (LCI) enhances lesion contrast and improves the examination performance. This systematic review and meta-analysis aimed to evaluate the effect of LCI on adenoma detection rate in adults who underwent colonoscopy.

We searched the Medline, PubMed, BIREME, LILACS, and Scientific Electronic Library Online databases for randomized controlled trials comparing the use of LCI versus white light imaging (WLI), published up to March 2023. The outcomes included lesion characteristics, number of adenomas per patient, and the additional polyp detection rate.

Sixteen studies were included in the analysis, which showed that LCI was more accurate than WLI in detecting adenomas, with an increased number of adenomas detected per patient. Although LCI performed well in terms of lesion size, morphology, and location, the subgroup analyses did not reveal any statistically significant differences between LCI and WLI. The addition of LCI did not result in significant improvements in the detection of serrated lesions, and there were no differences in the withdrawal time between groups.

LCI has been shown to be effective in detecting colonic lesions, improving the number of adenomas detected per patient and improving polyp detection rate without negatively affecting other quality criteria in colonoscopy.

Patients with long-standing inflammatory bowel disease (IBD) involving the colon are at higher risk of developing colorectal dysplastic or neoplastic lesions. While from sporadic colorectal cancer follows an "adenoma-carcinoma" sequence, IBD colitis-associated carcinogenesis is mainly related to an "inflammation-dysplasia-carcinoma" sequence. Currently, specific endoscopic surveillance strategies involving dye spray and virtual chromoendoscopy have been standardized, aiming for early CRC diagnosis. When detected, colitis-associated dysplasia should be classified according to standard classification, thus allowing for better treatment. Indeed, most IBD-associated dysplastic lesions can be treated with endoscopic resection, even though available procedures are usually more challenging than those in the general population. The higher frequency of severe submucosal fibrosis and the difficulty in the definition of lesions' margins account for this issue. Current endoscopic resection techniques include polypectomy, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Recent evidence suggests the relevance of en bloc resection, as this may be associated with lower rates of recurrence. Therefore, particularly for larger (>20 mm) lesions, ESD should be preferred, even though it is considered the most difficult technique due to frequent severe submucosal fibrosis. Considering the growing number of new endoscopic resective techniques, including underwater EMR or ESD, which in the general population have been suggested to lower procedure-related risks and may also allow a larger spread of advanced endoscopic resection in IBD. However, additional data are needed to assess the medium- and long-term efficacy of endoscopic resection of visible dysplasia in IBD patients, which are burdened by a high risk of local and, more importantly, metachronous recurrence.

With the widespread use of upper gastrointestinal endoscopy, more and more gastric polyps (GPs) are being detected. Traditional management strategies often rely on histopathologic examination, which can be time-consuming and may not guide immediate clinical decisions. This paper aims to introduce a novel classification system for GPs based on their potential risk of malignant transformation, categorizing them as "good", "bad", and "ugly". A review of the literature and clinical case analysis were conducted to explore the clinical implications, management strategies, and the system's application in endoscopic practice. Good polyps, mainly including fundic gland polyps and inflammatory fibrous polyps, have a low risk of malignancy and typically require minimal or no intervention. Bad polyps, mainly including hyperplastic polyps and adenomas, pose an intermediate risk of malignancy, necessitating closer monitoring or removal. Ugly polyps, mainly including type 3 neuroendocrine tumors and early gastric cancer, indicate a high potential for malignancy and require urgent and comprehensive treatment. The new classification system provides a simplified and practical framework for diagnosing and managing GPs, improving diagnostic accuracy, guiding individualized treatment, and promoting advancements in endoscopic techniques. Despite some challenges, such as the risk of misclassification due to similar endoscopic appearances, this system is essential for the standardized management of GPs. It also lays the foundation for future research into biomarkers and the development of personalized medicine.

The pathogenesis of non-ampullary duodenal epithelial tumors (NADETs) is not fully understood. NADETs that express gastric-type mucin phenotypes (G-NADETs) are noteworthy because of their high malignancy. Gastric foveolar metaplasia, from which G-NADETs originate, protects the duodenal mucosa from gastric acidity. As gastric acid secretion is affected by endoscopic gastric mucosal atrophy (EGMA), we hypothesized that EGMA would be associated with G-NADETs.

To evaluate the association between EGMA and the occurrence of G-NADETs.

This cross-sectional retrospective study investigated the relationship between EGMA and NADETs in 134 patients. The duodenum was divided into parts 1 (bulb), 2 (superior duodenal angle to the papilla), and 3 (anal side of the papilla to the horizontal part). The effects of gastric acidity and presence of Brunner's glands were considered. EGMA was divided into types C (no or mild atrophy) and O (severe atrophy). Mucin phenotype expressions in NADETs were divided into gastric, intestinal, gastrointestinal, and unclassifiable.

When NADETs were classified according to EGMA, 105 were classified as type C and 29 as type O. G-NADETs were present in 11.9% (16 cases) of all cases, and all 16 cases were of type C. Among G-NADETs, 93.8% (15 cases) were present in part 1 or 2. There was an association between G-NADETs and type C in part 1, and 50.0% (eight of 16 cases) of G-NADETs were associated with a current or previous Helicobacter pylori infection status. Additionally, all eight cases occurred in part 1.

G-NADETs were significantly associated with type C. Gastric acidity and Brunner's gland growth may be associated with G-NADETs.

In colorectal cancer screening with the fecal immunochemical test (FIT), the optimal follow-up after first-round colonoscopy for a positive FIT, particularly after negative colonoscopy, is unknown. Therefore, using Screening of Swedish Colons (SCREESCO) study data, we aimed to elucidate the risk factors for the detection of colorectal neoplasia in second-round colonoscopy, which can affect recommendations for the optimal follow-up.

We performed a cross-sectional analysis using data from SCREESCO participants undergoing colonoscopy after a positive 2-stool FIT, with a positivity cutoff value of ≥10 μg/g feces, in both the first and second rounds separated by a 2-year interval. We assessed the associations between colorectal neoplasia detection in second-round colonoscopy and participant characteristics, FIT concentrations, first-round colonoscopy results, and endoscopists' adenoma detection rates (ADRs), which were categorized as very low, low, intermediate, and high.

This study included 343 individuals. Despite negative first-round colonoscopies (n = 230), colorectal cancer and advanced colorectal neoplasia (ACN) were detected in 0.9% and 8.3% of participants in the second-round colonoscopy, respectively. An association was demonstrated between the first-round endoscopists' ADRs and the risk of second-round ACN detection. The multivariable odds ratios of the first-round intermediate and high ADRs, compared with the very low ADR, for second-round ACN detection were 0.17 (95% confidence interval [CI], 0.02-0.79) and 0.19 (95% CI, 0.04-0.86), respectively.

The impact of endoscopists' ADRs on ACN detection in subsequent-round colonoscopies underscores the importance of considering ADR for optimal follow-up after first-round colonoscopy in an FIT-based screening program.

High-definition virtual chromoendoscopy, along with targeted biopsies, is recommended for dysplasia surveillance in ulcerative colitis patients at risk for colorectal cancer. Computer-aided detection (CADe) systems aim to improve colonic adenoma detection, however their efficacy in detecting polyps and adenomas in this context remains unclear. This study evaluates the CADe Discovery™ system's effectiveness in detecting colonic dysplasia in ulcerative colitis patients at risk for colorectal cancer.

A prospective cross-sectional, non-inferiority, diagnostic test comparison study was conducted on ulcerative colitis patients undergoing colorectal cancer surveillance colonoscopy between January 2021 and April 2021. Patients underwent virtual chromoendoscopy (VCE) with iSCAN 1 and 3 with optical enhancement. One endoscopist, blinded to CADe Discovery™ system results, examined colon sections, while a second endoscopist concurrently reviewed CADe images. Suspicious areas detected by both techniques underwent resection. Proportions of dysplastic lesions and patients with dysplasia detected by VCE or CADe were calculated.

Fifty-two patients were included, and 48 lesions analyzed. VCE and CADe each detected 9 cases of dysplasia (21.4% and 20.0%, respectively; p=0.629) in 8 patients and 7 patients (15.4% vs. 13.5%, respectively; p=0.713). Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy for dysplasia detection using VCE or CADe were 90% and 90%, 13% and 5%, 21% and 2%, 83% and 67%, and 29.2% and 22.9%, respectively.

The CADe Discovery™ system shows similar diagnostic performance to VCE with iSCAN in detecting colonic dysplasia in ulcerative colitis patients at risk for colorectal cancer.

Postendoscopic submucosal dissection (ESD) coagulation syndrome (PECS) prevention is one of the common postoperative complications of colorectal ESD. Considering the increasing incidence of PECS, it is critical to investigate various prevention methods. The objective of this study was to evaluate the efficacy of transrectal drainage tubes (TDTs) in PECS prevention in patients following colorectal ESD.

From July 2022 to July 2023, a multicenter, randomized controlled clinical trial was conducted in 3 hospitals in China. Patients with superficial colorectal lesions ≥20 mm who had undergone ESD for a single lesion were enrolled. Initially, 229 patients were included in the study and 5 were excluded. Two hundred twenty-four were randomly assigned to the TDT and non-TDT group in the end. This open-label study utilized a parallel design with a 1:1 allocation ratio, and endoscopists and patients were not blind to the randomization, and a 24 Fr drainage tube was inserted approximately 10-15 cm above the anus after the ESD under the endoscopy and tightly attached to a drainage bag. The TDTs were removed in 1-3 days following the ESD.

A total of 229 eligible patients were enrolled in this study, and 5 patients were excluded. Ultimately, 224 patients were assigned to the TDT group (n = 112) and non-TDT group (n = 112). The median age for the patients was 63.45 years (IQR 57-71; 59 men [52.68%]) in the TDT group and 60.95 years (IQR 54-68; 60 men [53.57%]) in the non-TDT group. Intention-to-treat analysis showed patients in the TDT group had a lower incidence of PECS than patients in the non-TDT group (7 [6.25%] vs 20 [17.86%]; relative risk, 0.350; 95% confidence interval [CI], 0.154-0.795; P = 0.008). In the subgroup analysis, TDTs were found to prevent PECS in patients of the female gender (odd ratio, 0.097; 95% CI, 0.021-0.449; P = 0.001), tumor size <4 cm (odd ratio, 0.203; 95% CI, 0.056-0.728; P = 0.011), tumor located in the left-sided colorectum (odd ratio, 0. 339 95% CI, 0.120-0.957; P = 0.035), and shorter procedure time (<45 minutes) (odd ratio, 0.316; 95% CI, 0.113-0.879; P = 0.023). The tube fell off in 1 case (0.89%) accidentally ahead of time. No TDT-related complication was observed.

The results from this randomized clinical study indicate that the application of TDTs effectively reduced the incidence of PECS in patients after colorectal ESD ( chictr.org.cn Identifier: ChiCTR2200062164).

Endoscopic resection (ER) of non-ampullary duodenal epithelial tumors (NADETs) is associated with a high incidence of delayed bleeding (DB). While previous reports have identified composite risk factors for delayed adverse events, including both DB and delayed perforation, the specific factors associated with DB remain unclear. This study aimed to identify factors associated with DB after ER of NADETs.

This retrospective study included 335 consecutive patients who underwent ER for a NADET between January 2004 and December 2023. Participants were divided into the DB and non-DB groups. We compared baseline characteristics and clinical outcomes between the two groups to identify factors associated with DB. ER included endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) techniques. DB was defined as bleeding that required endoscopic hemostasis or transfusion after ER. Complete mucosal closure (CMC) was defined as the complete closure of the defect with no endoscopically visible exposure of the defect.

Overall, 128 ESD procedures and 207 non-ESD procedures were performed. DB occurred in 13 patients (3.9%) and its incidence was lower when CMC was achieved (1.1% vs. 13.9%, P < 0.001). Multivariate analysis revealed the use of antithrombotic agents (odds ratio (OR) 3.8; 95% confidence interval (CI): 1.0-14.6, P = 0.048) and a defect circumference ≥ 1/2 (OR 6.2; 95% CI 1.2-30.5, P = 0.029) as risk factors for DB, and CMC (OR 0.19, 95% CI 0.038-0.95, P = 0.043) as a protective factor. Among the 66 patients with risk factors, including the use of antithrombotic agents and/or a defect circumference ≥ 1/2, CMC reduced the incidence of DB (4.5% [2/44], vs. 31.8% [7/22], P = 0.005).

We identified significant factors associated with DB after duodenal ER. Particularly, in patients with risk factors for DB, CMC can reduce the incidence of DB.

The detection rate of proximal sessile serrated lesion (PSSLDR) is linked to the incidence and mortality of colorectal cancer. However, research on second forward view (SFV) examinations for PSSLDR remains limited. This first randomized controlled trial assessed the impact of the proximal SFV on the PSSLDR.

Patients were randomized into 2 groups during proximal colonoscopy: standard colonoscopy (SC) and SFV. The SC group underwent a standard examination, whereas the SFV group underwent a second examination of the proximal colon (cecum to splenic flexure). The primary outcome was PSSLDR, with secondary outcomes, including the proximal polyp detection rate (PPDR), proximal adenoma detection rate (PADR), and lesion miss rate, compared between the 2 groups.

Among 246 patients (SC = 124; SFV = 122), SFV significantly improved the PSSLDR by 7.4% compared with SC (9.8% vs 2.4%, P = 0.017). SFV increased the PPDR by 20.2% (55.7% vs 35.5%, P = 0.002) and PADR by 12.7% (37.7% vs 25%, P = 0.039). Multivariate analysis revealed that sessile serrated lesions (odds ratio [OR] = 7.70, 95% confidence interval [CI] [1.58, 37.59]), inflammatory polyps (OR = 4.24, 95% CI [1.73, 10.39]), and lesion size (OR = 0.76, 95% CI [0.60, 0.96]) were associated with proximal missed lesions. The overall polyp miss rate was 52.9%, with miss rates of 61.0% for polyps <5 mm, 80% for sessile serrated lesions, and 42.2% for adenomas. Furthermore, 12.3% of patients experienced changes in surveillance intervals from SFV examination.

SFV examination of the proximal colon significantly improved the PSSLDR by 7.4%, PPDR by 20.2%, and PADR by 12.7%, while shortening the detection interval by 12.3%, making it a valuable and cost-effective addition to routine colonoscopy.

Studies on the clinical outcomes after detecting low-grade dysplasia (LGD) in patients with inflammatory bowel disease (IBD) are insufficient. This study evaluated the clinical features, frequency, and risk factors for advanced neoplasia in patients with IBD after an LGD diagnosis.

The medical records of 166 patients with IBD from six university hospitals in Korea from 2010 to 2019 were reviewed retrospectively. LGD was diagnosed in all patients during surveillance. The frequency and risk factors for advanced neoplasia were evaluated, and the clinical features of patients with and without advanced neoplasia were compared.

Advanced neoplasia developed in 12 patients (six with large LGD, three with tubulovillous adenoma, and three with high-grade dysplasia), and all cases developed from UC. Patients with advanced neoplasia had significantly higher Mayo scores, and colitis-associated dysplasia was more common than sporadic lesions (83.3% vs. 29.9%; p<0.001). Multivariate analysis showed that colitis-associated LGD significantly increased the risk of developing advanced neoplasia (odds ratio [OR], 10.516; 95% confidence interval [CI], 2.064-53.577). Among patients with colitis-associated lesions, a significant risk factor for advanced neoplasia was a prior history of LGD (OR, 9.429; 95% CI, 1.330-66.863).

Advanced neoplasia developed in 7.2% of patients with IBD and LGD. Most advanced neoplasms developed from colitis-associated lesions, and the risk was higher in patients with a history of LGD before index colonoscopy.