A total of 6626 patients with CRC who were initially referred for endoscopic polypectomy were enrolled from the Surveillance Epidemiology and End Results Database.

Results: Most enrolled patients (6557/6626, 99.0%) were at T0-T1 stage (American Joint Committee on Cancer staging system). Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to reduce selection bias, which resulted in balanced groups of patients with and without lymphadenectomy, with no difference in CSS (p = .99 and .074, respectively). In the subgroup analysis, insufficient lymphadenectomy (lymph node yield [LNY] < 12) was associated with poor CSS compared with no lymphadenectomy. The multivariate analysis identified adequate lymphadenectomy with an LNY ≥ 12 as an independent favorable prognostic factor. However, nearly half of the patients (59/127, 46.5%) referred for lymph node resection did not undergo adequate lymphadenectomy.

The prognosis of CSS cannot be improved by lymphadenectomy for most patients (T0-T1) who are referred for endoscopic therapy because of the low rate of lymph node metastasis. Nonetheless, adequate lymphadenectomy should be performed instead of diagnostic lymph node resection if lymph node involvement is suspected.

Endoscopic Submucosal Dissection (ESD) has emerged as a pivotal technique for the minimally invasive treatment of early gastrointestinal cancers, offering benefits such as reduced trauma, lower complication rates, and cost-effectiveness. Despite its advantages, the selection of optimal biomaterials for submucosal injection poses significant challenges. Current materials used in clinical settings often suffer from rapid diffusion, requiring multiple injections and potentially causing localized inflammation. These issues underscore the importance of identifying more effective submucosal injection materials to minimize postoperative complications and enhance patient outcomes. Recent advancements have highlighted the potential of hydrogels in this context, favored for their ability to maintain mucosal elevation longer and support wound healing. This review comprehensively examines the development and application of hydrogels in ESD, focusing on their physicochemical properties, biocompatibility, and the clinical implications of their use. These issues discuss various formulations of hydrogels, their mechanisms of action, and comparative analyses with traditional materials. Furthermore, the review explores ongoing innovations and future perspectives in hydrogel research, aiming to catalyze further advancements in ESD techniques. STATEMENT OF SIGNIFICANCE: This review critically examines hydrogel technologies in endoscopic submucosal dissection for gastrointestinal cancers, highlighting their role in improving procedural outcomes and patient recovery. It explores hydrogels' ability to enhance mucosal elevation, reduce complications, and accelerate healing, offering insights into their transformative potential in medical treatments. The findings emphasize the development of innovative materials that could significantly advance clinical practices in gastrointestinal cancer management.

Computer-aided diagnosis (CADx) is anticipated to enhance the prediction of colorectal polyp histology. This study aims to compare the diagnostic accuracy of CADx in the optical diagnosis of colorectal polyps, evaluating its performance against that of both experienced and inexperienced endoscopists.

The protocol of this study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42024585097). Three electronic databases including MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched in September 2024. A bivariate random effects model was employed. The primary outcome was the comparison of sensitivity and specificity between CADx and experienced endoscopists; the secondary outcome was the comparison between CADx and inexperienced endoscopists.

Twenty-one studies involving 5477 polyps were included. The pooled sensitivities of CADx and experienced endoscopists were 0.87 (95% confidence interval [CI] 0.82-0.91) and 0.88 (95% CI 0.83-0.91), respectively (P = 0.93). The pooled specificities of CADx and experienced endoscopists were 0.85 (95% CI 0.78-0.90) and 0.87 (95% CI 0.82-0.92), respectively (P = 0.53). In nine studies comparing CADx with inexperienced endoscopists, the pooled sensitivities were 0.88 (95% CI 0.82-0.92) for CADx and 0.85 (95% CI 0.78-0.90) for inexperienced endoscopists (P = 0.46). The pooled specificities were 0.84 (95% CI 0.78-0.88) for CADx and 0.77 (95% CI 0.70-0.83) for inexperienced endoscopists (P = 0.16).

Computer-aided diagnosis does not demonstrate superior diagnostic accuracy in optical diagnosis of colorectal polyps compared to endoscopists, regardless of their experience level.

The healthcare sector generates 8% of greenhouse gas emissions in the USA, of which gastrointestinal (GI) endoscopy is the third largest contributor. Single-use tools are a major contributor to modifiable waste generation during GI endoscopy. Through a quality improvement initiative, we aimed to reduce endoscopy waste by urging gastroenterologists to be mindful of tools used during polypectomies by avoiding using multiple tools.We discussed green endoscopy initiatives in monthly journal club and business meetings. Over 14 weeks, 210 patients were included in the pre-intervention group and 112 in the post-intervention group.At baseline, 34% of colonoscopies required no intervention, 32% required one tool (either biopsy forceps or a snare), and 33% required multiple tools. After the intervention, the use of just one tool increased (17 percentage point increase; P=0.003) and the use of multiple tools decreased significantly (16 percentage point decrease; P=0.002). The odds ratio for use of a single tool compared with multiple tools after the intervention was 3.0 (95%CI 1.6 to 5.5; P=0.005).This single-center quality improvement study noted a significant change in practice patterns favoring the use of a single tool over multiple tools during colonoscopies after an environmentally conscious practice intervention was applied. This intervention can be readily applied to reduce endoscopy-related waste.

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.

Accurate measurement of polyp size during colonoscopy is crucial for informing clinical decisions such as resection technique and surveillance scheduling. This study aimed to compare the accuracy of polyp size measurement when using a virtual scale endoscope (VSE) or snare-based polyp size measurement.This randomized controlled trial enrolled 221 patients undergoing screening, surveillance, or diagnostic outpatient colonoscopies. Study subjects were randomized to have polyps detected during the colonoscopy measured for size either using the VSE or a snare of known size to estimate the size of each polyp. All polyps were measured for reference size directly after their removal from the colon using a digital caliper and before formalin fixation.93 polyps were included in the VSE group and 102 in the snare group. The VSE demonstrated significantly higher relative accuracy (80.0% [95%CI 77.0%-82.9%]) compared with snare-based size estimation (66.4% [95%CI 62.4%-70.5%]; P < 0.001). Misclassification rates were lower with the VSE for polyps >2 mm (13.1% vs. 39.3%) and >3 mm (22.6% vs. 55.4%). For diminutive polyps, the VSE better prevented misclassification of >5 mm polyps as 1-5 mm (21.4% vs. 73.0%). The VSE also outperformed snare-based estimation in measuring within 10% of the reference standard size (30.1% vs. 18.6%) and had lower rates of size underestimation (36.5% vs. 65.7%).Using the VSE improves the accuracy of polyp size measurement during colonoscopy in comparison with snare-based size estimation. In clinical scenarios, the VSE reduced misclassifications at clinically relevant size thresholds 2, 3, and 5 mm, which is relevant for the correct choice of polypectomy technique or when implementing resect-and-discard strategies.

 Cold snare EMR (CS-EMR) in large flat nonpedunculated colonic lesions (LFNPCLs) is an alternative to the standard EMR procedure with a better safety profile, but scientific evidence on its efficacy is unavailable. This study aimed to compare the recurrence rate between the two techniques at 6 months. Secondary aims were comparison of the safety profile and procedure-related outcomes.

 This was a noninferiority, multicenter, open-label, randomized controlled trial of consecutive large (≥ 20 mm) LFNPCLs without suspicious features of submucosal invasion.

 229 patients were randomized to receive CS-EMR (n = 115) or EMR (n = 114). The median lesion size was 25 mm and 74.6 % were adenomas. The trial was stopped early by clinical consensus according to a safety monitoring board. At first surveillance colonoscopy (n = 220) the recurrence rate was significantly greater in the CS-EMR group than in the EMR group: 33.0 % vs. 16.2 % (P = 0.004) and 34.7 % vs. 14.8 % (P = 0.001) in the intention-to-treat and per-protocol analyses, respectively. According to the subgroup analysis, the recurrence rate was significantly greater after CS-EMR for LFNPCLs ≥ 30 mm (43.1 % vs. 18.2 %). There was no difference in the rate of adverse events. The use of clips was more common in the EMR group (52.6 % vs. 27.8 %).

 The recurrence rate of LFNPCLs after CS-EMR was significantly greater than after the standard hot technique. A similar safety profile was found between groups.

Accurate endoscopic characterization of colorectal lesions is essential for predicting histology but remains difficult. We studied the impact of a social network workgroup on level of characterization of colorectal lesions by gastroenterology residents.

We prospectively involved residents who characterized 25 and 40 colorectal lesions in two different questionnaires over 1 year. Three groups were considered: regulars who were already part of the workgroup before the first evaluation, newcomers who joined in during evaluation, and reluctant who did not. Participants rated each lesion according to the CONECCT classification (hyperplastic polyp [IH], sessile serrated lesion [IS], adenoma [IIA], high-risk adenoma or superficial adenocarcinoma [IIC], borderline invasive adenocarcinoma [IIC+], or deeply invasive adenocarcinoma [III]) and their progression score over 1 year was assessed. Correct histological status was defined by pathology reports or combined criteria between histology and expert opinion for high-risk adenoma or adenocarcinoma.

Of the 117 participants, 82.9% completed the two questionnaires, with 16.5% regulars, 71.1% newcomers, and 12.4% reluctant. For similar starting levels, progression in characterization was +2 (95% confidence interval [CI] 1-3; P <0.001) for newcomers and +2 (95% CI -0.5-4); P = 0.122) for reluctant. The regulars had a higher starting level with a +0.5 (95% CI -2 to 2; P = 0.691) progression score.

Gastroenterology resident 1-year use of a social network workgroup does not improve their skills in characterizing colorectal neoplasia. Further intensive training is needed to improve the characterization level of gastroenterology residents.

Endoscopic full-thickness resection (EFTR) has emerged as a transformative technique for managing gastrointestinal (GI) lesions, previously deemed unsuitable for endoscopic removal. Unlike conventional endoscopic resection methods, such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), EFTR enables en bloc excision of both intraluminal and subepithelial lesions by resecting all layers of the GI wall, followed by defect closure to prevent complications. The introduction of the full-thickness resection device (FTRD®) has significantly enhanced the feasibility and safety of EFTR, particularly in the colon and upper GI tract, with increasing adoption worldwide. This review provides a comprehensive analysis of FTRD®, focusing on its clinical applications, procedural methodology, and comparative efficacy against other endoscopic resection techniques. The indications and contraindications for EFTR are explored, highlighting its utility in treating non-lifting adenomas, subepithelial tumours, and T1 carcinomas without lymph node involvement. This review synthesizes current clinical data and FTRD® advantages. Despite its strengths, EFTR via FTRD® incorporates challenges such as limitations in lesion size, procedural complexity, and potential adverse events. Strategies for overcoming these challenges, including hybrid techniques and modifications in procedural approach, are examined. The review also emphasizes the need for further research to optimize surveillance strategies and determine the long-term clinical impact of EFTR in GI lesion management. By integrating recent evidence, this paper provides valuable insights into the evolving role of EFTR in therapeutic endoscopy.

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.

We compared the frequency of post-polypectomy bleeding or injured submucosal arteries between cold snare polypectomy (CSP) and endoscopic mucosal resection (EMR) for nonpedunculated colorectal polyps.

This was a prospective, randomized, single-center study. Patients who underwent CSP or EMR for 10-19-mm nonpedunculated polyps were enrolled in CSP and EMR groups, and we compared the patient and polyp characteristics, the number of clips used, clinical outcomes, adverse events, and pathological features of the resected polyps between these groups. The primary outcome was the presence of injured arteries in the submucosal layer of the resected polyps examined histologically. The secondary outcomes were immediate bleeding and delayed bleeding.

Fifty-three patients with 60 eligible polyps were enrolled. The numbers of polyps/patients were 30/26 in the CSP group and 30/27 in the EMR group. The patient and polyp characteristics were similar between the groups. The total number of hemostatic clips used for hemostasis or prophylactic clipping was significantly greater in the EMR group compared to the CSP group (78 vs. 10, p < 0.001). The frequency of immediate bleeding after CSP was similar to that after EMR [6.7% (2/30) vs. 13% (4/30), p = 0.39]. Delayed bleeding did not occur in either group. The presence of injured submucosal arteries after CSP was significantly less frequent than that after EMR: 10% (3/30) versus 67% (20/30), p < 0.001.

In the resection of 10-19-mm nonpedunculated colorectal polyps, CSP may decrease post-polypectomy bleeding without prophylactic clipping compared to EMR as it results in fewer injured submucosal arteries. www.clinicaltrials.gov (NCT05930041).

Delayed postpolypectomy bleeding occurs in approximately 1%-2% of all patients undergoing colonoscopic polypectomy, and this rate increases to 6% in patients with large (>2 cm) colon polyps. Sucralfate can protect the mucosa and promote its healing. This study was conducted to investigate whether colonoscopic spraying of sucralfate powder on polypectomy wounds can prevent delayed postoperative bleeding.

This randomized controlled trial included patients with polyps (size ≥0.5 cm) who had undergone colonoscopic polypectomy at our hospital between May 2023 and January 2024. After polypectomy, the patients received standard treatment for immediate bleeding. Then, they were randomly allocated to either a sucralfate group (prophylactic spraying of sucralfate powder [3 g] on polypectomy wounds) or a control group. All patients were monitored for delayed bleeding within 28 days after colonoscopy.

A total of 160 patients were divided into the sucralfate and control groups (80 per group). The baseline characteristics were balanced between the groups. The rate of delayed postpolypectomy bleeding (0% vs 6.3%, respectively; P = 0.029) and postpolypectomy overt bloody stool (2.4% vs 18.8%, respectively; P = 0.001) were lower in the sucralfate group than in the control group. The duration of freedom from delayed bleeding was longer in the sucralfate group than in the control group ( P = 0.024). Multivariate Cox regression analysis confirmed the additional sucralfate spray as an independent factor against postpolypectomy overt bloody stool (relative risk, 0.03; 95% confidence interval, 0.003-0.43; P = 0.009).

Colonoscopic spraying of sucralfate powder is a safe approach with potential to reduce the risk of delayed postpolypectomy bleeding. Trial registration: NCT05817656.

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.

The full thickness resection is an innovative technique that enables non-exposed endoscopic full-thickness resection (EFTR) of superficial and subepithelial gastrointestinal lesions. This retrospective, multicenter study evaluated the effectiveness and safety of EFTR in gastroduodenal and colorectal resections.

Data from 105 consecutive EFTR procedures at 6 Polish endoscopic centers were analyzed. Patients were divided into three groups: 'difficult adenoma', adenocarcinoma, or subepithelial lesion (SEL). Outcomes assessed were R0 resection and adverse event rates, with subgroup analysis.

The study included 105 patients (mean age: 67 ± 10.3 years; 59% male): 48 (46%) with 'difficult adenoma', 31 (30%) with adenocarcinoma, and 26 (25%) with SEL. Of these, 82 patients (78%) underwent colorectal EFTR, while 23 (22%) underwent gastroduodenal EFTR. Technical success was achieved in 101 procedures (96%), with a median time of 30 (20; 40) minutes. Among the technically successful EFTRs, R0 resection was confirmed in 86 patients (97%): 18 (95%) in the SEL group, 45 (100%) in the 'difficult adenoma' group, and 23 (92%) in the adenocarcinoma group (p = 0.1806). In 13 EFTR procedures (13%), a scar from a previous endoscopic resection was removed without any pathological lesion. Curative resections were obtained in 21 (88%) patients in the SEL group and 20 (67%) patients in the adenocarcinoma group (p = 0.0001). Clinical adverse events occurred in 12 patients (11%): Clavien-Dindo grade I (5%), II (2%), and IIIb (5%).

EFTR is reasonably safe and effective for resection of colorectal and gastroduodenal lesions, which would otherwise most likely require surgical treatment.

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.

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.

The 2024 updates of the Chinese Society of Clinical Oncology (CSCO) Clinical Guidelines for the diagnosis and treatment of colorectal cancer emphasize standardizing cancer treatment in China, highlighting the latest advancements in evidence-based medicine, healthcare resource access, and precision medicine in oncology. These updates address disparities in epidemiological trends, clinicopathological characteristics, tumor biology, treatment approaches, and drug selection for colorectal cancer patients across diverse regions and backgrounds. Key revisions include adjustments to evidence levels for intensive treatment strategies, updates to regimens for deficient mismatch repair (dMMR)/ microsatellite instability-high (MSI-H) patients, proficient mismatch repair (pMMR)/ microsatellite stability (MSS) patients who have failed standard therapies, and rectal cancer patients with low recurrence risk. Additionally, recommendations for digital rectal examination and DNA polymerase epsilon (POLE)/ DNA polymerase delta 1 (POLD1) gene mutation testing have been strengthened. The 2024 CSCO Guidelines are based on both Chinese and international clinical research, as well as expert consensus, ensuring their relevance and applicability in clinical practice, while maintaining a commitment to scientific rigor, impartiality, and timely updates.

Endoscopic submucosal dissection is increasingly promoted for the treatment of all large nonpedunculated colorectal polyps (LNPCPs) to cure potential low-risk cancers (superficial submucosal invasion without additional high-risk histopathologic features). The effect of a universal en bloc strategy on oncologic outcomes for the treatment of LNPCPs in the right colon is unknown. We evaluated this in a large Western population.

A prospective cohort of patients referred for endoscopic resection (ER) of LNPCPs was analyzed. Patients found to have cancer after ER and those referred directly to surgery were included. The primary outcome was to determine the proportion of right colon LNPCPs with low-risk cancer.

Over 180 months until June 2023, 3294 sporadic right colon LNPCPs in 2956 patients were referred for ER at 7 sites (median size 30 [interquartile range 22.5-37.5] mm). A total of 63 (2.1%) patients were referred directly to surgery, and cancer was proven in 56 (88.9%). A total of 2851 (96.4%) of 2956 LNPCPs underwent ER (median size 35 [interquartile range 25-45] mm), of which 75 (2.6%) were cancers. The overall prevalence of cancer in the right colon was 4.4% (n = 131 of 2956). Detailed histopathologic analysis was possible in 115 (88%) of 131 cancers (71 after ER, 44 direct to surgery). After excluding missing histopathologic data, 23 (0.78%) of 2940 sporadic right colon LNPCPs were low-risk cancers.

The proportion of right colon LNPCPs referred for ER containing low-risk cancer amenable to endoscopic cure was <1%, in a large, multicenter Western cohort. A universal endoscopic submucosal dissection strategy for the management of right colon LNPCPs is unlikely to yield improved patient outcomes given the minimal impact on oncologic outcomes.

gov, Numbers: NCT01368289, NCT02000141.

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.

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".

Colorectal serrated lesions (SLs) are precursors of colorectal carcinoma via the serrated neoplasia pathway. However, the success rate of endoscopic resection of large SLs is low. Therefore, this study aimed to determine the safety and efficacy of underwater EMR (UEMR) for SLs sized 10 to 20 mm.

This 2-center, prospective, observational study included patients with at least 1 SL sized 10 to 20 mm. We resected the SLs by UEMR and performed tattooing at the resection site. Surveillance colonoscopy was performed 12 months postoperatively to evaluate local recurrence. The primary outcome was the complete resection rate of UEMR, which was defined as en bloc resection with no serrated tissue in the 4 marginal biopsy samples and histologically negative margins.

UEMR was performed for 65 SLs in 58 patients, with a median lesion size of 14 mm. The en bloc, R0 resection, and complete resection rates were 87.7% (57 of 65), 61.5% (40 of 65), and 60.0% (39 of 65), respectively. Adverse events included 1 (1.5%) immediate bleeding and 1 (1.5%) delayed perforation. Surveillance colonoscopy was performed in 50 patients with 57 scars, and the rates of identification for tattoos and scars were 94.7% (54 of 57) and 100% (57 of 57), respectively. The recurrence rate was 5.3% (3 of 57), and all 3 recurrent lesions were completely resected endoscopically.

This 2-center prospective study demonstrated that UEMR for SLs sized 10 to 20 mm was comparable to previous conventional EMR outcomes.

Post-endoscopic mucosal resection (EMR) bleeding, or clinically significant post-EMR bleeding, is influenced by factors such as polyp size, right-sided colonic lesions, laterally spreading tumors, anticoagulant use, and comorbidities like cardiovascular or chronic renal disease. The optimal prophylactic therapy for post-EMR bleeding remains unknown, with no consensus on specific criteria for its application. Moreover, prophylactic measures, including clipping, suturing, and coagulation, have produced mixed results. Selective clipping in high-risk patients is cost-effective, whereas universal clipping is not. Studies and meta-analyses indicate that routine prophylactic clipping does not generally reduce post-polypectomy bleeding but may be beneficial in cases of large proximal lesions. Some studies have revealed that the post-polypectomy bleeding risk after EMR of transverse colonic lesions is lower than that of the ascending colon and caecum, suggesting limited efficacy of clipping in the transverse colon. Cost-effectiveness studies support selective clipping in high-risk groups, and newer static agents such as PuraStat are alternatives; however, their cost-effectiveness is undetermined. Further research is required to establish clear guidelines and refine prophylactic strategies to prevent post-EMR bleeding.

The optimal methods for removing polyps remain controversial, especially for polyps ≤ 10 mm. We aim to combine the latest evidence to evaluate and compare the effectiveness and safety of cold snare polypectomy (CSP) and hot snare polypectomy (HSP) in the removal of colorectal polyps ≤ 10 mm in size.

We performed an extensive search across multiple databases, including PubMed, Embase, Cochrane, and Web of Science, with the search period ending in April 2023, for randomized, controlled trials comparing the effectiveness and/or safety of CSP and HSP for the removal of ≤ 10 mm colorectal polyps. The final outcomes included complete resection rate, operation time, and postoperative adverse event (including immediate bleeding, delayed bleeding, and perforation) rates.

A total of 14 eligible randomized, controlled trials were included involving 7,460 patients and 15,829 polyps. The incidence of immediate bleeding was observed to be more prevalent in CSP in contrast to HSP, and the disparity was statistically notable (OR = 2.18, 95 % CI: 1.43-3.30, I2 = 36 %, p = 0.0003). The incidence of delayed bleeding was observed to be lower in CSP in contrast to HSP, and this difference was statistically significant (OR = 0.30, 95 % CI: 0.15-0.58, I2 = 0 %, p = 0.0003). Procedure time: both total colonoscopy time and specific polypectomy time were shorter in CSP versus HSP (MD = -5.92, 95 % CI: -9.70 to -2.14, I2 = 96 %, p = 0.002; MD = -0.56, 95 % CI: -0.91 to -0.20, I2 = 77 %, p = 0.002). There were no statistically significant differences in complete resection and polyp retrieval rate between CSP and HSP.

CSP is as effective and safe as HSP for ≤ 10 mm colorectal polyps, while effectively reducing the risk of delayed bleeding and shortening procedure time.

BACKGROUND : Accurate polyp size measurement is important for polyp risk stratification and decision-making regarding polypectomy and surveillance. Recently, a virtual scale (VS) function has been developed that allows polyp size measurement through projection of an adaptive VS onto colorectal polyps during real-time endoscopy. We aimed to evaluate the VS in terms of variability and systematic differences. METHODS : We conducted a video-based study with 120 colorectal polyps, measured by eight dedicated colorectal gastroenterologists (experts) and nine gastroenterology residents following endoscopy training (trainees). Three endoscopic measurement methods were compared: (1) visual, (2) snare and (3) VS measurement. We evaluated the method-specific variance (as measure of variability) in polyp size measurements and systematic differences between these methods. RESULTS : Variance in polyp size measurements was significantly lower for VS measurements compared to visual and snare measurements for both experts (0.52 vs. 1.59 and 1.96, p < 0.001) and trainees (0.59 vs. 2.21 and 2.53, p < 0.001). VS measurement resulted in a higher percentage of polyps assigned to the same size category by all endoscopists compared to visual and snare measurements (experts: 69 % vs. 55 % and 59 %; trainees: 67 % vs. 51 % and 47 %) and reduced the maximum difference between individual endoscopists regarding the percentage of polyps assigned to the ≥ 10 mm size category (experts: 1.7 % vs. 10.0 % and 5.0 %; trainees: 2.5 % vs. 6.7 % and 11.7 %). Systematic differences between methods were < 0.5 mm. CONCLUSIONS : Use of the VS leads to lower polyp size measurement variability and more uniform polyp sizing by individual endoscopists compared to visual and snare measurements.

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.

Large rectal adenomatous polyps are not uncommon. Proctectomy sparing interventions are favored when feasible. We present a case of a 62-year-old woman, who presented with diarrhea for several years. Colonoscopy revealed a very large 60 mm rectal polyp, biopsied as tubulovillous adenoma. This was successfully resected using a staged approach with endoscopic mucosal resection and trans-anal endoscopic microsurgery. Endoscopic mucosal resection removed 70% of the lesion with central scarred not amenable to resection but amenable to transanal excision. Pathology demonstrated tubulovillous adenoma with negative margins. Flexible sigmoidoscopy at 6-month follow-up revealed well healed scar without recurrence or residual disease. This demonstrates a staged resection for a large rectal polyp which is minimally invasive and organ preserving.

Histological analysis of regular duodenal biopsies to study morphologic changes after duodenal ablation for type 2 diabetes (T2D) and metabolic syndrome is hampered by variability in tissue orientation. We designed an optimized tissue acquisition protocol using duodenal cold snare resections to create tissue microarrays (TMAs) and to allow for single-cell RNA sequencing (scRNA-seq).

The open-label DIRECT study included patients undergoing an upper gastrointestinal interventional endoscopy for non-duodenal indications. All underwent one ot two single-piece duodenal cold snare resections. Endpoints were safety, adequate histological orientation of specimen and TMA, and tissue dissociation quality for scRNA-seq. The optimized tissue acquisition protocol was validated in a duodenal ablation study, EMINENT-2.

In DIRECT, nine patients were included in whom a total of 16 cold snare resections were obtained. No severe adverse events (SAEs) occurred. Eighty percent of specimens and corresponding TMAs showed optimal tissue orientation. Further improvement was achieved by reducing tissue damage during endoscopic retrieval and improving histologic evaluation by eliminating ink use and pinning the tissue on cork. High-quality tissue dissociation scores for scRNA-seq were achieved in 13 of 18 samples (72%). In EMINENT-2, 38 cold snares were obtained without SAEs, histopathologic analysis showed good orientation in all samples, and dissociation scores for scRNA-seq were qualified in 35/38 (92%) samples.

Duodenal cold snare resection is safe and can provide high-quality tissue for optimally oriented TMAs and high-quality tissue dissociation scores for scRNA-seq (Clinicaltrials.gov, NCT06333093, NCT05984238). This approach will allow mechanistic studies about the effects of duodenal ablation on metabolic syndrome and T2D.

Due to the greater risks of adverse events (AEs) and the lower rate of submucosal invasive cancer (SMIC), large proximal colonic polyps are frequently treated by piecemeal endoscopic mucosal resection (EMR) in the West. However, this implies the risk of surgery to radicalize non-curative endoscopic resection in case of early colorectal cancer (CRC). We evaluated procedure outcomes in patients undergoing ESD for proximal colonic lesions at risk of SMIC.

All consecutive patients with lesions at risk of SMIC proximal to splenic flexure referred for ESD at a tertiary center were prospectively included from 2019 to 2021. En bloc, R0, and curative resection rates were primary outcomes, while length of hospitalization, AEs, need for surgery due to AEs, and recurrence rates were secondary outcomes.

A total of 116 patients (mean age: 68.4±10.91 years; men: 69.8%) were included. En bloc, R0, and curative resection rates were 84.5%, 78.4%, and 72.4%, respectively. T1 adenocarcinoma was reported in 25% of lesions (29/116). Eleven patients (9.5%) underwent secondary surgery due to non-curative resections; residual disease was found in one patient. Most frequent AE was intra-procedural perforation (9.9%); no AE required surgery. Median follow-up was 36 months; three of 97 recurrences (3.1%) at 6 months and one of 85 recurrence (1.2%) at 36 months were reported, which were all endoscopically treated.

In expert hands, ESD is effective and safe for proximal colonic lesions at risk of SMIC for the favorable balance between risk of AEs and benefit of avoiding unnecessary surgery, even for early CRC.

 Piecemeal endoscopic mucosal resection (EMR) of large (≥ 20 mm) nonpedunculated colorectal polyps (LNPCPs) is succeeded by a 6-month surveillance endoscopy to evaluate the post-EMR scar for recurrence. Data from expert centers suggest that routine tattoo placement and scar biopsies can be omitted, but data from community hospitals are lacking.

 The agreement between optical assessment and histological confirmation by routine biopsies was evaluated in a post-hoc analysis of the STAR-LNPCP study (NTR7477), containing prospective data on 6-month post-EMR scar assessments in 30 Dutch community hospitals (October 2019 to May 2022). A standardized protocol was followed for documentation of optical characteristics, imaging, and biopsy of the post-EMR scar. RESULTS : In 1277 post-EMR scar assessments, identification of the scar was achieved in 1215/1277 (95 %). Tattoo placement did not influence scar identification. Scar biopsy was performed in 1050/1215 cases (86 %). Recurrences were seen in 200/1050 cases (19 %). There was good agreement between optical assessment of recurrence and histological confirmation (Cohen's kappa 0.78 [95 %CI 0.73-0.83]). The negative and positive predictive values were 98 % (95 %CI 97 %-99 %) and 74 % (95 %CI 68 %-80 %), respectively. A higher false-positive rate was seen after prior use of clips (11 % vs. 5 %; P = 0.02). Dedicated endoscopists identified the scar more often (96 % vs. 88 %; P < 0.001), and showed a lower optical recurrence miss rate (1 % vs. 3 %; P = 0.11) compared with nondedicated endoscopists. CONCLUSION : Based on this multicenter community hospital study, routine tattoo placement and scar biopsies of the post-EMR scar can be omitted. Assessment of post-EMR scars by dedicated endoscopists is advised.

Background/Objectives: Endoscopic resection with lift polypectomy using submucosal injection (SI) for large non-pedunculated colorectal polyps is recommended to facilitate complete mucosal resection and decrease the risk of perforation; however, there are no studies comparing the safety and efficacy of large polypectomies with and without lift polypectomy. We aimed to evaluate the feasibility and safety of the polypectomy technique without SI compared to the routine use of SI. Methods: We performed a single tertiary center retrospective study evaluating all consecutive large non-pedunculated colorectal polyps (≥20 mm) referred to expert endoscopists in polypectomy from 2018 through 2021. We collected and analyzed data on demographics, polyp characteristics, resection technique, complications, and polyp recurrence in 6-12 months. Results: In 200 large non-pedunculated colonic polyp resections, 110 (55%) were performed with SI. The median polyp size was slightly larger in SI (30 mm IQR [20, 40] vs. 25 mm IQR [20, 30] in no-SI, p < 0.05), with a range of 20 to 130 mm. There were no differences in delayed bleeding rates. No perforation was noted in the no-SI group, and five perforations occurred in the SI group, without a statistically significant difference between groups. There was no statistically significant difference in the polyp recurrence rate at 6-12 months between the no-SI and SI groups (12% vs. 8% in no-SI vs. SI, respectively, p = 0.48). Conclusions: Complete removal of large non-pedunculated polyps without SI is feasible and safe in this large series. This approach had similar rates of clinically significant post-polypectomy bleeding and a non-significant difference in perforation rate compared to polyp resection with routine use of SI. Randomized trials are warranted to further assess the safety and efficacy of this approach.

Early colorectal cancer (ECC) is commonly resected endoscopically. Perforation is a devastating complication of endoscopic resection. We aimed to identify the characteristics and predictive risk factors for perforation related to endoscopic resection of ECC.

This nationwide retrospective multicenter study included patients with ECC who underwent endoscopic resection. We investigated the demographics, endoscopic findings at the time of treatment, and histopathological characteristics of the resected specimens. Logistic regression analysis was used to investigate the clinical factors associated with procedure-related perforations. Survival analysis was conducted to assess the impact of perforation on the overall survival of patients with ECC.

This study included 965 participants with a mean age of 63.4 years. The most common endoscopic treatment was conventional endoscopic mucosal resection (n=573, 59.4%), followed by conventional endoscopic submucosal dissection (n=259, 26.8%). Thirty-three patients (3.4%) experienced perforations, most of which were managed endoscopically (n=23/33, 69.7%). Patients who undergo endoscopic submucosal dissection-hybrid and precut endoscopic mucosal resection have a higher risk of perforation than those who undergo conventional endoscopic mucosal resection (odds ratio, 78.65 and 39.72, p<0.05). Procedure-related perforations were not associated with patient survival.

Perforation after endoscopic resection had no significant impact on the prognosis of ECC. The type of endoscopic resection was a crucial predictor of perforation. Large-scale prospective studies are needed to further investigate endoscopic resection of ECC.

We investigated the clinical practice patterns of Korean endoscopists for the endoscopic resection of colorectal polyps.

From September to November 2021, an online survey was conducted regarding the preferred resection methods for colorectal polyps, and responses were compared with the international guidelines.

Among 246 respondents, those with <4 years, 4-9 years, and ≥10 years of experience in colonoscopy practices accounted for 25.6%, 34.1%, and 40.2% of endoscopists, respectively. The most preferred resection methods for non-pedunculated lesions were cold forceps polypectomy for ≤3 mm lesions (81.7%), cold snare polypectomy for 4-5 mm (61.0%) and 6-9 mm (43.5%) lesions, hot endoscopic mucosal resection (EMR) for 10-19 mm lesions (72.0%), precut EMR for 20-25 mm lesions (22.0%), and endoscopic submucosal dissection (ESD) for ≥26 mm lesions (29.3%). Hot EMR was favored for pedunculated lesions with a head size <20 mm and stalk size <10 mm (75.6%) and for those with a head size ≥20 mm or stalk size ≥10 mm (58.5%). For suspected superficial and deep submucosal lesions measuring 10-19 mm and ≥20 mm, ESD (26.0% and 38.6%) and surgery (36.6% and 46.3%) were preferred, respectively. The adherence rate to the guidelines ranged from 11.2% to 96.9%, depending on the size, shape, and histology of the lesions.

Adherence to the guidelines for endoscopic resection techniques varied depending on the characteristics of colorectal polyps. Thus, an individualized approach is required to increase adherence to the guidelines.