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.

Nonlifting large nonpedunculated colorectal polyps (NL-LNPCPs) account for 15% of LNPCPs and are effectively managed by endoscopic mucosal resection (EMR) with adjunctive cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST). Recurrence rates >10% at surveillance colonoscopy are however a significant limitation. We aimed to compare the outcomes of CAST plus margin thermal ablation (MTA) versus CAST alone for NL-LNPCPs.Prospective observational data on consecutive patients with NL-LNPCPs treated by EMR and CAST at a single tertiary center were retrospectively evaluated. Two cohorts were established: the pre-MTA period (January 2012-June 2017) and the MTA period (July 2017-October 2023). The primary outcome was the residual/recurrent adenoma (RRA) rate at first surveillance colonoscopy (SC1). Secondary outcomes included the RRA rate at SC2 and adverse events.Over 142 months, 300 patients underwent EMR and CAST for LNPCP: 103 lesions pre-MTA and 197 with MTA. At SC1 and SC2, recurrence was lower in the MTA cohort compared with the pre-MTA cohort (5.0% vs. 18.8% and 0.8% vs. 10.0%, respectively; both P<0.001). Adverse events were similar between the two cohorts for deep mural injury types III-V (pre-MTA 2.9% vs. MTA 5.6%; P=0.29) and delayed bleeding (pre-MTA 8.7% vs. MTA 7.1%; P=0.49). On multivariate analysis, MTA was the only variable independently associated with a reduced likelihood of recurrence (odds ratio 0.20, 95%CI 0.07-0.54; P=0.001).For NL-LNPCPs, MTA in combination with CAST is safe and effective and reduces recurrence at SC1 in comparison with CAST alone.

Real-time endoscopic rectal lesion characterization employing artificial intelligence (AI) and near-infrared (NIR) imaging of the fluorescence perfusion indicator agent Indocyanine Green (ICG) has demonstrated promise. However, commercially available fluorescence endoscopes do not possess the flexibility and anatomical reach capabilities of colonoscopy while commercial flexible scopes do not yet provide beyond visible spectral imaging. This limits the application of this AI-NIR classification technology. Here, to close this technical gap, we present our development of a colonoscope-compatible flexible imaging probe for NIR-ICG visualization combined with a full field of view machine learning (ML) algorithm for fluorescence quantification and perfusion pattern cross-correlation (including first in human testing). The imaging probe is capable of 133µm minimum object resolution, with a maximum working distance of 50mm and an excitation illumination power of 52mW with 75o average field of illumination (meaning minimum device tip distance from target is 13 mm for a 2 cm polyp). The system demonstrated ex-vivo and in-vivo NIR visualization of clinically relevant concentrations of ICG in both resected and in situ (extracorporeally) colon in patients undergoing colorectal resection. A previously developed AI-NIR perfusion quantification algorithm was applied to videos of a bench model of varying ICG flow captured with the developed flexible system with added ML features generated full field of view pixel-level fluorescence time-series measurements capable of distinguishing distinct ICG flow regions in the image via correlative dynamic fluorescence intensity profiles. Jaccard Index comparison of the AI -generated flow regions against manually delineated flow regions resulted in 79% accuracy. While further clinical validation of the AI-NIR polyp classification method is on-going (in the Horizon Europe Awarded CLASSICA project), other use case applications of NIR colonoscopy include simpler perioperative perfusion assessment in patients undergoing colorectal resection and combination with targeted agents in development thus encouraging continuing development and design optimization of this flexible NIR imaging probe to enable clinical and commercial translation.

Endoscopic mucosal resection (EMR) is traditionally performed using electrosurgical cautery (hot snare) to resect premalignant colorectal polyps. Recent data have suggested the superior safety of cold EMR (c-EMR), even for polyps ≥20 mm in size. We aimed to perform a systematic review and meta-analysis to assess the safety and efficacy of c-EMR compared with traditional (hot) EMR (h-EMR).

We performed a comprehensive systematic review ending in December 2024. The primary outcome of interest was the odds of delayed bleeding for c-EMR compared with h-EMR of nonpedunculated colorectal polyps ≥20 mm in size. Odds ratios (ORs) with 95% confidence intervals (CIs) are reported. The secondary outcomes included early bleeding, perforation, and polyp recurrence. Publication bias was assessed using the classic fail-safe test. Forest plots were used to report the pooled effect estimates. Heterogeneity was assessed using I2 .

Our systematic review identified 1,632 unique citations, a total of 3 randomized controlled trials and 4 nonrandomized comparative studies were identified and included in the primary analyses. Four additional cohort studies were included in the secondary analyses. On random-effects modeling, c-EMR was associated with a significantly lower risk of delayed bleeding (OR 0.25, 95% CI 0.11-0.57, P = 0.001, I2 = 0%), early bleeding (OR 0.34, 95% CI 0.2-0.6, P < 0.001, I2 = 0%), and perforation (OR 0.14, 95% CI 0.04-0.51, P = 0.003, I2 = 0%) than h-EMR. c-EMR was associated with a higher rate of recurrence (OR 1.81, 95% CI 1.01-3.25, P = 0.045, I2 = 72%).

c-EMR has a superior safety profile to h-EMR for nonpedunculated colorectal polyps ≥20 mm in size, but strategies to manage the higher odds of recurrence remain essential.

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.

Delayed post-polypectomy bleeding (DPPB) can occur up to a month following the procedure but is typically seen within the first week. Tranexamic acid (TXA) is a member of a class of drugs called antifibrinolytic agents. It reduces fibrinolysis by slowing down the conversion of plasminogen to plasmin, which may prevent bleeding. The goal of this pilot study is to assess the feasibility of using tranexamic acid after endoscopic mucosal resection (EMR) of large (≥2 cm) non-pedunculated colorectal polyps (LNPCPs) to prevent DPPB.

This was a single centre feasibility study conducted at the Kingston Health Sciences Centre in 2021. After the polypectomy was completed, IV tranexamic acid was given [1 gram of TXA in 100 mL of normal saline] and infused over a 10-min interval. The participants received tranexamic acid 1 gram PO TID to be taken for 5 days.

A total of 25 patients were enrolled with a mean polyp size of 3 cm. Intraprocedural bleeding occurred in 7 patients (28%) and all of these were treated with soft coagulation. Two patients had clipping for suspected muscle injury. All 25 patients received IV TXA post-procedure. Sixteen patients (64%) took every dose of the prescribed pills. One patient presented with post-polypectomy bleeding. All patients completed the day 30 follow-up phone call. There were no major adverse events.

TXA to prevent delayed post-polypectomy bleeding (DPPB) was feasible to use with no major adverse events reported. A randomized controlled study will be needed to see if TXA can significantly reduce DPPB.

Endoscopic mucosal resection (EMR) of superficial nonampullary duodenal epithelial tumors (SNADETs) is challenging, and to date, only a few studies assessed the clinical outcomes of EMR in the duodenum. The aim of this study was to evaluate the efficacy and safety of EMR for the treatment of SNADETs >10 mm.

This is a single-center retrospective study reporting data from a cohort of consecutive patients undergoing EMR of large (>1 cm) SNADETs between January 2017 and December 2021.

A total of 81 patients with 83 lesions underwent EMR (70 conventional EMR, 13 underwater EMR). The median size was 20 mm (range: 10-60 mm). The mean procedure time was 45 ± 30 min, and the en-bloc resection rate was 47%. In all patients, SNADETs were successfully removed (i.e. technical success). Delayed bleeding occurred in 5 (6%) of EMRs. One delayed perforation occurred, which was managed surgically. Recurrence rate was 20% with a median follow-up period of 20.5 months. Recurrence was detected at the first endoscopic follow-up in 88% of cases, and all recurrences were successfully treated endoscopically. Lesion size (P = 0.04), previous endoscopic resection (P = 0.05), and piecemeal resection (P = 0.05) were independent risk factors of local recurrence after EMR on multivariate-adjusted analysis.

Large duodenal adenomas can be effectively managed by EMR. However, duodenal EMR of large lesions carries a significant risk of early recurrence, with a nonnegligible risk of adverse events. Lesion dimension, piecemeal resection, and previous endoscopic resection were associated with a higher recurrence rate. Close endoscopic follow-up is recommended given the high incidence of early recurrence, which can be successfully treated endoscopically.

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.

We will review the current management of colonic perforations, with particular emphasis on iatrogenic perforations caused by colonoscopy, the leading etiology. We will focus on recently developed endoscopic techniques and technologies that obviate morbid emergency surgery (the standard management approach in years past).

Colonic perforations are rare but potentially fatal complications of both diagnostic and therapeutic colonoscopy resulting in death in approximately 5% of cases with the mortality increasing with delay in diagnosis and treatment. As novel endoscopic techniques and tools have flourished in recent years, our approach to management of these perforations has evolved. With the availability of newer tools such as over the scope clips, enhanced through the scope clips and novel endoscopic suturing devices, colonic perforations can be managed effectively in many or most patients without the morbidity of surgical interventions.

With expanding use of colonoscopy, inadvertent outcomes such as perforations are bound to increase as well. Early diagnosis permits minimally invasive, nonsurgical, endoscopic management in most cases if the expertise and tools are available. Centers with high colonoscopy volumes including therapeutic procedures would be well served to invest in the requisite technologies and expertise.

The efficacy of colorectal endoscopic mucosal resection (EMR) is limited by recurrence and the necessity for conservative surveillance. Margin thermal ablation (MTA) after EMR has reduced the incidence of recurrence at the first surveillance colonoscopy at 6 months (SC1). Whether this effect is durable to second surveillance colonoscopy (SC2) is unknown. We evaluated long-term surveillance outcomes in a cohort of LNPCPs that have undergone MTA.

LNPCPs undergoing EMR and MTA from four academic endoscopy centres were prospectively recruited. EMR scars were evaluated at SC1 and in the absence of recurrence, SC2 colonoscopy was conducted in a further 12 months. A historical control arm was generated from LNPCPs that underwent EMR without MTA. The primary outcome was recurrence at SC2 in all LNPCPs with a recurrence-free scar at SC1.

1152 LNPCPs underwent EMR with complete MTA over 90 months until October 2022. 854 LNPCPs underwent SC1 with 29/854 (3.4%) LNPCPs demonstrating recurrence. 472 LNPCPs free of recurrence at SC1 underwent SC2. 260 LNPCPs with complete SC2 follow-up formed the control arm from January 2012 to May 2016. Recurrence at SC2 was significantly less in the MTA arm versus controls (1/472 (0.2%) vs 9/260 (3.5%); p<0.001)).

LNPCPs that have undergone successful EMR with MTA and are free of recurrence at SC1 are unlikely to develop recurrence in subsequent surveillance out to 2 years. Provided the colon is cleared of synchronous neoplasia, the next surveillance can be potentially extended to 3-5 years. Such an approach would reduce costs and enhance patient compliance.

Introduction Colorectal cancer (CRC) represents a major global health burden, significantly impacting mortality rates and healthcare systems worldwide. CRC screening through colonoscopy enables early detection and removal of precancerous polyps. While standard polypectomy suffices for small polyps, larger ones require endoscopic mucosal resection (EMR). Though post-EMR surveillance is crucial for preventing recurrence, it remains unclear whether follow-up by general gastroenterologists yields comparable outcomes to surveillance by interventional specialists. This distinction carries significant implications for resource allocation, particularly given the limited availability of interventional gastroenterologists whose expertise is needed for other complex procedures. Our study examines this unexplored question by comparing post-EMR surveillance outcomes between these provider groups. Methods We conducted a retrospective study at the Saint Louis Veterans Affairs (VA) Health Care System of patients presenting for follow-up of colorectal polyp EMR between January 2019 and December 2022. Pre-defined variables extracted from the electronic medical record system were then analyzed to discern significant differences between general and interventional gastroenterologists' outcomes. The primary outcome includes the rate of biopsy of scars after EMR between both groups. Additional outcomes include the number of polyps detected, detection of residual tissue at the EMR site, EMR site recurrence requiring polypectomy and mode of polypectomy, recommended surveillance interval suggested by the endoscopist, and the pathology of the EMR site biopsy. Results A total of 59 (N = 59) patients (median age: 67, mean age: 66.5 ± 6.6 years) met the inclusion criteria of our study. General gastroenterologists were more likely to biopsy the EMR site compared to interventional gastroenterologists (65% vs. 40%, p = 0.047). There was no difference in overall pathology detected when comparing general and interventional gastroenterologists (p = 0.074). While no EMR site biopsies were obtained in 16 patients (27.1%), there were no differences in the pathology of patients undergoing biopsy of the scar. Additionally, no significant differences were found in the Boston Bowel Preparation Score, number of polyps detected, detection of residual tissue at the EMR site, EMR site recurrence requiring polypectomy, or recommended surveillance interval. Conclusion Our study provides evidence that the outcomes of post-EMR follow-up are largely comparable between general and interventional gastroenterologists. Although general gastroenterologists exhibit higher rates of EMR site biopsy, the associated pathology shows no significant difference.

Large nonpedunculated colorectal polyps (LNPCPs) have a greater than average risk of malignancy, incomplete resection/recurrence and complications associated with treatment. Appropriate management of these lesions is crucial to prevent cancer and reduce harm. The British Society of Gastroenterologists (BSG) and the Association of Coloproctologists of Great Britain and Ireland (ACPGBI) published guidelines for the management of LNPCPs in 2015. The aim of this work was to evaluate the case mix and outcomes from a single centre's multidisciplinary approach to managing such lesions against the key performance indicators (KPIs) set within these national guidelines.

Cohort study from a single centre over a 2-year period, January 2020 to December 2022.

After exclusions, a total of 229 cases were discussed. Most complex polyps were treated endoscopically, with conservative management recommended in 22 cases where patients had significant comorbidities and were unlikely to benefit from therapy. The overall surgical intervention rate (including transanal endoscopic microsurgery/per anal excision) was 14%. Of the cases treated endoscopically, there was residual polyp detected in 3.9% at 12-months' follow-up. Complications were rare. There was a single case of perforation following endoscopic submucosal dissection and no significant postprocedure bleeds. There were no perforations following endoscopic mucosal resection, although postpolypectomy bleeding requiring admission occurred in 4%. Sixty-eight per cent of patients were treated within 56 days of multidisciplinary team (MDT) discussion, despite the timeframe being within a period of huge disruption due to the global COVID pandemic. KPI standards published by the BSG were therefore met.

MDT management of complex polyps (LNPCPs) is effective and meets the standards set by national guidance. Patient outcomes following treatment for complex polypectomy are improved when the most appropriate procedure is performed by the most appropriate operator. Discussion at a complex polyp MDT can facilitate this approach.

This study investigated the incidence of lymph node metastasis and long-term outcomes in patients with T1 colorectal cancer where endoscopic submucosal dissection (ESD) resulted in noncurative treatment. It is focused on those with deep submucosal invasion, a factor considered a weak predictor of lymph node metastasis in the absence of other risk factors.

This nationwide, multicenter, prospective study conducted a post-hoc analysis of 141 patients with T1 colorectal cancer ≥20 mm where ESD of the lesion resulted in noncurative outcomes, characterized by poor differentiation, deep submucosal invasion (≥1000 μm), lymphovascular invasion, high-grade tumor budding, or positive vertical margins. Clinicopathologic features and patient prognoses focusing on lesion sites and additional surgery requirements were evaluated. Lymph node metastasis incidence in the low-risk T1 group, identified by deep submucosal invasion as the sole high-risk histological feature, was assessed.

Lymph node metastasis occurred in 14% of patients undergoing additional surgery post-noncurative endoscopic submucosal dissection for T1 colorectal cancer. In the low-risk T1 group, in the absence of other risk factors, the frequency was 9.7%. The lymph node metastasis rates in patients with T1 colon and rectal cancers did not differ significantly (14% vs. 16%). Distant recurrence was observed in one patient (2.3%) in the ESD only group and in one (1.0%) in the additional surgery group, both of whom had had rectal cancer removed.

The risk of lymph node metastasis or distant occurrence was not negligible, even in the low-risk T1 group. The findings suggest the need for considering additional surgery, particularly for rectal lesions (Clinical Trial Registration: UMIN000010136).

To investigate the potential of prophylactic closure of mucosal defects to prevent adverse events following endoscopic resection of superficial layers of the gastrointestinal (GI) wall.

Systematic review and meta-analysis.

We searched PubMed, Embase, Web of Science and the Cochrane Library for studies eligible for inclusion in our meta-analysis from inception to February 2022.

We compared the effects of closure versus non-closure of mucosal defects with respect to adverse events including delayed bleeding, delayed perforation and postpolypectomy coagulation syndrome (PPCS). We used a random-effects model for all analyses. Subgroup analyses were performed based on gastrointestinal sites, surgical procedures and study designs.

In total, this study includes 11 383 patients from 28 studies. For delayed bleeding, closure group was associated with a lower incidence (Risk Ratio [RR]: 0.40, 95% Confidence interval [CI]: 0.30 to 0.53, p<0.001; I2=25%) and consistent results were observed in the subgroups. Also, for delayed perforation, a combined analysis of all sites and surgical methods showed a protective effect of prophylactic closure of mucosal defects (RR: 0.42, 95% CI: 0.22 to 0.82, p=0.01; I2=0%). Similar results were observed in the subgroup analyses, despite the wide CIs. Regarding the PPCS, neither the pooled RRs nor the subgroup analyses showed significant differences.

Prophylactic closure of mucosal defects is beneficial in reducing the incidence of delayed bleeding and delayed perforation after endoscopic resection, but there is no significant difference in reducing the incidence of PPCS.

Conventional hot snare endoscopic mucosal resection (H-EMR) is effective for the management of large (≥20 mm) non-pedunculated colon polyps (LNPCPs) however, electrocautery-related complications may incur significant morbidity. With a superior safety profile, cold snare EMR (C-EMR) of LNPCPs is an attractive alternative however evidence is lacking. We conducted a randomised trial to compare the efficacy and safety of C-EMR to H-EMR.

Flat, 15-50 mm adenomatous LNPCPs were prospectively enrolled and randomly assigned to C-EMR or H-EMR with margin thermal ablation at a single tertiary centre. The primary outcome was endoscopically visible and/or histologically confirmed recurrence at 6 months surveillance colonoscopy. Secondary outcomes were clinically significant post-EMR bleeding (CSPEB), delayed perforation and technical success.

177 LNPCPs in 177 patients were randomised to C-EMR arm (n=87) or H-EMR (n=90). Treatment groups were equivalent for technical success 86/87 (98.9%) C-EMR versus H-EMR 90/90 (100%); p=0.31. Recurrence was significantly greater in C-EMR (16/87, 18.4% vs 1/90, 1.1%; relative risk (RR) 16.6, 95% CI 2.24 to 122; p<0.001).Delayed perforation (1/90 (1.1%) vs 0; p=0.32) only occurred in the H-EMR group. CSPEB was significantly greater in the H-EMR arm (7/90 (7.8%) vs 1/87 (1.1%); RR 6.77, 95% CI 0.85 to 53.9; p=0.034).

Compared with H-EMR, C-EMR for flat, adenomatous LNPCPs, demonstrates superior safety with equivalent technical success. However, endoscopic recurrence is significantly greater for cold snare resection and is currently a limitation of the technique.

NCT04138030.

Endoscopic mucosal resection (EMR) is the recommended technique for colon polypectomy for nonpedunculated lesions that are >20 mm in size not requiring excision. Dual-channel EMR (DC-EMR) uses an endoscope with two working channels to facilitate easier submucosal injection, snare resection, and clip closure of polypectomy defects. There is also promising early literature indicating that this endoscopic modality can reduce the overall learning curve present for single-channel colonoscopy EMR. This chapter will describe the steps and techniques required to perform DC-EMR, potential complications, recommended postprocedure surveillance, and future directions.

Resection of colorectal polyps has been shown to decrease the incidence and mortality of colorectal cancer. Large nonpedunculated colorectal polyps are often referred to expert centers for endoscopic resection, which requires relevant information to be conveyed to the therapeutic endoscopist to allow for triage and planning of resection technique. The primary objective of this study was to establish minimum expected standards for the referral of large nonpedunculated colonic polyps for potential endoscopic resection.

A Delphi method was used to establish consensus on minimum expected standards for the referral of large colorectal polyps among a panel of international endoscopy experts. The expert panel was recruited through purposive sampling, and 3 rounds of surveys were conducted to achieve consensus. Quantitative and qualitative data were analyzed for each round.

A total of 24 international experts from diverse continents participated in the Delphi study, resulting in consensus on 19 statements related to the referral of large colorectal polyps. The identified factors, including patient demographic characteristics, relevant medications, lesion factors, photodocumentation, and the presence of a tattoo, were deemed important for conveying the necessary information to therapeutic endoscopists. The mean scores for the statements, which were scored on a scale of 1 to 10, ranged from 7.04 to 9.29, with high percentages of experts considering most statements as a very high priority. Subgroup analysis according to continent revealed some variations in consensus rates among experts from different regions.

The identified consensus statements can aid in improving the triage and planning of resection techniques for large colorectal polyps, ultimately contributing to the reduction of colorectal cancer incidence and mortality.

Endoscopic closure is an essential technique to perform safe advanced endoscopy. Without appropriate closure of a defect, patients can experience spillage of fecal contents into the peritoneal cavity resulting in abdominal sepsis. The essential components to performing endoscopic closure are assessing the defect appropriately and choosing the correct closure technique. Assessing the defect involves five separate elements: timing, size, depth, shape, blood flow, and location in the colon or rectum. Understanding how each of these elements contributes toward a successful closure allows an endoscopist to choose the proper technique for closure. There have been many types of closure techniques described in the literature but the most common are through the scope clips, over the scope clips, and endoscopic suturing. There are advantages and disadvantages of each of these closure techniques. In this manuscript, we will discuss these common techniques as well as some additional techniques and the situations where they can be employed.

Piecemeal endoscopic mucosal resection (pEMR) is the best approach to resect large lateral spreading tumors (LST, > 20 mm width). However, it is associated with early recurrence (ER) and late recurrence (LR). This study aims to assess the risk factors associated with ER and LR and to validate different predictive scores (SMSA, SERT, and BCM) in identifying the risk of ER and LR after LST resected by pEMR in a European cohort.

Retrospective observational cohort study, based on a prospectively collected database, of large LST submitted to pEMR.

A total of 108 patients were included in the study and the incidence rates of ER and LR were 22 % and 8 %, respectively. The lesion's size, SERT, and BCM scores were independent predictor factors of ER (p-value < 0.05), while the lesion's site and BCM score were independent predictor factors of LR (p-value < 0.05). For the prediction of ER, the SERT score (cut-off > 1) presented the highest AUROC (0.758 vs 0.697 from BCM and 0.647 from SMSA). Regarding LR, the BCM model (cut-off > 2) presented the highest AUROC (0.817 vs 0.708 from SERT and 0.691 from SMSA).

We present the first external validation of the three scores mentioned in an European cohort. SERT and BCM scores had an acceptable performance in predicting ER and LR. However, the BCM model was the only score that proved to be an independent predictor of both ER and LR, proving to be valuable for both applications.

Recognition of submucosal invasive cancer (SMIC) in large (≥20 mm) nonpedunculated colonic polyps (LNPCPs) informs selection of the optimal resection strategy. LNPCP location, morphology, and size influence the risk of SMIC; however, currently no meaningful application of this information has simplified the process to make it accessible and broadly applicable. We developed a decision-making algorithm to simplify the identification of LNPCP subtypes with increased risk of potential SMIC.

Patients referred for LNPCP resection from September 2008 to November 2022 were enrolled. LNPCPs with SMIC were identified from endoscopic resection specimens, lesion biopsies, or surgical outcomes. Decision tree analysis of lesion characteristics identified in multivariable analysis was used to create a hierarchical classification of SMIC prevalence.

2451 LNPCPs were analyzed: 1289 (52.6%) were flat, 1043 (42.6%) nodular, and 118 (4.8%) depressed. SMIC was confirmed in 273 of the LNPCPs (11.1%). It was associated with depressed and nodular vs. flat morphology (odds ratios [ORs] 35.7 [95%CI 22.6-56.5] and 3.5 [95%CI 2.6-4.9], respectively; P<0.001); rectosigmoid vs. proximal location (OR 3.2 [95%CI 2.5-4.1]; P<0.001); nongranular vs. granular appearance (OR 2.4 [95%CI 1.9-3.1]; P<0.001); and size (OR 1.12 per 10-mm increase [95%CI 1.05-1.19]; P<0.001). Decision tree analysis targeting SMIC identified eight terminal nodes: SMIC prevalence was 62% in depressed LNPCPs, 19% in nodular rectosigmoid LNPCPs, and 20% in nodular proximal colon nongranular LNPCPs.

This decision-making algorithm simplifies identification of LNPCPs with an increased risk of potential SMIC. When combined with surface optical evaluation, it facilitates accurate lesion characterization and resection choices.

Colorectal cancer is a highly prevalent malignancy and a significant driver of cancer mortality and health-related expenditure worldwide. Polyp removal reduces the incidence and mortality of colorectal cancer. In 2024, endoscopists have an array of resection modalities at their disposal. Each technique requires a unique skillset and has individual advantages and limitations. Consequently, resection in the colorectum requires an evidence-based algorithm approach that considers these factors.

A literature review of endoscopic resection for colonic neoplasia was conducted. Best supporting scientific evidence was summarized for the endoscopic resection of diminutive polyps, large ≥20 mm lesions and polyps containing invasive cancer. Factors including resection modality, complications and lesion selection were explored to inform an algorithm approach to colorectal resection.

Endoscopic resection in the colorectum is not a one-size-fits-all approach. Detailed understanding of polyp size, location, morphology and predicted histology are critical factors that inform appropriate endoscopic resection practice.

Minimally invasive innovations have transformed coloproctology. Specific to colorectal cancer (CRC), there has been a shift towards less invasive surgical techniques and use of endoscopic resection as an alternative for low risk T1 CRC. The role of endoscopic resection is however much more extensive: It is now considered the first line management strategy for most large (≥ 20 mm) non-pedunculated colorectal polyps, the majority of which are benign. This is due to the well-established efficacy, safety, and cost-effectiveness of endoscopic techniques compared to surgery. Multiple endoscopic modalities now exist with distinct risk-benefit profiles and their outcomes are further improved by site-specific technical modifications, auxiliary techniques, and adverse event mitigation strategies. Endoscopic capacity continues to evolve with emerging endoscopic techniques and expanding applications, particularly in the confines of a multi-disciplinary setting.

Precision endoscopy in the management of colorectal polyps and early colorectal cancer has emerged as the standard of care. It includes optical characterization of polyps and estimation of submucosal invasion depth of large nonpedunculated colorectal polyps to select the appropriate endoscopic resection modality. Over time, several imaging modalities have been implemented in endoscopic practice to improve optical performance. Among these, image-enhanced endoscopy systems and magnification endoscopy represent now well-established tools. New advanced technologies, such as endocytoscopy and confocal laser endomicroscopy, have recently shown promising results in predicting the histology of colorectal polyps. In recent years, artificial intelligence has continued to enhance endoscopic performance in the characterization of colorectal polyps, overcoming the limitations of other imaging modes. In this review we retrace the path of precision endoscopy, analyzing the yield of various endoscopic imaging techniques in personalizing management of colorectal polyps and early colorectal cancer.

The management of bulky neoplastic lesions in the digestive tract has historically been a surgical pursuit. With advancements in endoscopic techniques, particularly endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), a paradigm shift toward organ preservation has been initiated. These endoscopic methods, developed incrementally since the 1980s, have progressively enabled curative management of lesions with minimal morbidity, challenging the previously unchallenged domain of surgery.

This review traces the evolution of endoscopic resection from snare polypectomy and EMR to sophisticated ESD, highlighting the technological innovations that have expanded the scope of endoscopic resection. It discusses the intricacies of various EMR techniques like underwater EMR, anchoring EMR, and hybrid EMR, alongside traction-assisted methods and the use of viscous solutions for submucosal injection. Additionally, the manuscript delves into the advancements in ESD, emphasizing traction strategies, knife technology, and the optimization of endoscopes. The benefits of these advancements are weighed against the challenges in anatomopathological interpretation posed by piecemeal resections.

The continuous amelioration of endoscopic resection techniques has significantly improved the outcomes of digestive tract lesion management, particularly in achieving R0 resections and reducing recurrence rates. These advancements represent a monumental step toward minimizing the invasiveness of lesion management. However, despite the progress, the necessity for early follow-up post-EMR remains due to the non-negligible recurrence rates, underscoring the need for a rigorous postoperative surveillance regimen. Furthermore, our review suggests that while ESD has transformed the therapeutic landscape, its widespread adoption hinges on further simplification, safety enhancement, and acceleration of the procedure, possibly through innovations like adaptive traction devices.

Endoscopic mucosal resection (EMR) is the preferred treatment for non-invasive large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs) but is associated with an early recurrence rate of up to 30%. We evaluated whether standardised EMR training could reduce recurrence rates in Dutch community hospitals.

In this multicentre cluster randomised trial, 59 endoscopists from 30 hospitals were randomly assigned to the intervention group (e-learning and 2-day training including hands-on session) or control group. From April 2019 to August 2021, all consecutive EMR-treated LNPCPs were included. Primary endpoint was recurrence rate after 6 months.

A total of 1412 LNPCPs were included; 699 in the intervention group and 713 in the control group (median size 30 mm vs 30 mm, 45% vs 52% size, morphology, site and access (SMSA) score IV, 64% vs 64% proximal location). Recurrence rates were lower in the intervention group compared with controls (13% vs 25%, OR 0.43; 95% CI 0.23 to 0.78; p=0.005) with similar complication rates (8% vs 9%, OR 0.93; 95% CI 0.64 to 1.36; p=0.720). Recurrences were more often unifocal in the intervention group (92% vs 76%; p=0.006). In sensitivity analysis, the benefit of the intervention on recurrence rate was only observed in the 20-40 mm LNPCPs (5% vs 20% in 20-29 mm, p=0.001; 10% vs 21% in 30-39 mm, p=0.013) but less evident in ≥40 mm LNPCPs (24% vs 31%; p=0.151). In a post hoc analysis, the training effect was maintained in the study group, while in the control group the recurrence rate remained high.

A compact standardised EMR training for LNPCPs significantly reduced recurrences in community hospitals. This strongly argues for a national dedicated training programme for endoscopists performing EMR of ≥20 mm LNPCPs. Interestingly, in sensitivity analysis, this benefit was limited for LNPCPs ≥40 mm.

NTR7477.

Appendiceal orifice lesions are often managed operatively with limited or oncologic resections. The aim is to report the management of appendiceal orifice mucosal neoplasms using advanced endoscopic interventions.

Patients with appendiceal orifice mucosal neoplasms who underwent advanced endoscopic resections between 2011 and 2021 with either endoscopic mucosal resection (EMR), endoscopic mucosal dissection (ESD), hybrid ESD, or combined endoscopic laparoscopic surgery (CELS) were included from a prospectively collected dataset. Patient and lesion details and procedure outcomes are reported.

Out of 1005 lesions resected with advanced endoscopic techniques, 41 patients (4%) underwent appendiceal orifice mucosal neoplasm resection, including 39% by hybrid ESD, 34% by ESD, 15% by EMR, and 12% by CELS. The median age was 65, and 54% were male. The median lesion size was 20 mm. The dissection was completed piecemeal in 49% of patients. Post-procedure, one patient had a complication within 30 days and was admitted with post-polypectomy abdominal pain treated with observation for 2 days with no intervention. Pathology revealed 49% sessile-serrated lesions, 24% tubular adenomas, and 15% tubulovillous adenomas. Patients were followed up for a median of 8 (0-48) months. One patient with a sessile-serrated lesion experienced a recurrence after EMR which was re-resected with EMR.

Advanced endoscopic interventions for appendiceal orifice mucosal neoplasms can be performed with a low rate of complications and early recurrence. While conventionally lesions at the appendiceal orifice are often treated with surgical resection, advanced endoscopic interventions are an alternative approach with promising results which allow for cecal preservation.

Colonoscopy remains the primary method for preventing colorectal cancer. Traditionally, hot snare polypectomy (HSP) was the method of choice for removing polyps larger than 5 mm. Yet, for polyps smaller than 10 mm, cold snare polypectomy (CSP) has become the favored approach. Lately, the use of CSP has expanded to include the removal of sessile polyps that are between 10 and 20 mm in size. Our systematic review and meta-analysis aimed to evaluate the safety of cold snare polypectomy (CSP) compared to hot snare polypectomy (HSP) for resecting polyps measuring 10-20 mm. We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, and Cochrane databases up to April 2020 to find studies that directly compared CSP to HSP for polyps larger than 10 mm. Our main focus was on assessing the risk of delayed bleeding after polypectomy; a secondary focus was the incidence of any adverse events that required medical intervention post procedure. Our search yielded three comparative studies, two observational studies, and one randomized controlled trial (RCT), together encompassing 1,193 polypectomy procedures. Of these, 485 were performed using CSP and 708 with HSP. The pooled odds ratio (OR) for post-polypectomy bleeding (PPB) was 0.36 (95% confidence interval {CI}: 0.02, 7.13), with a Cochran Q test P-value of 0.11 and an I2 of 53%. For the risk of any adverse events necessitating medical care, the pooled OR was 0.15 (95% CI: 0.01, 2.29), with a Cochran Q test P-value of 0.21 and an I2 of 35%. The quality of the two observational studies was deemed moderate, and the RCT was only available in abstract form, preventing quality assessment. Our analysis suggests that there is no significant difference in the incidence of delayed post-polypectomy bleeding or other adverse events requiring medical attention between CSP and HSP for polyps measuring 10-20 mm.

Post-polypectomy bleeding (PPB) remains a significant procedure-related complication, with multiple risk factors determining the risk including patient demographics, polyp characteristics, endoscopist expertise, and techniques of polypectomy. Immediate PPB is usually treated promptly, but management of delayed PPB can be challenging. Cold snare polypectomy is the optimal technique for small sessile polyps with hot snare polypectomy for pedunculated and large sessile polyps. Topical hemostatic powders and gels are being investigated for the prevention and management of PPB. Further studies are needed to compare these topical agents with conventional therapy.

There is scarce data focused on recurrence neoplasia rate (RR) after piecemeal endoscopic mucosal resection (pEMR) of 10-19 mm non-pedunculated colorectal lesions (NPL). We aimed to analyze the RR after pEMR of 10-19 mm NPL, identify risk factors for its development and compare it with RR after pEMR of ≥ 20 mm NPL.

Retrospective cohort-study including all ≥10 mm NPL resected by pEMR in our center between 2018-2022 with an early repeat colonoscopy (ERC). RR was defined as recurrence neoplasia identified in the ERC EMR scar with virtual chromoendoscopy or histological confirmation.

A total of 444 NPL were assessed, 124 (27.9%) with 10-19 mm. In the ERC, performed a median of 6 months after pEMR, RR was significantly lower for 10-19 mm NPL compared to ≥ 20 mm NPL (13/124 vs 68/320, p = 0.005). In subgroup analysis, RR after pEMR of 15-19 mm NPL was significantly higher compared to 10-14 mm NPL (13/98 vs 0, p = 0.041) but not significantly different compared to ≥ 20 mm NPL (13/98 vs 68/320, p = 0.073). In multivariable analysis, size of NPL (HR 1.501, 95% CI 1.012-2.227, p = 0.044) was the only independent risk factor identified for RR for 10-19 mm NPL.

Although the early RR after pEMR of 10-19 mm NPL is significantly lower compared to ≥ 20 mm NPL, it is non-negligible (10.5%) and appears to be the highest among 15-19 mm NPL. The size of the lesion was the only independent risk factor for RR. Our findings should be accounted in the selection of the most appropriate post-polypectomy endoscopic surveillance.

Lower gastrointestinal bleeding (LGIB) is a common emergency with substantial associated morbidity and mortality. Elective colonoscopy plays an essential role in management, with an even more important role for radiology in the acute setting. Recent advances in the management of patients with LGIB warrant review as the management has recently evolved.

To provide a comprehensive and updated overview of advances in the approach to patients with LGIB METHODS: We performed a comprehensive literature search to examine the current data for this narrative review supplemented by expert opinion.

The incidence of LGIB is increasing worldwide, partly related to an ageing population and the increasing use of antithrombotics. Diverticulosis continues to be the most common aetiology of LGIB. Pre-endoscopic risk stratification tools, especially the Oakland score, can aid appropriate patient triage. Adequate resuscitation continues to form the basis of management, while appropriate management of antithrombotics is crucial to balance the risk of worsening bleeding against increased cardiovascular risk. Radiological imaging plays an essential role in the diagnosis and treatment of acute LGIB, especially among unstable patients. Colonoscopy remains the gold-standard test for the elective management of stable patients.

The management of LGIB has evolved significantly in recent years, with a shift towards radiological interventions for unstable patients while reserving elective colonoscopy for stable patients. A multidisciplinary approach is essential to optimise the outcomes of patients with LGIB.

During the last two decades, organised colorectal cancer (CRC) screening has been widely implemented. It remains to be established if screen-detected CRC (SD-CRC) is associated with reduced long-term requirements for treatment as compared with patients with non-screen-detected CRC (NSD-CRC).

This nationwide cohort study evaluated differences in treatment and healthcare contacts from the date of diagnosis to two years after comparing patients with SD-CRC and NSD-CRC. Data were collected from national healthcare registers, including patients aged 50-75 years and diagnosed with CRC between January 1st 2014 and March 31st 2018. Analyses were stratified into UICC stages and adjusted for sex, 5-year age groups, type of cancer (colonic/rectal), and Charlson comorbidity index score to address healthy user bias.

In total, 12,040 patients were included, 4708 with SD-CRC and 7332 with NSD-CRC. In patients with SD-CRC, the duration of hospitalisation and rate of emergency surgery were reduced by 38 % (relative risk [RR] = 0.62) and 66 % (RR = 0.34), respectively. Moreover, this group was characterised by a 75 % reduction in oncological outpatient visits (RR = 0.35) and a reduced number of treatments with chemotherapy (RR = 0.57) and radiotherapy (RR = 0.50). There were no significant differences between the two populations in the rates of metastasectomy and the number of contacts with primary healthcare providers.

Compared to patients with NSD-CRC, patients with SD-CRC experience less hospitalisation and treatment within the first two years after diagnosis.

To investigate the clinical characteristics and risk factors of delayed bleeding after intestinal polypectomy in children, and to provide a theoretical basis for clinical surgical intervention of intestinal polyps.

A retrospective analysis was conducted on the clinical data of 2 456 children with intestinal polyps who underwent endoscopic high-frequency electrocoagulation loop resection in the Endoscopy Center of Children's Hospital Affiliated to Zhengzhou University from January 2014 to December 2021. According to the presence or absence of delayed bleeding after surgery, they were divided into bleeding group with 79 children and non-bleeding group with 2 377 children. A multivariate logistic regression analysis was used to investigate the risk factors for delayed bleeding. The receiver operating characteristic (ROC) curve was used to investigate the value of various indicators in predicting delayed bleeding.

Of all 2 456 children, 79 (3.22%) experienced delayed bleeding, among whom 5 children with severe delayed bleeding underwent emergency colonoscopy for hemostasis and 74 received conservative treatment, and successful hemostasis was achieved for all children. There were significant differences between the bleeding and non-bleeding groups in age, body mass index, constipation rate, location of lesion, time of endoscopic procedure, resection method (P<0.05). Children with a diameter of polyps of 6-10 mm and >20 mm were more likely to develop delayed bleeding after resection (P<0.05). The multivariate logistic regression analysis showed that endoscopic operation time, polyp diameter, and resection method were significantly associated with delayed bleeding (P<0.05). The ROC curve analysis showed that the endoscopic operation time, polyp diameter, and resection method had a good value in predicting delayed bleeding after intestinal polypectomy, with an area under the ROC curve of 0.706, 0.688, and 0.627, respectively.

Endoscopic high-frequency electrocoagulation loop resection has a lower incidence of delayed bleeding in children with intestinal polyps, and the endoscopic operation time, polyp diameter, and resection method are closely associated with the occurrence of postoperative delayed bleeding.

 As endoscopic mucosal resection (EMR) of large (≥ 20 mm) adenomatous nonpedunculated colonic polyps (LNPCPs) becomes widely practiced outside expert centers, appropriate training is necessary to avoid failed resection and inappropriate surgical referral. No EMR-specific tool guides case selection for endoscopists learning EMR. This study aimed to develop an EMR case selection score (EMR-CSS) to identify potentially challenging lesions for "EMR-naïve" endoscopists developing competency.

 Consecutive EMRs were recruited from a single center over 130 months. Lesion characteristics, intraprocedural data, and adverse events were recorded. Challenging lesions with intraprocedural bleeding (IPB), intraprocedural perforation (IPP), or unsuccessful resection were identified and predictive variables identified. Significant variables were used to form a numerical score and receiver operating characteristic curves were used to generate cutoff values.

 Of 1993 LNPCPs, 286 (14.4 %) were in challenging locations (anorectal junction, ileocecal valve, or appendiceal orifice), 368 (18.5 %) procedures were complicated by IPB and 77 (3.9 %) by IPP; 110 (5.5 %) procedures were unsuccessful. The composite end point of IPB, IPP, or unsuccessful EMR was present in 526 cases (26.4 %). Lesion size, challenging location, and sessile morphology were predictive of the composite outcome. A six-point score was generated with a cutoff value of 2 demonstrating 81 % sensitivity across the training and validation cohorts.

 The EMR-CSS is a novel case selection tool for conventional EMR training, which identifies a subset of adenomatous LNPCPs that can be successfully and safely attempted in early EMR training.

The effect of organized colorectal cancer (CRC) screening on type of primary treatment remains sparsely investigated. This study evaluated the difference in primary treatment strategy between patients diagnosed with screen-detected (SD-CRC) and non-screen-detected colorectal cancer (NSD-CRC) in a national CRC screening program.

This was a retrospective national register-based cohort study. Data on patients aged between 50 and 75 years and diagnosed with SD-CRC or NSD-CRC were retrieved from the national colorectal cancer screening database and the Danish Colorectal Cancer Group database. Outcomes related to surgical invasiveness were compared between the two cohorts. Differences were expressed as relative risks using log-binomial generalized linear regression models. UICC stage IV specific outcomes were analyzed using the same method. All analyses were adjusted for sex, age, type of cancer (colonic/rectal), and Charlson comorbidity index.

The study included 4707 patients with SD-CRC and 7328 with NSD-CRC. Therapeutic flexible endoscopy (SD-CRC: n = 636 vs. NSD-CRC: n = 334, RR: 2.50, P < 0.001), (robotic-assisted) laparoscopic resection ((n = 616 vs. n = 773, RR: 1.27, P < 0.001), n = 2759 vs. n = 3471, RR: 1.11, P < 0.001), and radical resection (n = 3890 vs. n = 4834, RR: 1.02, P = 0.002) were significantly more frequent in the SD-CRC group. The rates of emergency priority (n = 32 vs. n = 562, RR: 0.09, P < 0.001), open surgery (n = 391 vs. n = 1410, RR: 0.53, P < 0.001), supplementary organ resection (n = 259 vs. n = 860, RR: 0.56, P < 0.001), and stoma formation (n = 526 vs. n = 1040, RR: 0.89, P = 0.007) were significantly lower in the SD-CRC group. The rate of patients undergoing surgery with UICC stage IV disease was significantly higher in the SD-CRC group (SD-CRC: n = 262, NSD-CRC: n = 994, RR: 1.43, P < 0.001).

SD-CRC remained associated with less invasive primary surgical treatment following adjustment for potential healthy user bias. UICC stage IV disease may be less advanced in patients with SD-CRC.

The colonoscopic-assisted laparoscopic wedge resection (CAL-WR) is proven to be an effective and safe alternative to a segmental colon resection (SCR) for large or complex benign colonic polyps that are not eligible for endoscopic removal. This analysis aimed to evaluate the costs of CAL-WR and compare them to the costs of an SCR.

A single-centre 90-day 'in-hospital' comparative cost analysis was performed on patients undergoing CAL-WR or SCR for complex benign polyps between 2016 and 2020. The CAL-WR group consisted of 44 patients who participated in a prospective multicentre study (LIMERIC study). Inclusion criteria were (1) endoscopically unresectable benign polyps; (2) residual or recurrence after previous polypectomy; or (3) irradically resected low risk pT1 colon carcinoma. The comparison group, which was retrospectively identified, included 32 patients who underwent an elective SCR in the same period.

Colonoscopic-assisted laparoscopic wedge resection was associated with significantly fewer complications (7% in the CAL-WR group vs. 45% in the SCR group, P < 0.001), shorter operation time (50 min in the CAL-WR group vs. 119 min in the SCR group, P < 0.001), shorter length of hospital stay (median length of stay 2 days in the CAL-WR group vs. 4 days in the SCR group, P < 0.001) and less use of surgical resources (reduction in costs of 32% per patient), resulting in a cost savings of €2372 (£2099 GBP) per patient (P < 0.001).

Given the clinical and financial benefits, CAL-WR should be recommended for complex benign polyps that are not eligible for endoscopic resection before major surgery is considered.

Background and study aims The advantages of endoscopic submucosal dissection (ESD) over endoscopic mucosal resection for large colorectal neoplasms are well established; however, the technical challenges and lack of adequate training in ESD limit its widespread adoption in Western countries. Methods A literature search was performed in Medline, Embase, Web of Science, and the Cochrane Library for studies conducted in non-Asian countries evaluating the effectiveness of colorectal ESD. A random effects model was used to obtain pooled en bloc, R0 resection rates, and adverse events (AEs). Results Thirty-three studies comprising 3,958 ESD procedures met the inclusion criteria. Of the polyps, 96.7% (2,817 of 2913) were ≥ 2 cm. Pooled en bloc resection (31 studies), R0 resection (29 studies), and curative resection rates were 84.6% (95% confidence interval [CI] [83.3%-85.9%]), 75.6% (95% CI [74.1%-77.0%]), and 81.9% (95% CI [78.6%-84.9%]), respectively. Surgery for invasive cancer was performed in 4.8% (23 studies). ESD-related perforation (25 studies) was observed in 5.5% and bleeding in 4.1% (delayed bleeding 3.4%). 1.8% of patients underwent surgery for procedure-related complications. A high degree of heterogeneity was observed for en bloc resection, R0 resection, and curative resection. Heterogeneity for AEs (perforation [I 2 13%], delayed bleeding [I 2 30%], and overall bleeding [I 2 49%]) was low to moderate. Conclusions The effectiveness of colorectal ESD for large colorectal polyps and early colorectal cancers is improving in Western countries, and recent resection rates are comparable to that seen in Asia. Colorectal perforation is still observed in about 5% of ESD; however, < 2% of patients need emergency surgery for AEs.