A 75-year-old man presented to our hospital complaining of abdominal distention. He underwent lower gastrointestinal endoscopic examination, which indicated a raised tumor of 20 mm in diameter in the sigmoid colon transition region of the rectum. Endoscopic mucosal resection was performed with the aims of treatment and diagnosis. Histopathological examination revealed a moderately differentiated adenocarcinoma with neuroendocrine carcinoma, which was classified as a mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN). The tumor had highly invaded the submucosa and positive vertical margins. Computed tomography showed no obvious lymph node metastasis or distant metastasis, so the patient underwent high-level anterior resection of the remaining lesion. The final diagnosis was MiNEN, pT3(SS), INFb, Ly1c, V0, Pn1a, pPM0, pDM0, pRM0, pN1a, and pStage IIIb (TNM Classification of Malignant Tumors, 8th Edition). The patient is recurrence free at 3 years without postoperative adjuvant therapy. We report this case with a review of the literature.

Although a novel submucosal injection material consisting of a fully synthetic, self-assembling peptide solution, PuraLift, has recently become commercially available in Japan, there are a few reports regarding the usefulness of this solution. The aim of this study was to investigate the feasibility of PuraLift for conventional endoscopic mucosal resection (EMR) in clinical practice.

This multicenter retrospective study was conducted at the endoscopy units of five institutions from January 2023 to May 2023. Consecutive patients who underwent EMR with PuraLift for 5-20-mm colorectal lesions were included in the introduction of this solution at each institute. The primary endpoint was the "effective resection" rate, defined as pathological complete resection, with "effective injection" defined as requiring no more than one additional injection due to adequate maintenance of mucosal lifting during EMR.

In total, 110 lesions in 70 patients were treated by conventional EMR using PuraLift. En-bloc resection was performed for 109 (99%) lesions, and complete resection was performed for 102 (93%) lesions. More than 95% of the lesions were neoplastic. Additional injections were required in only two lesions. Both were single additional injections, and the median overall injection volume was 1.5 mL. Therefore, the effective injection rate was 93% (95% confidence interval, 86%-96%). No adverse events occurred during the study period.

Although direct comparison with other materials is required, PuraLift seems feasible as an injection material for EMR.

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

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

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

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

Mucosal healing is the mainstream goal of modern treat-to-target strategy as it is associated with a significantly more favorable disease course in IBD patients with either ulcerative colitis or Crohn's disease. Recent advances in endoscopic imaging technologies have overcome the traditional concept of mucosal healing assessed with conventional white light imaging, allowing for multiple levels of endoscopic healing up to the boundaries of molecular and functional evaluation. In this review, we focused on conventional and emerging strategies to assess endoscopic healing in ulcerative colitis and ileocolonic Crohn's disease, examining their pros and cons in real life practice.

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.

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.

Cold snaring is now the preferred resection method for the majority of colorectal polyps encountered during colonoscopy. A key advantage of cold resection over resection utilizing electrocautery is a substantially lower risk of delayed hemorrhage. Cold snare resection is preferred for all lesions ≤10 mm and for nondysplastic sessile serrated lesions of any size but should be avoided when lesions have a significant risk of submucosal invasion or fibrosis. Cold snare resection can be considered for certain lesions 11-19 mm in size and some lateral spreading lesions ≥20 mm. This review discusses tips and techniques to optimize cold snare resection.

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

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

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

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

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

The mucin-rich variant of traditional serrated adenoma (MR-TSA), pathologically defined by the presence of goblet cells comprising over 50% of the lesion compared to the absorptive epithelial eosinophilic cytoplasm, was recently introduced as one morphological variants of traditional serrated adenoma (TSA). This study aimed to characterize the endoscopic and clinicopathological characteristics of MR-TSAs.

Lesions pathologically diagnosed as TSAs at our hospital between 2011 and 2023 were reviewed. We analyzed the endoscopic and clinicopathological features of 49 MR-TSAs and 236 conventional TSAs (C-TSAs). Furthermore, immunohistochemical and genetic analyses were performed to ensure that there were no discrepancies with our previous study.

MR-TSAs, like C-TSAs, were often located in the sigmoid colon and rectum, with no significant difference in lesion size. Macroscopically, MR-TSAs frequently appeared as type 0-Is with a weak reddish color and had a mucous cap, less often exhibiting a pinecone-like or coral-shaped appearance compared to C-TSAs (p < 0.001). Magnifying endoscopy showed expanded crypt openings in 80% of MR-TSAs (p < 0.001). Both groups had similar IIIH and IVH pit patterns. Immunohistochemical analysis revealed that MUC5AC was expressed more frequently in MR-TSAs than in C-TSAs. Additionally, genetic analysis showed that MR-TSAs more frequently harbored the BRAF mutation than C-TSAs (p < 0.001), whereas MR-TSAs less frequently harbored the KRAS mutation than C-TSAs (p = 0.047).

MR-TSAs, frequently harboring the BRAF but not KRAS mutation, exhibited several distinct endoscopic findings, including a sessile morphology, lack of pinecone-like or coral-like appearance, weak reddish color, and mucous cap.

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.

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.

The aim of this study was to clarify the endoscopic characteristics of colorectal hamartomatous polyps, including solitary juvenile polyp (JP) and solitary Peutz-Jeghers polyp (PJP).

We reviewed the clinicopathological and endoscopic findings of 151 colorectal polyps with a diagnosis of solitary JP or solitary PJP. The clinicopathological and endoscopic findings of 119 JPs and 32 PJPs were retrospectively compared.

Endoscopic findings included significantly higher incidences of erosion, whitish exudates, and chicken-skin mucosa in JPs compared with PJPs. A lobular surface was more common in PJPs. Magnified narrow-band imaging endoscopic findings indicated that expanded crypt openings, sparse marginal crypt epithelia, and proliferation of capillary vessels were characteristic of JPs. Branching structures were more prevalent in PJPs. Magnifying chromoendoscopy found a predominance of star-like pit patterns and decreased pit densities in JPs, whereas tubular and branching pit patterns were more frequent in PJPs. Neither type of polyp was found to contain adenomas, dysplasia, or malignant cells. Combinations of specific characteristic endoscopic findings in the JPs and PJPs showed high diagnostic accuracy for those polyps.

Solitary JPs and PJPs in the colorectum manifested characteristic endoscopic findings, and combinations of specific characteristic endoscopic findings may be useful for endoscopic diagnosis of solitary JPs and PJPs.

The prevalence of colorectal cancer (CRC) in patients with ulcerative colitis (UC) is higher than in the general population, in Latin America there is a progressive increase of UC, and information about CRC screening in inflammatory bowel disease (IBD) is scarce. The aim of this study was to analyze the findings of endoscopic surveillance of CRC in patients with IBD according to available technology.

Multicenter, cross-sectional, analytical study conducted in Latin American countries, in patients with UC, predominantly with more than 8 years of diagnosis and different degrees of disease activity. Surveillance colonoscopies were performed according to available technology. Risk factors for dysplasia detection were analyzed.

One hundred and forty-four patients, 55.5% women, mean age 47.3 (range 17.1 to 90; SD 15.64) years and mean duration of disease 12.71 (range 0.64 to 57.13; SD 8.08) years. Forty-nine lesions were identified, 18 corresponded to dysplasia. The detection rate of dysplasia per lesion and per procedure was 36.7% and 12.5%, respectively. By logistic regression analysis, the duration of disease (OR 1.12;95%CI:1.047 to 1.215, P = .002) and the presence of post-inflammatory polyps (OR 3.4;95%CI:1.11 to 10.36, P = .031) were risk factors for higher detection of dysplasia. Digital chromoendoscopy was associated with greater detection of dysplasia (OR 4.99, 95%CI: 1.092 to 22.864, P = .038).

In our region, the duration of disease and the presence of post-inflammatory polyps were the factors with the highest association for dysplasia detection, and digital chromoendoscopy with directed biopsies was the technique of choice. The implementation of a specific surveillance program in colonoscopy in IBD is an effective strategy to achieve high detection rates.

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

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

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

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

Recent therapeutic innovations in the management of inflammatory bowel disease (IBD) have significantly improved patient outcomes, leading to increased life expectancy and reducing the necessity for total colectomy. However, this prolonged disease duration increases the cumulative risk for dysplasia and eventually colorectal cancer development. Therefore, timely detection and correct characterization of emerging dysplastic lesions is of great importance in longstanding IBD. This narrative review aims to elucidate the current state of advanced endoscopic imaging for dysplasia characterization in inflammatory bowel disease.

Endoscopic resection (ER) is widely performed to treat early colorectal cancer. However, additional surgery for pathological T1 colorectal cancer (pT1CRC) after ER is controversial because of the imprecise prediction of lymph node metastasis (LNM). Recently, several patients of pT1CRC with lymphoid follicular replacement (LFR) without LNM have been reported. This study aimed to investigate the clinicopathological features and risk of LNM in patients with pT1CRC with LFR.

We retrospectively analyzed patients who underwent ER or surgical resection and were diagnosed with pT1CRC between January 2010 and December 2020. We defined pT1CRC with LFR as the replacement of a part of the lymphoid follicular component within the submucosal area by adenocarcinoma, with no invasion into other submucosal areas.

Among the 600 eligible patients, the incidence rate of pT1CRC with LFR was 6.7% (40/600). Patients with pT1CRC with LFR represented 14.3% (37/258) of the endoscopically treated patients and 0.9% (3/342) of the surgically treated patients. For patients with pT1CRC with LFR, 80.0% (32/40) had flat and depressed lesions, and 35.0% (14/40) had submucosal invasion depth ≥1000 μm. Patients with pT1CRC with LFR had negative lymphovascular invasion, differentiated type, and budding grade 1. In the median follow-up of 61 months, patients with pT1CRC with LFR had no LNM.

The presence of LFR in pT1CRC may be associated with a low risk of LNM. In patients with pT1CRC with LFR, follow-up without additional surgery is possible even if the submucosal invasion depth is ≥1000 μm.

Background: Endoscopic submucosal dissection (ESD) is a reliable method that can replace surgery in the treatment of early colorectal cancer under certain conditions. Aim: The aim of the study was to analyze factors influencing the ESD procedure in early colorectal cancer, with the intention of improving its effectiveness. Patients and Methods: We conducted a multicenter, retrospective cohort study on 214 patients who underwent ESD procedures for early colorectal cancer from January 2016 to October 2023. Results:En bloc resection was achieved in 197 (92.1%) of ESD procedures, R0 resection in 149 (69.6%), and curative resection in 54 (40.9%). The submucosal invasion was classified as level 1 (SM1) in 96 cases (45.3%), level 2 (SM2) in 61 cases (28.8%), and level 3 (SM3) in 36 cases (17%). R0 resection was achieved more often in the rectum-92 (81.4%), compared to the right-24 (64.9%) and left colon-33 (61.1%), p = 0.009. In rectal tumors, R0 resection was achieved in 51 (98.1%) SM1 invasion, 27 (73%) SM2 invasion, and 13 (65%) SM3 invasion (p < 0.001). Lateral and vertical resection margins were positive in 12 (7.7%) and 52 (25.2%) cases, respectively. Vertical resection margins were statistically more often positive in lesions located in the right colon-11 cases (28.9%) and left colon-21 cases (38.9%), than in rectum-20 cases (17.5%); p = 0.010. Complications were found in 32 (15%) cases of ESD procedure-perforation in 12 cases (5.6%) and delayed bleeding in four cases (1.9%). Procedures performed in the right colon were associated with a significantly higher risk of any complications (30%) and perforations (15%) than those performed in the rectum (10.3% and 2.6%) or the left colon (13.8% and 5.2%; p = 0.016; p = 0.015), respectively. Conclusions: ESD for early colon cancer is a viable strategy due to its effectiveness and low complication rate. The ESD technique performed in the rectum yields the best results; however, in the right colon, it still requires careful attention.

Endoscopic resection techniques for colorectal tumors are constantly evolving with improvements.

Over the past decade, there has been a paradigm shift toward cold polypectomy for the removal of small lesions (<10 mm), known as the "cold revolution". In recent years, underwater endoscopic mucosal resection (EMR) has emerged as an alternative to conventional EMR and has been gaining popularity for resection of intermediate and large-sized lesions (≥10 mm). Although colorectal endoscopic submucosal dissection (ESD) requires a high level of advanced skills, improvements in dissection techniques and devices have facilitated the procedure. In Japan, the safety and efficacy of ESD for resecting large lesions (≥20 mm) have been demonstrated in a large-scale, multicenter, prospective cohort study (CREATE-J). ESD is also being increasingly adopted in Western countries. As endoscopic resection continues to advance and include large and more complex defects, a variety of closure techniques and new devices are being developed. Meanwhile, the number of endoscopic resections for T1-colorectal cancer (T1-CRC), including those intended for total excisional biopsy, has been increasing owing to the aging population and improvements in endoscopic technique.

This review provides a broad summary of endoscopic resection for colorectal tumors including advancements in closure techniques and devices for mucosal defects, as well as the potential role of endoscopic resection for patients with T1-CRC.

Background and study aims Long-standing ulcerative colitis (UC) is associated with an increased risk of developing colorectal neoplasia. Both dye-based chromoendoscopy (DCE) and virtual chromoendoscopy (VCE) increase detection of neoplastic lesions. In this prospective randomized controlled trial (RCT), we compared the neoplasia detection rate between DCE and i-scan VCE in patients with long-standing UC. Patient and methods In four European hospitals, 131 patients with long-standing UC (disease duration > 8 years) were randomized to either DCE with methylene blue 0.1% (n = 66) or i-scan VCE (n = 65). All procedures were performed by trained endoscopists. Biopsies were taken from all visible lesions and the surrounding mucosa. Results The mean number of neoplastic lesions detected per colonoscopy was not significantly different between DCE (0.27) and i-scan VCE (0.37) ( P = 0.41). Similarly, there was no significant difference in neoplasia detection rate between DCE (19.7%) and VCE (27.7%) (odds ratio0.64, 95% confidence interval 0.28-1.50, P = 0.31). However, the per lesion neoplasia detection rate was significantly higher with i-scan VCE compared to DCE (27.6% vs 15.3%, P = 0.036). Both withdrawal and total procedure time were on average 10.0 and 9.9 minutes shorter using i-scan VCE (both P < 0.001). Conclusions This multicenter, prospective RCT showed no significant difference in neoplasia detection between DCE and i-scan VCE in long-standing UC. However, use of i-scan VCE was associated with a lower false-positive rate and a significantly shorter procedure time compared with DCE. I-scan VCE, therefore, could be a valid replacement for DCE in UC surveillance colonoscopies.

Endoscopic resection is currently the treatment of choice for laterally spreading tumors (LSTs). Endoscopic sub-mucosal dissection (ESD) can achieve higher enbloc resection and R0 resection, albeit at a slightly higher risk of complications. Given scarce data on ESD from India, we performed a retrospective analysis of our experience with colorectal ESD (CR-ESD) to know its clinical efficacy and complications as well as to assess the learning curve of CR-ESD in non-endemic-areas.

Retrospective analysis of prospectively maintained datasheet performed. All patients with large (>2cm), complex or recurrent colorectal LST who underwent ESD at our center between 2012 and 2021 were included in the study. Various baseline lesion-related parameters, procedure-related parameters, enbloc resection (ER) rates, R0 margins and adverse event rates were retrieved. CUSUM analysis was performed to calculate the minimum required procedures to achieve competency in CR-ESD.

Total 149 patients were included in the study; mean patient age was 61.36±18.21 years. Most patients had lesions in rectum (n=102; 68.5%) followed by sigmoid colon (n=25; 16.8%). The mean lesion size was 46.62 ± 25.46 mm and the mean procedure duration for ESD was 219.30 ± 150.05 min. ER was achieved in 94.6% of lesions. R0 resection was achieved in 132 patients (88.6%). Overall, six (4%) adverse events were noted, of which one required surgical intervention. As many as 105 patients (70.5%) had adenomatous lesions on histology. Seventy-four patients underwent follow-up colonoscopy, of which three had a recurrence of adenomatous lesions and five had post-resection stricture requiring endoscopic dilation. CUSUM curve analysis calculated the learning curve for ESD was 47 resections for ER and 55 for the occurrence of AEs, with a composite CUSUM at 47 procedures.

CR-ESD even in non-endemic area is associated with high en bloc resection rates, R0 resection rates and acceptable complication profile. Approximately 50 cases of CR-ESD are required to achieve competency.

Approximately 7% of the polyps resected endoscopically have an adenocarcinoma focus, with no previous endoscopic evidence of malignancy. This raises the question of whether endoscopic resection has been curative. Furthermore, there is no consensus on what the endoscopic and histological criteria for good prognosis are, the appropriate follow-up strategy and what are the long-term results. The aim of the retrospective study by Fábián et al was to evaluate the occurrence of local relapse or distant metastasis in those tumors that were resected endoscopically compared to those that underwent oncologic surgery. They concluded that, regardless of the treatment strategy chosen, there was a higher recurrence rate than described in the literature and that adherence to follow-up was poor. The management approach for an endoscopically benign polyp histologically confirmed as adenocarcinoma depends on the presence of any of the previously described poor prognostic histological factors. If none of these factors are present and the polyp has been completely resected en bloc (R0), active surveillance is considered appropriate as endoscopic resection is deemed curative. These results highlight, once again, the need for further multicentric clinical practice studies to obtain more evidence for the purpose of establishing appropriate treatment and follow-up strategies.

Large nonpedunculated colorectal polyps ≥ 20 mm (LNPCPs) comprise 1% of all colorectal lesions. LNPCPs are more likely to contain advanced histology such as high-grade dysplasia and submucosal invasive cancer (SMIC). Endoscopic resection is the first-line approach for management of these lesions. Endoscopic resection options include endoscopic mucosal resection (EMR), cold-snare EMR (EMR), endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR). This review aimed to critically evaluate current endoscopic resection techniques.

Evidence-based selective resection algorithms should inform the most appropriate endoscopic resection technique. Most LNPCPs are removed by conventional EMR but there has been a trend toward C-EMR for endoscopic resection of LNPCPs. More high-quality trials are required to better define the limitations of C-EMR. Advances in our understanding of ESD technique, has clarified its role within the colorectum. More recently, the development of a full thickness resection device (FTRD) has allowed the curative endoscopic resection of select lesions.

Endoscopic resection should be regarded as the principle approach for all LNPCPs. Underpinned by high-quality research, endoscopic resection has become more nuanced, leading to improved patient outcomes.

We previously demonstrated that a favorable long-term prognosis indicated that endoscopic submucosal dissection (ESD) could be the standard treatment for large colorectal epithelial neoplasms, but the usefulness of ESD for local residual or recurrent tumors with submucosal fibrosis has not been fully demonstrated. The aim of the present study was to assess the usefulness of ESD for local residual or recurrent colorectal tumors.

We conducted a nationwide multicenter prospective study to evaluate the outcomes of ESD for colorectal tumors. In this post hoc analysis, a total of 54 local residual or recurrent colorectal tumors in 54 patients were included, and we analyzed the short-term and long-term outcomes of ESD for these lesions.

The median size of the lesions was 16.0 (interquartile range [IQR] 11-25) mm. ESD was completed in 53 cases (98.1%) with a median procedure time of 65.0 min, but it was discontinued in one case because of submucosal cancer invasion. En bloc resection was achieved in 52 cases (96.3%), whereas R0 resection was achieved in 45 cases (83.3%). Intraoperative perforation was observed in four cases (7.4%) and delayed perforation in one (1.9%), but all cases could be managed conservatively. Delayed bleeding was not observed. There were no significant differences in short-term outcomes between the rectal and colonic lesions. There was no recurrence of the tumor during the median follow-up period of 60 (IQR 50-64) months.

An analysis of our multicenter prospective study suggests that ESD is an effective salvage management for local residual or recurrent colorectal lesions.

Cold snare polypectomy (CSP) and underwater endoscopic mucosal resection (UEMR) have been developed recently, in addition to conventional methods, but adverse events of each method have not been fully clarified. We compared the outcomes of each method for the appropriate choice.

Patients who underwent CSP, endoscopic mucosal resection (EMR)/hot snare polypectomy (HSP), or UEMR for small and intermediate-sized colorectal polyps between April 2017 and June 2020 were retrospectively examined. The rate of adverse events and recurrences due to each method were determined as the main outcomes. Clinical factors related to adverse events were examined.

A total of 1,025 patients with 3,163 polyps underwent polypectomy using any of the methods. CSP, EMR/HSP, and UEMR were performed for 704 (22.2%), 2,145 (67.8%), and 314 polyps (9.9%), and the median size for each method was 4, 6, and 7 mm, respectively. Delayed bleeding for CSP, EMR/HSP, and UEMR was 0%, 0.2%, and 0.6% (p = 0.15), and perforation was 0%, 0.1%, and 0%, respectively (p = 0.62). Recurrence after CSP, EMR/HSP, and UEMR was 0.3%, 0.09%, and 1.3%, respectively (p < 0.01). Recurrence for UEMR was significantly higher in the early stage of procedure introduction (p = 0.015). Oral anticoagulants were the risk factor for delayed bleeding (p < 0.01, respectively).

There was no significant difference regarding adverse events among each method for small and intermediate-sized polyps, although the recurrence rate after UEMR was higher than other methods.

The pocket-creation method (PCM) was developed to overcome the technical difficulties of endoscopic submucosal dissection (ESD), although opening the pocket remains challenging. We developed a novel technique of PCM with single-clip traction (PCM-CT), which uses a reopenable clip as a traction device to maintain stability during the procedure. No prospective study has compared the efficacy of PCM-CT and PCM. This study aimed to investigate the effectiveness of PCM-CT vs. PCM in a randomized controlled trial.

This randomized controlled clinical trial was conducted at four Japanese institutions. Patients with superficial colorectal neoplastic lesions were included following Japanese guidelines for colorectal cancer. Seven moderately experienced endoscopists performed the ESD procedures using either PCM-CT or PCM.

100 patients were enrolled in the study. Compared with PCM, PCM-CT achieved significantly faster mean (SD) dissection speed (21.4 [10.8] vs. 27.0 [14.5] mm2/min [95%CI 0.5 to 10.7], P = 0.03), and reduced the mean procedure time (81.8 [57.9] vs. 64.8 [47.6] minutes [95%CI -38.2 to 4.3], P = 0.12) and pocket-opening time (37.8 [33.0] vs. 30.0 [28.9] minutes [95%CI -20.2 to 4.6], P = 0.22). En bloc and R0 resection rates were not significantly different between the two groups (100% vs. 100%, P >0.99; 100% vs. 96%, P = 0.50, respectively). No significant differences were observed in adverse events between the two groups.

ESD facilitated by the novel PCM-CT method appeared to be significantly faster than PCM. Both methods achieved high R0 resection rates.

Tip-in endoscopic mucosal resection (EMR) has a high en bloc resection rate for large colorectal neoplasms. However, non-experts' performance in Tip-in EMR has not been investigated. We investigated whether Tip-in EMR can be achieved effectively and safely even by non-experts.

This retrospective study included consecutive patients who underwent Tip-in EMR for 15-25 mm colorectal nonpedunculated neoplasms at a Japanese tertiary cancer center between January 2014 and December 2020. Baseline characteristics, treatment outcomes, learning curve of non-experts, and risk factors of failing self-achieved en bloc resection were analyzed.

A total of 597 lesions were analyzed (438 by experts and 159 by non-experts). The self-achieved en bloc resection (69.8% vs 88.6%, P < 0.001) and self-achieved R0 resection (58.3% vs 76.5%, P < 0.001) rates were significantly lower in non-experts with <10 cases of experience than in experts, but not in non-experts with >10 cases. Adverse event (P = 0.165) and local recurrence (P = 0.892) rates were not significantly different between experts and non-experts. Risk factors of failing self-achieved en bloc resection were non-polypoid morphology (OR 3.4, 95% CI 1.6-7.3, P = 0.001), lesions with an underlying semilunar fold (OR 3.6, 95% CI 1.6-7.3, P < 0.001), positive non-lifting sign (OR 3.1, 95% CI 1.2-8.0, P = 0.023), and non-experts with an experience of ≤10 cases (OR 3.6, 95% CI 2.1-6.3, P < 0.001).

The clinical outcomes of Tip-in EMR for 15-25 mm lesions performed by non-experts were favorable.

Background and study aims Sessile serrated lesions (SSLs) are precursor lesions in the serrated neoplasia pathway that lead to invasive carcinoma from dysplasia arising from SSLs. This study aimed to elucidate the clinicopathological and endoscopic features of SSLs with and without dysplasia or carcinoma. Patients and methods We reviewed the clinicopathological and endoscopic data from all colorectal lesions pathologically diagnosed as SSLs at Juntendo University Hospital, Tokyo, Japan, between 2011 and 2022. In addition to conventional endoscopic findings, we retrospectively evaluated magnifying endoscopic findings with narrow-band imaging (NBI) or blue laser imaging (BLI) using the Japan NBI Expert Team system and analyzed pit patterns using magnified chromoendoscopic images. Results Of the 2,132 SSLs, 92.5%, 4.7%, 1.8%, and 0.9% had no dysplasia, low-grade dysplasia, high-grade dysplasia, and submucosal invasive carcinoma, respectively. Older age, the proximal colon, and larger lesions were more frequently associated with SSLs with dysplasia or carcinoma. However, 41.3% of the SSLs with dysplasia or carcinoma were ≤ 10 mm in size. Endoscopic findings, such as (semi)pedunculated morphology, double elevation, central depression, and reddishness, were frequently found in SSLs with dysplasia or carcinoma. Furthermore, magnifying endoscopy using NBI or BLI and magnifying chromoendoscopy showed high sensitivity, specificity, and accuracy for diagnosing dysplasia or carcinoma within SSLs. Conclusions SSLs with and without dysplasia or carcinoma exhibit distinct clinicopathological and endoscopic features. In an SSL series, conventional endoscopic characteristics in addition to use of magnifying endoscopy may be useful for accurately diagnosing advanced histology within an SSL.

The detection of early colorectal cancer (CRC) is increasing through the implementation of screening programs. This increased detection enhances the likelihood of minimally invasive surgery and significantly lowers the risk of recurrence, thereby improving patient survival and reducing mortality rates. T1 CRC, the earliest stage, is treated endoscopically in cases with a low risk of lymph node metastasis (LNM). The advantages of endoscopic treatment compared with surgery include minimal invasiveness and limited tissue disruption, which reduce morbidity and mortality, preserve bowel function to avoid colectomy, accelerate recovery, and improve cost-effectiveness. However, T1 CRC has a risk of LNM. Thus, selection of the appropriate treatment between endoscopic treatment and surgery, while avoiding overtreatment, is challenging considering the potential for complete resection, LNM, and recurrence risk.

Polyps greater than 30 mm are classified as "giants". Their endoscopic removal represents a technical challenge. The choice of the endoscopic removal technique is important because it provides a resection sample for precise histopathological staging. This is pivotal for diagnostic, prognostic, and management purposes.

From a retrospective analysis, we obtained a sample of 38 giant polyps. Eighteen polypectomies were performed using the epinephrine volume reduction (EVR) method, nine polypectomies utilized endo-looping or clipping methods, and 11 patients underwent surgery.

We obtained en bloc resection with the EVR method in all cases; histology confirmed the correct indication for endoscopic resection in all cases. Moreover, no early or delayed complications were observed, and no patient required hospitalization. Using endo-looping or clipping methods, we observed advanced histology in 1/9 (11.1%) cases, while another patient (1/9, 11.1%) had delayed bleeding. Among patients who underwent surgery, 5/11 (45.5%) were deemed overtreated and three had post-surgical complications.

We propose EVR as an alternative technique for giant polyp resection due to its safety, effectiveness, cost-efficiency, and the advantage of avoiding the need to postpone polypectomy to a later time. Further prospective studies might help improve this experience and enhance the technique.

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.

Real-time visualization of red blood cell flow inside subepithelial microvessels is performed with magnifying endoscopy. However, microvascular blood flow velocity in the colorectum has not been investigated. Here, we aimed to evaluate the blood flow velocity of microvessels of colonic polyps and to compare it with that of surrounding mucosa. We examined 50 lesions, including 30 adenomas (ADs) and 20 hyperplastic polyps (HPs). Blood flow velocities of lesions and their surrounding mucosa were evaluated using magnifying blue laser imaging (BLI) prior to endoscopic resection. Calculation of mean blood flow velocities was based on mean movement distance of one tagged red blood cell using split video images of magnifying BLI. Mean microvascular blood flow velocity was significantly lower in ADs (1.65±0.66 mm/sec; range 0.46-2.90) than in HPs (2.83±1.10 mm/sec; 1.07-4.50) or the surrounding mucosa (3.73±1.11 mm/sec; 1.80-6.20; P <0.001). The blood flow velocity rate compared with the surrounding mucosa was significantly lower in ADs (0.41±0.16; 0.10-0.82) than in HPs (0.89±0.25; 0.46-1.51; P <0.001). We found that mean microvascular blood flow velocity was significantly lower in ADs than in HPs and the surrounding non-neoplastic mucosa. These findings indicate that a novel dynamic approach with microvascular blood flow velocity using magnifying endoscopy may be useful in assessing physiological differences between ADs and HPs.

Inflammatory bowel disease (IBD) increases risk of dysplasia and colorectal cancer. Advanced endoscopic techniques allow for the detection and characterization of IBD dysplastic lesions, but specialized training is not widely available. We aimed to develop and validate an online training platform to improve the detection and characterization of colonic lesions in IBD: OPtical diagnosis Training to Improve dysplasia Characterization in Inflammatory Bowel Disease (OPTIC-IBD).

We designed a web-based learning module that includes surveillance principles, optical diagnostic methods, approach to characterization, and classifications of colonic lesions using still images and videos. We invited gastroenterologists from Canada, Italy, and the United Kingdom with a wide range of experience. Participants reviewed 24 educational videos of IBD colonic lesions, predicted histology, and rated their confidence. The primary endpoint was to improve accuracy in detecting dysplastic lesions after training on the platform. Furthermore, participants were randomized 1:1 to get additional training or not, with a final assessment occurring after 60 days. Diagnostic performance for dysplasia and rater confidence were measured.

A total of 117 participants completed the study and were assessed for the primary endpoint. Diagnostic accuracy improved from 70.8% to 75.0% (P = .002) after training, with the greatest improvements seen in less experienced endoscopists. Improvements in both accuracy and confidence were sustained after 2 months of assessment, although the group randomized to receive additional training did not improve further. Similarly, participants' confidence in characterizing lesions significantly improved between before and after the course (P < .001), and it was sustained after 2 months of assessment.

The OPTIC-IBD training module demonstrated that an online platform could improve participants' accuracy and confidence in the optical diagnosis of dysplasia in patients with IBD. The training platform can be widely available and improve endoscopic care for people with IBD. (Clinical trial registration number: NCT04924543.).

A new subtype of serrated lesions, superficially serrated adenoma (SuSA), has been proposed as a lesion that histopathologically exhibits the morphological features of both conventional adenomas and serrated lesions and is difficult to classify as either one. SuSA has been elucidated to be a precursor lesion of KRAS-type traditional serrated adenoma. It has also been reported that SuSA may have malignant potential. We report a case treated with endoscopic submucosal dissection and detailed observation. Endoscopy revealed a raised lesion with a two-tier raised appearance in the sigmoid colon: a tall pinecone-like reddish structure and flattened whitish elevation on white light imaging. Magnifying narrow-band imaging revealed conspicuous blood vessels in the pinecone-like structure and slightly dilated reticular vessels in the flattened area. Crystal violet staining showed that the pinecone-like structure had a type IV_H pit pattern and the flattened area had a stellate to slightly elongated type III_H pit pattern diagnosed based on Kudo's classification and other pit pattern classification systems. Ki67-positive cells were distributed in the basal and middle layers of the gland in the flattened elevated area. Genetic analysis results were positive for KRAS mutation and negative for BRAF mutation. Histopathological examination revealed a traditional serrated adenoma in the pinecone-like structure and SuSA in the adjacent flattened elevated area.

Patients with a long history of ulcerative colitis (UC) are at risk of developing a significant complication known as UC-associated neoplasia (UCAN). To reduce the risk of UCAN and the associated mortality, the current guidelines recommend initiating surveillance colonoscopy 8-10 years after confirmation of UC diagnosis. In recent years, advancements in endoscopic diagnostic technologies, including magnifying and image-enhancing techniques, have allowed for the production of high-contrast images that emphasize mucosal structures, vascular patterns, and color tones. Recently, image-enhanced endoscopy technologies have become available and offer the potential to improve the qualitative endoscopic assessment of UCAN. The use of high-definition chromoendoscopy enables the evaluation of subtle mucosal patterns in the colon. Magnifying narrow-band imaging facilitates the visualization of mucosal vascular structures. Texture and color enhancement imaging processes structure, color tone, and brightness aspects more appropriately, whereas linked color imaging optimizes the emphasis on mucosal and vascular redness. Both techniques are expected to excel in the depiction of subtle color variations and mucosal changes characteristic of UCAN. This article provides an overview of the current status and future challenges regarding the use of various image-enhanced endoscopy techniques in the diagnosis of UCAN.

In this Clinical Practice Update (CPU), we provide guidance on the appropriate use of different polypectomy techniques. We focus on polyps <2 cm in size that are most commonly encountered by the practicing endoscopist, including use of classification systems to characterize polyps and various polypectomy methods. We review characteristics of polyps that require complex polypectomy techniques and provide guidance on which types of polyps require more advanced management by a therapeutic endoscopist or surgeon. This CPU does not provide a detailed review of complex polypectomy techniques, such as endoscopic submucosal dissection, which should only be performed by endoscopists with advanced training.

This expert review was commissioned and approved by the American Gastroenterological Association (AGA) Institute CPU Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. These Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. BEST PRACTICE ADVICE 1: A structured visual assessment using high-definition white light and/or electronic chromoendoscopy and with photodocumentation should be conducted for all polyps found during routine colonoscopy. Closely inspect colorectal polyps for features of submucosally invasive cancer. BEST PRACTICE ADVICE 2: Use cold snare polypectomy for polyps <10 mm in size. Cold forceps polypectomy can alternatively be used for 1- to 3-mm polyps where cold snare polypectomy is technically difficult. BEST PRACTICE ADVICE 3: Do not use hot forceps polypectomy. BEST PRACTICE ADVICE 4: Clinicians should be familiar with various techniques, such as cold and hot snare polypectomy and endoscopic mucosal resection, to ensure effective, safe, and optimal resection of intermediate-size polyps (10-19 mm). BEST PRACTICE ADVICE 5: Consider using lifting agents or underwater endoscopic mucosal resection for removal of sessile polyps 10-19 mm in size. BEST PRACTICE ADVICE 6: Serrated polyps should be resected using cold resection techniques. Submucosal injection may be helpful for polyps >10 mm if margins cannot be well delineated. BEST PRACTICE ADVICE 7: Use hot snare polypectomy to remove pedunculated lesions >10 mm in size. BEST PRACTICE ADVICE 8: Do not routinely use clips to close resection sites for polyps <20 mm. BEST PRACTICE ADVICE 9: Refer patients with polyps to endoscopic referral centers in the context of size ≥20 mm, challenging polypectomy location, or recurrent polyp at a prior polypectomy site. BEST PRACTICE ADVICE 10: Tattoo lesions that may need future localization at endoscopy or surgery. Tattoos should be placed in a location that will not interfere with subsequent attempts at endoscopic resection. BEST PRACTICE ADVICE 11: Refer patients with nonpedunculated polyps with clear evidence of submucosally invasive cancer for surgical evaluation. BEST PRACTICE ADVICE 12: Understand the endoscopy suite's electrosurgical generator settings appropriate for polypectomy or postpolypectomy thermal techniques.