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INTRODUCTION:Polyp size determination plays an important role in endoscopic decision making and follow-up determination. However, there is a lack of knowledge of endoscopist accuracy for polyp sizing and efficacy of available tools for size measurement. Our aim was to compare the accuracy of visual assessment, snare, forceps, and virtual scale endoscope (VSE) in estimating polyp size among a diverse group of endoscopists.METHODS:We conducted a prospective video-based study. One hundred twenty polyps measured and recorded along with all available measurement tools were randomized to visual assessment, snare, forceps, or VSE group. Eleven endoscopists conducted video-based measurement using the randomized measurement tool. Primary outcome was relative accuracy in polyp size measurement compared with caliper measurement immediately postresection.RESULTS:One thousand three hundred twenty measurements were performed. VSE had statistically significantly higher relative accuracy when compared to forceps (79.3 vs 71.3%; P < 0.0001). Forceps had statistically significantly higher relative accuracy when compared to visual assessment (71.3 vs 63.6%; P = 0.0036). There was no statistically significant difference when comparing visual assessment and snare-based measurements (63.6 vs 62.8%; P = 0.797). Overall, 21.5% of polyps >5 mm were misclassified as ≤5 mm and 17.3% of polyps ≥10 mm were misclassified as <10 mm. VSE had the lowest percentage of polyps >5 mm misclassified as ≤5 mm (2.6%), polyps ≤5 mm misclassified as >5 mm (5.1%), and polyps <10 mm misclassified as ≥10 mm (1.7%).DISCUSSION:Visual size estimation of polyps is inaccurate independently of training level, sex, and specialty. Size measurement accuracy can be improved using forceps and yields the highest relative accuracy when an adaptive scale technology is used.

BackgroundEndoscopy is the gold standard for the treatment of postoperative gastric leaks (GL). Large fistulas are associated with high rate of treatment failure. The objective of this study was to assess the clinical efficacy of a combining technique using a covered stent (CS) crossing through pigtails (PDs) for large postsurgical GL leaks.MethodsAll consecutive patients with large (> 10 mm) postsurgical GL treated endoscopically with a combination of a CS and PDs were included in a single-center retrospective study. The primary endpoint was the rate of GL closure.ResultsA total of 29 patients were included. Twenty-five patients underwent sleeve gastrectomy. The fistula (median diameter 15 mm) was diagnosed 6 days (IQR 4–9) after surgery. Technical success was observed in all procedures. After a median follow-up of 10.7 months (IQR 3.8–20.7), GL closure was observed in 82.7% with a median time of 63 days (IQR 40–90). Surgical management was finally necessary in four patients after a median of 186 days (IQR 122–250). No complications related to combined endoscopic treatment were observed especially stent migration during the follow-up.ConclusionAn endoscopic strategy combining CS crossing through PDs appears to be effective, safe and well tolerated for the treatment of large GL.

Main recommendations 1. ESGE/ESGAR recommend computed tomographic colonography (CTC) as the radiological examination of choice for the diagnosis of colorectal neoplasia. Strong recommendation, high quality evidence. ESGE/ESGAR do not recommend barium enema in this setting. Strong recommendation, high quality evidence. 2. ESGE/ESGAR recommend CTC, preferably the same or next day, if colonoscopy is incomplete. The timing depends on an interdisciplinary decision including endoscopic and radiological factors. Strong recommendation, low quality evidence. ESGE/ESGAR suggests that, in centers with expertise in and availability of colon capsule endoscopy (CCE), CCE preferably the same or the next day may be considered if colonoscopy is incomplete. Weak recommendation, low quality evidence. 3. When colonoscopy is contraindicated or not possible, ESGE/ESGAR recommend CTC as an acceptable and equally sensitive alternative for patients with alarm symptoms. Strong recommendation, high quality evidence. Because of lack of direct evidence, ESGE/ESGAR do not recommend CCE in this situation. Very low quality evidence. ESGE/ESGAR recommend CTC as an acceptable alternative to colonoscopy for patients with non-alarm symptoms. Strong recommendation, high quality evidence. In centers with availability, ESGE/ESGAR suggests that CCE may be considered in patients with non-alarm symptoms. Weak recommendation, low quality evidence. 4. Where there is no organized fecal immunochemical test (FIT)-based population colorectal screening program, ESGE/ESGAR recommend CTC as an option for colorectal cancer screening, providing the screenee is adequately informed about test characteristics, benefits, and risks, and depending on local service- and patient-related factors. Strong recommendation, high quality evidence. ESGE/ESGAR do not suggest CCE as a first-line screening test for colorectal cancer. Weak recommendation, low quality evidence. 5. ESGE/ESGAR recommend CTC in the case of a positive fecal occult blood test (FOBT) or FIT with incomplete or unfeasible colonoscopy, within organized population screening programs. Strong recommendation, moderate quality evidence. ESGE/ESGAR also suggest the use of CCE in this setting based on availability. Weak recommendation, moderate quality evidence. 6. ESGE/ESGAR suggest CTC with intravenous contrast medium injection for surveillance after curative-intent resection of colorectal cancer only in patients in whom colonoscopy is contraindicated or unfeasible. Weak recommendation, low quality evidence. There is insufficient evidence to recommend CCE in this setting. Very low quality evidence. 7. ESGE/ESGAR suggest CTC in patients with high risk polyps undergoing surveillance after polypectomy only when colonoscopy is unfeasible. Weak recommendation, low quality evidence. There is insufficient evidence to recommend CCE in post-polypectomy surveillance. Very low quality evidence. 8. ESGE/ESGAR recommend against CTC in patients with acute colonic inflammation and in those who have recently undergone colorectal surgery, pending a multidisciplinary evaluation. Strong recommendation, low quality evidence. 9. ESGE/ESGAR recommend referral for endoscopic polypectomy in patients with at least one polyp ≥6 mm detected at CTC or CCE. Follow-up CTC may be clinically considered for 6–9-mm CTC-detected lesions if patients do not undergo polypectomy because of patient choice, comorbidity, and/or low risk profile for advanced neoplasia. Strong recommendation, moderate quality evidence. Source and scope This is an update of the 2014–15 Guideline of the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR). It addresses the clinical indications for the use of imaging alternatives to standard colonoscopy. A targeted literature search was performed to evaluate the evidence supporting the use of computed tomographic colonography (CTC) or colon capsule endoscopy (CCE). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence.

IntroductionPer-oral endoscopic myotomy (POEM) is effective in achalasia. The objective of this study was to evaluate the short-term clinical efficacy of POEM in non-achalasia esophageal motility disorders (NAEMD).Patients and methodsPatients with NAEMD diagnosed by high-resolution manometry were included in a retrospective multicentric study. For each individual case, two controls paired on gender and age were matched: one with type I/II achalasia and one with type III achalasia. The clinical response, defined by an Eckardt score ≤ 3, was assessed at 3 and 6 months.ResultsNinety patients (mean age 66 years, 57 men) were included, 30 patients with NAEMD (13 jackhammer esophagus, 6 spastic esophageal disorders, 4 nutcracker esophagus, and 7 esophagogastric junction obstruction), 30 patients with type I–II achalasia, and 30 patients with type III achalasia. The 3-month response rates were 80% (24/30), 90% (27/30), and 100% (30/30) in NAEMD, type I–II achalasia and type III achalasia, respectively (p < 0.01). Eckardt scores improved from preoperative baseline in all groups (median scores 2.0 after POEM vs. 6.5 before POEM, 1.3 vs. 7.2, and 0.5 vs. 6.1 in NAEMD, type I//I and Type III, respectively). No predictive factor of response was identified. In NAEMD patients, there was a significant improvement of dysphagia, regurgitation, and chest pain scores. The 6-month response rates were 63.2% (12/19), 95.5% (21/22), and 87.0% (20/23) in NAEMD, type I–II achalasia and type III achalasia, respectively (p = 0.03).ConclusionAlthough less effective than in achalasia, POEM is an effective treatment for NAEMD. Long-term follow-up data are needed to further confirm that POEM may be a valid treatment of NAEMD.

Impedance and voltage of monopolar currents are directly related. By replacing air with saline solution, a change in behavior of these currents are achieved in endoscopy, resulting in a desired coagulation effect. However, the underlying electrophysical mechanisms of this effect remain poorly explained. This investigation assessed the relationship between the electrical parameters and the surrounding environment for three high-voltage monopolar coagulation currents commonly used for therapeutic endoscopy. Six consecutive applications per setting and per environment were performed with dissection knife on porcine kidney. When transitioning from air to saline immersion, a 99% decrease in impedance was observed for all current settings tested (Air Range : 4400–8150 Ω, Saline Range : 64–71 Ω; p  < 0.01 for all settings). This resulted in a 52-78% reduction in peak voltage (Air Range : 920–1165 V, Saline Range : 257–499 V; p  < 0.01 for all settings), and a 237-2030% increase in power delivered (Air Range : 3–19 W, Saline Range : 50–117 W; p  < 0.01 for all settings). The dramatic decrease in impedance results in a sharp reduction of voltage, explaining the coagulation effect observed when passing from air to saline-immersion therapeutic endoscopy.

INTRODUCTION:The adoption of colorectal endoscopic submucosal dissection (ESD) is still limited in the West. A recent randomized trial showed that ESD is more effective and only slightly riskier than piecemeal endoscopic mucosal resection; reproducibility outside expert centers was questioned. We evaluated the results according to the annual case volume in a multicentric prospective cohort.METHODS:Between September 2019 and September 2022, colorectal ESD was consecutively performed at 13 participating centers classified as low volume (LV), middle volume (MV), and high volume (HV). The main procedural outcomes were assessed. Multivariate and propensity score matching analyses were performed.RESULTS:Three thousand seven hundred seventy ESDs were included. HV centers treated larger and more often colonic lesions than MV and LV centers. En bloc, R0, and curative resection rates were 95.2%, 87.4%, and 83.2%, respectively, and were higher at HV than at MV and LV centers. HV centers also achieved a faster dissection speed. Delayed bleeding and surgery for complications rates were 5.4% and 0.8%, respectively, without significant differences. The perforation rate (overall: 9%) was higher at MV than at LV and HV centers. Lesion characteristics, but not volume center, were independently associated with both R1 resection and perforation. However, after propensity score matching, R0 rates were significantly higher at HV than at LV centers, and perforation rates were significantly higher at MV than at HV centers.DISCUSSION:Colorectal ESD can be successfully implemented in the West, even in nonexpert centers. However, difficult lesions must still be referred to experts.

INTRODUCTION:When initial resection of rectal neuroendocrine tumors (r-NETs) is not R0, persistence of local residue could lead to disease recurrence. This study aimed to evaluate the interest of systematic resection of non-R0 r-NET scars.METHODS:Retrospective analysis of all the consecutive endoscopic revisions and resections of the scar after non-R0 resections of r-NETs.RESULTS:A total of 100 patients were included. Salvage endoscopic procedure using endoscopic submucosal dissection or endoscopic full-thickness resection showed an R0 rate of near 100%. Residual r-NET was found in 43% of cases.DISCUSSION:In case of non-R0 resected r-NET, systematic scar resection by endoscopic full-thickness resection or endoscopic submucosal dissection seems necessary.

BackgroundFor large non-pedunculated rectal polyps, en bloc resection via endoscopic submucosal dissection (ESD) is typically recommended due to presumed higher risk of submucosal invasive cancer (SMIC) compared with the colon; however, data on cancer risk by location remain controversial.ObjectiveUsing the French ESD registry, we compared SMIC rates in large non-pedunculated colorectal polyps in the rectum versus colon. Procedural outcomes were also compared.DesignFrom September 2019 to September 2022, all large non-pedunculated polyps resected by ESD in 13 centres were included. Oncological and procedural outcomes were analysed using propensity score matching (PSM) and inverse probability weighting, accounting for relevant influencing factors. A subgroup analysis was performed on cases from the three largest centres, where such polyps were exclusively treated with ESD.ResultsAmong 3770 lesions, 3310 were analysed. Rectal lesions were larger (56.0 (40; 75) mm vs 47.0 (37; 62) mm), more often granular (80.0% vs 59.4%) and mixed nodular (54.0% vs 32.5%) (p<0.001). After PSM, submucosal cancer rates were not significantly different between rectal and colonic lesions of similar size and morphology (9.8% vs 8.9%, p=0.52). En bloc (97.7% vs 97.3%, p=0.757) and R0 resection rates (89.7% vs 89.5%, p=0.937) were also comparable. Perforation (5.5% vs 7.9%, p=0.057) and surgery for complications (0.1% vs 1.1%, p=0.051) showed a non-significant trend towards higher rates in colonic procedures. Subgroup analysis from the three centres exclusively performing ESD for large non-pedunculated polyps confirmed these findings.ConclusionIn our multicentre registry, large non-pedunculated polyps do not show a higher prevalence of SMIC in the rectum compared with colon, when adjusted for relevant factors such as size and morphology. Therefore, risk features, rather than location, should guide the choice of resection technique. Technical outcomes were comparable between rectal and colonic ESD, with a trend for higher complication rates in the colon.Trial registration numberNCT04592003.

Background: Gastric per oral endoscopic esophageal myotomy (G-POEM) is a promising procedure to treat refractory gastroparesis. The safety profile of G-POEM is an important topic because gastroparesis is a functional pathology, with a procedure whose effectiveness is between 50 and 65% depending on the studies. Objectives: We present this retrospective multicenter study, with the aim of establishing a safety profile, focusing on serious adverse events (AEs). Design: This was a multicenter observational cohort study conducted in five French expert centers. Methods: All patients who underwent G-POEM for refractory gastroparesis between 2015 and 2021 were included for analysis. AEs were classified into per endoscopic, early postoperative, and late postoperative, up to 1 month. Their severity was assessed using Dindo–Clavien and American Society for Gastrointestinal Endoscopy classification. The primary objective was to evaluate the rate of G-POEM severe AEs. Secondary objectives were to document other postoperative AEs, and to identify predictive factors. Results: In all, 217 patients were included: 81 men and 136 women, mean age 52 ± 17 years. The average procedural time was 44 ± 14 min (12–78). The average hospital stay was 3.7 ± 2.3 days. The AEs rate classified as Clavien–Dindo ⩾3 was 0.4% (one delayed bleeding requiring blood transfusion and endoscopic management). There were no deaths or patients admitted to intensive care unit. The rates of mucosotomy and capnoperitoneum were 3.7 and 1.8%, respectively, without clinical consequences. Most patients (81.5%) did not experience any AE. Three cases of dumping syndrome occurred, quickly managed by dietary measures. Conclusion: Our study confirms the safety of G-POEM with less than 0.5% of serious AEs, medically managed. This outcome makes this a procedure to have a good benefit–risk ratio.

IntroductionDifferent treatments exist for Zenker diverticulum. We compared flexible endoscopic myotomy of the cricopharyngeal muscle, using a technique called the “window technique” in order to improve the field of view, to surgical approaches.Materials and methodsPatients were retrospectively included and divided into a gastrointestinal group, with flexible endoscopic myotomy, and an ear–nose–throat treatments group with either rigid endoscopic treatment, either cervicotomy. We evaluated effectiveness in terms of quality of life (on a scale on 0 to 10) safety and technical aspects of each procedure.ResultsA total 106 patients who underwent 128 interventions were included. Rigid endoscopic procedures were the shortest (p < 0.001), with no difference for adverse event. Endoscopic approaches, flexible and rigid ones, were associated with shorter time to intake resumption (1 and 3 days, respectively, vs 6 after cervicotomy) and shorter length of hospital stay (3 and 4 days, respectively, vs 7 after cervicotomy) (p = 0.001). Post-operative QoL was better after flexible endoscopy (9/10) and open cervicotomy (9/10) than after rigid endoscopy (7/10) (p = 0.004). Patients declared fewer residual symptoms after open cervicotomy (77% of low symptomatic patients) and flexible endoscopy (80%) than after rigid endoscopy (43%) (p = 0.003). Conversion to open surgery was more frequent during rigid than flexible endoscopies (18% vs 0%, p = 0.0008).ConclusionFlexible endoscopic approach of Zenker diverticulum treatment seems to be safe and effective and may be an alternative to surgical approaches. Myotomy can be eventually helped by the window technique.