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Background:  Computer-aided diagnosis (CADx) enables the distinction between neoplastic and non-neoplastic polyps during colonoscopy. We aimed to estimate the patient-level benefit and harm of CADx., Methods:  We conducted a comparative analysis on data from the EndoBRAIN international clinical trial, evaluating the effect of optical diagnosis during colonoscopy with and without CADx. Three hypothetical scenarios were compared: "endoscopist-alone" and "CADx-assisted" leave-in-situ strategies (leaving non-neoplastic rectosigmoid polyps ≤ 5 mm), and "total removal" (removing all detected polyps). Primary outcomes included patient-level colonoscopy-related cost and surveillance interval agreement (colorectal cancer risk category). Estimates were calculated based on national reimbursement rates and guidelines in four countries., Results:  We analyzed 1134 patients (59 % men, median age 67 years) with 1716 polyps. Compared with total removal, the endoscopist-alone and CADx-assisted leave-in-situ strategies reduced the removed polyps per patient from 1.51 (95 %CI 1.48-1.54) to 1.18 (95 %CI 1.16-1.20) and 1.12 (95 %CI 1.00-1.14), respectively; however, 0.023 (95 %CI 0.015-0.033) and 0.021 (95 %CI 0.014-0.031) neoplasms per patient were left in situ, respectively. The mean colonoscopy cost decreased by $44 (endoscopist alone) and $46 (CADx assistance) in the USA, $22 and $19 in the UK, $21 and $19 in Japan, and $32 and $30 in Norway, respectively. Surveillance interval agreement decreased to 99.2 % (endoscopist alone) and 99.0 % (CADx assistance) in the USA, 99.8 % and 99.8 % in the UK, 97.9 % and 97.1 % in Japan, and 99.9 % and 99.9 % in Norway, respectively., Conclusions:  Both endoscopist-alone and CADx-assisted optical diagnosis reduce colonoscopy costs. The risk of missed adenomas and surveillance interval deviations appear marginal., Competing Interests: I. Barua has provided consultancy to AbbVie. M. Bretthauer has been a regulatory witness for Paion.J.E. East served on clinical advisory boards of Paion and Satisfai Health, and has received speakerʼs fees from Falk, Jannsen, and Medtronic. M. Misawa has received speakerʼs fees from Olympus Corp. and a licensing fee from Cybernet System Corp. Y. Mori has received consultancy and speakerʼs fees, and has devices on loan from Olympus Corp. and has received a licensing fee from Cybernet System Corp. A. Rastogi has received research grants and consultancy fees from both Olympus America and Boston Scientific. S.O. Frigstad, S. Gulati, A. Haji, N. Halvorsen, C. Hassan, B. Hayee, O. Holme, M. Kalager, S. Kudo, M. Løberg, K. Mori, J.A. Nilson, and O. Olabintan declare that they have no conflict of interest., (Thieme. All rights reserved.)

Objectives: To develop a procedure that matches magnifying endoscopic images with narrow-band imaging to 3D tissue structures using a tissue-clearing technique and to qualitatively and quantitatively analyze specified structures in gastrointestinal neoplasms., Methods: Endoscopically resected formalin-fixed paraffin-embedded gastrointestinal tissues (three esophagus, four stomach, seven colon) were made transparent by ethyl cinnamate. They were then subjected to fluorescent staining of nuclei and blood vessels followed by 3D imaging using a confocal laser scanning microscope. A one-to-one correspondence between magnifying endoscopic and 3D reconstructed images was established using vessels and crypts with characteristic shapes as guides, and the depth and caliber of specified vessels were measured., Results: All tissues were optically cleared, which allowed 3D visualization of vascular structures and nuclei in all layers. In the esophagus, intraepithelial papillary capillary loops and subepithelial capillary networks were identified. In the upper part of the stomach, polygonal subepithelial capillary loops surrounding the pits were observed, while in the lower part, surface epithelium with ridge-like structures and coiled vessels were observed. A honeycomb pit structure and surrounding vascular structures were identified in the colon. Quantitative analysis showed the various contrasts of a single continuous vessel in the endoscopic image were due to different depths at which the vessel tortuously ran., Conclusion: We established a procedure to allow one-to-one correspondence between magnifying endoscopic and 3D reconstructed images and to measure the depth and caliber of endoscopically visualized vessels of interest. This method is expected to improve endoscopic diagnosis and further the development of endoscopic imaging technologies., (© 2025 The Author(s). Digestive Endoscopy published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

This review outlines the implementation of artificial intelligence (AI) into colonoscopy procedures which includes its history, processes, and challenges. We highlight the importance of the collaborative effort between medical and computer science researchers in the development of AI tools in colonoscopy, particularly focusing on the roles of computer-aided detection (CADe) and computer-aided characterization (CADx) in a real time analysis of colonoscopy videos. Some of the proposed technologies are considered to improve the important clinical outcomes of patients such as adenoma detection rate in colonoscopy. Regulatory approval is considered mandatory before introducing AI tools into the market owing to the potential risks associated with the introduction of AI tools in healthcare. We share the experience of obtaining regulatory approval for EndoBRAIN in Japan, emphasizing the challenges in establishing examination criteria and performance levels at the period. Reimbursement is also identified as necessary for the widespread adoption of medical innovation. With the introduction of reimbursement for a CADe tool in Japan in 2024, we expect to accelerate implementation of AI in colonoscopy in general. Despite regulatory approval and reimbursement, concerns are raised with regard to the assessment of the balance between benefits and harms of AI in colonoscopy. Questions about its impact on cancer prevention, healthcare burden, patient acceptance, and effectiveness across different populations remain unsolved. The lack of clinical guidelines for AI in colonoscopy emphasizes the need for a rigorous assessment of available evidence in optimizing the adoption of AI in colonoscopy practice. While it is always exciting to strive for medical innovation, ensuring rigorous evaluation to optimize patient care is mandatory to improve the quality of health and society., Competing Interests: MM: Olympus Corp. (lecture fees) and Cybernet System Corp. (loyalty fee) SK: Olympus Corp. (lecture fees) and Cybernet System Corp. (loyalty fee) YM: Olympus Corp. (lecture fees, consultancy and equipment on loan) and Cybernet System Corp. (loyalty fee), (Copyright © Japan Medical Association.)

Background and Aims: The long-term treat-to-target (T2T) approach in ulcerative colitis (UC) aims for endoscopic remission, but variability among endoscopists and a lack of precision in relapse prediction both limit its clinical usefulness. A recently reported white-light imaging (WLI) artificial intelligence (AI) model helps standardize diagnosis, although challenges remain. Therefore, we attempted to combine a narrow-band imaging (NBI) AI model with the WLI AI model to determine whether these challenges can be overcome., Methods: This post hoc analysis of a prospective study evaluated the efficacy of combining AI-assisted WLI and NBI models in predicting clinical relapse in patients with UC over a 12-month follow-up period. A total of 102 patients with UC in clinical remission were included, and the combined AI models were used during colonoscopy to assess relapse risk., Results: The study found that within the same AI-based Mayo endoscopic subscore category, patients with vascular activity were more likely to experience clinical relapse than those with vascular healing. Compared with the WLI model alone, the specificity of the combined method significantly increased from 42.2% (95% confidence interval [CI]: 32.1%-52.9%) to 61.5% (95% CI: 50.7%-71.2%) (P = .013) with its sensitivity being maintained., Conclusions: The sequential use of WLI and NBI AI models can provide better stratification of relapse risk compared with using either model alone, offering a more accurate and personalized approach to treatment intensification. This dual-model AI approach aligns with the T2T approach in UC management., (© The Author(s) 2025. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Backgrounds and Aims: The Mayo endoscopic subscore [MES] is the most popular endoscopic disease activity measure of ulcerative colitis [UC]. Artificial intelligence [AI]-assisted colonoscopy is expected to reduce diagnostic variability among endoscopists. However, no study has been conducted to ascertain whether AI-based MES assignments can help predict clinical relapse, nor has AI been verified to improve the diagnostic performance of non-specialists., Methods: This open-label, prospective cohort study enrolled 110 patients with UC in clinical remission. The AI algorithm was developed using 74 713 images from 898 patients who underwent colonoscopy at three centres. Patients were followed up after colonoscopy for 12 months, and clinical relapse was defined as a partial Mayo score > 2. A multi-video, multi-reader analysis involving 124 videos was conducted to determine whether the AI system reduced the diagnostic variability among six non-specialists., Results: The clinical relapse rate for patients with AI-based MES = 1 (24.5% [12/49]) was significantly higher [log-rank test, p = 0.01] than that for patients with AI-based MES = 0 (3.2% [1/31]). Relapse occurred during the 12-month follow-up period in 16.2% [13/80] of patients with AI-based MES = 0 or 1 and 50.0% [10/20] of those with AI-based MES = 2 or 3 [log-rank test, p = 0.03]. Using AI resulted in better inter- and intra-observer reproducibility than endoscopists alone., Conclusions: Colonoscopy using the AI-based MES system can stratify the risk of clinical relapse in patients with UC and improve the diagnostic performance of non-specialists., (© The Author(s) 2024. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation.)

Background: Artificial intelligence (AI) has significantly impacted medical imaging, particularly in gastrointestinal endoscopy. Computer-aided detection and diagnosis systems (CADe and CADx) are thought to enhance the quality of colonoscopy procedures., Summary: Colonoscopy is essential for colorectal cancer screening but often misses a significant percentage of adenomas. AI-assisted systems employing deep learning offer improved detection and differentiation of colorectal polyps, potentially increasing adenoma detection rates by 8%-10%. The main benefit of CADe is in detecting small adenomas, whereas it has a limited impact on advanced neoplasm detection. Recent advancements include real-time CADe systems and CADx for histopathological predictions, aiding in the differentiation of neoplastic and nonneoplastic lesions. Biases such as the Hawthorne effect and potential overdiagnosis necessitate large-scale clinical trials to validate the long-term benefits of AI. Additionally, novel concepts such as computer-aided quality improvement systems are emerging to address limitations facing current CADe systems., Key Messages: Despite the potential of AI for enhancing colonoscopy outcomes, its effectiveness in reducing colorectal cancer incidence and mortality remains unproven. Further prospective studies are essential to establish the overall utility and clinical benefits of AI in colonoscopy., (© 2024 S. Karger AG, Basel.)

Background and Aim: Accurate stratification of the risk of lymph node metastasis (LNM) following endoscopic resection of submucosal invasive (T1) colorectal cancer (CRC) is imperative for determining the necessity for additional surgery. In this systematic review, we evaluated the efficacy of prediction of LNM by artificial intelligence (AI) models utilizing whole slide image (WSI) in patients with T1 CRC., Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was conducted through searches in PubMed (MEDLINE), Embase, and the Cochrane Library for relevant studies published up to December 2023. The inclusion criteria were studies assessing the accuracy of hematoxylin and eosin-stained WSI-based AI models for predicting LNM in patients with T1 CRC., Results: Four studies met the criteria for inclusion in this systematic review. The area under the receiver operating characteristic curve for these AI models ranged from 0.57 to 0.76. In the three studies in which AI performance was compared directly with current treatment guidelines, AI consistently exhibited a higher area under the receiver operating characteristic curve. At a fixed sensitivity of 100%, specificities ranged from 18.4% to 45.0%., Conclusions: Artificial intelligence models based on WSI can potentially address the issue of diagnostic variability between pathologists and exceed the predictive accuracy of current guidelines. However, these findings require confirmation by larger studies that incorporate external validation., (© 2024 The Author(s). Journal of Gastroenterology and Hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Brain tumor in children can induce hemianopia, a loss of conscious vision, profoundly impacting their development and quality of life, yet no effective intervention exists for this pediatric population. This study aimed to explore the feasibility, safety, and potential effectiveness of a home-based audiovisual stimulation in immersive virtual-reality (3D-MOT-IVR) to improve visual function and functional vision., Methods: In a phase 2a, open-labeled, nonrandomized, single-arm study, conducted from July 2022 to October 2023 (NCT05065268), 10 children and adolescents with stable hemianopia were enrolled to perform 20-min sessions of 3D-MOT-IVR every other day for six weeks from home. We assessed feasibility by monitoring adoption, adherence and completion rates, remote data transfer and qualitative feedback. Safety was evaluated using validated cybersickness questionnaires. Comprehensive vision assessments following standardized low-vision evaluation procedures were conducted pre- and post-intervention, with follow-ups at 1- and 6 months., Findings: The home-based 3D-MOT-IVR intervention proved both feasible and safe, with no reported adverse events. All participants completed the prescribed stimulations and the pre- and post-intervention assessment points, 90% completed the follow-ups. Nine out of ten participants showed clinically meaningful enhancement in visual function and/or functional vision, namely binocular visual field restoration and increased reading speed, but two showed concomitant deterioration in monocular visual field. These positive effects were sustained at the 6-month follow-up. Exploratory outcomes revealed a significant positive correlation between the performance at the 3D-MOT-IVR intervention and the visual perception at the binocular visual field test., Interpretation: Our findings underscore the feasibility and safety of home-based audiovisual stimulation in immersive virtual-reality as a potential intervention for improving visual perception in children/adolescents with hemianopia consecutive to a pediatric brain tumor. These promising results lay a strong foundation for a larger randomized controlled trial, offering hope for a meaningful breakthrough in visual rehabilitation for this vulnerable population., Funding: Meagan Bebenek Foundation and University Health Network Foundation., Competing Interests: The authors declare no conflict of interest., (© 2024 The Author(s).)

Objectives: This study evaluates risk factors for lymph node metastasis (LNM) in T2 colorectal cancer to refine patient selection for endoscopic resection., Methods: We reviewed records from consecutive patients who had undergone curative surgical resection of T2 colorectal cancer at our institution in Japan between April 2001 and December 2021. Data on conventional clinicopathologic variables were retrieved from the pathology reports at the time of surgery. The clinicopathological features included patient age, sex, tumor diameter, morphology, tumor location, lymphatic invasion, vascular invasion, tumor differentiation, carcinoembryonic antigen and carbohydrate antigen 19-9 levels, number of lymph node dissections, presence of adenoma component, and LNM., Results: Among the patients (338 men, 320 women), 170 (25.8%) exhibited LNM. Multivariate logistic regression identified three independent risk factors for LNM: lymphatic invasion (odds ratio [OR], 32.6; 95% confidence interval [CI], 17.3-61.4; p < 0.0001), female sex (OR, 1.70; 95% CI, 1.10-2.62; p = 0.02), and elevated carcinoembryonic antigen levels (OR, 2.56; 95% CI, 1.10-5.96; p = 0.03)., Conclusions: Lymphatic invasion, female sex, and high carcinoembryonic antigen levels significantly increase the risk of LNM in T2 colorectal cancer., Competing Interests: None., (© 2024 The Author(s). DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Background and Aims: Multiple computer-aided detection (CADe) software programs have now achieved regulatory approval in the United States, Europe, and Asia and are being used in routine clinical practice to support colorectal cancer screening. There is uncertainty regarding how different CADe algorithms may perform. No objective methodology exists for comparing different algorithms. We aimed to identify priority scoring metrics for CADe evaluation and comparison., Methods: A modified Delphi approach was used. Twenty-five global leaders in CADe in colonoscopy, including endoscopists, researchers, and industry representatives, participated in an online survey over the course of 8 months. Participants generated 121 scoring criteria, 54 of which were deemed within the study scope and distributed for review and asynchronous e-mail-based open comment. Participants then scored criteria in order of priority on a 5-point Likert scale during ranking round 1. The top 11 highest priority criteria were re-distributed, with another opportunity for open comment, followed by a final round of priority scoring to identify the final 6 criteria., Results: Mean priority scores for the 54 criteria ranged from 2.25 to 4.38 after the first ranking round. The top 11 criteria after round 1 of ranking yielded mean priority scores ranging from 3.04 to 4.16. The final 6 highest priority criteria, including a tie for first-place ranking, were (1, tied) sensitivity (average, 4.16) and (1, tied) separate and independent validation of the CADe algorithm (average, 4.16); (3) adenoma detection rate (average, 4.08); (4) false-positive rate (average, 4.00); (5) latency (average, 3.84); and (6) adenoma miss rate (average, 3.68)., Conclusions: This is the first reported international consensus statement of priority scoring metrics for CADe in colonoscopy. These scoring criteria should inform CADe software development and refinement. Future research should validate these metrics on a benchmark video data set to develop a validated scoring instrument., Competing Interests: Disclosure The following authors disclosed financial relationships: Y. Mori: speaker fees from and consultant for Olympus Corporation; and ownership interest in Cybernet System Corp. M. Misawa: speaker fees from Olympus Corporation; ownership interest in Cybernet System Corp. J.E. East: consultant for and ownership interest in Satisfai Health; and speaker fees from Medtronic. C. Hassan: consultant for Odin, Fujifilm, Olympus, and NEC. A. Repici: consultant for Medtronic; consultant for and research support from Fujifilm; research support and speaker fees from Boston Scientific and Norgine; and research support from Olympus and Pentax. M.F. Byrne: chairman and founder: Satisfai Health. D. von Renteln: research funding from and consultant for ERBE, Pendopharm, and Fujifilm; research funding from Ventage and Pentax; and consultant for Boston Scientific. D.G. Hewett: consultant for and speaker fees from Olympus Australia Pty Ltd and Fresenius Kabi Pty Ltd; and speaker fees from Boston Scientific Pty Ltd. C. Ogawa Matsubayashi: employee and Vice President of Innovation for AI Medical Service Inc. O.F. Ahmad: speaker fees from Olympus Corporation and Medtronic. P. Sharma: consultant for Olympus Corporation, Boston Scientific, and Salix Pharmaceuticals, Cipla, Medtronic, Takeda, Samsung Bioepis, CDx, and Exact Science; and research support from Fujifilm, Erbe Medical, and Ironwood Pharmaceuticals. S.A. Gross: consultant for Cook, Medtronic, and Olympus. N. Mansour: consultant for Iterative Health. A. Cherubini: Senior Vice President of Science, AI, and Data for Cosmo Intelligent Medical Devices. N.N. Dinh: President of Cosmo Intelligent Medical Devices. X. Xiao: Co-Founder and Chief Scientist and Equity holder in Wision Ltd. P. Mountney: CEO of Odin Vision. J. González-Bueno Puyal: senior research scientist for Odin Vision. D. Zur: CEO of Magentiq Eye. H. Seibt: Global Product Manager Digital Solutions of Pentax Medical Europe. G. Little: Executive Director and Global Head of Marketing, Digital Health, for Olympus Corporation of the Americas. S. LaRocco: Vice President and Global Head, Customer Solutions Business Unit, for Olympus Corporation of the Americas. S. Conjeti: Global Product Lead for Olympus Europa SE & Co. H. Shimada: Clinical Marketing Manager for Fujifilm Healthcare Americas Corporation. T.M. Berzin: consultant for Wision AI, Medtronic, Boston Scientific, Magentiq Eye, and RSIP Vision. J.R.G. Brown: consultant for Medtronic and Olympus. All other authors disclosed no financial relationships. J.E. East is funded by the National Institute for Health ResearchOxford Biomedical Research Centre. This project was funded via the Duke Internal Medicine Residency Faculty Resident Research Grant. This project received no industry funding sources. The views expressed are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: The resect-and-discard strategy allows endoscopists to replace post-polypectomy pathology with real-time prediction of polyp histology during colonoscopy (optical diagnosis). We aimed to investigate the benefits and harms of implementing computer-aided diagnosis (CADx) for polyp pathology into the resect-and-discard strategy., Methods: In this systematic review and meta-analysis, we searched MEDLINE, Embase, and Scopus from database inception to June 5, 2024, without language restrictions, for diagnostic accuracy studies that assessed the performance of real-time CADx systems, compared with histology, for the optical diagnosis of diminutive polyps (≤5 mm) in the entire colon. We synthesised data for three strategies: CADx-alone, CADx-unassisted, and CADx-assisted; when the endoscopist was involved in the optical diagnosis, we synthesised data exclusively from diagnoses for which confidence in the prediction was reported as high. The primary outcomes were the proportion of polyps that would have avoided pathological assessment (ie, the proportion optically diagnosed with high confidence; main benefit) and the proportion of polyps incorrectly predicted due to false positives and false negatives (main harm), directly compared between CADx-assisted and CADx-unassisted strategies. We used DerSimonian and Laird's random-effects model to calculate all outcomes. We used Higgins I 2 to assess heterogeneity, the Grading of Recommendations, Assessment, Development, and Evaluation approach to rate certainty, and funnel plots and Egger's test to examine publication bias. This study is registered with PROSPERO, CRD42024508440., Findings: We found 1019 studies, of which 11 (7400 diminutive polyps, 3769 patients, and 185 endoscopists) were included in the final meta-analysis. Three studies (1817 patients and 4086 polyps [2148 neoplastic and 1938 non-neoplastic]) provided data to directly compare the primary outcome measures between the CADx-unassisted and CADx-assisted strategies. We found no significant difference between the CADx-assisted and CADx-unassisted strategies for the proportion of polyps that would have avoided pathological assessment (90% [88-93], 3653 [89·4%] of 4086 polyps diagnosed with high confidence vs 90% [95% CI 85-94], 3588 [87·8%] of 4086 polyps diagnosed with high confidence; risk ratio 1·01 [95% CI 0·99-1·04; I 2 =53·49%; low-certainty evidence; Egger's test p=0·18). The proportion of incorrectly predicted polyps was lower with the CADx-assisted strategy than with the CADx-unassisted strategy (12% [95% CI 7-17], 523 [14·3%] of 3653 polyps incorrectly predicted with a CADx-assisted strategy vs 13% [6-20], 582 [16·2%] of 3588 polyps incorrectly diagnosed with a CADx-unassisted strategy; risk ratio 0·88 [95% CI 0·79-0·98]; I 2 =0·00%; low-certainty evidence; Egger's test p=0·18)., Interpretation: CADx did not produce benefit nor harm for the resect-and-discard strategy, questioning its value in clinical practice. Improving the accuracy and explainability of CADx is desired., Funding: European Commission (Horizon Europe), the Japan Society of Promotion of Science, and Associazione Italiana per la Ricerca sul Cancro., Competing Interests: Declaration of interests CHas reports consultancy fees from Fujifilm and Medtronic. YM reports consultancy fees, speaking honoraria, and equipment loan from Olympus, and license fee for the co-developed artificial intelligence medical devices from Cybernet System (in the field of colonoscopy, one of which has been included in the analysis in this Article). AR reports consultancy fees from Fujifilm, Olympus, and Medtronic. DvR reports research grants from Fujifilm, Eberhard & Robert Bosch Elektronik (ERBE), and Boston Scientific; speaker fees from Fujifilm, ERBE, Boston Scientific, and Medtronic; support for attending meetings from Fujifilm and ERBE, and endoscopy device loan from Fujifilm and ERBE. ER reports speaking honoraria from Fujifilm; consultancy fees from Medtronic; and speaker fees from Fujifilm. OP reports speaker fees from Medtronic, Boston Scientific, AbbVie, Falk, Luvos, and Olympus. ED reports consulting fees from Olympus, Fujifilm, Ambu, InterVenn, Norgine, and Exact Science; speaker fees from Olympus, GI Supply, Norgine, IPSEN-Mayoly, and Fujifilm; and endoscopy device loan from Fujifilm. POV reports research grant from European Comission (Horizon Europe 101057099). PS reports research grants from ERBE, Fujifilm, Nippon Electric Company, and Sebela; and consulting fees from Olympus, Boston Scientific, Salix Pharmaceuticals, Cipla, Medtronic, Takeda, Samsung Bioepis, and CDx. DKR reports research grants from Olympus, Sebela Pharmaceuticals, and ERBE; consulting fees from Olympus, Sebela Pharmaceuticals, Boston Scientific, and Laborie Medical; speaker fees from Boston Scientific, Laborie Medical, and Medtronic; and ownership of stock in Satisfai Health. PB reports research grants from NEC-Europe, Boston Scientific, and 3-D matrix and consulting fees from Fujifilm. GA reports research grants from the European Society of Gastrointestinal Endoscopy, consulting fees from Medtronic and Cosmo IMD, and speaker fees from Medtronic. JWL reports speaker fees from Olympus and Fujifilm. MMe reports license fee for the co-developed artificial intelligence medical devices from Cybernet System (in the field of colonoscopy, one of which has been included in the analysis in this Article) and consulting fees and speaker fees from Olympus. S-eK reports license fees for the co-developed artificial intelligence medical devices from Cybernet System (in the field of colonoscopy, one of which has been included in the analysis in this Article) and speaker fees from Olympus. RM reports research grants from ERBE, Fujifilm, Olympus, Pentax, and Boston Scientific. All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Objective: To develop and externally validate an updated artificial intelligence (AI) prediction system for stratifying the risk of lymph node metastasis (LNM) in T2 colorectal cancer (CRC)., Background: Recent technical advances allow complete local excision of T2 CRC, traditionally treated with surgical resection. Yet, the widespread adoption of this approach is hampered by the inability to stratify the risk of LNM., Methods: Data from patients with pT2 CRC undergoing surgical resection between April 2000 and May 2022 at one Japanese and one Italian center were analyzed. Primary goal was AI system development for accurate LNM prediction. Predictors encompassed 7 variables: age, sex, tumor size, tumor location, lymphovascular invasion, histologic differentiation, and carcinoembryonic antigen level. The tool's discriminating power was assessed through area under the curve, sensitivity, and specificity., Results: Out of 735 initial patients, 692 were eligible. Training and validation cohorts comprised of 492 and 200 patients, respectively. The AI model displayed an area under the curve of 0.75 in the combined validation data set. Sensitivity for LNM prediction was 97.8%, and specificity was 15.6%. The positive and the negative predictive value were 25.7% and 96%, respectively. The false negative rate was 2.2%, and the false positive was 84.4%., Conclusions: Our AI model, based on easily accessible clinical and pathologic variables, moderately predicts LNM in T2 CRC. However, the risk of false negative needs to be considered. The training of the model including more patients across western and eastern centers - differentiating between colon and rectal cancers - may improve its performance and accuracy., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Submucosal invasive (T1) colorectal cancer is a significant clinical management challenge, with an estimated 10% of patients developing extraintestinal lymph node metastasis. This condition necessitates surgical resection along with lymph node dissection to achieve a curative outcome. Thus, the precise preoperative assessment of lymph node metastasis risk is crucial to guide treatment decisions after endoscopic resection. Contemporary clinical guidelines strive to identify a low-risk cohort for whom endoscopic resection will suffice, applying stringent criteria to maximize patient safety. Those failing to meet these criteria are often recommended for surgical resection, with its associated mortality risks although it may still include patients with a low risk of metastasis. In the quest to enhance the precision of preoperative lymph node metastasis risk prediction, innovative models leveraging artificial intelligence or nomograms are being developed. Nevertheless, the debate over the ideal sensitivity and specificity for such models persists, with no consensus on target metrics. This review puts forth postoperative mortality rates as a practical benchmark for the sensitivity of predictive models. We underscore the importance of this method and advocate for research to amass data on surgical mortality in T1 colorectal cancer. Establishing specific benchmarks for predictive accuracy in lymph node metastasis risk assessment will hopefully optimize the treatment of T1 colorectal cancer.

Colonoscopy is the gold standard for detecting and resecting adenomas or early stage cancers to reduce the incidence and mortality rates of colorectal cancer. In a recent observational study, texture and color enhancement imaging (TXI) was reported to improve polyp detection during colonoscopy. This randomized controlled trial involving six Japanese institutions aims to confirm the superiority of TXI over standard white-light imaging (WLI) in detecting colorectal lesions during colonoscopy. During the 1-year study period, 960 patients will be enrolled, with 480 patients in the TXI and WLI groups. The primary endpoint is the mean number of adenomas detected per procedure. The secondary endpoints include adenoma detection rate, advanced adenoma detection rate, polyp detection rate, flat polyp detection rate, depressed lesion detection rate, mean polyps detected per procedure, sessile serrated lesion (SSL) detection rate, mean SSLs detected per procedure and adverse events., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background & Aims: Computer-aided diagnosis (CADx) assists endoscopists in differentiating between neoplastic and non-neoplastic polyps during colonoscopy. This study aimed to evaluate the impact of polyp location (proximal vs. distal colon) on the diagnostic performance of CADx for ≤5 mm polyps., Methods: We searched for studies evaluating the performance of real-time CADx alone (ie, independently of endoscopist judgement) for predicting the histology of colorectal polyps ≤5 mm. The primary endpoints were CADx sensitivity and specificity in the proximal and distal colon. Secondary outcomes were the negative predictive value (NPV), positive predictive value (PPV), and the accuracy of the CADx alone. Distal colon was limited to the rectum and sigmoid., Results: We included 11 studies for analysis with a total of 7782 polyps ≤5 mm. CADx specificity was significantly lower in the proximal colon compared with the distal colon (62% vs 85%; risk ratio (RR), 0.74; 95% confidence interval [CI], 0.72-0.84). Conversely, sensitivity was similar (89% vs 87%); RR, 1.00; 95% CI, 0.97-1.03). The NPV (64% vs 93%; RR, 0.71; 95% CI, 0.64-0.79) and accuracy (81% vs 86%; RR, 0.95; 95% CI, 0.91-0.99) were significantly lower in the proximal than distal colon, whereas PPV was higher in the proximal colon (87% vs 76%; RR, 1.11; 95% CI, 1.06-1.17)., Conclusion: The diagnostic performance of CADx for polyps in the proximal colon is inadequate, exhibiting significantly lower specificity compared with its performance for distal polyps. Although current CADx systems are suitable for use in the distal colon, they should not be employed for proximal polyps until more performant systems are developed specifically for these lesions., (Copyright © 2024 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Caregiving is often associated with negative physical and mental health outcomes, and as the COVID-19 pandemic escalated, caregivers experienced more burden and provided more care with substantially less support. Digital resources may have been one way caregivers managed demands for care and needs for information. This mixed-methods study included surveys and semi-structured interviews with caregivers ( n = 11) to describe experiences and use of digital health resources during the COVID-19 pandemic. Caregivers most often provided significant physical care and experienced reduced or no social support during the pandemic. Caregivers reported the need for improving the quality of telehealth services and digital health resources. COVID-19 will not likely be the last pandemic faced by contemporary society. Measures should be taken to reduce the anticipated negative impacts on caregivers and those receiving care during future pandemics., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In the management of ulcerative colitis (UC), histological remission is increasingly recognized as the ultimate goal. The absence of neutrophil infiltration is crucial for assessing remission. This study aimed to develop an artificial intelligence (AI) system capable of accurately quantifying and localizing neutrophils in UC biopsy specimens to facilitate histological assessment., Methods: Our AI system, which incorporates semantic segmentation and object detection models, was developed to identify neutrophils in hematoxylin and eosin-stained whole slide images. The system assessed the presence and location of neutrophils within either the epithelium or lamina propria and predicted components of the Nancy Histological Index and the PICaSSO Histologic Remission Index. We evaluated the system's performance against that of experienced pathologists and validated its ability to predict future clinical relapse risk in patients with clinically remitted UC. The primary outcome measure was the clinical relapse rate, defined as a partial Mayo score of ≥3., Results: The model accurately identified neutrophils, achieving a performance of 0.77, 0.81, and 0.79 for precision, recall, and F-score, respectively. The system's histological score predictions showed a positive correlation with the pathologists' diagnoses (Spearman's ρ = 0.68-0.80; P < .05). Among patients who relapsed, the mean number of neutrophils in the rectum was higher than in those who did not relapse. Furthermore, the study highlighted that higher AI-based PICaSSO Histologic Remission Index and Nancy Histological Index scores were associated with hazard ratios increasing from 3.2 to 5.0 for evaluating the risk of UC relapse., Conclusions: The AI system's precise localization and quantification of neutrophils proved valuable for histological assessment and clinical prognosis stratification., (Copyright © 2024 AGA Institute. Published by Elsevier Inc. All rights reserved.)

This systematic review evaluated the current status of AI-assisted colonoscopy to identify histologic remission and predict the clinical outcomes of patients with ulcerative colitis. The use of artificial intelligence (AI) has increased substantially across several medical fields, including gastrointestinal endoscopy. Evidence suggests that it may be helpful to predict histologic remission and relapse, which would be beneficial because current histological diagnosis is limited by the inconvenience of obtaining biopsies and the high cost and time-intensiveness of pathological diagnosis. MEDLINE and the Cochrane Central Register of Controlled Trials were searched for studies published between January 1, 2000, and October 31, 2023. Nine studies fulfilled the selection criteria and were included; five evaluated the prediction of histologic remission, two assessed the prediction of clinical outcomes, and two evaluated both. Seven were prospective observational or cohort studies, while two were retrospective observational studies. No randomized controlled trials were identified. AI-assisted colonoscopy demonstrated sensitivity between 65 %-98 % and specificity values of 80 %-97 % for identifying histologic remission. Furthermore, it was able to predict future relapse in patients with ulcerative colitis. However, several challenges and barriers still exist to its routine clinical application, which should be overcome before the true potential of AI-assisted colonoscopy can be fully realized., Competing Interests: Conflict of interest The authors have no conflicts of interest to declare., (Copyright © 2024 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Computer-aided diagnosis (CADx) allows prediction of polyp histology during colonoscopy, which may reduce unnecessary removal of nonneoplastic polyps. However, the potential benefits and harms of CADx are still unclear., Purpose: To quantify the benefit and harm of using CADx in colonoscopy for the optical diagnosis of small (≤5-mm) rectosigmoid polyps., Data Sources: Medline, Embase, and Scopus were searched for articles published before 22 December 2023., Study Selection: Histologically verified diagnostic accuracy studies that evaluated the real-time performance of physicians in predicting neoplastic change of small rectosigmoid polyps without or with CADx assistance during colonoscopy., Data Extraction: The clinical benefit and harm were estimated on the basis of accuracy values of the endoscopist before and after CADx assistance. The certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. The outcome measure for benefit was the proportion of polyps predicted to be nonneoplastic that would avoid removal with the use of CADx. The outcome measure for harm was the proportion of neoplastic polyps that would be not resected and left in situ due to an incorrect diagnosis with the use of CADx. Histology served as the reference standard for both outcomes., Data Synthesis: Ten studies, including 3620 patients with 4103 small rectosigmoid polyps, were analyzed. The studies that assessed the performance of CADx alone (9 studies; 3237 polyps) showed a sensitivity of 87.3% (95% CI, 79.2% to 92.5%) and specificity of 88.9% (CI, 81.7% to 93.5%) in predicting neoplastic change. In the studies that compared histology prediction performance before versus after CADx assistance (4 studies; 2503 polyps), there was no difference in the proportion of polyps predicted to be nonneoplastic that would avoid removal (55.4% vs. 58.4%; risk ratio [RR], 1.06 [CI, 0.96 to 1.17]; moderate-certainty evidence) or in the proportion of neoplastic polyps that would be erroneously left in situ (8.2% vs. 7.5%; RR, 0.95 [CI, 0.69 to 1.33]; moderate-certainty evidence)., Limitation: The application of optical diagnosis was only simulated, potentially altering the decision-making process of the operator., Conclusion: Computer-aided diagnosis provided no incremental benefit or harm in the management of small rectosigmoid polyps during colonoscopy., Primary Funding Source: European Commission. (PROSPERO: CRD42023402197)., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-2865.

Approximately 10% of submucosal invasive (T1) colorectal cancers demonstrate extraintestinal lymph node metastasis, necessitating surgical intervention with lymph node dissection. The ability to identify T1b (submucosal invasion depth ≥ 1000 µm) as a risk factor for lymph node metastasis via pre-treatment endoscopy is crucial in guiding treatment strategies. Accurately distinguishing T1b from T1a (submucosal invasion depth < 1000 µm) or dysplasia remains a significant challenge for artificial intelligence (AI) systems, which require high and consistent diagnostic capabilities. Moreover, as endoscopic therapies like endoscopic full-thickness resection and endoscopic intermuscular dissection evolve, and the focus on reducing unnecessary surgeries intensifies, the initial management of T1 colorectal cancers via endoscopic treatment is anticipated to increase. Consequently, the development of highly accurate and reliable AI systems is essential, not only for pre-treatment depth assessment but also for post-treatment risk stratification of lymph node metastasis. While such AI diagnostic systems are still under development, significant advancements are expected in the near future to improve decision-making in T1 colorectal cancer management., Competing Interests: Conflict of interest The authors (Katsuro Ichimasa, Shin-ei Kudo, Masashi Misawa, Yuki Takashina, Khay Guan Yeoh, and Hideyuki Miyachi) hereby declare no conflict of interest regarding this review article entitled “Role of the artificial intelligence in the management of T1 colorectal cancer”. No relevant disclosures., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background and Aims: Image-enhanced endoscopy has attracted attention as a method for detecting inflammation and predicting outcomes in patients with ulcerative colitis (UC); however, the procedure requires specialist endoscopists. Artificial intelligence (AI)-assisted image-enhanced endoscopy may help nonexperts provide objective accurate predictions with the use of optical imaging. We aimed to develop a novel AI-based system using 8853 images from 167 patients with UC to diagnose "vascular-healing" and establish the role of AI-based vascular-healing for predicting the outcomes of patients with UC., Methods: This open-label prospective cohort study analyzed data for 104 patients with UC in clinical remission. Endoscopists performed colonoscopy using the AI system, which identified the target mucosa as AI-based vascular-active or vascular-healing. Mayo endoscopic subscore (MES), AI outputs, and histologic assessment were recorded for 6 colorectal segments from each patient. Patients were followed up for 12 months. Clinical relapse was defined as a partial Mayo score >2 RESULTS: The clinical relapse rate was significantly higher in the AI-based vascular-active group (23.9% [16/67]) compared with the AI-based vascular-healing group (3.0% [1/33)]; P = .01). In a subanalysis predicting clinical relapse in patients with MES ≤1, the area under the receiver operating characteristic curve for the combination of complete endoscopic remission and vascular healing (0.70) was increased compared with that for complete endoscopic remission alone (0.65)., Conclusions: AI-based vascular-healing diagnosis system may potentially be used to provide more confidence to physicians to accurately identify patients in remission of UC who would likely relapse rather than remain stable., Competing Interests: Disclosure The following authors disclosed financial relationships: Y. Maeda: grants from the Japan Society for the Promotion of Science during the conduct of the study. S. Kudo and M. Misawa: consultant and speaker fees from Olympus Corp. All of the other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Purpose : To study the incidence of postoperative anti-elevation syndrome in relation to the magnitude of anterior transposition of the inferior oblique. Methods : A retrospective chart review was conducted for all patients submitted to anterior transposition of the inferior oblique from 2000 to 2020. Anti-elevation syndrome was defined as limitation of elevation of the abducting eye, resulting in a secondary upshoot of the contralateral adducting eye. Results : A total of 312 eyes of 170 patients were enrolled in the study. The incidence of anti-elevation syndrome was 20.4% when the inferior oblique was positioned 4 mm posterior to the temporal border of the inferior rectus insertion; 23.5% when sutured 2 mm posterior to the temporal border of the inferior rectus insertion and 32.8% when placed at the same level of the inferior rectus insertion with two sutures vertically aligned. When the posterior border of the inferior oblique was horizontally aligned with the anterior border and positioned adjacent to the inferior rectus insertion, in a "J shape" fashion, the incidence of anti-elevation was 41.8%. Conclusions : The anterior transposition of the inferior oblique with "J" deformity increases the risk of anti-elevation syndrome. Additionally, placing the sutures more anteriorly than 2 mm posterior to the inferior rectus insertion increases the incidence of this finding.

The patient was a 50-year-old Japanese woman who was diagnosed with total-colitis-type ulcerative colitis (UC) at the age of 26 years. She was treated with mesalazine and azathioprine, and her disease activity was well controlled. At the age of 50 years, the patient was experiencing fever, abdominal pain, diarrhea, bloody stool, and anal pain, which led to a diagnosis of a relapse of UC. Although steroid therapy was administered and tended to improve her symptoms, fecaloid vaginal discharge occurred, and rectovaginal fistula (RVF) was confirmed. Colostomy was performed, and infliximab was initiated as maintenance therapy for UC. All symptoms improved, and RVF closure was confirmed 6 months after the initiation of infliximab. To date, she has been free from relapse of UC. There have been only a few reports of UC complicated by RVF, and this condition is often difficult to treat. To the best of our knowledge, no other case of UC complicated by RVF in which the fistula was closed after treatment with colostomy and infliximab has been previously reported; thus, our report of the present case is valuable to the literature., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 Katsube et al.)

Background and Aim: Computer-aided detection (CADe) systems can efficiently detect polyps during colonoscopy. However, false-positive (FP) activation is a major limitation of CADe. We aimed to compare the rate and causes of FP using CADe before and after an update designed to reduce FP., Methods: We analyzed CADe-assisted colonoscopy videos recorded between July 2022 and October 2022. The number and causes of FPs and excessive time spent by the endoscopist on FP (ET) were compared pre- and post-update using 1:1 propensity score matching., Results: During the study period, 191 colonoscopy videos (94 and 97 in the pre- and post-update groups, respectively) were recorded. Propensity score matching resulted in 146 videos (73 in each group). The mean number of FPs and median ET per colonoscopy were significantly lower in the post-update group than those in the pre-update group (4.2 ± 3.7 vs 18.1 ± 11.1; P < 0.001 and 0 vs 16 s; P < 0.001, respectively). Mucosal tags, bubbles, and folds had the strongest association with decreased FP post-update (pre-update vs post-update: 4.3 ± 3.6 vs 0.4 ± 0.8, 0.32 ± 0.70 vs 0.04 ± 0.20, and 8.6 ± 6.7 vs 1.6 ± 1.7, respectively). There was no significant decrease in the true positive rate (post-update vs pre-update: 95.0% vs 99.2%; P = 0.09) or the adenoma detection rate (post-update vs pre-update: 52.1% vs 49.3%; P = 0.87)., Conclusions: The updated CADe can reduce FP without impairing polyp detection. A reduction in FP may help relieve the burden on endoscopists., (© 2024 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Aims: Benefits of computer-aided detection (CADe) in detecting colorectal neoplasia were shown in many randomized trials in which endoscopists' behavior was strictly controlled. However, the effect of CADe on endoscopists' performance in less-controlled setting is unclear. This systematic review and meta-analyses were aimed at clarifying benefits and harms of using CADe in real-world colonoscopy., Methods: We searched MEDLINE, EMBASE, Cochrane, and Google Scholar from inception to August 20, 2023. We included nonrandomized studies that compared the effectiveness between CADe-assisted and standard colonoscopy. Two investigators independently extracted study data and quality. Pairwise meta-analysis was performed utilizing risk ratio for dichotomous variables and mean difference (MD) for continuous variables with a 95% confidence interval (CI)., Results: Eight studies were included, comprising 9782 patients (4569 with CADe and 5213 without CADe). Regarding benefits, there was a difference in neither adenoma detection rate (44% vs 38%; risk ratio, 1.11; 95% CI, 0.97 to 1.28) nor mean adenomas per colonoscopy (0.93 vs 0.79; MD, 0.14; 95% CI, -0.04 to 0.32) between CADe-assisted and standard colonoscopy, respectively. Regarding harms, there was no difference in the mean non-neoplastic lesions per colonoscopy (8 studies included for analysis; 0.52 vs 0.47; MD, 0.14; 95% CI, -0.07 to 0.34) and withdrawal time (6 studies included for analysis; 14.3 vs 13.4 minutes; MD, 0.8 minutes; 95% CI, -0.18 to 1.90). There was a substantial heterogeneity, and all outcomes were graded with a very low certainty of evidence., Conclusion: CADe in colonoscopies neither improves the detection of colorectal neoplasia nor increases burden of colonoscopy in real-world, nonrandomized studies, questioning the generalizability of the results of randomized trials., (Copyright © 2024 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objectives: Computer-aided characterization (CADx) may be used to implement optical biopsy strategies into colonoscopy practice; however, its impact on endoscopic diagnosis remains unknown. We aimed to evaluate the additional diagnostic value of CADx when used by endoscopists for assessing colorectal polyps., Methods: This was a single-center, multicase, multireader, image-reading study using randomly extracted images of pathologically confirmed polyps resected between July 2021 and January 2022. Approved CADx that could predict two-tier classification (neoplastic or nonneoplastic) by analyzing narrow-band images of the polyps was used to obtain a CADx diagnosis. Participating endoscopists determined if the polyps were neoplastic or not and noted their confidence level using a computer-based, image-reading test. The test was conducted twice with a 4-week interval: the first test was conducted without CADx prediction and the second test with CADx prediction. Diagnostic performances for neoplasms were calculated using the pathological diagnosis as reference and performances with and without CADx prediction were compared., Results: Five hundred polyps were randomly extracted from 385 patients and diagnosed by 14 endoscopists (including seven experts). The sensitivity for neoplasia was significantly improved by referring to CADx (89.4% vs. 95.6%). CADx also had incremental effects on the negative predictive value (69.3% vs. 84.3%), overall accuracy (87.2% vs. 91.8%), and high-confidence diagnosis rate (77.4% vs. 85.8%). However, there was no significant difference in specificity (80.1% vs. 78.9%)., Conclusions: Computer-aided characterization has added diagnostic value for differentiating colorectal neoplasms and may improve the high-confidence diagnosis rate., (© 2023 Japan Gastroenterological Endoscopy Society.)

Objectives: Japanese guidelines include high-grade (poorly differentiated) tumors as a risk factor for lymph node metastasis (LNM) in T1 colorectal cancer (CRC). However, whether the grading is based on the least or most predominant component when the lesion consists of two or more levels of differentiation varies among institutions. This study aimed to investigate which method is optimal for assessing the risk of LNM in T1 CRC., Methods: We retrospectively evaluated 971 consecutive patients with T1 CRC who underwent initial or additional surgical resection from 2001 to 2021 at our institution. Tumor grading was divided into low-grade (well- to moderately differentiated) and high-grade based on the least or predominant differentiation analyses. We investigated the correlations between LNM and these two grading analyses., Results: LNM was present in 9.8% of patients. High-grade tumors, as determined by least differentiation analysis, accounted for 17.0%, compared to 0.8% identified by predominant differentiation analysis. A significant association with LNM was noted for the least differentiation method ( p < 0.05), while no such association was found for predominant differentiation ( p = 0.18). In multivariate logistic regression, grading based on least differentiation was an independent predictor of LNM ( p = 0.04, odds ratio 1.68, 95% confidence interval 1.00-2.83). Sensitivity and specificity for detecting LNM were 27.4% and 84.1% for least differentiation, and 2.1% and 99.3% for predominant differentiation, respectively., Conclusions: Tumor grading via least differentiation analysis proved to be a more reliable measure for assessing LNM risk in T1 CRC compared to grading by predominant differentiation., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

The present study examined the therapeutic effects of preoperative neoadjuvant chemoradiation therapy (NACRT) and predictive factors for complete clinical remission, compared the prognosis and costs of abdominoperineal resection (APR) and the "watch and wait" method (WW), and evaluated the usefulness of WW. In our department, patients with stage II-III lower rectal cancer requiring APR receive NACRT. NACRT was performed as a preoperative treatment (52 Gy + S-1: 80-120 mg/day × 25 days). Eight weeks after the completion of NACRT, rectal examination, endoscopic, computed tomography, and magnetic resonance imaging findings were evaluated to assess its therapeutic effects. APR was indicated for patients in whom endoscopic findings suggested a residual tumor in which a deep ulcer or marginal swelling remained or lymph node metastasis. However, WW was selected for patients who refused APR after informed consent was obtained. In the APR and WW groups, 5- and 20-year treatment costs after CRT were calculated using the Medical Fee Points of Japan in 2020. No significant differences were observed in 3-year disease-free survival rates for either parameter between the two groups. Regarding expenses, treatment costs were lower in the WW group than in the APR group. Organ preservation using active surveillance with CRT for rectal cancer requiring APR is feasible with the achievement of endoluminal complete remission., Competing Interests: Competing InterestsThe authors declare no competing interests., (© The Author(s), under exclusive licence to Indian Association of Surgical Oncology 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Objectives: Lymph node metastasis (LNM) prediction for T1 colorectal cancer (CRC) is critical for determining the need for surgery after endoscopic resection because LNM occurs in 10%. We aimed to develop a novel artificial intelligence (AI) system using whole slide images (WSIs) to predict LNM., Methods: We conducted a retrospective single center study. To train and test the AI model, we included LNM status-confirmed T1 and T2 CRC between April 2001 and October 2021. These lesions were divided into two cohorts: training (T1 and T2) and testing (T1). WSIs were cropped into small patches and clustered by unsupervised K-means. The percentage of patches belonging to each cluster was calculated from each WSI. Each cluster's percentage, sex, and tumor location were extracted and learned using the random forest algorithm. We calculated the areas under the receiver operating characteristic curves (AUCs) to identify the LNM and the rate of over-surgery of the AI model and the guidelines., Results: The training cohort contained 217 T1 and 268 T2 CRCs, while 100 T1 cases (LNM-positivity 15%) were the test cohort. The AUC of the AI system for the test cohort was 0.74 (95% confidence interval [CI] 0.58-0.86), and 0.52 (95% CI 0.50-0.55) using the guidelines criteria (P = 0.0028). This AI model could reduce the 21% of over-surgery compared to the guidelines., Conclusion: We developed a pathologist-independent predictive model for LNM in T1 CRC using WSI for determination of the need for surgery after endoscopic resection., Trial Registration: UMIN Clinical Trials Registry (UMIN000046992, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr&#95;view.cgi?recptno=R000053590)., (© 2023 Japan Gastroenterological Endoscopy Society.)

Purpose: To identify the inflammatory cytokine profile in the aqueous humor (AH) of patients with intraocular inflammation (IOI) after intravitreal administration of brolucizumab (IVBr) for neovascular age-related macular degeneration., Methods: Eight eyes from seven patients with IOI after initial IVBr (IVBrIOI +) were enrolled. Sixteen eyes from 16 patients without IOI after IVBr (IVBrIOI -) and aflibercept (IVA) were used as controls. AH samples were analyzed using a multiplex immunoassay., Results: C-C motif chemokine ligand (CCL)2, C-X-C motif chemokine ligand (CXCL)1, CXCL10, CXCL13, interleukin (IL)-6, IL-8, IL-10, matrix metalloproteinase (MMP)-1, MMP-9, granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), intercellular adhesion molecule (ICAM)-1, E-selectin, and P-selectin levels were significantly higher in IVBrIOI + than in IVBrIOI - and IVA. Vascular endothelial growth factor (VEGF) was significantly lower in IVBrIOI - compared to that in IVBrIOI + and IVA. In the IVBrIOI + group, there were significant correlations between CCL2, CXCL1, IL-6, IL-8, IL-10, G-CSF, GM-CSF, ICAM-1, and E-selectin, which also exhibited significant correlations in the IVBrIOI - group., Conclusion: The number of inflammatory cytokines increases during IOI, which is associated with type IV hypersensitivity and vascular inflammation. Some cytokines exhibit correlations even in non-inflamed eyes, indicating a subclinical response to IVBr., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Competing Interests: MM and SK received speaking honoraria from Olympus Corporation and received licensing fees according to sales of products called the EndoBRAIN series, which is a type of AI-assisted colonoscopy software launched in Japan and some other Asian countries. These licensing fees are not associated with the following patents: SK and MM have patents (Japan patents 6059271 and 6580446) related to AI algorithms, which are licensed to Cybernet Systems and Showa University. Patent-related royalties are assigned to Showa University. YM received speaking honoraria, consultant fees, and device loans from Olympus Corporation and received licensing fees according to sales of the EndoBRAIN series.

Objectives: Endoscopic submucosal dissection (ESD) is an effective procedure for the en bloc resection of colorectal neoplasms. However, risk factors for local recurrence after ESD have not been identified. This study aimed to evaluate such risk factors after ESD for colorectal neoplasms., Methods: This retrospective study included 1344 patients with 1539 consecutive colorectal lesions who underwent ESD between September 2003 and December 2019. We investigated various factors associated with local recurrence in these patients. The main outcomes were the incidence of local recurrence and its relationship with clinicopathological factors during long-term surveillance., Results: The en bloc resection rate was 98.6%, the R0 resection rate was 97.2%, and the histologically complete resection rate was 92.7%. Local recurrence was observed in 7/1344 (0.5%) patients and the median follow-up period was 72 months (range 4-195 months). The incidence of local recurrence was significantly higher in lesions ≥40 mm in diameter (hazard ratio [HR] 15.68 [1.88-130.5]; p = 0.011), piecemeal resection (HR 48.42 [10.7-218.7]; p < 0.001), non-R0 resection (HR 41.05 [9.025-186.7]; p < 0.001), histologically incomplete resection (HR 16.23 [3.627-72.63]; p <0.001), and severe fibrosis (F2; HR 9.523 [1.14-79.3]; p = 0.037)., Conclusions: Five risk factors for local recurrence after ESD were identified. Patients with such factors should undergo careful surveillance colonoscopy., Competing Interests: Masashi Misawa is an Associate Editor of Digestive Endoscopy. The other authors declare no conflict of interest., (© 2023 The Authors. DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Introduction: Kawasaki disease (KD) patients with a high risk of coronary artery aneurysm (CAA) development are well characterized and targeted for intensified primary intravenous immunoglobulin (IVIG) treatment. However, the characteristics of KD patients with a low CAA risk are less well-known., Methods: The present study was a secondary analysis of Prospective Observational study on STRAtified treatment with Immunoglobulin plus Steroid Efficacy for Kawasaki disease (Post RAISE), a multicenter, prospective cohort study of KD patients in Japan. The target of the analysis was patients with a Kobayashi score <5 who were predicted to respond to IVIG. The incidence of CAA during the acute phase, the primary outcome, was assessed based on all echocardiographic evaluations performed between week 1 (days 5-9) and month 1 (days 20-50) after the start of primary treatment. Multivariable logistic regression was used to identify the independent risk factors of CAA during the acute phase, based on which a decision tree was created to identify a subpopulation of patients with KD with a low CAA risk., Results: Multivariate analysis found that a baseline maximum Z score >2.5, age <12 months at fever onset, nonresponsiveness to IVIG, low neutrophils, high platelets and high C-reactive protein were independent predictors of CAA during the acute phase. The decision tree created by using these risk factors identified 679 KD patients who had a low incidence of CAA during the acute phase (4.1%) and no medium or large CAA., Conclusions: The present study identified a KD subpopulation with a low CAA risk comprising around a quarter of the entire Post RAISE cohort., Competing Interests: M.M. received an honorarium from the Japan Blood Products Organization, Teijin Pharma Ltd., and Nihon Pharmaceutical Co, Ltd. outside the submitted work. Y.M. received a Health Science and Labor Research Grant and grants from the Tokyo Metropolitan Government Hospitals, the Japan Agency for Medical Research and Development, the Center for Clinical Trials of the Japan Medical Association, the Japan Science and Technology Agency, the New Energy and Industrial Technology Development Organization, and the Japan Society for the Promotion of Science outside the submitted work. None of these entities were involved in this study in any manner. The other authors have no conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

This study conducted fundamental research to develop a more effective BNCT targeting cancer stem cells. We constructed plasmids that induced the overexpression of L-type amino acid transporter 1 (LAT1) tagged with tdTomato on the cytoplasmic membranes of CD133 expressing cancer cells. After transfection of the plasmids into a glioblastoma cell line (T98G), several clones overexpressing LAT1-tdTomato in the hypoxic microenvironment of the spheroids formed from each clone were obtained. Confocal laser microscopic observation confirmed that signals from LAT1-tdTomato overlapped with immunofluorescence signals from the second antibody binding to CD133 in the hypoxic microenvironment of the spheroids. As CD133-positive cells in the hypoxic microenvironment of T98G spheroids have cancer stem cell characteristics, LAT1 seems to be selectively overexpressed in cancer stem cell-like cells. An RI tracer method showed that cells overexpressing LAT1-tdTomato in the hypoxic microenvironment of spheroids incorporate 14C-BPA much more than cells that do not overexpress LAT1-tdTomato. Neutron radiation experiments showed a more significant regression in spheroids formed with clones than in spheroids formed with parental cells when spheroids were treated with 10BPA. These results suggest that BNCT combined with gene therapy targeting cancer stem cells is more effective in glioblastoma therapy., (©2023 by Radiation Research Society. All rights of reproduction in any form reserved.)

Objectives: Meticulous inspection of the mucosa during colonoscopy, represents a lengthier withdrawal time, but has been shown to increase adenoma detection rate (ADR). We investigated if artificial intelligence-aided speed monitoring can improve suboptimal withdrawal time., Methods: We evaluated the implementation of a computer-aided speed monitoring device during colonoscopy at a large academic endoscopy center. After informed consent, patients ≥18 years undergoing colonoscopy between 5 March and 29 April 2021 were examined without the use of the speedometer, and with the speedometer between 29 April and 30 June 2021. All colonoscopies were recorded, and withdrawal time was assessed based on the recordings in a blinded fashion. We compared mean withdrawal time, percentage of withdrawal time ≥6 min, and ADR with and without the speedometer., Results: One hundred sixty-six patients in each group were eligible for analyses. Mean withdrawal time was 9 min and 6.6 s (95% CI: 8 min and 34.8 s to 9 min and 39 s) without the use of the speedometer, and 9 min and 9 s (95% CI: 8 min and 45 s to 9 min and 33.6 s) with the speedometer; difference 2.3 s (95% CI: -42.3-37.7, p  = 0.91). The ADRs were 45.2% (95% CI: 37.6-52.8) without the speedometer as compared to 45.8% (95% CI: 38.2-53.4) with the speedometer ( p  = 0.91). The proportion of colonoscopies with withdrawal time ≥6 min without the speedometer was 85.5% (95% CI: 80.2-90.9) versus 86.7% (95% CI: 81.6-91.9) with the speedometer ( p  = 0.75)., Conclusions: Use of speed monitoring during withdrawal did not increase withdrawal time or ADR in colonoscopy., Clinicaltrials.gov Identifier: NCT04710251.

Janus transition metal dichalcogenides (TMDCs), with dissimilar chalcogen atoms on each side of TMDCs, have garnered considerable research attention because of the out-of-plane intrinsic polarization in monolayer TMDCs. Although a plasma process has been proposed for synthesizing Janus TMDCs based on the atomic substitution of surface atoms at room temperature, the formation dynamics and intermediate electronic states have not been completely examined. In this study, we investigated the intermediate state between MoSe 2 and Janus MoSeS during plasma processing. Atomic composition analysis and atomic-scale structural observations revealed the intermediate partially substituted Janus (PSJ) structure. Combined with theoretical calculations, we successfully clarified the characteristic Raman modes in the intermediate PSJ structure. The PL exhibited discontinuous transitions that could not be explained by the theoretical calculations. These findings will contribute toward understanding the formation process and electronic-state modulation of Janus TMDCs.

Transition metal dichalcogenides (TMDCs) are promising two-dimensional (2D) materials for next-generation optoelectronic devices; they can also provide opportunities for further advances in physics. Structuring 2D TMDC sheets as nanoribbons has tremendous potential for electronic state modification. However, a bottom-up synthesis of long TMDC nanoribbons with high monolayer selectivity on a large scale has not yet been reported yet. In this study, we successfully synthesized long W x O y nanowires and grew monolayer WS 2 nanoribbons on their surface. The supply of source atoms from a vapor-solid bilayer and chemical reaction at the atomic-scale interface promoted a self-limiting growth process. The developed method exhibited a high monolayer selection yield on a large scale and enabled the growth of long (∼100 μm) WS 2 nanoribbons with electronic properties characterized by optical spectroscopy and electrical transport measurements. The produced nanoribbons were isolated from W x O y nanowires by mechanical exfoliation and used as channels for field-effect transistors. The findings of this study can be used in future optoelectronic device applications and advanced physics research.

Objectives: A "resect-and-discard" strategy has been proposed for diminutive adenomas in the colorectum. However, this strategy is sometimes difficult to implement because of the lack of confidence in differentiating low-grade adenoma (LGA) from advanced lesions such as high-grade adenoma or carcinoma. To perform real-time precise diagnosis of LGA with high confidence, we assessed whether endocytoscopy (EC) diagnosis, considering normal pit-like structure (NP-sign), an excellent indicator of LGA, could have additional diagnostic potential compared with conventional modalities., Methods: All the neoplastic lesions that were observed by non-magnifying narrow-band imaging (NBI), magnifying NBI (M-NBI), magnifying pit pattern, and EC prior to pathological examination between 2005 and 2018 were retrospectively investigated. The neoplastic lesions were classified into two categories: LGA and other neoplastic lesions. We assessed the differential diagnostic ability of EC with NP-sign between LGA and other neoplastic lesions compared with that of NBI, M-NBI, pit pattern, and conventional EC in terms of sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC)., Results: A total of 1376 lesions from 1097 patients were eligible. The specificity (94.9%), accuracy (91.5%), and area under the receiver operating characteristic curve (0.95) of EC with NP-sign were significantly higher than those of NBI, M-NBI, pit pattern, and conventional EC., Conclusions: EC diagnosis with NP-sign has significantly higher diagnostic performance for predicting colorectal LGA compared with the conventional modalities and enables stratification of neoplastic lesions for "resect-and-discard" with higher confidence., Competing Interests: None., (© 2023 The Authors. DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Purpose: Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for early gastric cancer. However, perforations may happen and cause peritonitis during ESD. Thus, there is a potential demand for a computer-aided diagnosis system to support physicians in ESD. This paper presents a method to detect and localize perforations from colonoscopy videos to avoid perforation ignoring or enlarging by ESD physicians., Method: We proposed a training method for YOLOv3 by using GIoU and Gaussian affinity losses for perforation detection and localization in colonoscopic images. In this method, the object functional contains the generalized intersection over Union loss and Gaussian affinity loss. We propose a training method for the architecture of YOLOv3 with the presented loss functional to detect and localize perforations precisely., Results: To qualitatively and quantitatively evaluate the presented method, we created a dataset from 49 ESD videos. The results of the presented method on our dataset revealed a state-of-the-art performance of perforation detection and localization, which achieved 0.881 accuracy, 0.869 AUC, and 0.879 mean average precision. Furthermore, the presented method is able to detect a newly appeared perforation in 0.1 s., Conclusions: The experimental results demonstrated that YOLOv3 trained by the presented loss functional were very effective in perforation detection and localization. The presented method can quickly and precisely remind physicians of perforation happening in ESD. We believe a future CAD system can be constructed for clinical applications with the proposed method., (© 2023. CARS.)

The number of artificial intelligence (AI) tools for colonoscopy on the market is increasing with supporting clinical evidence. Nevertheless, their implementation is not going smoothly for a variety of reasons, including lack of data on clinical benefits and cost-effectiveness, lack of trustworthy guidelines, uncertain indications, and cost for implementation. To address this issue and better guide practitioners, the World Endoscopy Organization (WEO) has provided its perspective about the status of AI in colonoscopy as the position statement. WEO Position Statement: Statement 1.1: Computer-aided detection (CADe) for colorectal polyps is likely to improve colonoscopy effectiveness by reducing adenoma miss rates and thus increase adenoma detection; Statement 1.2: In the short term, use of CADe is likely to increase health-care costs by detecting more adenomas; Statement 1.3: In the long term, the increased cost by CADe could be balanced by savings in costs related to cancer treatment (surgery, chemotherapy, palliative care) due to CADe-related cancer prevention; Statement 1.4: Health-care delivery systems and authorities should evaluate the cost-effectiveness of CADe to support its use in clinical practice; Statement 2.1: Computer-aided diagnosis (CADx) for diminutive polyps (≤5 mm), when it has sufficient accuracy, is expected to reduce health-care costs by reducing polypectomies, pathological examinations, or both; Statement 2.2: Health-care delivery systems and authorities should evaluate the cost-effectiveness of CADx to support its use in clinical practice; Statement 3: We recommend that a broad range of high-quality cost-effectiveness research should be undertaken to understand whether AI implementation benefits populations and societies in different health-care systems., (© 2023 Japan Gastroenterological Endoscopy Society.)

Background: Homonymous hemianopsia (HH) corresponds to vision loss in one hemi-field secondary to retro-chiasmal injury. Patients with HH experience difficulties in scanning and orientation in their environment. Near vision daily activities such as reading can also be impaired. There is an unmet need for standardized vision rehabilitation protocols for HH. We investigated the effectiveness of biofeedback training (BT), used for vision rehabilitation in patients with central vision loss, in individuals with HH., Methods: In this prospective pilot pre/post study, 12 participants, with HH consecutive to brain injury, performed 5 weekly BT sessions for 20 min each under supervision using the Macular Integrity Assessment microperimeter. BT consisted of relocation of the retinal locus 1-4° toward the blind hemi-field. Outcomes measured post-BT were paracentral retinal sensitivity, visual acuity (near vision), fixation stability, contrast sensitivity, reading speed, and visual functioning questionnaire. Statistical analysis was performed using Bayesian paired t-tests., Results: Paracentral retinal sensitivity significantly increased by 2.7 ± 0.9 dB in the treated eye in 9/11 of the participants. Significant improvements with medium-to-large effect size were observed for fixation stability (8/12 participants), contrast sensitivity (6/12 participants) and near vision visual acuity (10/12 participants). Reading speed increased by 32.5 ± 32.4 words per minute in 10/11 participants. Quality of vision scores improved significantly with large effect size for visual ability, visual information and mobility., Conclusion: BT led to encouraging improvements in visual functions and functional vision in individuals with HH. Further confirmation with larger trials is required., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Misawa, Pyatova, Sen, Markowitz, Markowitz, Reber and Daibert-Nido.)

Background and Aims: Artificial intelligence (AI) tools aimed at improving polyp detection have been shown to increase the adenoma detection rate during colonoscopy. However, it is unknown how increased polyp detection rates by AI affect the burden of patient surveillance after polyp removal., Methods: We conducted a pooled analysis of 9 randomized controlled trials (5 in China, 2 in Italy, 1 in Japan, and 1 in the United States) comparing colonoscopy with or without AI detection aids. The primary outcome was the proportion of patients recommended to undergo intensive surveillance (ie, 3-year interval). We analyzed intervals for AI and non-AI colonoscopies for the U.S. and European recommendations separately. We estimated proportions by calculating relative risks using the Mantel-Haenszel method., Results: A total of 5796 patients (51% male, mean 53 years of age) were included; 2894 underwent AI-assisted colonoscopy and 2902 non-AI colonoscopy. When following U.S. guidelines, the proportion of patients recommended intensive surveillance increased from 8.4% (95% CI, 7.4%-9.5%) in the non-AI group to 11.3% (95% CI, 10.2%-12.6%) in the AI group (absolute difference, 2.9% [95% CI, 1.4%-4.4%]; risk ratio, 1.35 [95% CI, 1.16-1.57]). When following European guidelines, it increased from 6.1% (95% CI, 5.3%-7.0%) to 7.4% (95% CI, 6.5%-8.4%) (absolute difference, 1.3% [95% CI, 0.01%-2.6%]; risk ratio, 1.22 [95% CI, 1.01-1.47])., Conclusions: The use of AI during colonoscopy increased the proportion of patients requiring intensive colonoscopy surveillance by approximately 35% in the United States and 20% in Europe (absolute increases of 2.9% and 1.3%, respectively). While this may contribute to improved cancer prevention, it significantly adds patient burden and healthcare costs., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Ludwig angina cases that could only be recognized by unmasking., Competing Interests: The other authors have stated explicitly that there are no conflicts of interest in connection with this article., (© 2023 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.)

The influx of intestinal bacteria-derived lipopolysaccharide (LPS) into the blood has attracted attention as a cause of diseases. The aim of this study is investigating the associations between the influx of LPS, dietary factors, gut microbiota, and health status in the general adult population. Food/nutrient intake, gut microbiota, health status and plasma LPS-binding protein (LBP; LPS exposure indicator) were measured in 896 residents (58.1% female, mean age 54.7 years) of the rural Iwaki district of Japan, and each correlation was analyzed. As the results, plasma LBP concentration correlated with physical (right/left arms' muscle mass [ β = -0.02, -0.03]), renal (plasma renin activity [ β = 0.27], urine albumin creatinine ratio [ β = 0.50]), adrenal cortical (cortisol [ β = 0.14]), and thyroid function (free thyroxine [ β = 0.05]), iron metabolism (serum iron [ β = -0.14]), and markers of lifestyle-related diseases (all Q s < 0.20). Plasma LBP concentration were mainly negatively correlated with vegetables/their nutrients intake (all βs ≤ -0.004, Q s < 0.20). Plasma LBP concentration was positively correlated with the proportion of Prevotella ( β = 0.32), Megamonas ( β = 0.56), and Streptococcus ( β = 0.65); and negatively correlated with Roseburia ( β = -0.57) (all Q s < 0.20). Dietary factors correlated with plasma LBP concentration correlated with positively (all β s ≥ 0.07) or negatively (all β s ≤ -0.07) the proportion of these bacteria (all Q s < 0.20). Our results suggested that plasma LBP concentration in the Japanese general adult population was associated with various health issues, and that dietary habit was associated with plasma LBP concentration in relation to the intestinal bacteria.

Competing Interests: There are no conflicts of interest.