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EMR is the mainstay of therapy for large colorectal polyps. Local recurrence after EMR is common and can be reduced using margin ablation. Our aim was to evaluate recurrence rates when using hybrid argon plasma coagulation (h-APC) ablation after EMR.Adult patients (aged 18-89 years) undergoing EMR of nonpedunculated colorectal polyps ≥20 mm were enrolled in a prospective multicenter study. h-APC was used to ablate all defect margins and also the resection surface in selected cases. The primary study outcome was recurrence rates found during the first follow-up colonoscopy. Secondary outcomes were technical success and adverse event rates.EMR with h-APC ablation was used in 101 polyps (84 patients, 46.4% women). EMR with h-APC ablation was technically successful in all cases (median EMR time, 15 minutes; median h-APC ablation time, 4 minutes). Median polyp size was 30 mm (range, 20-60). Resected polyps were either adenomas (68/101 [67.3%]), sessile serrated lesions (27/101 [27%]), or adenocarcinomas (6/101 [6%]). The post-EMR recurrence rate was 2.2% (2/91) (95% confidence interval, .27-7.71). All 6 patients with cancer (intramucosal cancer, 4; T1sm cancer, 2) were found to have complete eradication of the primary tumor after EMR with h-APC, and none had lymph node metastasis. Four serious adverse events occurred in 3 patients (2 delayed bleeding [2.4%], 1 abdominal pain [1.2%], and 1 microperforation [1.2%]. All serious adverse events resolved with either endoscopic or antibiotic treatment only.EMR with h-APC showed a high technical success rate, low adverse event rate, and very low post-EMR recurrence rates. (Clinical trial registration number: NCT04015765.).

Complete polyp resection is the main goal of endoscopic removal of large colonic polyps. Resection techniques have evolved in recent years and endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR) with margin ablation, cold snare polypectomy (CSP), cold EMR, and underwater EMR have been introduced. Yet, efficacy of these techniques with regard to local recurrence rates (LRRs)To analyze LRR of large colonic polyps in a systematic review and meta-analysis.MEDLINE, EMBASE, EBM Reviews, and CINAHL were searched for prospective studies reporting LRR or incomplete resection rate (IRR) after colonic polypectomy of polyps ≥ 10 mm, published between January 2011 and July 2021. Primary outcome was LRR for polyps ≥ 10 mm.Six thousand nine hundred and twenty-eight publications were identified, of which 34 prospective studies were included. LRR for polyps ≥ 10 mm at up to 12 mo' follow-up was 11.0% (95%CI, 7.1%-14.8%; 15 studies; 4904 polyps). ESD (1.7%; 95%CI, 0%-3.4%; 3 studies, 221 polyps) and endoscopic mucosal resection with margin ablation (3.3%; 95%CI, 2.2%-4.5%; 2 studies, 947 polyps) significantly reduced LRRLRR is significantly lower after ESD or EMR with routine margin ablation; thus, these techniques should be considered standard for endoscopic removal of large colorectal polyps. Other techniques, such as CSP, cold EMR, and underwater EMR require further evaluation in prospective studies before their routine implementation in clinical practice can be recommended.

Background and Aims Optical polyp diagnosis using image-enhanced endoscopy (IEE) allows for real-time histology prediction of colorectal polyps. The aim of this study was to evaluate a recently introduced IEE modality (Optivista [OV]; Pentax Medical, Tokyo, Japan) in a randomized controlled trial. Methods In a prospective cohort of subjects (ages 45-80 years) undergoing elective screening, surveillance, or diagnostic colonoscopy, all colorectal polyps between 1 and 5 mm underwent IEE assessment. Study subjects were randomized before their colonoscopy procedure to undergo optical polyp diagnosis using either OV IEE or iScan (IS) IEE. A validated IEE scale (NBI International Colorectal Endoscopic classification) was used for optical polyp diagnosis. The primary outcome was the agreement of surveillance intervals determined when using OV IEE compared with IS IEE in reference with pathology-based surveillance intervals. Secondary outcomes were the percentage of surveillance intervals that could be given on the same day as the procedure, percentage of pathology tests avoided, diagnostic performance, and negative predictive value (NPV) of optical diagnosis for rectosigmoid adenomas. Results Four hundred ten patients were enrolled in the trial. The polyp detection rate was 58.6%, and the adenoma detection rate was 38.8%. The proportion of correct surveillance interval assignment when using OV or IS IEE was 96.5% versus 96.0% (P = .75). A total of 65.1% of patients could be given same-day surveillance intervals when using OV IEE versus 73.1% for IS IEE (P = .07). The NPV for rectosigmoid adenomas (including sessile serrated adenomas) was 97.5% when using OV IEE and 88.2% when using IS IEE. Using high-confidence optical diagnosis instead of pathology would have resulted in a 44.3% elimination of required pathology examinations for OV IEE versus 52.8% for IS IEE (P = .34). Conclusions Optical diagnosis using OV and IS IEE both surpassed the 90% benchmark of surveillance interval assignment, and no significant difference with regard to correct surveillance interval assignment was found. OV IEE surpassed the ≥90% NPV for rectosigmoid adenomas, whereas IS IEE did not. (Clinical trial registration number: NCT 03515343.)

Background Virtual autopsy by using CT imaging has been introduced as an alternative to conventional autopsy and has resulted in an increase in acceptance of autopsy by relatives. Because direct inspection and tissue acquisition is not possible by imaging alone, various endoscopic techniques can be considered of complementary usefulness. Objectives We present the first series of sequential endoscopic techniques including natural orifice transluminal access for minimally invasive autopsy. Setting University hospital, legal medicine department. Subjects Twenty deceased subjects. Intervention Various flexible endoscopic modalities including EUS, with biopsy or EUS-guided FNA, were attempted. This included transluminal intra-abdominal endoscopic exploration with tissue sampling in a few cases. Main Outcome Measurements Completeness of inspection of the luminal and extraluminal cavity as well as tissue acquisition. Results Complete upper GI endoscopy was performed in 17 of 20 and EUS in 8 of 8 cases. In addition, transgastric intra-abdominal endoscopy was successfully performed in 5 cases. Adequate histology from biopsy and EUS-guided puncture could be obtained in case of short time intervals post mortem. In 1 case, a rupture of the gastric cardia with bleeding was diagnosed as a significant unexpected finding. New minor pathological findings were revealed on EGD (6/17), GI EUS (3/8), and transgastric inspection (4/5). Limitations Limited number of cases for all procedures. Conclusion Minimally invasive autopsy by using multiple endoscopic techniques for imaging and tissue acquisition is feasible. The significant value of this technique, in combination with virtual autopsy compared with classic autopsy, warrants further evaluation.

Background and Aims The adenoma detection rate (ADR) is an important colonoscopy quality parameter. A longer withdrawal time is associated with increased adenoma detection; however, the effect of cecal insertion time on adenoma detection is unclear. The aim of this study was to evaluate if cecal insertion time is associated with adenoma detection. Methods The study included 50- to 89-year-old subjects undergoing an elective outpatient colonoscopy as part of a randomized trial on cap-assisted colonoscopy. The primary outcome was the adjusted mean number of adenomas per patient across quartiles of lengthening patient insertion times. Secondary outcomes included the mean number of advanced adenomas, ADR, and advanced ADR. Adjusted regression analysis was applied to assess for a possible trend. Results Among 1043 included study subjects, the median cecal insertion time was 5.3 minutes (interquartile range [IQR], 3.5-8.1) and the median withdrawal time was 8.6 minutes (IQR, 7.1-10.7). Cecal insertion time was not associated with withdrawal time ( P = .950). The mean number of adenomas per patient decreased across increasing insertion time quartiles from 1.1 to .7, corresponding to a 11% decline per quartile ( P = .031). Similarly, the number of advanced adenomas decreased from .15 to .06, corresponding to a 7% decline per quartile ( P = .013). The observed decrease in adenoma detection was similar for proximal and distal adenomas. Endoscopists' individual insertion times were not associated with adenoma detection. Conclusions A longer cecal insertion time was associated with a decreased detection of adenomas and advanced adenomas. A long insertion time may be a marker for a more difficult examination that requires a longer withdrawal time to assure adequate examination and adenoma detection. (Clinical trial registration number: NCT01935180.)

Background New therapies are needed for pancreatic cancer. Objective To determine the feasibility and safety of a new endoscopic treatment. Secondary endpoints were to determine effects on tumor growth measured with CT scan and to find the overall survival. Design A cohort study of patients with local progression of advanced pancreatic adenocarcinoma after neoadjuvant therapy. The cryotherm probe (CTP), a flexible bipolar device that combines radiofrequency with cryogenic cooling, was used under EUS guidance. Setting San Raffaele Hospital, Milan, Italy; University Medical Center, Hamburg-Eppendorf, Germany. Patients A total of 22 patients (male/female 11/11; mean age 61.9 years) were enrolled from September 2009 to May 2011. Intervention Radiofrequency heating: 18 W; pressure for cooling: 650 psi (Pounds per Square Inch); application time: depending on tumor size. Main Outcome Measurements Feasibility was evaluated during the procedure. A clinical and radiologic follow-up was planned. Results The CTP was successfully applied in 16 patients (72.8%); in 6 it was not possible because of stiffness of the GI wall and of the tumor. Amylase arose in 3 of 16 patients; none had clinical signs of pancreatitis. Late complications arose in 4 cases: 3 were mostly related to tumor progression. Median postablation survival time was 6 months. A CT scan was performed in all patients, but only in 6 of 16 was it possible to clearly define the tumor margins after ablation. In these patients, the tumor appeared smaller compared with the initial mass (P = .07). Limitations Small sample of patients, difficulty of objectifying the size of the ablated zone by CT scan. Conclusion EUS-guided CTP ablation is feasible and safe. Further investigations are needed to demonstrate progression-free survival and local control.

Background Although endoscopic resection techniques have been established for definitive therapy of mucosal neoplasia, complete histopathological assessment or resection of subepithelial lesions is not reliably possible. Objective To overcome these limitations, a novel endoscopic full-thickness resection (EFTR) and closure technique was developed. Design Animal survival study. Animals Eight female domestic pigs. Interventions Two-centimeter artificial distal colonic lesions were created endoscopically. EFTR of the lesions was attempted using a prototype device, which consists of a large transparent plastic cap with a preloaded snare and a modified over-the-scope clip. After the procedure, half of the animals were killed after 7 days, and the other half after 28 days. Main Outcome Measurements Complete resection (all markings included in the specimen), technical success, complication rates, and wound healing on follow-up autopsy and histology. Results EFTR of healthy colonic tissue was possible in all cases; 2 additional clips had to be placed for complete closure in 1 case. In 1 animal, the preloaded closure failed, and the animal was prematurely killed. All other animals had an uneventful postoperative course. Necropsy and histopathological evaluation demonstrated well-healed resection sites with no evidence of intra-abdominal infection or inadvertent organ inclusion. Limitations Animal model, resection of healthy tissue. Conclusion This novel device allows for reliable full-thickness resection and closure of 2-cm specimens of the colonic wall in a single procedure as well as reliable wound healing of EFTR defects.

Background Endoscopic full-thickness resection (eFTR) is a minimally invasive method for en bloc resection of GI lesions. Objective The aim of this pilot study was to evaluate the feasibility of a grasp-and-snare technique for eFTR combined with an over-the-scope clip (OTSC) for defect closure. Design Nonsurvival animal study. Setting Animal laboratory. Animals Fourteen female domestic pigs. Interventions The eFTR was performed in porcine colons using a novel tissue anchor in combination with a standard monofilament snare and 14 mm OTSC. In the first group (n = 20), closure of the colonic defects with OTSC was attempted after the resection. In the second group (n = 8), an endoloop was used to secure the resection base before eFTR was performed. Results In the first group (n = 20), eFTR specimens ranged from 2.4 to 5.5 cm in diameter. Successful closure was achieved in 9 out of 20 cases. Mean burst pressure for OTSC closure was 29.2 mm Hg (range, 2-90; SD, 29.92). Injury to adjacent organs occurred in 3 cases. Lumen obstruction due to the OTSC closure occurred in 3 cases. In the second group (n = 8), the diameter of specimens ranged from 1.2 to 2.2 cm. Complete closure was achieved in all cases, with a mean burst pressure of 76.6 mm Hg (range, 35-120; SD, 31). Lumen obstruction due to the endoloop closure occurred in one case. No other complications or injuries were observed in the second group. Limitations Nonsurvival setting. Conclusions Colonic eFTR using the grasp-and-snare technique is feasible in an animal model. Ligation of the resection base with an endoloop before eFTR seems to reduce complication rates and improve closure success and leak test results despite yielding smaller specimens.

Background and Aims The recently developed technique of per-oral endoscopic myotomy (POEM) has been shown to be effective for the therapy of esophageal motility disorders. Limited information is available about POEM adverse events (AEs). Methods POEM was performed on 241 patients (58% male; mean age, 47.4 ± 16.4 years) under general anesthesia over 61 months. The main outcome was the rate of intra- and post-procedural AEs. Post-procedural checks comprised clinical and laboratory examinations and endoscopy, with further follow-ups performed at 3, 6, and 12 months. Results Of the 241 procedures, 238 were successfully completed (mean procedure time, 100.2 ± 39.5 min). Reasons for abortion were excessive submucosal fibrosis preventing submucosal tunneling. Three patients had severe procedural-related AEs (SAE rate, 1.2%); 1 case of pneumothorax required intra-procedural drainage, and 2 patients had delayed SAEs (1 ischemic gastric cardia perforation and 1 hemothorax, both leading to surgery). The overall rate of minor AEs was 31.1%, mainly prolonged intra-procedural bleeding (>15 min hemostasis) and defects of the mucosa overlying the tunnel; none led to clinically relevant signs or symptoms. Patients experiencing any AE had a significantly prolonged hospital stay ( P = .037) and a trend toward prolonged procedure time ( P = .094). Neck/upper thoracic emphysema and free abdominal air were noted in 31.5% and 35.7%, respectively (95.3% drained), but without relevant sequelae. Conclusions POEM has a low rate of SAEs; minor AEs are more frequent but lack a consistent definition. Therefore, based on our experience and literature analysis, we suggest a classification of AEs for POEM. (Clinical trials registration number: NCT01405417.)

Background One of the main challenges of natural orifice transluminal endoscopic surgery (NOTES) remains the development of safe and reliable tools. In this study, we introduce the first absorbable ligatures specifically designed for NOTES. Objective To determine the feasibility of a new absorbable ligation loop (NOTES loop) and to compare this new type of suture with the nonabsorbable loop (Endoloop) most commonly used until now. Design Prospective, comparative animal trial/survival animal study (observation period 21 days) with subsequent histopathological assessment (blinded observer design). Setting Veterinarian center. Subjects This study used 12 female domestic piglets. Intervention Every pig underwent two transgastric uterine horn ligations, one with an absorbable loop and one with a nonabsorbable loop. Additional uterine horn resections on both sides were done on 6 pigs. Main Outcome Measurements Intervention success, loop reliability, foreign-body reaction, extent of inflammatory response (μm). Results Transgastric flexible intra-abdominal ligation of the uterine horns was performed safely with both loops in all cases. During a 3-week observation period, 11 of 11 NOTES loops and 10 of 11 Endoloops were reliable. Microscopically, foreign-body reaction was minimal around both sutures ( P = .303). The overall inflammatory response was larger around the Endoloops ( P = .046). Uterine horn resection had an influence on the extent of inflammation. Limitations Animal study. Conclusion Ligation was feasible with both loops. The absorbable loops were reliable during a 3-week observation period and can be recommended for use during NOTES appendectomies.

Background Endoscopic submucosal dissection (ESD) is a minimally invasive method for en bloc removal of GI lesions. Current ESD methods and devices have limitations, including long procedure times, technical difficulty, safety, and availability. Objective The aim of this study was to evaluate a blunt submucosal dissection technique and compare it with ESD by using the insulated-tip (IT) knife. Design Randomized, controlled, animal study. Setting Animal facility laboratory. Intervention Twelve gastric lesions were marked by using electrocautery. After submucosal injection, a circumferential mucosal incision was created. ESD was then performed by using either the IT knife 2 (n = 6) or the flexible endoscopic Maryland dissector (n = 6). Main Outcome Measurements Median time for IT knife ESD versus median time for Maryland dissector ESD. Results Median time (IQR) for IT knife ESD was 43 minutes (range 36-50 minutes). The median time (IQR) for Maryland dissector ESD was 32 minutes (range 22-41 minutes; P = .09). The resection specimens obtained with the Maryland dissector tended to be larger, with a median (IQR) of 20.2 cm 2 (range 16.4-23 cm 2 ) when compared with specimens resected with the IT knife, which yielded a median (IQR) resection area of 15.9 cm 2 (14.8-18.7 cm 2 ; P = .08). Complete en-bloc resection including all of the electrocautery markings was achieved in all cases. There were no perforations. There were two minor hemorrhages in the IT knife group and 3 in the Maryland dissector group. Limitations Nonsurvival setting, small sample size. Conclusion The flexible Maryland dissector was demonstrated to be efficient, safe, and feasible for facilitating gastric ESD in a live animal model.

Esophageal intramural pseudodiverticulosis is a rare idiopathic condition characterized by multiple saccular diverticula of the esophageal wall created by dilated ducts of submucosal glands. The diverticula arise in thickened mucosa and submucosa, while the underlying muscle layer remains intact. To the best of our knowledge, no reports exist to date of acute esophageal dissection with perforation after barotrauma in a patient with esophageal pseudodiverticulosis. Spontaneous esophageal perforation or Boerhaave’s syndrome, a life-threatening disease, seems to be the next related etiology with respect to treatment strategies. Despite advances in surgery and critical care, esophageal perforation continues to carry a high morbidity and mortality. Although endoscopic stenting has been successfully performed, surgical repair is still the mainstay of therapy in patients who are seen within 24 hours of perforation.

The full-thickness Plicator allows transmural suturing at the gastroesophageal (GE) junction to restructure the antireflux barrier. Studies of the Plicator procedure to date have been limited to placement of a single transmural suture to create the endoscopic gastroplication.The purpose of this study was to evaluate the safety and efficacy of placing multiple transmural sutures for the treatment of GERD.Open-label, prospective, multicenter study.Four tertiary-referral centers.Subjects with symptomatic GERD who require daily maintenance proton pump inhibitor (PPI) therapy. Study exclusions were hiatal hernia3 cm, grades III and IV esophagitis, Barrett's epithelium, and esophageal dysmotility.Forty-one patients received two or more transmural sutures placed linearly in the anterior gastric cardia approximately 1 cm below the GE junction.Six months after the procedure, median GERD-health-related quality of life (HRQL) improved 76% compared with off-medication baseline (6.0 vs 25.0, P.001), with 75% of patients (32/40) achieving50% improvement in their baseline GERD-HRQL score. Six months after the procedure, daily PPI therapy was eliminated in 70% of patients (28/40). Heartburn symptoms improved 80% compared with off-medication baseline (16.0 vs 84.0, P.001). Median esophagitis grade improved 75% compared with baseline (0.0 vs 1.0, P = .005). Esophageal pH assessed as median distal esophageal-acid exposure (percentage time pH4.0) improved 38% compared with baseline (9.0 vs 11.0, P.020; nominal P value for a single statistical test: significance removed upon the Bonferroni adjustment for multiple testing of data) and manometric outcomes were also improved compared with baseline (median lower esophageal sphincter resting pressure improved 25% [10.0 vs 6.0, P.017; nominal P value for a single statistical test: significance removed upon the Bonferroni adjustment for multiple testing of data]) and median amplitude of contraction improved 11% (70.0 vs 62.0, P.037; nominal P value for a single statistical test: significance removed upon the Bonferroni adjustment for multiple testing of data).Small sample size. No randomized comparison with a single implant group.Endoscopic full-thickness plication with multiple serially placed implants was safe and effective in reducing GERD symptoms, medication use, esophageal-acid exposure, and esophagitis.

Background The endoscopic full-thickness Plicator device was initially developed to provide an endoscopic treatment option for patients with GERD. Because the endoscopic full-thickness Plicator enables rapid and easy placement of transmural sutures, comparable with surgical sutures, we used the Plicator device for endoscopic treatment or prevention of GI-wall defects. Objective To describe the outcomes and complications of endoscopic full-thickness suturing during EMR and for the treatment of gastric-wall defects. Design A report of 4 cases treated with the endoscopic full-thickness suturing between June 2006 and April 2007. Setting A large tertiary-referral center. Patients Four subjects received endoscopic full-thickness suturing. The subjects were women, with a mean age of 67 years. Interventions Of the 4 subjects, 3 received endoscopic full-thickness suturing during or after an EMR. One subject received endoscopic full-thickness suturing for treatment of a fistula. Main Outcome Measurements Primary outcome measurements were clinical procedural success and procedure-related adverse events. Results The mean time for endoscopic full-thickness suturing was 15 minutes. In all cases, GI-wall patency was restored or ensured, and no procedure-related complications occurred. All subjects responded well to endoscopic full-thickness suturing. Limitations The resection of one GI stromal tumor was incomplete. Because of the Plicator's 60F distal-end diameter, endoscopic full-thickness suturing could only be performed with the patient under midazolam and propofol sedation. The durable Plicator suture might compromise the endoscopic follow-up after EMR. Conclusions The endoscopic full-thickness Plicator permits rapid and easy placement of transmural sutures and seems to be a safe and effective alternative to surgical intervention to restore GI-wall defects or to ensure GI-wall patency during EMR procedures.

received POEM. Only one case received laparoscopic Heller Dor surgery because of patient’s wish. Male was 127 cases and female was 173 cases. Average age was 45 y.o. (from 3 to 87 y.o.). Suffering period from dysphagia was 10.1 years on average (0.4-62.4). 41 cases of sigmoid achalasia were involved. Ten consecutive surgical failures also received POEM. Clinical Results: Initial success rate of POEM was 98.2% (Eckerdt score 3) and final success rate was 100%. In 5 cases second POEM procedure was successfully carried out. The reasons for second POEM procedure were either incomplete myotomy at primary POEM (2 cases) or advanced sigmoid achalasia (3 cases). Second POEM improved Eckerd score below 3 in all cases. Operating time was 110.2 (50-245 min). Length of myotomy was 14.1 cm on average (esophagus 11.2 cm, stomach 2.9 cm). Major complication was nothing. 9 minor complications were experienced; one pneumothorax due to air insufflation, one intramucosal hematoma, one local peritonitis at lessor omentum and 6 mucosal injuries during the procedure. All of them are conservatively treated. Eckerdt score was 6.13 before POEM and dramatically decreased 1.37 in 2 months later, and 1.33 in one year later (statistically significant, Wilcoxon, Signed-ranks test, P 0.01). LES resting pressure was 27.3 mmHg before POEM and reduced to 13.4 mmHg after POEM (statistically significant, Paired T test, P 0.01). 4.9% in 300 cases received regular dose PPI to control post-POEM GERD. In all cases GERD symptom were easily controlled. There is no severe GERD which needs laparoscopic fundoplication. Conclusions: Final success rate (Eckerdt score 3) of POEM in 300 cases was 100% and middle-term outcome of POEM was excellent with no recurrence of dysphagia.