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Background and study aims: Distinguishing pancreatic adenocarcinoma from other pancreatic masses remains challenging with current imaging techniques. This prospective study aimed to evaluate the accuracy of a new procedure, imaging the microcirculation pattern of the pancreas by contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) with a new Olympus prototype echo endoscope. Patients and methods: 35 patients presenting with solid pancreatic lesions were prospectively enrolled. All patients had conventional B mode and power Doppler EUS. After an intravenous bolus injection of 2.4 ml of a second-generation ultrasound contrast agent (SonoVue) CEH-EUS was then performed with a new Olympus prototype echo endoscope (xGF-UCT 180). The microvascular pattern was compared with the final diagnosis based on the pathological examination of specimens from surgery or EUS-guided fine-needle aspiration (EUS-FNA) or on follow-up for at least 12 months. Results: The final diagnoses were: 18 adenocarcinomas, 9 neuroendocrine tumors, 7 chronic pancreatitis, and 1 stromal tumor. Power Doppler failed to display microcirculation, whereas harmonic imaging demonstrated it in all cases. Out of 18 lesions with a hypointense signal on CEH-EUS, 16 were adenocarcinomas. The sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy of hypointensity for diagnosing pancreatic adenocarcinoma were 89 %, 88 %, 88 %, 89 %, and 88.5 %, compared with corresponding values of 72 %, 100 %, 77 %, 100 %, and 86 % for EUS-FNA. Of five adenocarcinomas with false-negative results at EUS-FNA, four had a hypointense echo signal at CEH-EUS. Conclusions: CEH-EUS with the new Olympus prototype device successfully visualizes the microvascular pattern in pancreatic solid lesions, and may be useful for distinguishing adenocarcinomas from other pancreatic masses. [ABSTRACT FROM AUTHOR]

Background and Aims: We aimed to evaluate the feasibility, safety and efficacy of endoscopic submucosal dissection for recurrent rectal neoplastic lesions after transanal microsurgery of superficial rectal neoplasms., Methods: Multicenter retrospective study., Main Outcomes: recurrence at first endoscopic follow-up, En bloc, R0 and curative resections., Results: 39 patients were included. 71 % percent of lesions were located in the lower rectum, 57 % reached the pectineal line. 67 % were laterally spreading tumor granular type, 33 % were protruding lesions. Median size was 41 mm (IQR 30 - 60). Median operation time was 70 min (IQR 35 - 97). 92 % were successfully resected en bloc. R0 and curative resection rates were 77 % and 71 %, respectively. Perirectal fat was visualized in 10 patients, none of them required surgery. One significant hematochezia (3 %), two stenosis (6 %) and one untreatable anal incontinence (3 %) occurred. Median hospital stay after endoscopic submucosal dissection was 2 days (IQR 1-2). Median period for the first endoscopy follow-up was 6 months (IQR 4-8). A single post endoscopic submucosal dissection recurrence adenoma was found during follow-up (3 %), occurring after a non-en bloc resection., Conclusion: Endoscopic submucosal dissection is a good option for safely achieving high rates of complete en bloc resection in cases of recurrent superficial rectal tumor after transanal microsurgery., Competing Interests: Conflict of interest - Ali Jaafar has no conflict of interest. - Xavier Dray is co-founder and shareholder of Augmented Endoscopy. He has received consultant fees from Norgine and Provepharm. He has received lecture fees from Fujifilm, Medtronic, MSD, Norgine, Pfizer and Sandoz. - Jeremie Jacques has received workshop fees from Olympus, Fujifilm, Erbe, Pentax and Boston. He has received hospitality from Janssen and Abbvie. - Romain Legros has received workshop fees from Olympus, Fujifilm, Erbe, Pentax and Boston. - Sarah Leblanc has received workshop fees from Olympus and Boston. She has received congresses fees from Fujifilm. She is laboratory board for Alfasigma. - Vincent Lepilliez has received workshops fees from Olympus. He has refunded fees from Medtronic on JFHOD 2023. - Arthur Berger has received fees from Fujifilm, Norgine, Creo medical and Janssen. - Edouard Chabrun has received workshops fees from Norgine. - Yann Le Baleur is expert training consultant for Ovesco Endoscopy and Duomed. - Mathieu Pioche is co-founder of A-TRACT. He has received ESD formation fees from Olympus, Pentax and Erbe. He has received formation fees from Norgine and Provepharm. - Maximilien Barret is consulting for Medtronic, Sanofi and Fujifilm. He has participated in boards for Norgine and Ambu. He has received interventions fees from Dr. Falk Pharma. He organized training sessions for Olympus. He participated in research funding for Pentax - Timothee Wallenhorst, Thibault Degand and Felix Corre had no conflict of interest. - Marion Schaefer has received lecture and workshops fees from Boston scientific, workshop fees from Duomed Endoscopy and Erbe, lecture fees from Norgine, Alfasigma and Ferring. She is consulting for Abbvie. She has received hospitality from Cook, Olympus, Janssen, MSD, Pfizer, Cousin, Ipsen and Takeda., (Copyright © 2024 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Introduction: The adoption of colorectal endoscopic submucosal dissection (ESD) is still limited in the West. A recent randomized trial showed that ESD is more effective and only slightly riskier than piecemeal endoscopic mucosal resection; reproducibility outside expert centers was questioned. We evaluated the results according to the annual case volume in a multicentric prospective cohort., Methods: Between September 2019 and September 2022, colorectal ESD was consecutively performed at 13 participating centers classified as low volume (LV), middle volume (MV), and high volume (HV). The main procedural outcomes were assessed. Multivariate and propensity score matching analyses were performed., Results: Three thousand seven hundred seventy ESDs were included. HV centers treated larger and more often colonic lesions than MV and LV centers. En bloc , R0, and curative resection rates were 95.2%, 87.4%, and 83.2%, respectively, and were higher at HV than at MV and LV centers. HV centers also achieved a faster dissection speed. Delayed bleeding and surgery for complications rates were 5.4% and 0.8%, respectively, without significant differences. The perforation rate (overall: 9%) was higher at MV than at LV and HV centers. Lesion characteristics, but not volume center, were independently associated with both R1 resection and perforation. However, after propensity score matching, R0 rates were significantly higher at HV than at LV centers, and perforation rates were significantly higher at MV than at HV centers., Discussion: Colorectal ESD can be successfully implemented in the West, even in nonexpert centers. However, difficult lesions must still be referred to experts., (Copyright © 2024 by The American College of Gastroenterology.)

Background and Aims: Circumferential endoscopic submucosal dissection (cESD) in the esophagus has been reported to be feasible in small Eastern case series. We assessed the outcomes of cESD in the treatment of early esophageal squamous cell carcinoma (ESCC) in Western countries., Methods: We conducted an international study at 25 referral centers in Europe and Australia using prospective databases. We included all patients with ESCC treated with cESD before November 2022. Our main outcomes were curative resection according to European guidelines and adverse events., Results: A total of 171 cESDs were performed on 165 patients. En bloc and R0 resections rates were 98.2% (95% confidence interval [CI], 95.0-99.4) and 69.6% (95% CI, 62.3-76.0), respectively. Curative resection was achieved in 49.1% (95% CI, 41.7-56.6) of the lesions. The most common reason for noncurative resection was deep submucosal invasion (21.6%). The risk of stricture requiring 6 or more dilations or additional techniques (incisional therapy/stent) was high (71%), despite the use of prophylactic measures in 93% of the procedures. The rates of intraprocedural perforation, delayed bleeding, and adverse cardiorespiratory events were 4.1%, 0.6%, and 4.7%, respectively. Two patients died (1.2%) of a cESD-related adverse event. Overall and disease-free survival rates at 2 years were 91% and 79%., Conclusions: In Western referral centers, cESD for ESCC is curative in approximately half of the lesions. It can be considered a feasible treatment in selected patients. Our results suggest the need to improve patient selection and to develop more effective therapies to prevent esophageal strictures., Competing Interests: Disclosure The following authors disclosed financial relationships: E. R. de Santiago: Consultant for Olympus and Apollo Endosurgery; speaker for Norgine and Casen Recordati. R. E. Pouw: Consultant for Medtronic BV and MicroTech Europe; speaker for Pentax. B. L. A. M. Weusten: Consultant and speaker for Pentax Medical; research grant support from Pentax Medical and Aqua Medical. J. Jacques: Consultant for Olympus, Pentax, Fujifilm, and ERBE Medical; speaker for Janssen. D. Libânio: Speaker for Olympus and Fujifilm Europe. M. Dinis-Robeiro: Consultant for Roche and Medtronic. All other authors disclosed no financial relationships. A. Herreros-de-Tejada: Consultant for Boston Scientific; speaker for Norgine, Creo Medical, Olympus, and Sonoscape., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: We aimed to compare the long-term outcomes of patients with high-risk T1 colorectal cancer (CRC) resected endoscopically who received either additional surgery or surveillance., Methods: We used data from routine care to emulate a target trial aimed at comparing 2 strategies after endoscopic resection of high-risk T1 CRC: surgery with lymph node dissection (treatment group) versus surveillance alone (control group). All patients from 14 tertiary centers who underwent an endoscopic resection for high-risk T1 CRC between March 2012 and August 2019 were included. The primary outcome was a composite outcome of cancer recurrence or death at 48 months., Results: Of 197 patients included in the analysis, 107 were categorized in the treatment group and 90 were categorized in the control group. From baseline to 48 months, 4 of 107 patients (3.7%) died in the treatment group and 6 of 90 patients (6.7%) died in the control group. Four of 107 patients (3.7%) in the treatment group experienced a cancer recurrence and 4 of 90 patients (4.4%) in the control group experienced a cancer recurrence. After balancing the baseline covariates by inverse probability of treatment weighting, we found no significant difference in the rate of death and cancer recurrence between patients in the 2 groups (weighted hazard ratio, .95; 95% confidence interval, .52-1.75)., Conclusions: Our study suggests that patients with high-risk T1 CRC initially treated with endoscopic resection may not benefit from additional surgery., Competing Interests: Disclosure J Albouys: Consultant for Boston Scientific; speaker for Mayoly; ESD training program for Fujifilm and Erbe; conference funding from Amgen. V Lepilliez: Consultant for and endoscopic training from Olympus. G Rahmi: Consultant for Medtronic, Fujifilm, and Apollo Endosurgery. M Barret: Endoscopic training sessions for Olympus; consultant for Fujifilm; research grant from Pentax. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Introduction: When initial resection of rectal neuroendocrine tumors (r-NETs) is not R0, persistence of local residue could lead to disease recurrence. This study aimed to evaluate the interest of systematic resection of non-R0 r-NET scars., Methods: Retrospective analysis of all the consecutive endoscopic revisions and resections of the scar after non-R0 resections of r-NETs., Results: A total of 100 patients were included. Salvage endoscopic procedure using endoscopic submucosal dissection or endoscopic full-thickness resection showed an R0 rate of near 100%. Residual r-NET was found in 43% of cases., Discussion: In case of non-R0 resected r-NET, systematic scar resection by endoscopic full-thickness resection or endoscopic submucosal dissection seems necessary., (Copyright © 2023 by The American College of Gastroenterology.)

Background: Liver cirrhosis and esophageal cancer share several risk factors, such as alcohol intake and excess weight. Endoscopic resection is the gold standard treatment for superficial tumors. Portal hypertension and coagulopathy may increase the bleeding risk in these patients. This study aimed to assess the safety and efficacy of endoscopic resection for early esophageal neoplasia in patients with cirrhosis or portal hypertension., Methods: This retrospective multicenter international study included consecutive patients with cirrhosis or portal hypertension who underwent endoscopic resection in the esophagus from January 2005 to March 2021., Results: 134 lesions in 112 patients were treated, including by endoscopic submucosal dissection in 101 cases (75 %). Most lesions (128/134, 96 %) were in patients with liver cirrhosis, with esophageal varices in 71 procedures. To prevent bleeding, 7 patients received a transjugular intrahepatic portosystemic shunt, 8 underwent endoscopic band ligation (EBL) before resection, 15 received vasoactive drugs, 8 received platelet transfusion, and 9 underwent EBL during the resection procedure. Rates of complete macroscopic resection, en bloc resection, and curative resection were 92 %, 86 %, and 63 %, respectively. Adverse events included 3 perforations, 8 delayed bleedings, 8 sepsis, 6 cirrhosis decompensations within 30 days, and 22 esophageal strictures; none required surgery. In univariate analysis, cap-assisted endoscopic mucosal resection was associated with delayed bleeding ( P  = 0.01)., Conclusions: In patients with liver cirrhosis or portal hypertension, endoscopic resection of early esophageal neoplasia appeared to be effective and should be considered in expert centers with choice of resection technique, following European Society of Gastrointestinal Endoscopy guidelines to avoid undertreatment., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background and study aims What distinguishes endoscopic submucosal dissection (ESD) from endoscopic mucosal resection is the need for three foot pedals to activate the electrosurgical unit, flushing and knife injection. The lack of connection between the various pedals of different shapes and brands leads to numerous pedals displacements and potential mistakes. The aim of this study was to evaluate an Innovative PEdal FIXator (IPEFIX) to reduce pedal mistakes during ESD. Methods This was a prospective, multicenter, randomized study. Consecutive ESD procedures were randomly assigned to two groups: a control group with the three pedals free and the IPEFIX group in which the three pedals were linked by IPEFIX. The main outcome evaluated was the number of foot mistakes (wrong pedal, foot push beside the pedal). Results A total of 107 ESDs were performed by eight experts in five centers. The median number of mistakes per hour of ESD procedure was 0/h in the IPEFIX group and 1.9/h in the control group ( P <0.001). The mean number of times to look down to control the position of the pedals was 2.2/h the IPEFIX group and 7.7/h in the control group ( P <0.001). Mean replacements of the pedals were 0./h in the IPEFIX group and 1.7/h in the control group ( P <0.001). Similar results were obtained in trainees in simulated ESD on animal models. Conclusions IPEFIX is a simple device to connect different pedals during endoscopic procedures. It helps to reduce the numbers of foot mistakes during ESD and improves operator comfort., Competing Interests: Conflict of Interest Dr YZET Clara have financial disclosures with ABBVIE, GALAPAGOS and JANSSEN. Pr PIOCHE Mathieu have participated to training session with Olympus, Pentax, Cook Dr RIVORY Jérôme have participated to training session with Olympus, Cook Dr LEPILLEZ Vincent have participated to training session with Olympus. Dr LEBLANC Sarah have participated to training session with Olympus, Norgine and Ovesco, and gave lecture to Alfasigma Pr JACQUES Jérémie have participated to training session with Olympus, Fuji, Erbe, Pentax and Lumendi, and gave lecture to Abbvie, Janssen, Norgine. Dr WALLENHORST Timothée, GRAINVILLE Thomas, LEGROS Romain, FIGUEIREDO Mariana, PERRON Léa, LAFEUILLE Pierre, MOCHET Mikael, VIRELY Mélia, LEPLAT-BONNEVIALE Peggy have no conflicts of interest or financial ties to disclose, (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background & Aims: Benign biliary strictures (BBS) are complications of chronic pancreatitis (CP). Endotherapy using multiple plastic stents (MPS) or a fully covered self-expanding metal stent (FCSEMS) are acceptable treatment options for biliary obstructive symptoms in these patients., Methods: Patients with symptomatic CP-associated BBS enrolled in a multicenter randomized noninferiority trial comparing 12-month treatment with MPS vs FCSEMS. Primary outcome was stricture resolution status at 24 months, defined as absence of restenting and 24-month serum alkaline phosphatase not exceeding twice the level at stenting completion. Secondary outcomes included crossover rate, numbers of endoscopic retrograde cholangiopancreatography (ERCPs) and stents, and stent- or procedure-related serious adverse events., Results: Eighty-four patients were randomized to MPS and 80 to FCSEMS. Baseline technical success was 97.6% for MPS and 98.6% for FCSEMS. Eleven patients crossed over from MPS to FCSEMS, and 10 from FCSEMS to MPS. For MPS vs FCSEMS, respectively, stricture resolution status at 24 months was 77.1% (54/70) vs 75.8% (47/62) (P = .008 for noninferiority intention-to-treat analysis), mean number of ERCPs was 3.9 ± 1.3 vs 2.6 ± 1.3 (P < .001, intention-to-treat), and mean number of stents placed was 7.0 ± 4.4 vs 1.3 ± .6 (P < .001, as-treated). Serious adverse events occurred in 16 (19.0%) MPS and 19 (23.8%) FCSEMS patients (P = .568), including cholangitis/fever/jaundice (9 vs 7 patients respectively), abdominal pain (5 vs 5), cholecystitis (1 vs 3) and post-ERCP pancreatitis (0 vs 2). No stent- or procedure-related deaths occurred., Conclusions: Endotherapy of CP-associated BBS has similar efficacy and safety for 12-month treatment using MPS compared with a single FCSEMS, with FCSEMS requiring fewer ERCPs over 2 years. (ClinicalTrials.gov, Number: NCT01543256.)., (Copyright © 2021. Published by Elsevier Inc.)

Background and study aims  Endoscopic full-thickness resection allows resection of early gastrointestinal neoplasms not amenable to conventional endoscopic resection techniques, due to their location, presence of submucosal fibrosis, or suspected deep mural invasion. It is typically achieved using a dedicated over-the-scope device (full-thickness resection device or FTRD). The aim of our study was to evaluate the feasibility, safety, and clinical outcomes of endoscopic full-thickness resection using an endoscopic submucosal dissection (ESD) knife. Patients and methods  Consecutive patients who underwent full-thickness endoscopic resection at six tertiary care centers from August 2010 to June 2017 were retrospectively included. We conducted a comparative analysis of patient characteristics, technical success, adverse events, and time to discharge between patients treated by a full-thickness resection using an ESD knife. Results  Twenty-one procedures were performed using an ESD knife. En-bloc resection and R0 resection rates were 95.2 % and 65 %, respectively. Clinical symptoms of perforation occurred in 66.7 %. There was no need for surgery or additional endoscopic procedures. Conclusion  Endoscopic full-thickness resection of early colorectal neoplasms using an ESD knife might be feasible and safe. It allows complete resection of lesions with no limitation in size. The technique may be preferable to an other-the-scope resection device in lesions larger than 20 mm, and to surgery in selected cases of low-risk T1 colorectal carcinomas, non-lifting adenomas, submucosal tumors, or technically challenging lesion locations., Competing Interests: Competing interests The authors declare that they have no conflict of interest.

Background: Current guidelines recommend performing esophagectomy after endoscopic resection for early esophageal cancer when the risk of lymph node metastasis or residual cancer is found to be significant and endoscopic treatment is therefore noncurative. Our aim was to assess the safety and oncological outcomes of esophagogastric resection in this specific clinical setting., Patients and Methods: A retrospective review from 2012 to 2018 was performed at four tertiary referral centers. All patients had a noncurative endoscopic resection of a clinical T1 esophageal cancer, followed by esophagectomy. Outcome measures were the rates of T0N0 specimens, overall survival, disease-free and cancer-specific survival, postoperative morbidity and mortality., Results: A total of 30 patients (13 with squamous cell carcinoma and 17 with adenocarcinoma) were included. The reasons for noncurative endoscopic resection were: positive vertical margins ( n  = 12), squamous cell carcinoma with muscularis mucosae or submucosal layer invasion ( n  = 3 and 9), adenocarcinoma with deep submucosal invasion ( n  = 11), poorly differentiated tumor ( n  = 6) and lymphovascular invasion ( n  = 6). Overall, 63% of the esophagi were T0N0: most residual lesions were T1a metachronous lesions, and four (13%) patients had advanced pT status ( n  = 3) or lymph node metastases ( n  = 2). Overall survival, disease-free survival and cancer-specific survival were 83%, 75%, and 90% respectively. A total of 43% of patients had severe postoperative complications, and postoperative mortality was 7%., Conclusion: In this cohort, esophagectomy allowed the resection of residual advanced cancer or lymph node metastases in 13% of cases, at the cost of 43% severe morbidity and 7% mortality. Therefore, the possibility of close follow up needs to be balanced with a highly morbid surgical management in these patients., Competing Interests: Conflict of interest statement: The authors declare that there is no conflict of interest., (© The Author(s), 2019.)

Digestive endoscopy has met an enormous progress over the last decade, both in terms of diagnosis and treatment of gastro-intestinal diseases. This review article presents the role of confocal endomicroscopy in the management of pancreatic cysts. Moreover, it resumes the most important novel therapeutic endoscopic techniques, some already available in expert centers such as G-POEM or biliary drainage by Axios stent system and spiral enteroscopy, as well as techniques undergoing validation such as the radiofrequency ablation of pancreatic tumors and the bariatric and metabolic endoscopy techniques., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

In 2019, gastric cancer still has high mortality. Gastric intestinal metaplasia (IGM) is an intermediate step in the process of carcinogenesis of intestinal adenocarcinoma. Gastroscopy with biopsies can detect the presence of MIG. Characterization in terms of intensity and distribution allows to stratify the risks and to target the population in which surveillance endoscopies are indicated for the purpose of detecting endoscopic resectable neoplasia in endoscopy., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Competing Interests: Competing interests: None declared.

Background and aims  This study aimed to evaluate the performance of Macroscopic On-site Evaluation (MOSE) using a novel endoscopic ultrasound (EUS) fine needle biopsy (FNB) needle (22-G Franseen-tip needle, Acquire, Boston Scientific Incorporated, Boston, Massachusetts, United States), and without using Rapid On-Site Evaluation (ROSE). Method  Between May 2016 and August 2016, all consecutive patients referred to our center for EUS tissue acquisition (TA) for solid lesions underwent EUS-FNB with the 22-G Franseen-tip needle unless contra-indicated. The operator performed MOSE. If no macroscopic core was visualized, a second pass was performed. The final diagnosis was defined as unequivocal histology from EUS-TA with compatible 18 months follow-up, surgical resection, or both. We retrospectively analyzed the performance of MOSE. Results  A total of 46 consecutive patients was included, and 54 solid lesions were biopsied. The endosonographer visualized core tissue in 93 % (50/54) of targets with a single pass, of which the pathologist confirmed histologic core fragments in 94 % (47/50). Four lesions required two passes, and the overall correlation between MOSE and histologic core fragments was 94 % (48/51). Diagnostic adequacy was 98 % (53/54) with one biliary target biopsied without significant material. The overall diagnostic accuracy was 94 %. Sensitivity, specificity, positive predictive value, and negative predictive value for malignancy were 92 %, 100 %, 100 %, and 81 %, respectively. No adverse events were reported. Conclusion  Our study demonstrated that MOSE using the 22-G Franseen-tip needle could limit needle passes by accurately estimating histologic core fragments. It also demonstrated that high diagnostic adequacy and accuracy of > 90 % could be achieved without ROSE.

Background: The therapeutic role of endoscopic papillectomy (EP) for early ampullary cancer (AC) is still controversial. The aim of the present study was to evaluate the curative potential of EP for early AC and to identify predictors of lymph node metastases (LNMs)., Methods: We retrospectively reviewed 173 patients who were prospectively included in a database and who underwent EP between 1999 and 2013. Adenocarcinoma was present in 28 resected specimens. An additional surgery was proposed in cases of duodenal submucosal infiltration, duct ingrowth, R1 resection or lymphovascular invasion. Clinicopathological information and outcomes were collected, and predictors of LNMs were evaluated., Results: Duodenal submucosal invasion was present in 16/28 cases and LNMs, in 9/28 cases. ACs of the biliopancreatic subtype were smaller (NS); 100 % had submucosal invasion, and 71 % had LNMs. Smaller tumour size, biliopancreatic subtype and submucosal invasion were significantly correlated with LNMs (p < 0.028, p < 0.028 and p < 0.014). Predictive factors of LNMs in the multivariate analysis were submucosal invasion and tumour size (OR 0.032, p < 0.023 and OR 0.711, p < 0.035). EP was curative in 100 % of cancers with R0 resection and no evidence of submucosal or lymphovascular invasion., Conclusion: EP may be curative for patients with AC limited to the duodenal mucosa or the sphincter of Oddi without lymphovascular invasion. Due to the presence of more invasive stages at diagnosis, EP may not be curative for ACs of the biliopancreatic subtype. The significance of tumour size is limited by other confounders, such as the histological subtype.

Introduction: Early reports of endoscopic submucosal dissection (ESD) in Europe suggested high complication rates and disappointing outcomes compared to publications from Japan. Since 2008, we have been conducting a nationwide survey to monitor the outcomes and complications of ESD over time., Material and Methods: All consecutive ESD cases from 14 centers in France were prospectively included in the database. Demographic, procedural, outcome and follow-up data were recorded. The results obtained over three years were compared to previously published data covering the 2008-2010 period., Results: Between November 2010 and June 2013, 319 ESD cases performed in 314 patients (62% male, mean (±SD) age 65.4 ± 12) were analyzed and compared to 188 ESD cases in 188 patients (61% male, mean (±SD) age 64.6 ± 13) performed between January 2008 and October 2010. The mean (±SD) lesion size was 39 ± 12 mm in 2010-2013 vs 32.1 ± 21 for 2008-2010 ( p  = 0.004). En bloc resection improved from 77.1% to 91.7% ( p  < 0.0001) while R0 en bloc resection remained stable from 72.9% to 71.9% ( p  = 0.8) over time. Complication rate dropped from 29.2% between 2008 and 2010 to 14.1% between 2010 and 2013 ( p  < 0.0001), with bleeding decreasing from 11.2% to 4.7% ( p  = 0.01) and perforations from 18.1% to 8.1% ( p  = 0.002) over time. No procedure-related mortality was recorded., Conclusions: In this multicenter study, ESD achieved high rates of en bloc resection with a significant trend toward better outcomes over time. Improvements in lesion delineation and characterization are still needed to increase R0 resection rates.

Background and study aim: As duodenal neuroendocrine tumors (NETs) are rare, their optimal management has not been clearly established. The aim of this study was to evaluate the feasibility and outcome of endoscopic treatment of duodenal NETs. Patients and methods: We reviewed the files of all patients who underwent endoscopic resection of a sporadic duodenal or ampullary NET between 1996 and 2014 at two centers. Results: A total of 29 patients with 32 uT1N0M0 NETs < 20 mm were included. Treatment consisted of endoscopic mucosal resection in 19 cases, and cap aspiration in 13 cases. Prior submucosal saline injection was used in 15 cases. Mortality was 3 % (one severe bleeding). Morbidity was 38 % (11/29). At post-resection analysis, mean tumor size was 8.9 mm (range 3 - 17 mm), 29 lesions were stage pT1, one was pT2, and 2 were pTx because of piecemeal resection. All NETs were well differentiated. A total of 27 lesions were classified as grade 1 and 5 were grade 2. The resection was R0, R1, and Rx for 16, 14, and 2 lesions, respectively. Three R1 patients underwent additional surgical treatment, with no residual tumor on the surgical specimen but with positive metastatic lymph nodes in two cases. One patient was lost to follow-up. Finally, 24 patients were included in the follow-up analysis. The median follow-up period was 56 months (range 6 - 175 months). Two patients presented a tumor recurrence during the follow-up period. Conclusions: Endoscopic treatment of small duodenal NETs was associated with significant morbidity, a difficulty in obtaining an R0 specimen, and the risk of lymph node metastasis. Nevertheless, it represents an interesting alternative in small grade 1 duodenal lesions and in patients at high surgical risk., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Aims: The differential diagnosis of solitary pancreatic cystic lesions is sometimes difficult. Needle-based confocal laser endomicroscopy (nCLE) performed during endoscopic ultrasound-fine-needle aspiration (EUS-FNA) enables real-time imaging of the internal structure of such cysts. Criteria have already been described for serous cystadenoma and intraductal papillary mucinous neoplasm (IPMN). The aims of the study were to determine new nCLE criteria for the diagnosis of pancreatic cystic lesions, to propose a comprehensive nCLE classification for the characterization of those lesions, and to carry out a first external retrospective validation ., Methods: Thirty-three patients with a lone pancreatic cystic lesion were included (CONTACT 1 study). EUS-FNA was combined with nCLE. Diagnosis was based on either pathology result (Group 1, n = 20) or an adjudication committee consensus (Group 2, n = 13). Six investigators, unblinded, studied cases from Group 1 and identified nCLE criteria for mucinous cystic neoplasm (MCN), pseudocyst (PC), and cystic neuroendocrine neoplasm (NEN). Four external reviewers assessed, blinded, the yield and interobserver agreement for the newly identified (MCN, PC) and previously described (IPMN, SC) criteria in a subset of 31 cases., Results: New nCLE criteria were described for MCN (thick gray line), PC (field of bright particles), and cystic NEN (black neoplastic cells clusters with white fibrous areas). These criteria correlated with the histological features of the corresponding lesions. In the retrospective validation, a conclusive nCLE result was obtained for 74 % of the cases (87 % "true" and 13 % "false" with respect to the final diagnosis). On this limited case series, the nCLE criteria showed a trend for high diagnostic specificity (>90 % for mucinous cysts, 100 % for non-mucinous cysts)., Conclusions: Based on this newly completed atlas of interpretation criteria, nCLE could facilitate the diagnosis of pancreatic cystic lesion types.

Colorectal polyps are frequent in the general population. The diagnostic is made by endoscopy. Polyp's characteristics determine the technic to be used to remove them. Transanal endoscopic microsurgery offers an alternative to radical surgery for large rectal polyps or rectal tumors with low risk of node invasion. One peace resection is necessary to evaluate the resection margins. Lymphatic invasion, ≥ 1 mm submucosae invasion, tumor budding and poorly differentiated tumor are the four main risk factors for node invasion. In case of high risk of lymph node invasion a radical surgery is recommended. Surveillance must be adapted to the polyp type, their number, size, presence of a carcinomatous component as well as age and clinical status of the patient.

In Europe, oesophageal cancers are diagnosed at an early stage in less than 10% of the cases. They are superficial tumours whose invasion is limited to the mucosae and the submucosa. Synchronous node invasion is the most important prognosis factor. Oesophagectomy is the benchmark treatment. Nowadays, endoscopic resection is a validated curative therapeutic alternative. Accurate endoscopic evaluation using chemical or virtual colouring as well as an echoendoscopy, followed by an expert pathological review, must be conducted beforehand. It can be realised for good prognosis tumours after evaluation of the synchronous node invasion or its risk. After completion, regular endoscopic follow-ups are compulsory to detect local relapse.

Background and Study Aims: The differential diagnosis of solitary pancreatic cystic lesions is frequently difficult. Needle-based confocal laser endomicroscopy (nCLE) performed during endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a new technology enabling real-time imaging of the internal structure of such cysts. The aim of this pilot study was to identify and validate new diagnostic criteria on nCLE for pancreatic cystic lesions., Patients and Methods: A total of 31 patients with a solitary pancreatic cystic lesion of unknown diagnosis were prospectively included at three centers. EUS-FNA was combined with nCLE. The final diagnosis was based on either a stringent gold standard (surgical specimen and/or positive cytopathology) or a committee consensus. Six nonblinded investigators reviewed nCLE sequences from patients with the most stringent final diagnosis, and identified a single feature that was only present in serous cystadenoma (SCA). The findings were correlated with the pathology of archived specimens. After a training session, four blinded independent observers reviewed a separate independent video set, and the yield and interobserver agreement for the criterion were assessed., Results: A superficial vascular network pattern visualized on nCLE was identified as the criterion. It corresponded on pathological specimen to a dense and subepithelial capillary vascularization only seen in SCA. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of this sign for the diagnosis of SCA were 87 %, 69 %, 100 %, 100 %, and 82 %, respectively. Interobserver agreement was substantial (κ = 0.77)., Conclusion: This new nCLE criterion seems highly specific for the diagnosis of SCA. The visualization of this criterion could have a direct impact on the management of patients by avoiding unnecessary surgery or follow-up.Clinicaltrials.gov NCT01563133., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Patients with familial adenomatous polyposis (FAP) and severe (stage IV) duodenal polyposis are candidates for pancreaticoduodenectomy, which has high morbidity. Little information is available about the feasibility of therapeutic endoscopy for these patients., Objective: To evaluate the long-term efficiency and risks of endoscopic therapy., Design: Retrospective study., Setting: A 2-referral center long-term cohort study., Patients: Thirty-five FAP patients (15 men, mean age 48 years) presenting with stage IV duodenal polyposis were included. Patients had a mean Spigelman classification score of 9.8 points (range 9-12 points) at their first examination., Interventions: Patients underwent a surveillance endoscopy, including lateral and axial viewing with chromoendoscopy while under sedation, along with 7 ± 4.8 therapeutic endoscopic sessions during a follow-up period of 9 ± 4.5 years (range 1-19 years) after their first endoscopy., Main Outcome Measurements: Treatment modalities, adverse events, and efficiency (evolution of the Spigelman score) were reviewed., Results: A total of 245 therapeutic endoscopies were performed and 15 adverse events (6%) occurred. During the follow-up period, Spigelman scores decreased in 95% of patients by 6 ± 2.2 points (P = .002). Modeling analysis showed that the mean Spigelman score decreased by 60% after 150 months., Limitations: Retrospective study and the duration of the follow-up, even though this is the longest follow-up reported in medical literature., Conclusion: Endoscopic treatment of severe duodenal polyposis in patients with FAP produces few adverse events and allows efficient downstaging of the polyposis. Long-term follow-up data did not reveal a high risk of invasive duodenal cancer in these patients., (Copyright © 2014 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Fully covered self-expanding metal stents (FCSEMS) are gaining acceptance for the treatment of benign biliary strictures. We performed a large prospective multinational study to study the ability to remove these stents after extended indwell and the frequency and durability of stricture resolution., Methods: In a nonrandomized study at 13 centers in 11 countries, 187 patients with benign biliary strictures received FCSEMS. Removal was scheduled at 10-12 months for patients with chronic pancreatitis or cholecystectomy and at 4-6 months for patients who received liver transplants. The primary outcome measure was removal success, defined as either scheduled endoscopic removal of the stent with no removal-related serious adverse events or spontaneous stent passage without the need for immediate restenting., Results: Endoscopic removal of FCSEMS was not performed for 10 patients because of death (from unrelated causes), withdrawal of consent, or switch to palliative treatment. For the remaining 177 patients, removal success was accomplished in 74.6% (95% confidence interval [CI], 67.5%-80.8%). Removal success was more frequent in the chronic pancreatitis group (80.5%) than in the liver transplantation (63.4%) or cholecystectomy (61.1%) groups (P = .017). FCSEMS were removed by endoscopy from all patients in whom this procedure was attempted. Stricture resolution without restenting upon FCSEMS removal occurred in 76.3% of patients (95% CI, 69.3%-82.3%). The rate of resolution was lower in patients with FCSEMS migration (odds ratio, 0.22; 95% CI, 0.11-0.46). Over a median follow-up period of 20.3 months (interquartile range, 12.9-24.3 mo), the rate of stricture recurrence was 14.8% (95% CI, 8.2%-20.9%). Stent- or removal-related serious adverse events, most often cholangitis, occurred in 27.3% of patients. There was no stent- or removal-related mortality., Conclusions: In a large prospective multinational study, removal success of FCSEMS after extended indwell and stricture resolution were achieved for approximately 75% of patients. ClincialTrials.gov number, NCT01014390., (Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Study Aims: Endoscopic submucosal dissection (ESD) provides a high en bloc resection rate for superficial colorectal tumors. The aims of this study were to assess the feasibility of ESD in France and to evaluate the complete resection rate at 1 year., Patients and Methods: Patients with superficial rectal tumors ≥ 10 mm in size were prospectively included in the study at nine French expert centers between February 2010 and June 2012. The study was stopped temporarily because of a high complication rate. Study recruitment resumed following remedial action., Results: A total of 45 patients were included (mean age 67 years; 24 males). The immediate perforation rate was 18 % (n = 8), and salvage surgery was not required. Six patients (13 %) had late bleeding, which was treated endoscopically in five patients and surgically in one patient who had required blood transfusion. The mortality rate was zero. The en bloc resection rate was 64 % (29/45), and the curative R0 resection rate was 53 % (24/45). Three patients (7 %) had an invasive tumor (two sm1, one T2). At 1-year follow-up, endoscopic examinations showed complete resection in 38 /43 patients (88 %). At the end of the study, after the remedial action, the en bloc resection rate had increased from 52 % to 82 %, and the perforation rate had decreased significantly from 34 % to 0 %., Conclusions: The study reflects the initial prospective experience of ESD in France, and suggests that curative R0 resection rates should increase and complication rates should decrease with experience and corrective actions., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: The ENKI-2 water-jet system for endoscopic submucosal dissection (ESD) combines submucosal saline pressure injection with dissection. The aim of this study was to compare ENKI-2 with a standard device in terms of procedure time and perforation rate during colorectal ESD., Methods: In this randomized comparative study, 10 30-mm-diameter lesions were created in the colon and rectum of 10 healthy adult pigs. The ESD procedure time and perforation rates were recorded for the ENKI-2 system and a standard Dual Knife method. Each pig had half the lesions dissected by ENKI-2 and half dissected by Dual Knife. One experienced and one inexperienced endoscopist took part in the study., Results: A total of 95 lesions were dissected (47 by ENKI-2 and 48 by Dual Knife). The experienced endoscopist was able to excise comparably sized 30-mm lesions using both techniques. The dissection time was shorter for ENKI-2 (18.9 vs. 25.6 minutes; P = 0.034) and the perforation rate was lower compared with the Dual Knife (one perforation [4 %] vs. nine perforations [36 %]; P = 0.011). The inexperienced endoscopist performed significantly larger dissections using the ENKI-2 (934 ± 405 mm2 vs. 673 ± 312 mm2; P = 0.021) despite pre-marking similarly sized artificial lesions. Multivariate analysis demonstrated that for all lesions the dissection time was significantly longer for lesions in the proximal colon (P = 0.001) and the distal colon (P < 0.0001) and shorter for the experienced operator (P < 0.0001). ENKI-2 shortened the dissection time, but not significantly (P = 0.093)., Conclusions: In experienced hands, the ENKI-2 system shortens dissection time and reduces the perforation rate. This effect was not statistically significant for an inexperienced operator. Dissection was faster in the rectum than the colon., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aim: Endoscopic submucosal dissection (ESD) is recommended for en bloc R0 resection of superficial esophageal neoplasms larger than 20  mm, but is high risk and time-consuming. In the tunnel technique, incisions at the lower and upper lesion edges are joined by a submucosal tunnel and then lateral incisions are made. The mucosa is thereby easily separated from the muscular layer. We report our experience of esophageal tunnel ESD., Patients and Methods: We retrospectively reviewed all consecutive esophageal tunnel ESDs performed at our unit between January 1 2010 and January 11 2013. Lesions were superficial esophageal neoplasms, UT1N0 at EUS. , Results: 11 patients underwent tunnel ESD (nine squamous cell carcinomas, two adenocarcinomas). Mean dissected surface area was 13.25 cm(2). Mean procedure duration was 76.7 minutes. All 11 resections were en bloc and 9/11 were R0. Complications were one subcutaneous emphysema with spontaneous resolution, and stenosis in 4/11 patients (36.4%) with resolution after 1-5 dilations., Conclusion: Tunnel ESD of superficial esophageal neoplasms is an interesting option, seeming to be faster and more effective than standard ESD, without higher morbidity., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Despite reports of randomized, control trials and cohort studies that do not support the use of drains, most surgeons routinely place prophylactic, intraperitoneal drains at the time of pancreatic resections. We sought to evaluate the outcome of elective pancreatic resection with or without prophylactic peripancreatic drainage. The primary outcome was the rate of postoperative complications. Total pancreatectomy and pancreatectomy for chronic pancreatitis were excluded., Methods: From September 2005 to February 2012, of the 375 patients who had pancreatic surgery, 242 were eligible for the study. A drain was used in 130 and no drain was used in 112 patients. The data for the 2 groups were recorded in a prospective database. The statistical analysis compared variables using Chi-square and Fisher's exact tests for categorical variables and the independent-samples t-test for continuous variables., Results: The demographic, operative, and pathologic data were similar between the 2 groups. There was no increase in the frequency or severity of the overall complications in the no drain group. In the drain and no drain groups, postoperative complications occurred in 64% and 67% of patients, respectively (P = .11); post-pancreatectomy hemorrhage occurred in 19% and 23% (P = .33); and pancreatic fistula occurred in 16% and 13% (P = .34). The requirement for an interventional procedure was equivalent for both of the groups (14.6% and 20.5%; P = .15). The median hospital stay was 16 days (range, 2-98) and 18 (range, 7-131; P = .18), and the 90-day hospital mortality was 5.4% and 4.5% (P = .49) in the drain and the no drain groups, respectively., Conclusion: In a tertiary, high-volume, Hepatobiliary and pancreatic (HBP) surgery center, the routine prophylactic draining of the abdominal cavity after pancreatic resection did not decrease the frequency or severity of postoperative complications. Prophylactic peripancreatic drainage also did not decrease the requirement for interventional procedures. Interventional radiology and transgastric endoscopic drainage of the post-pancreatectomy collection are feasible and improve patients' outcomes. Malnutrition and the type of operation were independent factors for postoperative complications., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background: Endoscopic submucosal dissection (ESD) allows en bloc resection of early neoplastic lesions of gastrointestinal tract. Lesions are lifted by submucosal fluid injection before circumferential incision and dissection. High-pressure fluid injection using water jet (WJ) technology is already used for lifting and dissection in surgery. The study was designed to assess WJ for ESD submucosal lifting and dissection., Methods: An experimental, randomized comparative, "in vivo" nonsurvival animal study on 12 pigs was designed. Stomach mucosal areas were delineated and resected using three ESD techniques: technique A-syringe injection and IT knife dissection; technique B-WJ continuous injection and IT knife dissection; technique C-WJ injection and WJ pulsed dissection. Injection and dissection speeds and complications rates were assessed., Results: Water jet continuous injection is faster than syringe injection (B faster than A, p = 0.001 and B nonsignificantly faster than C, p = 0.06). IT knife dissection is significantly faster after WJ continuous injection (B faster than A, p = 0.003). WJ pulsed dissection is significantly slower than IT knife dissection (C slower than A and B, both p < 0.001). The overall procedure speed was significantly higher and the immediate bleedings rate was significantly lower for technique B than A and C (overall procedure speed p = 0.001, immediate bleedings p = 0.032 and 0.038 respectively). There were no perforations with any technique., Conclusions: Water jet fluid continuous injection speeds up ESD, whereas pulsed WJ dissection does not.

Background: In cases with periampullary tumors, the practice of preoperative biliary drainage (PBD) is still debated without clear uniform indications. Our study focused on resectable cases with an obstructive jaundice candidate for curative surgery. Main endpoints were overall complication and mortality rates between patients treated with and without PBD., Methods: From January 2008 to November 2010, 100 consecutive patients with periampullary lesion underwent pancreatectomy. The rates of postoperative complications and mortality were compared between PBD and non-PBD patients., Results: The two groups were well matched for demographics, clinical, and operative characteristics. In patients who completed preoperative PBD protocol, biliary stent was placed systematically in 45 % of these cases without any clear indication. Post-PBD complication delayed surgery in 24 % of cases. Postoperative complications did not differ significantly between the two groups except for a significantly higher positive bile culture in PBD group (p = 0.001). There were seven cases of hospital mortality, four in PBD and three in non-PBD group. DFS was equal (32 months) in both groups (p = 0.55), and OS was 43 vs 32 months (p = 0.45)., Conclusion: PBD did not significantly increase the risk of overall postoperative complications, although it was associated to higher rate of biliary infections. PBD was not associated with any advantages in patients with a resectable periampullary lesion by reducing operative morbidity. PBD should be considered in selected patients when surgery has to be delayed.

We propose a novel approach for estimating a dense 3D model of neoplasia in colonoscopy using enhanced imaging endoscopy modalities. Estimating a dense 3D model of neoplasia is important to make 3D measurements and to classify the superficial lesions in standard frameworks such as the Paris classification. However, it is challenging to obtain decent dense 3D models using computer vision techniques such as Structure-from-Motion due to the lack of texture in conventional (white light) colonoscopy. Therefore, we propose to use enhanced imaging endoscopy modalities such as Narrow Band Imaging and chromoendoscopy to facilitate the 3D reconstruction process. Thanks to the use of these enhanced endoscopy techniques, visualization is improved, resulting in more reliable feature tracks and 3D reconstruction results. We first build a sparse 3D model of neoplasia using Structure-from-Motion from enhanced endoscopy imagery. Then, the sparse reconstruction is densified using a Multi-View Stereo approach, and finally the dense 3D point cloud is transformed into a mesh by means of Poisson surface reconstruction. The obtained dense 3D models facilitate classification of neoplasia in the Paris classification, in which the 3D size and the shape of the neoplasia play a major role in the diagnosis.

Background: EGD, with small-diameter endoscopes, is routinely performed via a nasal route in adults., Objective: To evaluate a new ultrathin one-plane bending videoendoscope for transnasal EGD., Design: Single center, prospective, randomized study., Setting: Edouard Herriot University Hospital., Patients: A total of 122 outpatients (median age, 49 years [18-81 years], 62 men and 60 women) were randomized into 2 groups (on a 2:1 basis) according to the endoscope used: (1) a standard 5.9-mm-diameter videoendoscope (80 patients) or (2) a one-plane bending high resolution 4.9-mm-diameter videoendoscope (42 patients)., Main Outcome Measurements: The operator assessed the quality of examination by using standard scores or a 100-mm visual scale. Patients quantified tolerance by using a 100-mm visual scale., Results: The duration of the procedure was the same in each group. The feasibility of transnasal insertion was significantly higher when using the 4.9-mm-diameter endoscope (97.61% [41/42 patients] vs 88.75% [71/80 patients], P<.05). The tolerance of EGD was significantly better in the group with the small videoendoscope, for global discomfort, pain, belching, and bloating. Similarly, acceptation of a new EGD in similar conditions was higher in group 2 (92.9% vs 80%, P<.05). The quality of examination (global, lavage, inflation, suction) was not different between the 2 groups., Limitations: Evaluation of patient tolerance and quality of examination was based on subjective features., Conclusions: Availability of a new ultrathin one-plane bending videoendoscope represents a major technical improvement for transnasal EGD, which significantly improves both feasibility and patient tolerance, without affecting the quality of the examination.