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Background and study aims Incomplete resection of 4- to 20-mm colorectal polyps occur frequently (> 10 %), putting patients at risk for post-colonoscopy colorectal cancer. We hypothesized that routine use of wide-field cold snare resection with submucosal injection (CSP-SI) might reduce incomplete resection rates (IRRs). Patients and methods Patients aged 45 to 80 years undergoing elective colonoscopies were enrolled in a prospective clinical study. All 4- to 20-mm non-pedunculated polyps were resected using CSP-SI. Post-polypectomy margin biopsies were obtained to determine IRRs through histopathology assessment. The primary outcome was IRR, defined as remnant polyp tissue found on margin biopsies. Secondary outcomes included technical success and complication rates. Results A total of 429 patients (median age 65 years, 47.1 % female, adenoma detection rate 40 %) with 204 non-pedunculated colorectal polyps 4 to 20 mm removed using CSP-SI were included in the final analysis. CSP-SI was technical successful in 97.5 % (199/204) of cases (5 conversion to hot snare polypectomy). IRR for CSP-SI was 3.8 % (7/183) (95 % confidence interval [CI] 2.7 %-5.5 %). IRR was 1.6 % (2/129), 16 % (4/25), and 3.4 % (1/29) for adenomas, serrated lesions, and hyperplastic polyps respectively. IRR was 2.3 % (2/87), 6.3 % (4/64), 4.0 % (6/151), and 3.1 % (1/32) for polyps 4 to 5 mm, 6 to 9 mm, Conclusions Use of CSP-SI results in lower IRRs compared to what has previously been reported in the literature for hot or cold snare polypectomy when not using wide-field cold snare resection with submucosal injection. CSP-SI showed an excellent safety and efficacy profile, however comparative studies to CSP without SI are required to confirm these results.

We investigated sleep disturbances, bowel movement (BM) kinetics, and travel experience with different bowel preparation regimens in a substudy of patients enrolled in a randomized multicenter Canadian clinical trial.Patients scheduled to have a colonoscopy between 7:30 am and 10:30 am (early morning) were randomized to (i) 4-L single-dose polyethylene glycol (PEG) given in the evening before, (ii) 2-L split-dose PEG (+bisacodyl 15 mg), or (iii) 4-L split-dose PEG. Patients scheduled to undergo a colonoscopy between 10:30 am and 4:30 pm (afternoon) were randomized to (iv) 2-L single-dose PEG (+bisacodyl 15 mg) in the morning, (v) 2-L split-dose PEG (+bisacodyl 15 mg), or (vi) 4-L split-dose PEG. Patients were asked to record information on BM kinetics, sleep, and travel to the endoscopy unit. Continuous and categorical variables were compared between groups using a Kruskal-Wallis test or χ 2 test, respectively. Intention-to-treat analyses were performed.Overall, 641 patients were included in this substudy. Patients undergoing early morning colonoscopies reported the most awakenings in the night when assigned to 4-L single-dose day-before PEG and the highest reduction in sleep hours when assigned to 4-L split-dose PEG. There were no significant between-group differences in urgent BMs, fecal incontinence episodes, or travel interruptions. Overall, 17% of those traveling for more than an hour had to stop for a BM during travel, with no significant difference between groups.Day-before and split-dose high-volume PEG regimens for colonoscopies scheduled before 10:30 am lead to the greatest sleep disturbance.

Background The risk of advanced pathology increases with polyp size, as does the potential for mismanagement when optical diagnosis is used. This study aimed to evaluate the proportion of patients who would be assigned inadequate surveillance intervals when different size cutoffs are adopted for use of optical diagnosis. Methods In a post hoc analysis of three prospective studies, the use of optical diagnosis was evaluated for three polyp size groups: 1–3, 1–5, and 1–10 mm. The primary outcome was the proportion of patients in whom advanced adenomas were found and optical diagnosis resulted in delayed surveillance. Secondary outcomes included agreements between surveillance intervals based on high confidence optical diagnosis and pathology outcomes, reduction in histopathological examinations, and proportion of patients who could receive an immediate surveillance recommendation. Results We included 3374 patients (7291 polyps ≤ 10 mm) undergoing complete colonoscopies (median age 66.0 years, 75.2 % male, 29.6 % for screening). The percentage of patients with advanced adenomas and either 2- or 7-year delayed surveillance intervals (n = 79) was 3.8 %, 15.2 %, and 25.3 % for size cutoffs of 1–3, 1–5, and 1–10 mm polyps, respectively (P Conclusion A 3-mm cutoff for clinical implementation of optical diagnosis resulted in a very low risk of delayed management of advanced neoplasia while showing high surveillance interval agreement with pathology and a one-third reduction in overall requirement for pathology examinations.

The aim of this study was to compare high-volume polyethylene glycol (PEG) with low-volume PEG with bisacodyl split-dosing regimens.Adult outpatients in 10 Canadian tertiary hospitals were randomized, stratified by morning or afternoon colonoscopy, to high-volume split-dose PEG (2 L + 2 L) (High-SD) or low volume (1 L + 1 L) + bisacodyl (15 mg) PEG (Low-SD), with a second randomization to liquid or low-residue diets. The primary end point, using noninferiority hypothesis testing, was adequate bowel cleansing (Boston Bowel Preparation Scale total score of ≥6, with each of 3 colonic segments subscores ≥2). Secondary objectives were willingness to repeat the preparation, withdrawal time, cecal intubation, and polyp detection rates.Over 29 months, 2314 subjects were randomized to High-SD (N = 1157) or Low-SD (N = 1157) (mean age, 56.2 ± 13.4 y; 52.1% women). Colonoscopy indications were 38.2% diagnostic, 36.8% screening, and 25.0% surveillance, with no between-group imbalances in patient characteristics. Low-SD satisfied noninferiority criteria vs High-SD for adequate bowel cleanliness with only marginally inferior results (90.1% vs 88.1%; P = .02; difference, 2.0%; 95% CI [0.0%; 4.5%]). High-SD was associated with lower willingness to repeat (66.9% vs 91.9%; P.01), was less well tolerated (7.3 ± 2.3 vs 8.1 ± 1.9; P.01), causing more symptoms. No differences in procedural outcomes were noted except for more frequent cecal intubation rates after High-SD (97.4% vs 95.6%; P = .02). Among the High-SD group, adequate bowel preparation was greater after a clear liquid diet (93.6% vs 87.9%; P.01), a finding not seen in the Low-SD group.Low-SD is noninferior to High-SD in providing adequate bowel preparation. Low-SD results in fewer symptoms, with greater willingness to repeat and tolerability. The overall impact of diet was modest.The study was approved by the research ethic boards from all sites and was registered at ClinicalTrials.gov (NCT02547571).

Background and aims Identification and photo-documentation of the ileocecal valve (ICV) and appendiceal orifice (AO) confirm completeness of colonoscopy examinations. We aimed to develop and test a deep convolutional neural network (DCNN) model that can automatically identify ICV and AO, and differentiate these landmarks from normal mucosa and colorectal polyps. Methods We prospectively collected annotated full-length colonoscopy videos of 318 patients undergoing outpatient colonoscopies. We created three nonoverlapping training, validation, and test data sets with 25,444 unaltered frames extracted from the colonoscopy videos showing four landmarks/image classes (AO, ICV, normal mucosa, and polyps). A DCNN classification model was developed, validated, and tested in separate data sets of images containing the four different landmarks. Results After training and validation, the DCNN model could identify both AO and ICV in 18 out of 21 patients (85.7%). The accuracy of the model for differentiating AO from normal mucosa, and ICV from normal mucosa were 86.4% (95% CI 84.1% to 88.5%), and 86.4% (95% CI 84.1% to 88.6%), respectively. Furthermore, the accuracy of the model for differentiating polyps from normal mucosa was 88.6% (95% CI 86.6% to 90.3%). Conclusion This model offers a novel tool to assist endoscopists with automated identification of AO and ICV during colonoscopy. The model can reliably distinguish these anatomical landmarks from normal mucosa and colorectal polyps. It can be implemented into automated colonoscopy report generation, photo-documentation, and quality auditing solutions to improve colonoscopy reporting quality.

ObjectiveProcedure-intense specialties, such as surgery or endoscopy, are a major contributor to the impact of the healthcare sector on the environment. We aimed to measure the amount of waste generated during endoscopic procedures and to understand the impact on waste of changing from reusable to single use endoscopes in the USA.DesignWe conducted a 5-day audit (cross-sectional study) of all endoscopies performed at two US academic medical centres with low and a high endoscopy volume (2000 and 13 000 procedures annually, respectively). We calculated the average disposable waste (excluding waste from reprocessing) generated during one endoscopic procedure to estimate waste of all endoscopic procedures generated in the USA annually (18 million). We further estimated the impact of changing from reusable to single-use endoscopes taking reprocessing waste into account.Results278 endoscopies were performed for 243 patients. Each endoscopy generated 2.1 kg of disposable waste (46 L volume). 64% of waste was going to the landfill, 28% represented biohazard waste and 9% was recycled. The estimated total waste generated during all endoscopic procedures performed in the USA annually would weigh 38 000 metric tons (equivalent of 25 000 passenger cars) and cover 117 soccer fields to 1 m depth. If all endoscopic procedures were performed with single-use endoscopes and accounting for reprocessing, the net waste mass would increase by 40%. Excluding waste from ancillary supplies, net waste generated from reprocessing and endoscope disposal would quadruple with only using single-use endoscopes.ConclusionThis quantitative assessment of the environmental impact of endoscopic procedures highlights that a large amount of waste is generated from disposable instruments. Transitioning to single-use endoscopes may reduce reprocessing waste but would increase net waste.

The virtual scale endoscope (VSE) allows projection of a virtual scale onto colorectal polyps allowing real-time size measurements. We studied the relative accuracy of VSE compared to visual assessment (VA) for the measuring simulated polyps of different size and morphology groups.We conducted a blinded randomized controlled trial using simulated polyps within a colon model. Sixty simulated polyps were evenly distributed across four size groups (1-5 mm,5-9.9 mm, 10-19.9 mm and ≥ 20 mm) and 3 Paris morphology groups (flat, sessile and pedunculated). Six endoscopists performed polyps' size measurements using random allocation of either VA or VSE.A total of 359 measurements were completed. The relative accuracy of VSE was significantly higher when compared to VA for all size groups 5mm (p=0.004; p0.001, p0.001). For polyps ≤ 5mm, the relative accuracy of VSE compared to VA was not significantly higher (p = 0.186). The relative accuracy of VSE was significantly higher when compared to VA for all morphology groups. VSE misclassified a lower percentage of 5 mm polyps as ≤ 5 mm (2.9%), ≥ 10 mm polyps as 10 mm (5.5%) and ≥ 20 mm polyps as 20 mm (21.7%) compared to VA (11.2; 24.7 and 52.3% respectively; p=0.008, p0.001 and p=0.003).VSE had significantly higher relative accuracies for every polyp size group or morphology type aside from diminutive. VSE enables endoscopist to better classify polyps into correct size categories at clinically relevant size thresholds of 5, 10 and 20 mm.

Background Serrated lesions are potential colorectal cancer precursors. This study evaluated the presence of total metachronous advanced neoplasia (T-MAN) at follow-up in patients with index serrated lesions compared with a matched cohort without serrated lesions. Methods Patients aged 45–74 years with serrated lesions were matched 2:1 by sex, age, synchronous polyps, and timing of index colonoscopy, to patients without serrated lesions. The primary outcome was T-MAN (advanced adenoma or high-risk serrated lesion) at follow-up. Secondary outcomes included presence of T-MAN stratified by synchronous polyps and serrated lesion characteristics. Results 1425 patients were included (475 patients, 642 serrated lesions; 950 controls; median follow-up 2.9 versus 3.6 years). Patients with serrated lesions had greater risk of T-MAN than those without (hazard ratio [HR] 6.1, 95 %CI 3.9–9.6). Patients with serrated lesions and high-risk adenoma (HRA) had higher risk of T-MAN than those with HRA alone (HR 2.6, 95 %CI 1.4–4.7); similarly, patients with serrated lesions plus low-risk adenoma (LRA) had higher risk than those with LRA alone (HR 7.0, 95 %CI 2.8–18.4), as did patients with serrated lesions without adenoma compared with no adenoma (HR 14.9, 95 %CI 6.5–34.0). Presence of proximal sessile serrated lesion (SSL; HR 9.3, 95 %CI 5.4–15.9), large SSL (HR 17.8, 95 %CI 7.4–43.3), and proximal large SSL (HR 25.0, 95 %CI 8.8–71.3), but not distal SSL, were associated with greater risk for T-MAN. Conclusion Patients with serrated lesions had higher risk for T-MAN regardless of synchronous adenomas. Patients with serrated lesions and HRA, and those with large or proximal SSLs, were at greatest risk.

Background: Cold snare polypectomy (CSP) is increasingly used for polypectomy and is recommended as first-line modality for small (

Background Clinical implementation of the resect-and-discard strategy has been difficult because optical diagnosis is highly operator dependent. This prospective study aimed to evaluate a resect-and-discard strategy that is not operator dependent. Methods The study evaluated a resect-and-discard strategy that uses the anatomical polyp location to classify colonic polyps into non-neoplastic or low risk neoplastic. All rectosigmoid diminutive polyps were considered hyperplastic and all polyps located proximally to the sigmoid colon were considered neoplastic. Surveillance interval assignments based on these a priori assumptions were compared with those based on actual pathology results and on optical diagnosis. The primary outcome was ≥ 90 % agreement with pathology in surveillance interval assignment. Results 1117 patients undergoing complete colonoscopy were included and 482 (43.1 %) had at least one diminutive polyp. Surveillance interval agreement between the location-based strategy and pathological findings using the 2020 US Multi-Society Task Force guideline was 97.0 % (95 % confidence interval [CI] 0.96–0.98), surpassing the ≥ 90 % benchmark. Optical diagnoses using the NICE and Sano classifications reached 89.1 % and 90.01 % agreement, respectively (P Conclusion The location-based resect-and-discard strategy achieved very high surveillance interval agreement with pathology-based surveillance interval assignment, surpassing the ≥ 90 % benchmark and outperforming optical diagnosis in surveillance interval agreement and the number of pathology examinations avoided.

Background Standard colonoscopy practice requires removal and histological characterization of almost all detected small ( Methods A post hoc analysis was performed on patients enrolled in a prospective study. The primary outcome was surveillance interval agreement of the PBRD strategy with pathology-based management according to 2020 US Multi-Society Task Force guidelines. Chart analysis also evaluated clinician adherence to pathology-based recommendations. One-sided testing was performed with a null-hypothesis of 90 % agreement with pathology-based surveillance intervals and a two-sided 96.7 % confidence interval (CI) using correction for multiple testing. Results 452 patients were included in the study. Surveillance intervals assigned using the PBRD strategy were correct in 97.8 % (96.7 %CI 96.3–99.3 %) of patients compared with pathology-based management. The PBRD strategy reduced pathology examinations by 58.7 % while providing 87.8 % of patients with immediate surveillance interval recommendations on the day of colonoscopy, compared with 47.1 % when using pathology-based management. Chart analysis of surveillance interval assignments showed 63.3 % adherence to pathology-based guidelines. Conclusion The PBRD strategy surpassed the 90 % agreement with the pathology-based standard for determining surveillance interval, reduced the need for pathology examinations, and increased the proportion of patients receiving immediate surveillance interval recommendations. The PBRD strategy does not require expertise in optical diagnosis and may replace histological characterization of small and diminutive colorectal polyps.

INTRODUCTION Bowel cleanliness has been shown to be superior with split-dose vs nonsplit preparations; we aimed to directly assess the poorly characterized comparative efficacies of split-dose vs same-day polyethylene glycol (PEG) regimens. METHODS In this study, one of a series of randomized trials performed across 10 Canadian endoscopy units, patients undergoing colonoscopies between 10:30 and 16:30 were allocated to PEG low-volume same-day (15 mg bisacodyl the day before, 2 L the morning of the procedure), low-volume split-dose (15 mg bisacodyl the day before, 1 L + 1 L), or high-volume split-dose (2 L + 2 L). Coprimary endpoints were adequate bowel cleansing based on the Boston Bowel Preparation Scale using in turn different threshold cutoffs. RESULTS Overall, 1,750 subjects were randomized equally across the 3 groups, with no differences in adequate bowel cleanliness rates (low-volume same-day, 90.5%; high-volume split-dose, 92.2%; P = 0.34; and low-volume split-dose, 87.9%; P = 0.17) for the Boston Bowel Preparation Scale ≥6 and 2 for each segment. Willingness to repeat the preparation was not significantly different between low-volume same-day (91.0%) and low-volume split-dose (92.5%; P = 0.40) but was greater than the high-volume split-dose (68.9%; P < 0.01). No significant differences were noted for withdrawal time, cecal intubation, or polyp detection rates. DISCUSSION In this large randomized trial of PEG regimens, low-volume same-day resulted in similar bowel cleanliness compared with high-volume or low-volume split-dosing. Willingness to repeat and tolerability were superior with low-volume same-day compared with high-volume split-dose and similar to low-volume split-dose.

SCOPUS: re.j, info:eu-repo/semantics/published

Colonoscopy and polypectomy reduce the incidence and mortality of colorectal cancer (CRC) by detecting and removing colorectal adenomas. Diminutive polyps (1–5 mm) account for 75% of all polyps found but rarely contain or progress to CRC. Although a high adenoma detection rate (ADR) is associated with improved cancer prevention, the increase in detection of diminutive polyps also increases costs associated with CRC prevention programs. This review provides an update on endoscopic management and considerations related to diminutive colorectal polyps. Recent studies show that only 0–4.3% of diminutive polyps show advanced features and progression into CRC is extremely rare. Advances in endoscopic imaging have improved the ADR for screening colonoscopy, mostly as a result of greater detection of diminutive and hyperplastic polyps. A resect and discard strategy for these low-risk diminutive polyps could reduce the need for pathologic assessment and is included in society guidelines with recommendations on imaging modalities, classification, and endoscopist benchmarks. To ensure complete resection, cold snare polypectomy is emerging as the most efficient and safest method of removal. A recent guideline review showed that fecal immunochemical testing is generally the preferred first-line screening test in average-risk adults. Post-polypectomy surveillance intervals may increase in the future as evidence on the management and outcomes of diminutive polyps which is assimilated. High detection rates of diminutive polyps result in more surveillance colonoscopies and higher healthcare costs, with unclear benefit for CRC prevention. Optical diagnosis and strategies such as resect and discard may help to reduce costs. The performance of high-quality colonoscopies and strict adherence to recommended surveillance intervals will also optimize the effectiveness of screening programs.

Background and study aims Optical real-time diagnosis (= resect-and-discard strategy) is an alternative to histopathology for diminutive colorectal polyps. However, clinical adoption of this approach seems sparse. We were interested in evaluating potential clinical uptake and barriers for implementation of this approach. Methods We conducted an international survey using the “Google forms” platform. Nine endoscopy societies distributed the survey. Survey questions measured current clinical uptake and barriers for implementing the resect-and-discard strategy, perceived cancer risk associated with diminutive polyps and potential concerns with using CT-colonography as follow-up, as well as non-resection of diminutive polyps. Results Eight hundred and eight endoscopists participated in the survey. 84.2 % (95 % CI 81.6 %–86.7 %) of endoscopists are currently not using the resect-and-discard strategy and 59.9 % (95 % CI 56.5 %–63.2 %) do not believe that the resect-and-discard strategy is feasible for implementation in its current form. European (38.5 %) and Asian (45 %) endoscopists had the highest rates of resect-and-discard practice, while Canadian (13.8 %) and American (5.1 %) endoscopists had some of the lowest implementation rates. 80.3 % (95 % CI 77.5 %–83.0 %) of endoscopists believe that using the resect-and-discard strategy for diminutive polyps will not increase cancer risk. 48.4 % (95 % CI 45.0 %–51.9 %) of endoscopists believe that leaving diminutive polyps in place is associated with increased cancer risk. This proportion was slightly higher (54.7 %; 95 % CI 53.6 %–60.4 %) when asked if current CT-colonography screening practice might increase cancer risks. Conclusion Clinical uptake of resect-and-discard is very low. Most endoscopists believe that resect-and-discard is not feasible for clinical implementation in its current form. The most important barriers for implementation are fear of making an incorrect diagnosis, assigning incorrect surveillance intervals and medico-legal consequences.

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.).

Diminutive and small colorectal polyps are common findings during colonoscopies, and rarely contain dysplastic elements and progress to colorectal cancer. With improving technology and the advent of artificial intelligence, detection rates of small or diminutive polyps and adenomas are rising, resulting in increasing costs associated with colonoscopy. Incomplete resection rates are an outcome of interest because it correlates with interval colorectal cancer. More effort is warranted to standardize training programs and sensitize endoscopists to the importance of personal performance as a quality metric of colonoscopy. This article reviews indications, methods, and recent developments in polypectomy for small and diminutive polyps.

Post-polypectomy surveillance intervals are currently determined based on pathology results.To evaluate a polyp-based resect and discard model that assigns surveillance intervals based solely on polyp number and size.Patients undergoing elective colonoscopies at the Montreal University Medical Center were enrolled prospectively. The polyp-based strategy was used to assign the next surveillance interval using polyp size and number. Surveillance intervals were also assigned using optical diagnosis for small polyps (10 mm). The primary outcome was surveillance interval agreement between the polyp-based model, optical diagnosis, and the pathology-based reference standard using the 2020 United States Multi-Society Task Force guidelines. Secondary outcomes included the proportion of reduction in required histopathology evaluations and proportion of immediate post-colonoscopy recommendations provided to patients.Of 944 patients (mean age 62.6 years, 49.3% male, 933 polyps) were enrolled. The surveillance interval agreement for the polyp-based strategy was 98.0% [95% confidence interval (CI): 0.97-0.99] compared with pathology-based assignment. Optical diagnosis-based intervals achieved 95.8% (95%CI: 0.94-0.97) agreement with pathology. When using the polyp-based strategy and optical diagnosis, the need for pathology assessment was reduced by 87.8% and 70.6%, respectively. The polyp-based strategy provided 93.7% of patients with immediate surveillance interval recommendationsThe polyp-based strategy achieved almost perfect surveillance interval agreement compared with pathology-based assignments, significantly reduced the number of required pathology evaluations, and provided most patients with immediate surveillance interval recommendations.

Serrated polyps are important colorectal cancer precursors and are most commonly located in the proximal colon, where post-polypectomy bleeding rates are higher. There is limited clinical trial evidence to guide best practices for resection of large serrated polyps (LSPs).In a multicenter trial, patients with large (≥20 mm) non-pedunculated polyps undergoing endoscopic mucosal resection (EMR) were randomized to clipping of the resection base or no clipping. This analysis is stratified by histologic subtype of study polyp(s), categorized as serrated [sessile serrated lesions (SSLs) or hyperplastic polyps (HPs)] or adenomatous, comparing clip vs control groups. The primary outcome was severe post-procedure bleeding within 30 days of colonoscopy.A total of 179 participants with 199 LSPs (191 SSLs and 8 HPs) and 730 participants with 771 adenomatous polyps were included in the study. Overall, 5 patients with LSPs (2.8%) experienced post-procedure bleeding compared with 42 (5.8%) of those with adenomas. There was no difference in post-procedure bleeding rates between patients in the clip vs control group among those with LSPs (2.3% vs 3.3%, respectively, difference 1.0%; P = NS). However, among those with adenomatous polyps, clipping was associated with a lower risk of post-procedure bleeding (3.9% vs 7.6%, difference 3.7%; P = .03) and overall serious adverse events (5.5% vs 10.6%, difference 5.1%; P = .01).The post-procedure bleeding risk for LSPs removed via EMR is low, and there is no discernable benefit of prophylactic clipping of the resection base in this group. This study indicates that the benefit of endoscopic clipping following EMR may be specific for2 cm adenomatous polyps located in the proximal colon.gov, Number: NCT01936948.

Background & Aims Failed bowel preparation for colonoscopy occurs commonly, but the optimal regimen for the subsequent attempt is unknown. High-volume preparations often are used but are not well studied. The objective of this study was to compare the efficacy, tolerability, and safety of 2 regimens for use after failed bowel preparation. Methods A multicenter, endoscopist-blinded randomized controlled trial was conducted in patients who previously failed bowel preparation despite adequate compliance. Patients were randomized to 1 of 2 split polyethylene glycol (PEG) regimens, preceded by 15 mg bisacodyl: PEG 2 L the evening before and 2 L the day of colonoscopy (PEG 2+2L+bisacodyl), or 4 L and 2 L (PEG 4+2L+bisacodyl). All patients followed a low-fiber diet on both the third and second day before the procedure, followed by a clear fluid diet the day before and the morning of the colonoscopy. The primary outcome was adequate bowel preparation, defined as a Boston Bowel Preparation Scale total score of 6 or higher, with all segment scores of 2 or higher. Secondary outcomes included adenoma detection rate, advanced adenoma detection rate, sessile serrated lesion detection, cecal intubation rate, tolerability, and adverse events. Results A total of 196 subjects were randomized at 4 academic centers in Canada (mean age, 60.7 y; SD, 11.4 y; 44.9% were women). There were no significant differences between the PEG 2+2L+bisacodyl and the PEG 4+2L+bisacodyl groups in achieving adequate bowel preparation (91.2% vs 87.6%; P = .44). There were no significant differences with regard to mean adenoma detection rate (37.4% vs 31.5%; P = .41), advanced adenoma detection rate (18.7% vs 11.2%; P = .16), sessile serrated lesion detection (8.8% vs 5.6%; P = .41), and cecal intubation rate (96.7% vs 92.1%; P = .19). The 2 regimens were similarly well tolerated, but PEG 2+2L+bisacodyl was associated with a higher willingness to repeat the bowel preparation (91.2% vs 66.2%; P Conclusions Split-dose 4 L-PEG with 15 mg bisacodyl, along with dietary restrictions, has similar efficacy as a higher-volume preparation, and should be considered for patients who previously failed bowel preparation ( ClinicalTrials.gov number, NCT02976805 ).

Colonoscopy is an effective screening procedure in colorectal cancer prevention programs; however, colonoscopy practice can vary in terms of lesion detection, classification, and removal. Artificial intelligence (AI)-assisted decision support systems for endoscopy is an area of rapid research and development. The systems promise improved detection, classification, screening, and surveillance for colorectal polyps and cancer. Several recently developed applications for AI-assisted colonoscopy have shown promising results for the detection and classification of colorectal polyps and adenomas. However, their value for real-time application in clinical practice has yet to be determined owing to limitations in the design, validation, and testing of AI models under real-life clinical conditions. Despite these current limitations, ambitious attempts to expand the technology further by developing more complex systems capable of assisting and supporting the endoscopist throughout the entire colonoscopy examination, including polypectomy procedures, are at the concept stage. However, further work is required to address the barriers and challenges of AI integration into broader colonoscopy practice, to navigate the approval process from regulatory organizations and societies, and to support physicians and patients on their journey to accepting the technology by providing strong evidence of its accuracy and safety. This article takes a closer look at the current state of AI integration into the field of colonoscopy and offers suggestions for future research.

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 study aim Delayed bleeding is a common adverse event following endoscopic mucosal resection (EMR) of large colorectal polyps. Prophylactic clip closure of the mucosal defect after EMR of nonpedunculated polyps larger than 20 mm reduces the incidence of severe delayed bleeding, especially in proximal polyps. This study aimed to evaluate factors associated with complete prophylactic clip closure of the mucosal defect after EMR of large polyps. Methods This is a post hoc analysis of the CLIP study (NCT01936948). All patients randomized to the clip group were included. Main outcome was complete clip closure of the mucosal resection defect. The defect was considered completely closed when no remaining mucosal defect was visible and clips were less than 1 cm apart. Factors associated with complete closure were evaluated in multivariable analysis. Results In total, 458 patients (age 65, 58 % men) with 494 large polyps were included. Complete clip closure of the resection defect was achieved for 338 polyps (68.4 %); closure was not complete for 156 (31.6 %). Factors associated with complete closure in adjusted analysis were smaller polyp size (odds ratio 1.06 for every millimeter decrease [95 % confidence interval 1.02–1.08]), good access (OR 3.58 [1.94–9.59]), complete submucosal lifting (OR 2.28 [1.36–3.90]), en bloc resection (OR 5.75 [1.48–22.39]), and serrated histology (OR 2.74 [1.35–5.56]). Conclusions Complete clip closure was not achieved for almost one in three resected large nonpedunculated polyps. While stable access and en bloc resection facilitate clip closure, most factors associated with clip closure are not modifiable. This highlights the need for alternative closure options and measures to prevent bleeding.

Optical diagnosis of diminutive colorectal polyps has been recently proposed as an alternative to histopathologic diagnosis. Recent developments in imaging techniques, new classification systems, and the use of artificial intelligence have allowed for increased viability of optical diagnosis. This review provides an up-to-date overview of optical diagnosis recommendations, classifications, outcomes, and recent developments. There are currently seven major classification systems and three major society recommendations for quality benchmarks for optical diagnosis of diminutive polyps. The NICE classification has been extensively studied and meets quality benchmarks for most imaging techniques but does not allow for the diagnosis of sessile serrated polyps (SSPs). The SIMPLE classification has met quality benchmarks for NBI and i-Scan and allows for the diagnosis of SSPs. Other classification systems need to be further studied to validate effectiveness. Computer-assisted diagnosis of colorectal polyps is a very promising recent development with first studies showing that society-recommended quality benchmarks for real-time colonoscopies on patients are being met. Limitations include a non-negligible percentage of failure to diagnose, low specificity, and low number of real-time diagnostic studies. More research needs to be performed to further understand the value of artificial intelligence for optical polyp diagnosis. Optical diagnosis of diminutive colorectal polyps is currently a viable strategy for experienced endoscopists using validated classifications and imaging-enhanced endoscopy. Artificial intelligence–based diagnosis could make optical diagnosis widely applicable but is currently in its early developmental stage.