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Bashar Qumseya,1 April Goddard,1 Amira Qumseya,2 David Estores,1 Peter V Draganov,1 Christopher Forsmark1 1Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL, USA; 2College of Public Health & Health Professions, Department of Biostatistics, Children’s Oncology Group Statistics & Data Center, University of Florida, Gainesville, FL, USACorrespondence: Bashar QumseyaDivision of Gastroenterology, Hepatology and Nutrition, University of Florida, P. O. Box 100214, 1329 SW 16th St., Suite 5251, Gainesville, FL, 32610-0214, USAEmail bashar.qumseya@medicine.ufl.eduIntroduction: Clinical practice guidelines can help physicians provide evidence-based, standardized clinical decisions. We aimed to assess physician attitudes toward and barriers to guideline adherence.Methods: We conducted a single center, cross-sectional, survey-based study. Physicians from many specialties participated in the study. All outcomes were measured using a validated survey tool. The primary outcome of interest was barriers to guideline adherence. Secondary outcomes included general attitudes toward guidelines and factors that could improve adherence to guidelines. Outcomes were measured by the survey tool. All outcomes were reported on a 5-point Likert scale.Results: The email survey was received by 1819 physicians with 400 responders (22% response rate). About 50% (n=200) were in practice for > 5 years, while 27% (n=107) were still in training. Trainees were less likely to understand the process of guideline development (RR= 0.76 [0.65– 0.88], p=0.0017), to have input in guideline development (RR= 0.52 [0.41– 0.65], p< 0.0001), and to report up-to-date knowledge in practice guidelines (RR=0.53 [0.30– 0.73], p=0.0002). Three factors were identified as major barriers to guideline adherence: complexity of guideline documents (61%, n=240), high number of weak or conditional recommendations (62%, n=245), and time constraints due to clinical responsibilities (65%, n=255). Factors that would improve guideline adherence included access to relevant guidelines at the point of care (87%), improved focus on guidelines during training (82%), and transparency on physician commercial affiliation (62%).Conclusion: Improved focus on guidelines during training and access to relevant guidelines at the point of care may be important to improve adherence to guidelines.Keywords: clinical practice guidelines, barriers, implementation

Background and Aims: Training in interventional endoscopy is offered by nonaccredited advanced endoscopy fellowship programs (AEFPs). The number of these programs has increased dramatically with a concurrent increase in the breadth and complexity of interventional endoscopy procedures. Accreditation is governed by competency-based education, yet what constitutes a "high-quality" nonaccredited AEFP has not been defined. Using an evidence-based consensus process, we aimed to establish standards for AEFPs., Methods: The RAND UCLA appropriateness method, a well-described modified Delphi process to develop quality indicators, was used. A task force established by the American Society for Gastrointestinal Endoscopy drafted potential quality indicators (structure, process, and outcome) in 6 categories: activity preceding training; structure of AEFPs; training in ERCP, EUS, and EMR; and luminal stent placement. Three rounds of iterative feedback from 20 experts were conducted. Round 0 involved discussion of project details. In round 1, experts independently ranked proposed quality indicators on a 9-point interval scale ranging from highly inappropriate (1) to highly appropriate (9). Next, proposed quality indicators were discussed and reworded in a group meeting followed by round 2, in which experts independently reranked proposed quality indicators and provided benchmarks (when applicable). The median score for each quality indicator was calculated. Mean absolute deviation from the median was calculated, and appropriateness of potential quality indicators was assessed using the BIOMED concerted action on appropriateness definition, P value method, and interpercentile range adjusted for symmetry definition. A quality indicator was deemed appropriate if the median score was ≥7 and met criteria for appropriateness using all 3 defined statistical methods., Results: Of 89 proposed quality indicators, 37 statements met criteria as appropriate for a quality indicator (activity preceding training, 2; structure of AEFPs, 10; training in ERCP, 7; training in EUS, 8; training in EMR, 7; luminal stent placement, 3). Minimum thresholds were defined for 19 relevant quality indicators for number of trainers, procedures during fellowship, and procedures before assessment of competence. Among the final appropriate quality indicators were that all trainees should undergo qualitative and quantitative competence assessments using validated tools at least quarterly with documented feedback throughout the training period and that trainees should track outcomes and relevant quality metrics for specific procedures., Conclusions: This consensus process using validated methodology established standards for an AEFP in an effort to ensure adequate training in the most commonly taught interventional endoscopic procedures (ERCP, EUS, EMR, and luminal stent placement) during fellowship. An important component of an AEFP is the use of competency-based assessments that are compliant with the Accreditation Council for Graduate Medical Education's Next Accreditation System, with the goal of ensuring that trainees achieve specific milestones in their progression to achieving cognitive and technical competency., Competing Interests: Disclosure The following authors disclosed financial relationships: G. A. Cote: Consultant for Interpace Diagnostics and Olympus Corporation; research support from Abbvie Pharmaceuticals. R. N. Keswani: Consultant for Medtronic and Boston Scientific. R. H. Yadlapati: Consultant for Medtronic, Phathom Pharmaceuticals, and StatLinkMD; research support from Ironwood Pharmaceuticals; advisory board with stock options in RJS Mediagnostix. T. M. Berzin: Consultant for Medtronic, Boston Scientific, Wision AI, Magentiq Eye, and RSIP Vision. P. Chahal: Consultant for Boston Scientific and Medtronic. J. Cohen: Consultant for Olympus America and Micro-Tech; stock owner in GI Windows, Virtual Health Partners, and Rom-Tech; owner of MD Medical Navigators. W. J. Coyle: Speaker for Abbvie, Pharm and Regeneron, and Pharm D. Early: Scientific advisory board for Guardant Health. N. M. Guda: Consultant for Boston Scientific and Hemostasis Inc LLC; speaker for Lupin Pharmaceuticals, India. S. Inamdar: Consultant for Pentax Medical. E. J. Shin: Consultant for Boston Scientific. U. D. Siddiqui: Consultant and speaker for Olympus, Boston Scientific, ConMed, Medtronic, and Cook Medical; research support from Olympus and Boston Scientific. All other authors disclosed no financial relationships., (Copyright © 2025 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Introduction: Hybrid endoscopic submucosal dissection (H-ESD), which utilizes ESD knife along with snare-based resection, has been developed to overcome the technical complexity of conventional ESD (C-ESD). The aim of this study was to compare the therapeutic outcomes of H-ESD vs C-ESD for nonpedunculated colorectal lesions ≥20 mm in size., Methods: We conducted a multicenter randomized controlled trial to compare H-ESD and C-ESD (Short-ESD trial). Patients with colorectal lesions between 20 and 50 mm in size were randomly assigned (1:1) to H-ESD or C-ESD. Primary outcome was procedure time/speed. Secondary outcomes were en bloc and complete (R0) resection rates and adverse event rates., Results: A total of 89 patients (median age 63 years; 49.3% women) with the median polyp size of 30 mm underwent H-ESD (n = 40) and C-ESD (n = 49). The mean procedure time of H-ESD was significantly shorter than that of C-ESD (41.1 ± 16.3 vs 54.3 ± 28.2 minutes; P = 0.007). The en bloc and R0 resection rates trended lower in the H-ESD vs C-ESD groups (77.5% vs 87.8%; P = 0.26% and 72.5% vs 79.6%; P = 0.46) without reaching statistical significance. Adverse event rate was similar between H-ESD and C-ESD (10% vs 8.2%; P = 1.00)., Discussion: Both H-ESD and C-ESD were safe and effective for resection of large colorectal lesions. H-ESD was associated with a shorter procedure time. H-ESD may represent a viable alternative to C-ESD, with the main advantage being easy applicability of a snare-based technique for colorectal lesions. Future studies are needed to further define the most suitable lesions for H-ESD, as to optimize efficiency and safety without compromising resection outcomes. ClinicaTrials.gov NCT NCT05347446., (Copyright © 2024 by The American College of Gastroenterology.)

Objectives: There have been significant advances in the management of large (≥20 mm) laterally spreading tumors (LSTs) or nonpedunculated colorectal polyps; however, there is a lack of clear consensus on the management of these lesions with significant geographic variability especially between Eastern and Western paradigms. We aimed to provide an international consensus to better guide management and attempt to homogenize practices., Methods: Two experts in interventional endoscopy spearheaded an evidence-based Delphi study on behalf of the World Endoscopy Organization Colorectal Cancer Screening Committee. A steering committee comprising six members devised 51 statements, and 43 experts from 18 countries on six continents participated in a three-round voting process. The Grading of Recommendations, Assessment, Development and Evaluations tool was used to assess evidence quality and recommendation strength. Consensus was defined as ≥80% agreement (strongly agree or agree) on a 5-point Likert scale., Results: Forty-two statements reached consensus after three rounds of voting. Recommendations included: three statements on training and competency; 10 statements on preresection evaluation, including optical diagnosis, classification, and staging of LSTs; 14 statements on endoscopic resection indications and technique, including statements on en bloc and piecemeal resection decision-making; seven statements on postresection evaluation; and eight statements on postresection care., Conclusions: An international expert consensus based on the current available evidence has been developed to guide the evaluation, resection, and follow-up of LSTs. This may provide guiding principles for the global management of these lesions and standardize current practices., (© 2024 The Authors. Digestive Endoscopy published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Objective: Endoscopic submucosal dissection (ESD) is a superior, minimally invasive technique compared with other snare-based endoscopic resection techniques for rectal neoplasms extending to the dentate line (RNDLs). However, performing a successful ESD in the anal canal can be challenging due to vascularity and limited scope stability. In this meta-analysis, we aim to evaluate the safety and efficacy of ESD for RNDLs., Methods: We performed a comprehensive electronic database search from January 2005 through January 2024 for studies evaluating outcomes of ESD performed for managing RNDLs. Pooled proportions were calculated using random-effect models. Heterogeneity was evaluated using I2 and Q statistics., Results: Data were extracted from 11 studies comprising 496 patients. The pooled en bloc resection rates were 93.60% (95% CI = 90.70-95.70). The pooled R0 resection rate was 80.60% (95% CI = 70.50-87.80). The pooled recurrence rate was 4.00% (95% CI = 2.40-6.50). There was no evidence of significant heterogeneity calculated using the Q test and I2 statistic. The main adverse events were anal pain, postprocedural bleeding, and anal stricture with pooled rates of 20.20% (95% CI = 14.80-26.90), 8.20% (95% CI = 4.70-14.0), and 3.50% (95% CI = 2.10-5.70), respectively., Conclusions: ESD is a safe and effective option for managing RNDLs with a low recurrence rate. Adverse events such as postprocedural perianal pain, postprocedural bleeding, and anal stenosis seem to be more common compared with colorectal ESD done for more proximal lesions. However, these can typically be managed conservatively or with minimally invasive endoscopic techniques., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: POEM is a mature procedure endorsed by societal guidelines as a first line therapy for achalasia and spastic esophageal disorders. Nonetheless, several questions remain, including expanding indications for POEM, periprocedural evaluation and management, and the optimal POEM technique to enhance clinical success while mitigating risk for reflux., Recent Findings: There is uncertainty regarding several technical aspects of the POEM myotomy; though aggregating evidence supports the use of real-time impedance planimetry to guide the myotomy. While post-POEM reflux remains a concerning long term sequela, there is an increasing focus on the potential role of endoscopic anti-reflux interventions. Lastly, with the widespread adoption of POEM, we continue to witness ongoing efforts to standardize post-procedural care and training in this procedure. POEM is no longer a novel but rather established procedure. Yet, this technique has continued to evolve, with the aim of optimizing treatment success while reducing adverse events and risk for post-procedural reflux., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background & Aims: There is significant variability in the immediate post-operative and long-term management of patients undergoing per-oral endoscopic myotomy (POEM), largely stemming from the lack of high-quality evidence. We aimed to establish a consensus on several important questions on the after care of post-POEM patients through a modified Delphi process., Methods: A steering committee developed an initial questionnaire consisting of 5 domains (33 statements): post-POEM admission/discharge, indication for immediate post-POEM esophagram, peri-procedural medications and diet resumption, clinic follow-up recommendations, and post-POEM reflux surveillance and management. A total of 34 experts participated in the 2 rounds of the Delphi process, with quantitative and qualitative data analyzed for each round to achieve consensus., Results: A total of 23 statements achieved a high degree of consensus. Overall, the expert panel agreed on the following: (1) same-day discharge after POEM can be considered in select patients; (2) a single dose of prophylactic antibiotics may be as effective as a short course; (3) a modified diet can be advanced as tolerated; and (4) all patients should be followed in clinic and undergo objective testing for surveillance and management of reflux. Consensus could not be achieved on the indication of post-POEM esophagram to evaluate for leak., Conclusions: The results of this Delphi process established expert agreement on several important issues and provides practical guidance on key aspects in the care of patients following POEM., (Copyright © 2024 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Postoperative stricture is a serious common adverse event after extensive endoscopic submucosal dissection (ESD) in the esophagus. Self-assembling peptide (SAP) gel has been shown to promote tissue healing and re-epithelialization. The aim of this study was to evaluate the effect of the SAP gel for esophageal stricture prevention after ESD., Methods: This was a multicenter prospective study of patients who underwent esophageal ESD followed by SAP gel application between March 2022 and December 2023. Patients were included if the ESD mucosal defect involved ≥50% of the circumference of the esophagus. High-risk cases were defined as mucosal defects ≥75% of the circumference. Stricture was defined as the inability to pass an endoscope ≥8.9 mm in diameter or a narrow-caliber lumen in a patient with symptoms., Results: A total of 43 patients (median age, 71 years; 81.4% male) underwent ESD (median resected specimen size, 50 mm) during the study period. SAP gel (median, 3 mL) was successfully applied in all cases (median time, 4 minutes). In aggregate, stricture occurred in 20.9% (9 of 43) of the cases. Stricture developed in 30.8% of the high-risk cases: 80% (4 of 5) after circumferential ESD and 19% (4 of 21) in those with defects ≥75% but <100% of the circumference. All cases of stricture resolved with endoscopic treatment. Three cases (6.9%) of postoperative bleeding occurred and were adequately managed endoscopically., Conclusions: We show that SAP gel application was easy, quick, and associated with a relatively low stricture rate comparable to other prophylactic methods. Additional comparative studies are needed to corroborate these preliminary findings., Competing Interests: Disclosure D. Yang: consultant for Olympus, Fujifilm, Boston Scientific, Medtronic, 3D-Matrix, Microtech, and Neptune Medical; and research grants from Microtech and 3D-Matrix. M. K. Hasan: consultant for Boston Scientific, Olympus, Neptune Medical, and Microtech. M. Gabr: consultant for Boston Scientific, Olympus, ConMed, 3D-Matrix, Fujifilm, and Adaptiv Endo. S. Jawaid: consultant for Lumendi, Creo Medical, and ConMed. M. Othman: consultant for Olympus, Boston Scientific, Creo Medical, Apollo Endosurgery, Lumendi, AbbVie, and Nestle; and research support from Boston Scientific, ConMed, Lucid Diagnostic, AbbVie, and Nestle. M. J. Rojas De Leon: Consultant for Boston Scientific. N. Sharma: consultant for Boston Scientific, Medtronic, Steris, and Olympus. P. V. Draganov: consultant for Olympus, Fujifilm, Boston Scientific, Medtronic, Microtech, Cook Medical, and 3D-Matrix. All other authors disclosed no financial relationships. The study was supported by a research grant from 3D-Matrix. 3D-Matrix was not involved in the design of the study, its conduct, analysis, or interpretation of study results. None of the authors participated in the development of the self-assembling peptide gel or benefit from its sales., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Objectives: Endoscopic papillectomy (EP) is a minimally invasive therapy for the management of ampullary adenomas (AA). We conducted this multicenter study to assess the incidence of and factors related to the recurrence of AA after EP in patients with familial adenomatous polyposis (FAP) compared to sporadic AA., Methods: We included patients who underwent EP for AA at 10 tertiary hospitals. Adenomatous tissue at the resection site at the time of surveillance endoscopies was considered recurrent disease., Results: In all, 257 patients, 100 (38.9%) with FAP and 157 (61%) patients with sporadic AA, were included. Over a median of 31 (range, 11-61) months, recurrence occurred in 48/100 (48%) of patients with FAP and 58/157 (36.9%) with sporadic AA (P = 0.07). Two (2%) FAP patients and 10 (6.3%) patients with sporadic AA underwent surgery for recurrence. On multivariable regression analysis, the recurrence in FAP was higher than in sporadic patients after the first year of follow-up. AA size (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.001, 1.056), periampullary extension (HR 2.5, 95% CI 1.5, 4.01), and biliary duct dilation (HR 2.04, 95% CI 1.2, 3.4) increased the risk, while en bloc resection (HR 0.6, 95% CI 0.41, 0.9) decreased the risk of recurrence., Conclusion: Recurrence rates are high after EP. Most recurrences in sporadic patients occur within the first year of follow-up, but after the first year of follow-up in patients with FAP. Recurrences are higher with larger adenomas, biliary duct dilation, and periampullary extensions, and may be mitigated by en bloc resection. These factors should be considered in decision-making with the patients., (© 2023 The Authors. Digestive Endoscopy published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Background and Aims: Opioid-induced esophageal dysfunction (OIED) often presents as spastic esophageal disorders (SEDs) and esophagogastric junction outflow obstruction (EGJOO). The aim of this study was to evaluate and compare clinical outcomes of peroral endoscopic myotomy (POEM) for SEDs and EGJOO among opioid users and nonusers., Methods: This propensity score (PS) matching study included consecutive opioid users and nonusers who underwent POEM for SEDs and EGJOO between January 2018 and September 2022. The following covariates were used for the PS calculation: age, sex, duration of symptoms, Eckardt score, type of motility disorder, and length of myotomy during POEM. Clinical response was defined as a post-POEM Eckardt score ≤3., Results: A total of 277 consecutive patients underwent POEM during the study period. PS matching resulted in the selection of 64 pairs of patients strictly matched 1:1 (n = 128) with no statistically significant differences in demographic, baseline, or procedural characteristics or in the parameters considered for the PS between the 2 groups. Clinical response to POEM was significantly lower among opioid users (51 of 64 [79.7%]) versus nonusers (60 of 64 [93.8%]) (P = .03) at a median follow-up of 18 months. Among opioid users, higher opioid dose (>60 morphine milligram equivalents per day) was associated with a higher likelihood of failure to respond to POEM (odds ratio, 4.59; 95% confidence interval, 1.31-3.98; P = .02)., Conclusions: Clinical response to POEM for SEDs and EGJOO is significantly lower among opioid users versus nonusers. There was a dose-relationship between opioids and response to POEM, with higher daily opioid usage associated with a higher likelihood of treatment failure., Competing Interests: Disclosure The following authors disclosed financial relationships: D. Yang: consultant for Olympus, Fujifilm, Apollo Endosurgery, Medtronic, and Microtech; and research support from Microtech and 3D-Matrix. M.K. Hasan: consultant for Boston Scientific and Olympus. P. V. Draganov: consultant for Olympus, Boston Scientific, Fujifilm, Cook Medical, and Medtronic. N. Sharma: consultant for Boston Scientific, Medtronic, Steris, and Olympus. J. H. Hwang: consultant for Boston Scientific, Olympus, Medtronic, Fujifilm, and Microtech. A. Sethi: consultant for Boston Scientific, Interscope, Medtronic, and Olympus; and research support from Boston Scientific and Fujifilm. P. Benias: consultant for Boston Scientific, Apollo Endosurgery, and Fujifilm. P. Kedia: consultant for Boston Scientific, Olympus, and Medtronic. S. Jawaid: consultant for Lumendi, Creo Medical, and ConMed. M. B. Ujiki: member of the advisory board for Boston Scientific and Apollo Endosurgery; and speaker for Gore and Medtronic. R. Kim: consultant for Medtronic, Cook Medical, and Apollo Endosurgery. M. Othman: consultant for Olympus, Boston Scientific, Creo Medical, Apollo Endosurgery, Lumendi, AbbVie, and Nestle; and research support from Boston Scientific, ConMed, Lucid Diagnostic, AbbVie, and Nestle. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Dr Yang is a consultant for Boston Scientific, Fujifilm, Olympus, Medtronic, Microtech, 3D-Matrix, and Neptune Medical. Dr Yang has received research grant support from 3D-Matrix and Microtech. Dr Draganov is a consultant for Boston Scientific, Fujifilm, Olympus, Medtronic, Microtech, and Cook Medical. Dr Hasan is a consultant for Boston Scientific, Olympus, Microtech, and Neptune Medical. Dr Arain is a consultant for Boston Scientific, Cook Medical, and Medtronic. Dr Cosgrove is a consultant for Boston Scientific and Cook Medical. All other authors disclosed no financial relationships relevant to this publication.

Competing Interests: Dr Yang is a consultant for Boston Scientific, Fujifilm, Olympus, Medtronic, Microtech, 3D-Matrix, and Neptune Medical. Dr Yang has received research grant support from 3D-Matrix and Microtech. Dr Draganov is a consultant for Boston Scientific, Fujifilm, Olympus, Medtronic, Microtech, and Cook Medical. Dr Hasan is a consultant for Boston Scientific, Olympus, Microtech, and Neptune Medical. Dr Arain is a consultant for Boston Scientific, Cook Medical, and Medtronic. All other authors disclosed no financial relationships relevant to this publication.

Background/aims: In this meta-analysis, we studied the safety and efficacy of endoscopic submucosal dissection (ESD) for colorectal dysplasia in patients with inflammatory bowel disease (IBD)., Methods: Multiple databases were searched, and studies were retrieved based on pre-specified criteria until October 2022. The outcomes assessed were resection rates, procedural complications, local recurrence, metachronous tumors, and the need for surgery after ESD in IBD. Standard meta-analysis methods were followed using the random-effects model, and I2% was used to assess heterogeneity., Results: Twelve studies comprising 291 dysplastic lesions in 274 patients were included with a median follow-up of 25 months. The pooled en-bloc resection, R0 resection, and curative resection rates were 92.5% (95% confidence interval [CI], 87.9%-95.4%; I2=0%), 81.5% (95% CI, 72.5%-88%; I2=43%), and 48.9% (95% CI, 32.1%-65.9%; I2=87%), respectively. The local recurrence rate was 3.9% (95% CI, 2%-7.5%; I2=0%). The pooled rates of bleeding and perforation were 7.7% (95% CI, 4.5%-13%; I2=10%) and 5.3% (95% CI, 3.1%-8.9%; I2=0%), respectively. The rates of metachronous recurrence and additional surgery following ESD were 10% (95% CI, 5.2%-18.2%; I2=55%) and 13% (95% CI, 8.5%-19.3%; I2=54%), respectively., Conclusions: ESD is safe and effective for the resection of dysplastic lesions in IBD with an excellent pooled rate of en-bloc and R0 resection.

Background and Aims: Positive vertical margins (VMs) are common after endoscopic submucosal dissection (ESD) of T1b esophageal cancer (EC) and are associated with an increased risk of recurrence. Traction during ESD provides better exposure of the submucosa and may allow deeper dissection, potentially reducing the risk of positive VMs. We conducted a retrospective multicenter study to compare the proportion of resections with positive VMs in ESD performed with versus without traction in pathologically staged T1b EC., Methods: Patients who underwent ESD revealing T1b EC (squamous or adenocarcinoma) at 10 academic tertiary referral centers in the United States (n = 9) and Brazil (n = 1) were included. Demographic and clinical data were abstracted. ESD using either traction techniques (tunneling, pocket) or traction devices (clip line, traction wire) were classified as ESD with traction (Tr-ESD) and those without were classified as conventional ESD without traction. The primary outcome was a negative VM. Multivariable logistic regression was used to assess associations with negative VMs., Results: A total of 166 patients with pathologically staged T1b EC underwent Tr-ESD (n = 63; 38%) or conventional ESD without traction (n = 103; 62%). Baseline factors were comparable between both groups. On multivariable analysis, Tr-ESD was found to be independently associated with negative VMs (odds ratio, 2.25; 95% confidence interval, 1.06-4.91; P = .037) and R0 resection (odds ratio, 2.83; 95% confidence interval, 1.33-6.23; P = .008)., Conclusion: Tr-ESD seems to be associated with higher odds of negative VMs than ESD without traction for pathologically staged T1b EC, and future well-conducted prospective studies are warranted to establish the findings of the current study., Competing Interests: Disclosure The following authors disclosed financial relationships: F. Maluf-Filho: Consultant for Boston Scientific, Cook, and Olympus America. P. V. Draganov: Consultant for Boston Scientific, Cook, Medtronic, Olympus, Fujifilm, MicroTech, and Merit. M. Al-Haddad: Research support from Amplified Sciences LLC, Cook Endoscopy, and Creatics LLC; consulting and teaching for Interpace Diagnostics. N. Fukami: Consultant for Boston Scientific and Olympus America. H. Aihara: Consultant for Boston Scientific, Fujifilm Medical Systems, Medtronics, ConMed, Creo Medical and 3-D Matrix. N. R. Sharma: Consultant for Covidien, Boston Scientific, Mauna Kea Technologies, US Endoscopy, and Merck Sharp & Dohme Corporation. A. Chak: Consultant for US Endoscopy and investment interest in Lucid Diagnostics. D. Yang: Consultant for Lumendi, Boston Scientific, and Steris. R. Singh: Consultant for Exelixis and Tempus. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Third-space endoscopy (TSE) is a subspecialty in interventional endoscopy that exploits the submucosa as a working space for the management of various gastrointestinal diseases. Over recent years, TSE has emerged as a viable alternative to surgery for the treatment of various conditions. The rapid dissemination and adoption of TSE has been largely supported by the advent of novel devices aimed to improve the efficacy and safety of these procedures. In this article, we review some of the recent developments in TSE devices and provide our initial experience with these instruments in clinical practice., (© 2023 Japan Gastroenterological Endoscopy Society.)

Introduction: The study aimed to develop international consensus recommendations on the safe use of lumen-apposing metal stents (LAMSs) for on- and off-label indications., Methods: Based on the available literature, statements were formulated and grouped into the following categories: general safety measures, peripancreatic fluid collections, endoscopic ultrasound (EUS)-biliary drainage, EUS-gallbladder drainage, EUS-gastroenterostomy, and gastric access temporary for endoscopy. The evidence level of each statement was determined using the Grading of Recommendations Assessment, Development, and Evaluation methodology.International LAMS experts were invited to participate in a modified Delphi process. When no 80% consensus was reached, the statement was modified based on expert feedback. Statements were rejected if no consensus was reached after the third Delphi round., Results: Fifty-six (93.3%) of 60 formulated statements were accepted, of which 35 (58.3%) in the first round. Consensus was reached on the optimal learning path, preprocedural imaging, the need for airway protection and essential safety measures during the procedure, such as the use of Doppler, and measurement of the distance between the gastrointestinal lumen and the target structure. Specific consensus recommendations were generated for the different LAMS indications, covering, among others, careful patient selection, the preferred size of the LAMS, the need for antibiotics, the preferred anatomic location of the LAMS, the need for coaxial pigtail placement, and the appropriate management of LAMS-related adverse events., Discussion: Through a modified international Delphi process, we developed general and indication-specific experience- and evidence-based recommendations on the safe use of LAMS., (Copyright © 2023 by The American College of Gastroenterology.)

Background and Aims: Video analysis has emerged as a potential strategy for performance assessment and improvement. We aimed to develop a video-based skill assessment tool for peroral endoscopic myotomy (POEM)., Methods: POEM was deconstructed into basic procedural components through video analysis by an expert panel. A modified Delphi approach and 2 validation exercises were conducted to refine the POEM assessment tool (POEMAT). Twelve assessors used the final POEMAT version to grade 10 videos. Fully crossed generalizability (G) studies investigated the contributions of assessors, endoscopists' performance, and technical elements to reliability. G coefficients below .5 were considered unreliable, between .5 and .7 as modestly reliable, and above .7 as indicative of satisfactory reliability., Results: After task deconstruction, discussions, and the modified Delphi process, the final POEMAT comprised 9 technical elements. G analysis showed low variance for endoscopist performance (.8%-24.9%) and high interrater variability (range, 63.2%-90.1%). The G score was moderately reliable (≥.60) for "submucosal tunneling" and "myotomy" and satisfactorily reliable (≥.70) for "active hemostasis" and "mucosal closure.", Conclusions: We developed and established initial content and response process validity evidence for the POEMAT. Future steps include appraisal of the tool using a wider range of POEM videos to establish and improve the discriminative validity of this tool., Competing Interests: Disclosure The following authors disclosed financial relationships: D. Yang: Consultant for Olympus, Fujifilm, Boston Scientific, Apollo Endosurgery, Medtronic, 3D-Matrix, Microtech, and Neptune Medical; and research grants from Microtech and 3D-Matrix. M.K. Hasan: Consultant for Boston Scientific and Olympus. P.V. Draganov: Consultant for Olympus, Boston Scientific, Fujifilm, Cook Medical, and Medtronic. S. Jawaid: Consultant for Lumendi, Creo Medical, and ConMed. M. Othman: Consultant for Olympus, Boston Scientific, Creo Medical, Apollo Endosurgery, Lumendi, AbbVie, and Nestle; and research support from Boston Scientific, ConMed, Lucid Diagnostic, AbbVie, and Nestle. N. Sharma: Consultant for Boston Scientific, Medtronic, Steris, and Olympus. A. Sethi: Consultant for Boston Scientific, Interscope, Medtronic, and Olympus; and research support from Boston Scientific and Fujifilm. M. Khashab: Consultant for Boston Scientific, Olympus, Medtronic, Apollo Endosurgery, Pentax, and Laborie; research support from Boston Scientific; and royalties from Elsevier and UpToDate. J. M. Dewitt: Consultant for Vyaire Medical Inc and Airel Diagnostics; and grant support from Vyaire Medical, Inc. H. Pohl: Consultant for InterVenn; and research grants from Steris and Cosmo. H. Aihara: Consultant for Olympus, Fujifilm, Boston Scientific, Medtronic, and 3D Matrix. R. Bechara: Consultant for Olympus, Medtronic, Pentax, and Pendopharm. N. Kumta: Consultant for Apollo Endosurgery, Boston Scientific, Olympus, and SafeHeal. A. A. Aadam: Consultant for Boston Scientific, Steris Endoscopy, and ERBE USA. R. Law: Consultant for Boston Scientific, ConMed, and Medtronic; and research support from Olympus. All other authors disclosed no financial relationships. This study was funded by a clinical research award grant from the American Society for Gastrointestinal Endoscopy., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: In light-emitting diode (LED) and LASER colonoscopy, linked color imaging (LCI) and blue light/laser imaging (BLI) are used for lesion detection and characterization worldwide. We analyzed the difference of LCI and BLI images of colorectal lesions between LED and LASER in a multinational study., Methods: We prospectively observed lesions with white light imaging (WLI), LCI, and BLI using both LED and LASER colonoscopies from January 2020 to August 2021. Images were graded by 27 endoscopists from nine countries using the polyp visibility score: 4 (excellent), 3 (good), 2 (fair), and 1 (poor) and the comparison score (LED better/similar/LASER better) for WLI/LCI/BLI images of each lesion., Results: Finally, 32 lesions (polyp size: 20.0 ± 15.2 mm) including 9 serrated lesions, 13 adenomas, and 10 T1 cancers were evaluated. The polyp visibility scores of LCI/WLI for international and Japan-expert endoscopists were 3.17 ± 0.73/3.17 ± 0.79 (p = 0.92) and 3.34 ± 0.78/2.84 ± 1.22 (p < 0.01) for LED and 3.30 ± 0.71/3.12 ± 0.77 (p < 0.01) and 3.31 ± 0.82/2.78 ± 1.23 (p < 0.01) for LASER. Regarding the comparison of lesion visibility about between LED and LASER colonoscopy in international endoscopists, a significant difference was achieved not for WLI, but for LCI. The rates of LED better/similar/LASER better for brightness under WLI were 54.5%/31.6%/13.9% (International) and 75.0%/21.9%/3.1% (Japan expert). Those under LCI were 39.2%/35.4%/25.3% (International) and 31.3%/53.1%/15.6% (Japan expert). There were no significant differences in the diagnostic accuracy and the comparison score of BLI images between LED and LASER., Conclusions: The differences of lesion visibility for WLI/LCI/BLI between LED and LASER in international endoscopists could be compared to those in Japanese endoscopists., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

This document from the American Society for Gastrointestinal Endoscopy (ASGE) provides a full description of the methodology used in the review of the evidence used to inform the final guidance outlined in the accompanying Summary and Recommendations document regarding the role of endoscopic submucosal dissection (ESD) in the management of early esophageal and gastric cancers. This guideline used the Grading of Recommendations, Assessment, Development and Evaluation framework and specifically addresses the role of ESD versus EMR and/or surgery, where applicable, for the management of early esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), and gastric adenocarcinoma (GAC) and their corresponding precursor lesions. For ESCC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >15 mm, whereas in patients with similar lesions ≤15 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for such patients with ESCC, whenever possible. For EAC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >20 mm, whereas in patients with similar lesions measuring ≤20 mm, the ASGE suggests either ESD or EMR. For GAC, the ASGE suggests ESD over EMR for patients with early-stage, well or moderately differentiated, nonulcerated intestinal type cancer measuring 20 to 30 mm, whereas for patients with similar lesions <20 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for patients with such lesions measuring ≤30 mm, whereas for lesions that are poorly differentiated, regardless of size, the ASGE suggests surgical evaluation over endosic approaches., (Copyright © 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Delayed bleeding is among the most common adverse events associated with endoscopic mucosal resection (EMR) of nonampullary duodenal polyps. We evaluated the rate of delayed bleeding and complete defect closure using a novel through-the-scope (TTS) suturing system for the closure of duodenal EMR defects., Methods: We reviewed the electronic medical records of patients who underwent EMR for nonampullary duodenal polyps of ≥ 10 mm and prophylactic defect closure with TTS suturing between March 2021 and May 2022 at centers in the USA. We evaluated the rates of delayed bleeding and complete defect closure., Results: 36 nonconsecutive patients (61 % women; mean [SD] age, 65 [12] years) underwent EMR of ≥ 10-mm duodenal polyps followed by attempted defect closure with TTS suturing. The mean (SD) lesion size was 29 (19) mm, defect size was 37 (25) mm; eight polyps (22 %) involved > 50 % of the lumen circumference. Complete closure was achieved in all cases (78 % with TTS suturing alone), using a median of one TTS suturing kit. There were no cases of delayed bleeding and no adverse events attributed to application of the TTS suturing device., Conclusion: Prophylactic closure of nonampullary duodenal EMR defects using TTS suturing resulted in a high rate of complete closure and no delayed bleeding events., Competing Interests: J. Cohen is a consultant for Olympus and Microtech, owns stock in GI windows and Romtech and is an owner of MD Medical Navigators. G.B. Haber has received consultancy and speakerʼs fees from Boston Scientific and Olympus, consultancy fees from Cook Medical, ERBE, OVESCO, and Endogastric Solutions; he is on the medical advisory boards of Covidien/ Medtronic, Microtech, and Aries Pharmaceutical for whom he is also a member of the speakersʼ bureau. A.C. Storm has received grants and consultancy fees from Apollo Endosurgery and Boston Scientific, grants from Endo-TAGSS, Endogenex, and Enterasense, and consultancy fees from ERBE, GI dynamics, and Olympus. S. Gordon has received consultancy fees from Boston Scientific. S. Singh has provided consultancy to Apollo Endosurgery. B. Qumseya has received consultancy fees from Medtronic and Assertio Management, and speaker's fees from Castle Biosciences. P.V. Draganov has provided consultancy to Boston Scientific, Cook Medical, Olympus, Lumendi, and Microtech. N.A. Kumta has provided consultancy to Apollo Endosurgery, Boston Scientific, Olympus, and SafeHeal. R. Kim has provided consultancy to Medtronic and Cook Medical. A. Hiroyuki has provided consultancy to Olympus America, Boston Scientific, and Fujifilm Medical Systems. S. Ngamruengphong has provided consultancy to Boston Scientific. M.A. Khashab has provided consultancy to Boston Scientific, Olympus America, Medtronic, Apollo Endosurgery, Pentax, and GI Supply. J.A. Almario, L.Y. Zhang, H. Ramberan, J.M. Adler, H. Pohl, A. Schlachtermann, A. Kumar, A. Canakis, and A. Shrigiriwar declare that they have no conflicts of interest., (Thieme. All rights reserved.)

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based summary and recommendations regarding the role of endoscopic submucosal dissection (ESD) in the management of early esophageal and gastric cancers. It is accompanied by the document subtitled "Methodology and Review of Evidence," which provides a detailed account of the methodology used for the evidence review. This guideline was developed using the Grading of Recommendations, Assessment, Development and Evaluation framework and specifically addresses the role of ESD versus EMR and/or surgery, where applicable, for the management of early esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), and gastric adenocarcinoma (GAC) and their corresponding precursor lesions. For ESCC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >15 mm, whereas in patients with similar lesions ≤15 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for such patients with ESCC, whenever possible. For EAC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >20 mm, whereas in patients with similar lesions measuring ≤20 mm, the ASGE suggests either ESD or EMR. For GAC, the ASGE suggests ESD over EMR for patients with early-stage, well- or moderately differentiated, nonulcerated intestinal type cancer measuring 20 to 30 mm, whereas for patients with similar lesions <20 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for patients with such lesions measuring ≤30 mm, whereas for lesions that are poorly differentiated, regardless of size, we suggest surgical evaluation over endoscopic approaches., (Copyright © 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and study aims Conventional endoscopic mucosal resection (C-EMR) is limited by low en-bloc resection rates, especially for large (> 20 mm) lesions. Underwater EMR (U-EMR) has emerged as an alternative for colorectal polyps and is being shown to improve en-bloc resection rates. We conducted a systematic review and meta-analysis comparing the two techniques. Methods Multiple databases were searched through November 2022 for randomized controlled trials (RCTs) comparing outcomes of U-EMR and C-EMR for colorectal polyps. Meta-analysis was performed to determine pooled proportions and relative risks (RRs) of R0 and en-bloc resection, polyp recurrence, resection time, and adverse events. Results Seven RCTs with 1458 patients (U-EMR: 739, C-EMR: 719) were included. The pooled rate of en-bloc resection was significantly higher with U-EMR vs C-EMR, 70.17% (confidence interval [CI] 46.68-86.34) vs 58.14% (CI 31.59-80.68), respectively, RR 1.21 (CI 1.01-1.44). R0 resection rates were higher with U-EMR vs C-EMR, 58.1% (CI 29.75-81.9) vs 44.6% (CI 17.4-75.4), RR 1.25 (CI 0.99-1.6). For large polyps (> 20 mm), en-bloc resection rates were comparable between the two techniques, RR 1.24 (CI 0.83-1.84). Resection times were comparable between U-EMR and C-EMR, standardized mean difference -1.21 min (CI -2.57 to -0.16). Overall pooled rates of perforation, and immediate and delayed bleeding were comparable between U-EMR and C-EMR. Pooled rate of polyp recurrence at surveillance colonoscopy was significantly lower with U-EMR than with C-EMR, RR 0.62 (CI 0.41-0.94). Conclusions Colorectal U-EMR results in higher en-bloc resection and lower recurrence rates when compared to C-EMR. Both techniques have comparable resection times and safety profiles., Competing Interests: Conflict of Interest Dr. Othman – Consultant for Abbvie, BSC, Olympus, Lumedni and ConMed Dr. Rodríguez – Consultant for Microtech Endoscopy. Dr. Draganov – Consultant for Olympus, Boston Scientific, Cook, Fujifilm, Medtronic, Merit, Lumendi, Steris, Microtech. The remaining authors have no conflict of interest to declare., (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 and study aims A single-operator, articulating, through-the-scope (TTS) traction device was recently developed to facilitate endoscopic submucosal dissection (ESD). Clinical data on the performance of this device are limited. We report an initial multicenter experience with ESD using this articulating TTS traction device. Patients and methods Retrospective analysis on all consecutive patients who underwent ESD using this traction device (T-ESD) at five centers between August 2021 and December 2022. Endpoints included: rates of en-bloc resection, R0 resection, curative resection, and adverse events. Results Thirty-six patients (median age 64.8 years; 47.2% women) underwent ESD (median lesion size 40 mm; interquartile range [IRQ]: 27.5-67.5) for lesions in the esophagus (n=2), stomach (n=8), sigmoid colon (n=6), and rectum (n=20). Submucosal fibrosis was encountered in one-third of the lesions (33.3%). Median ESD time was 104.6 minutes (IQR: 65-122). En-bloc, R0 and curative resection were achieved in 94.4%, 91.6%, and 97.2%, respectively. The single patient with non-curative resection of an invasive rectal adenocarcinoma underwent surgery. There were no cases of delayed bleeding or perforation. There was no recurrence on surveillance endoscopy (n=20) at a median of 6 months (IQR: 3.75-6). Conclusions This initial multicenter experience demonstrates high resection rates and excellent safety profile when performing ESD with this novel articulating TTS device. Dynamic real-time traction may lower the technical difficulty of ESD. Additional studies are needed to assess its cost-effectiveness and compare its usefulness with other traction devices and techniques during ESD., Competing Interests: Conflict of Interest D Yang is a consultant for Olympus, Fujifilm, Apollo Endosurgery, Medtronic and Microtech. DYang receives research support from Microtech and 3D-Matrix. MK Hasan is a consultant for Boston Scientific and Olympus. PV Draganov is a consultant for Olympus, Boston Scientific, Fujifilm, Cook Medical, and Medtronic. V Kumbhari is a consultant for Boston Scientific, Medtronic, FujiFilm, and has received research support from FujiFilm. M. Mizrahi is a consultant for Olympus, Boston Scientific, Fujifilm, Cook Medical, and Medtronic. A. Schlachterman is a consultant for Fujifilm, Lumendi, Apollo Endosurgery, Olympus. All other authors have nothing 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 and Aims: Large colon polyps removed by EMR can be complicated by delayed bleeding. Prophylactic defect clip closure can reduce post-EMR bleeding. Larger defects can be challenging to close using through-the-scope clips (TTSCs), and proximal defects are difficult to reach using over-the-scope techniques. A novel, through-the-scope suturing (TTSS) device allows direct closure of mucosal defects without scope withdrawal. The goal of this study was to evaluate the rate of delayed bleeding after the closure of large colon polyp EMR sites with TTSS., Methods: A multicenter retrospective cohort study was performed involving 13 centers. All defect closure by TTSS after EMR of colon polyps ≥2 cm from January 2021 to February 2022 were included. The primary outcome was rate of delayed bleeding., Results: A total of 94 patients (52% female; mean age, 65 years) underwent EMR of predominantly right-sided (n = 62 [66%]) colon polyps (median size, 35 mm; interquartile range, 30-40 mm) followed by defect closure with TTSS during the study period. All defects were successfully closed with TTSS alone (n = 62 [66%]) or with TTSS and TTSCs (n = 32 [34%]), using a median of 1 (interquartile range, 1-1) TTSS system. Delayed bleeding occurred in 3 patients (3.2%), with 2 requiring repeated endoscopic evaluation/treatment (moderate)., Conclusion: TTSS alone or with TTSCs was effective in achieving complete closure of all post-EMR defects, despite a large lesion size. After TTSS closure with or without adjunctive devices, delayed bleeding was seen in 3.2% of cases. Further prospective studies are needed to validate these findings before wider adoption of TTSS for large polypectomy closure., (Copyright © 2023 American Society for Gastrointestinal Endoscopy. All rights reserved.)

Background: Complete closure of large mucosal defects following colorectal endoscopic submucosal dissection (ESD) with through-the-scope (TTS) clips is oftentimes not possible. We aimed to report our early experience of using a novel TTS suturing system for the closure of large mucosal defects after colorectal ESD., Methods: We performed a retrospective multicenter cohort study of consecutive patients who underwent attempted prophylactic defect closure using the TTS suturing system after colorectal ESD. The primary outcome was technical success in achieving complete defect closure, defined as a < 5 mm residual mucosal defect in the closure line using TTS suturing, with or without adjuvant TTS clips., Results: 82 patients with a median defect size of 30 (interquartile range 25-40) mm were included. Technical success was achieved in 92.7 % (n = 76): TTS suturing only in 44 patients (53.7 %) and a combination of TTS suturing to approximate the widest segment followed by complete closure with TTS clips in 32 (39.0 %). Incomplete/partial closure, failure of appropriate TTS suture deployment, and the need for over-the-scope salvage closure methods were observed in 7.3 % (n = 6). One intraprocedural bleed, one delayed bleed, and three intraprocedural perforations were observed. There were no adverse events related to placement of the TTS suture., Conclusion: The TTS suture system is an effective and safe tool for the closure of large mucosal defects after colorectal ESD and is an alternative when complete closure with TTS clips alone is not possible., Competing Interests: H. Aihara is a consultant for Olympus America, Boston Scientific, Fujifilm Medical Systems, Medtronic, and 3 D Matrix. P.V. Draganov is a consultant for Olympus, Fujifilm, Boston Scientific, and Cook Medical. L.S. DʼSouza is a consultant/speaker for Apollo Endosurgery. S. Friedland is a consultant for Capsovision and Intuitive. M.K. Hasan is a consultant for Olympus and Boston Scientific. S. Jawaid is a consultant for Lumendi and Conmed. M.A. Khashab is a consultant for Boston Scientific, Olympus America, Medtronic, Apollo Endosurgery, Pentax, and GI Supply; he receives royalties from UpToDate and Elsevier. R. Kim is a consultant to Medtronic Inc. and Cook Medical. A. Kumar is a consultant for Olympus. S. Ngamruengphong is a consultant for Boston Scientific, Olympus, and Neptune Medical. M. Othman is a consultant for Olympus, Boston Scientific Corporation, Abbvie, ConMed, Creo Medical, Lumendi, and Apollo; he has received research grants from Lucid Diagnostics, AbbVie, and ConMed. A. Schlachterman is a consultant for FujiFilm, ConMed, Olympus, and Lumendi. A.C. Storm receives research grant support from Apollo Endosurgery, Boston Scientific, Endogenex, Endo-TAGSS, and Enterasense; he is a consultant for Apollo Endosurgery, Boston Scientific, ERBE Elecromedizin, GI Dynamics, Intuitive Surgical, and Olympus. D. Yang is a consultant for Olympus, Fujifilm, Apollo Endosurgery, and Medtronic. Jonathan M. Buscaglia, Andrew Canakis, Kenneth Chang, Jad Farha, Camille Hage, Amit Mehta, Bashar J. Qumseya, Hemchand Ramberan, Jason Samarasena, Brianna Shinn, and Linda Zhang declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background and study aims  Endoscopic removal of complex colorectal polyps (≥ 2 cm) can be technically challenging. A dual balloon endoluminal overtube platform (DBEP) was developed to facilitate colonoscopic polypectomy. The study purpose was to evaluate clinical outcomes with the DBEP for complex polypectomy. Patients and methods  This was an observational, prospective, multicenter Institutional Review Board-approved study. Between January 2018 and December 2020, safety and performance data were collected intra-procedurally and at 1 month post-procedure in patients undergoing intervention with the DBEP at three US centers. The primary endpoint was device safety and technical success of the procedure. Secondary endpoints included navigation time, total procedure time, and user feedback assessment post-procedure. Results  A total of 162 patients underwent colonoscopy with the DBEP. Of these, 144 (89 %) underwent 156 interventions successfully with DBEP (44.5 % endoscopic mucosal resection, 53.2 % hybrid endoscopic submucosal dissection (ESD)/ESD, 1.3 % other). In 13 patients (8 %), device challenges contributed to unsuccessful intervention. One mild device-related adverse event (AE) occurred. Procedural AE rate was 8.3 %. Median lesion size was 2.6 cm [range 0.5-12]. The investigators felt that navigating the device was easy/somewhat easy in 78.5 % of successful cases. Median total procedure time was 69 minutes [range, 19-213], median navigation time to lesion was 8 minutes [range, 1-80], And median polypectomy time was 33.5 minutes [range, 2-143]. Conclusions  Endoscopic colon polyp resection with the DBEP was safe with a high technical success rate. The DBEP has the potential to provide enhanced scope stability and visualization, traction, and a conduit for scope exchange. Further prospective randomized studies are warranted., Competing Interests: Competing interests Dr. Othman is a consultant for Olympus, Lumendi, Boston Scientific, AbbVie, ConMed, Covidian, Apollo Medical, Creo Medical and Neptun Medical and receives research support from Conmed, Lucid Diagnostic, Boston Scientific, AbbVie, Nestle and US Biotest. Dr. Diehl is a consultant for Boston Scientific, Olympus Corporation of America, Lumendi, Pentax, and Cook Medical. Dr. Khara is a consultant for Olympus. Dr. Yang is a consultant for Olympus, Microtech, Fujifilm, Apollo Endosurgery, and Medtronic and receives research support from Microtech and 3 D Matrix. Dr. Jawaid is a consultant for Conmed, Creo, and Lumendi. Dr. Draganov is a consultant for Boston Scientific, Olympus Corporation of America, Lumendi, FujiFilm Medical, and Microtech., (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/).)

Video 1., (© 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Over the years, our growing experience with endoscopic submucosal dissection along with technological advances has solidified our comfort and knowledge on working in the submucosa, also referred to as the "third space." Per-oral endoscopic myotomy (POEM) was the first prototype third-space endoscopy (TSE) procedure, demonstrating the feasibility and clinical utility of endoscopic esophagogastric myotomy via submucosal tunneling. The launch of POEM accelerated the evolution of TSE from a vanguard concept to an expanding field with a wide range of clinical applications. In this review, we discuss the status and future directions of multiple TSE interventions., (© The Author(s) 2023. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-sen University.)

Endoscopic submucosal dissection (ESD) is the preferred strategy for the resection of large superficial neoplasia throughout the gastrointestinal tract in Asian countries. The transition of ESD to the West has been slower because of various regional and training differences. Nonetheless, over the past couple of decades, the steady growth of ESD mentors in the West and the introduction of viable training pathways and dedicated devices and accessories have led to the increasing adoption of ESD and other third space endoscopic procedures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

BACKGROUND AND STUDY AIMS : Endoscopic ultrasound-guided through-the-needle biopsy (TTNB) of pancreatic cystic lesions (PCLs) is associated with a non-negligible risk for adverse events (AEs). We aimed to identify the hierarchic interaction among independent predictors for TTNB-related AEs and to generate a prognostic model using recursive partitioning analysis (RPA). PATIENTS AND METHODS : Multicenter retrospective analysis of 506 patients with PCLs who underwent TTNB. RPA of predictors for AEs was performed and the model was validated by means of bootstrap resampling. RESULTS : Mean cysts size was 36.7 mm. Most common diagnoses were intraductal papillary mucinous neoplasm (IPMN, 45 %), serous cystadenoma (18.8 %), and mucinous cystadenoma (12.8 %). Fifty-eight (11.5 %) AEs were observed. At multivariate analysis, age (odds ratio [OR] 1.32, 1.09-2.14; p = 0.05), number of TTNB passes (OR from 2.17, 1.32-4.34 to OR 3.16, 2.03-6.34 with the increase of the number of passes), complete aspiration of the cyst (OR 0.56, 0.31-0.95; p = 0.02), and diagnosis of IPMN (OR 4.16, 2.27-7.69; p < 0.001) were found to be independent predictors of AEs, as confirmed by logistic regression and random forest analyses. RPA identified three risk classes: high-risk (IPMN sampled with multiple microforceps passes, 28 % AEs rate), low-risk (1.4 % AE rate, including patients < 64 years with other-than-IPMN diagnosis sampled with ≤ 2 microforceps passes and with complete aspiration of the cyst) and middle-risk class (6.1 % AEs rate, including the remaining patients). CONCLUSION : TTNB should be selectively used in the evaluation of patients with IPMN. The present model could be applied during patient selection as to optimize the benefit/risk of TTNB., Competing Interests: S.F. Crinò has received speaker's fees from Steris Endoscopy. A. Larghi has provided consultancy to Pentax and Boston Scientific, and has received teaching fees from Medtronic and Boston Scientific. D. Yang has provided consultancy to Olympus, Boston Scientific, Lumendi, and Steris Endoscopy. P.V. Draganov has provided consultancy to Olympus, Boston Scientific, Cook Medical, Merit, Fujifilm, Microtech, Lumendi, and Steris. J.R. Aparicio has provided consultancy to Boston Scientific. C. Robles-Medranda has provided consultancy to Pentax Medical, Boston Scientific, Steris, Medtronic, Motus, Micro-tech, G-Tech Medical Supply, CREO Medical, and Mediconsgroup. A. Repici has provided consultancy to Boston Scientific and Medtronic, and has received grant support from Fujifilm. The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Flexible endoscopic cricopharyngeal myotomy and septotomy offer a minimally invasive transluminal option for the treatment of symptomatic Zenker's diverticulum (ZD). There is currently no consensus regarding postoperative follow-up imaging. We suggest a standardized computed tomography (CT) esophagram protocol for radiographic evaluation of postoperative findings., Methods: Single center retrospective analysis of patients with symptomatic ZD who underwent flexible endoscopic diverticulotomy and postoperative imaging with CT esophagram from January 2015 to March 2020. An experienced radiologist blinded to the initial imaging reports prospectively interpreted all CT esophagram findings, in order to minimize bias., Results: Twenty-one patients underwent CT esophagram following flexible endoscopic diverticulotomy for ZD. Diverticulotomy was technically successful in all patients. Most common findings on imaging included: atelectasis (13/21; 62%), persistent esophageal diverticulum (7/21; 33%), pneumomediastinum (3/21; 14%), aspiration (2/21; 10%), and extraluminal air and contrast extravasation consistent with focal esophageal perforation (1/21; 5%)., Conclusions: We describe a standardized, simple, and accessible CT esophagram protocol for postoperative imaging of patients with post-flexible endoscopic cricopharyngeal myotomy and septotomy for ZD. CT esophagram facilitates a definitive exclusion of focal esophageal perforation as a postoperative complication of flexible endoscopic diverticulotomy by ruling out extraluminal air and contrast extravasation., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tgh.amegroups.com/article/view/10.21037/tgh-20-269/coif). DY reports that he is a consultant for Boston Scientific, Lumendi, and Steris, outside the submitted work; PVD reports that he is a consultant for Boston Scientific, Olympus, Cook Medical, Lumendi, and Microtech, outside the submitted work. The other authors have no conflicts of interest to declare., (2022 Translational Gastroenterology and Hepatology. All rights reserved.)

Objectives: Endoscopic submucosal dissection is a technically demanding procedure. The pilot study aimed to prospectively evaluate the efficacy and safety of a novel single-operator through-the-scope dynamic traction device among trainees with limited endoscopic submucosal dissection (ESD) experience., Methods: Randomized, controlled, pilot study comparing traction-assisted ESD (T-ESD) versus conventional ESD (C-ESD) in an ex-vivo porcine stomach model. Trainees were randomized to group 1 (T-ESD followed by C-ESD) and group 2 (C-ESD followed by T-ESD). Lesions were created on the gravity-dependent area of the stomachs. The primary outcome was submucosal dissection speed. Secondary outcomes included differences in en-bloc resection, adverse events, and workload, assessed by the National Aeronautical and Space Administration Task Load Index (NASA-TLX)., Results: Five trainees performed two T-ESD and two C-ESD each, for a total of 20 procedures. Submucosal dissection speed was significantly faster in the T-ESD group compared to the C-ESD group (43.32 ± 22.61 vs. 24.19 ± 15.86 mm 2 /min; p = 0.042). En-bloc resection was achieved in 60% with T-ESD and 70% with C-ESD ( p = 1.00). The muscle injury rate was higher in the C-ESD group (50% vs. 10%; p = 0.21) with 1 perforation reported with C-ESD and none with T-ESD. NASA-TLX physical demand was lower with T-ESD compared to C-ESD (4.5 ± 2.17 vs. 6.9 ± 2.50; p = 0.03)., Conclusion: T-ESD resulted in faster submucosal dissection and less physical demand when compared to C-ESD, as performed by trainees in an ex-vivo gravity-dependent model. Future studies are needed to assess its role in human ESD cases., Competing Interests: Dennis Yang is a consultant for Olympus, Fujifilm, Apollo Endosurgery, Medtronic, and Microtech. Hiroyuki Aihara is a consultant for Olympus, Fujifilm, Boston Scientific, Medtronic, and 3D Matrix. Kambiz Kadkhodayan has no disclosures. Mustafa A. Arain is a consultant for Boston Scientific, Olympus, Cook Medical, and Medtronic. Muhammad K. Hasan is a consultant for Boston Scientific and Olympus. Peter V. Draganov is a consultant for Olympus, Boston Scientific, Fujifilm, Cook Medical, and Medtronic. All other authors have nothing to disclose. The authors received no financial incentive, including no consulting fees, relating to this study or the devices used in this study., (© 2022 The Authors. DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Background and Aims: The outcomes of endoscopic submucosal dissection (ESD) for T1b esophageal cancer (EC) and its recurrence rates remain unclear in the West. Using a multicenter cohort, we evaluated technical outcomes and recurrence rates of ESD in the treatment of pathologically staged T1b EC., Methods: We included patients who underwent ESD of T1b EC at 7 academic tertiary referral centers in the United States (n = 6) and Brazil (n = 1). We analyzed demographic, procedural, and histopathologic characteristics and follow-up data. Time-to-event analysis was performed to evaluate recurrence rates., Results: Sixty-six patients with pathologically staged T1b EC after ESD were included in the study. A preprocedure staging EUS was available in 54 patients and was Tis/T1a in 27 patients (50%) and T1b in 27 patients (50%). En-bloc resection rate was 92.4% (61/66) and R0 resection rate was 54.5% (36/66). Forty-nine of 66 patients (74.2%) did not undergo surgery immediately after resection and went on to surveillance. Ten patients had ESD resection within the curative criteria, and no recurrences were seen in a 13-month (range, 3-18.5) follow-up period in these patients. Ten of 39 patients (25.6%) with noncurative resections had residual/recurrent disease. Of the 10 patients with noncurative resection, local recurrence alone was seen in 5 patients (12.8%) and metastatic recurrence in 5 patients (12.8%). On univariate analysis, R1 resection had a higher risk of recurrent disease (hazard ratio, 6.25; 95% confidence interval, 1.29-30.36; P = .023)., Conclusions: EUS staging of T1b EC has poor accuracy, and a staging ESD should be considered in these patients. ESD R0 resection rates were low in T1b EC, and R1 resection was associated with recurrent disease. Patients with noncurative ESD resection of T1b EC who cannot undergo surgery should be surveyed closely, because recurrent disease was seen in 25% of these patients., (Copyright © 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and study aims  Optical coherence tomography (OCT) is a new technology available for evaluation of indeterminate biliary strictures. It allows under-the-surface visualization and preliminary studies have confirmed standardized characteristics associated with malignancy. The aim of this study is to evaluate the first interobserver agreement in identifying previously agreed upon OCT criteria and diagnosing of malignant versus benign disease. Patients and methods  Fourteen endoscopists were asked to review an atlas of reference clips and images of eight criteria derived from expert consensus A total of 35 de-identified video clips were then evaluated for presence of the eight criteria and for final diagnosis of malignant versus benign using the atlas as reference Intraclass correlation (ICC) analysis was done to evaluate interrater agreement. Results  Clips of 23 malignant lesions and 12 benign lesions were scored. Excellent interobserver agreement was seen with dilated hypo-reflective structures (0.85) and layering effacement (0.89); hyper-glandular mucosa (0.76), intact layering (0.81), and onion-skin layering (0.77); fair agreement was seen with scalloping (0.58), and thickened epithelium (0.4); poor agreement was seen with hyper-reflective surface (0.36). The diagnostic ICC for both neoplastic (0.8) and non-neoplastic (0.8) was excellent interobserver agreement. The overall diagnostic accuracy was 51 %, ranging from 43 % to 60 %. Conclusions  Biliary OCT is a promising new modality for evaluation of indeterminate biliary strictures. Interobserver agreement ranged from fair to almost perfect on eight previously identified criteria. Interobserver agreement for malignancy diagnosis was substantial (0.8). Further studies are needed to validate this data., Competing Interests: Competing interests Amy Tyberg: Consultant for Ninepoint Medical, Endogastric Solutions, Obalon Therapeutics. Avik Sarkar has done consulting work for US Endoscopy and Obalon Therapeutics. Haroon Shahid has done consulting work for US Endoscopy. Michel Kahaleh has received grants support from Boston Scientific, Fujinon, W.L. Gore, Apollo Endosurgery, Cook Endoscopy, GI Dynamics, Merit Medical, Interscope Med, Olympus, ERBE, and MI Tech. He is a consultant for Boston Scientific and Laboratories Inc., ABBvie. None of those funding was related to this paper., (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 and study aims  Gastroparesis post-lung transplant (LTx) can lead to increased risk of gastroesophageal reflux (GER) and accelerated graft dysfunction. We aimed to evaluate the efficacy and safety of gastric per-oral endoscopic myotomy (G-POEM), a promising tool in patients with refractory gastroparesis, for managing refractory gastroparesis and GER in post-LTx patients. Patents and methods  This was a multicenter retrospective study on post-LTx patients who underwent G-POEM for management of gastroparesis and GER that were refractory to standard medical therapy. The primary outcome was clinical success post-G-POEM. Secondary outcomes included the rate of post-G-POEM objective esophageal pH exam normalization, rate of gastric emptying scintigraphy (GES) normalization, technical success, and adverse events. Results  A total of 20 patients (mean age 54.7 ± 14.1 years, Female 50 %) underwent G-POEM at a median time of 13 months (interquartile range 6.5-13.5) post-LTx. All G-POEM procedures were technically successful. Clinical success was achieved in 17 (85 %) patients during a median follow-up time of 8.9 (IQR: 3-17) months post-G-POEM. Overall GCSI and two of its subscales (bloating and postprandial fullness/early satiety) improved significantly following G-POEM. Two patients (10 %) developed post-procedural AEs (delayed bleeding 1, pyloric stenosis 1, both moderate in severity). Post-G-POEM GES improvement was achieved in 12 of 16 patients (75 %). All 20 patients were on proton pump inhibitors pre-G-POEM, as opposed to five post-G-POEM. Post-G-POEM PH study normalization was noted in nine of 10 patients (90 %) who underwent both pre- and post-G-poem pH testing. Conclusions  G-POEM is a promising noninvasive therapeutic tool for management of refractory gastroparesis and GER post-LTx., Competing Interests: Competing interests Dr. Hwang is a consultant for Boston Scientific, Olympus, and Medtronic, Dr. Draganov is a consultant for Olympus, Boston Scientific, Cook, Lumendi, Microtech. Dr. Zuchelli is a consultant for Boston Scientific, Dr. Piraka is a recipient of study funding from Aries and US Endoscopy, Dr. Khashab is a consultant for Boston Scientific, Olympus, and Medtronic., (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 and Aims: Ablation of resection margins after EMR of large nonpedunculated colorectal polyps decreases recurrence. Margin marking before EMR (EMR-MM) may represent an alternative method to achieve a healthy resection margin. We aimed to determine the efficacy of EMR-MM in reducing neoplasia recurrence., Methods: We conducted a single-center historical control study of EMR cases (EMR-MM vs conventional EMR) for nonpedunculated polyps ≥20 mm between 2016 and 2021. For EMR-MM, cautery marks were placed along the lateral margins of the polyp with the snare tip. EMR was then performed to include resection of the healthy mucosa containing the marks. We compared recurrence at surveillance colonoscopy after EMR-MM versus historical control subjects. Multivariable logistic regression was performed to identify factors associated with recurrence., Results: Two hundred ten patients with 210 polyps (median size, 30 mm; interquartile range: 25-40) underwent EMR-MM (n = 74) or conventional EMR (n = 136). Patient and lesion characteristics were similar between the groups. At a median follow-up of 6 months, the recurrence rate was lower with EMR-MM (6/74; 8%) compared with historical control subjects (39/136; 29%) (P < .001). EMR-MM was not associated with an increased rate of adverse events. On multivariable analysis, EMR-MM remained the strongest predictor of recurrence (odds ratio, .20; 95% confidence interval, .13-.64; P = .003) aside from polyp size (odds ratio, 2.81; 95% confidence interval, 1.35-6.01; P = .008)., Conclusions: In this single-center historical control study, EMR-MM of large nonpedunculated colorectal polyps reduced the recurrence risk by 80% when compared with conventional EMR. This simple technique may provide an alternative to margin ablation., (Copyright © 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)