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Background and Aim: Endoscopic submucosal dissection (ESD) is considered the best modality for achieving en bloc resection of larger neoplastic mucosal lesions in the upper and lower gastrointestinal (GI) tract. Multiple devices are available for ESD, and refinements continue to be made to develop devices that improve the safety and efficiency of performing ESD. Submucosal injection with viscous fluids like glycerol, which prolong submucosal expansion, could facilitate the procedure. We aimed to evaluate the safety and performance of the new Erbe HYBRIDknife® flex, which combines electrosurgical dissection with waterjet-assisted injection in a slim and flexible form factor., Methods: In a prospective animal study with six pigs, four endoscopists, each with 10-20 years of experience in ESD, performed 28 esophageal ESDs. One half was performed with physiological saline injectate, the other half with fructose-added glycerol. Various performance aspects were evaluated on a five-point scale [5 = best], including dissection properties, handling, and usability., Results: No perforations or major bleeding occurred. All resections were performed en bloc, with one technical failure (3.6%, 1 of 28). Performance scores were similar for saline and glycerol (4.5 ± 0.31 vs. 4.5 ± 0.32, P  = 0.36), as was dissection speed (13 ± 6.2 mm 2 /min vs. 15 ± 6.1 mm 2 /min, P  = 0.22)., Conclusions: We demonstrated that esophageal ESD can be performed safely and rapidly using HYBRIDknife flex, with excellent performance evaluation by the endoscopists. Combining this device with glycerol or saline is precise and effective for ESD, although experience could compensate for the theoretical disadvantage of using normal saline., (© 2024 The Author(s). JGH Open published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Mucosal gastric atrophy and intestinal metaplasia (IM) increase the risk for the development of gastric cancer (GC) as they represent a field for development of dysplasia and intestinal-type gastric adenocarcinoma., Methods: We have investigated the expression of two dysplasia markers, CEACAM5 and TROP2, in human antral IM and gastric tumors to assess their potential as molecular markers., Results: In the normal antral mucosa, weak CEACAM5 and TROP2 expression was only observed in the foveolar epithelium, while inflamed antrum exhibited increased expression of both markers. Complete IM exhibited weak CEACAM5 expression at the apical surface, but no basolateral TROP2 expression. On the other hand, incomplete IM demonstrated high levels of both CEACAM5 and TROP2 expression. Notably, incomplete IM with dysplastic morphology (dysplastic incomplete IM) exhibited higher levels of CEACAM5 and TROP2 expression compared to incomplete IM without dysplastic features (simple incomplete IM). In addition, dysplastic incomplete IM showed diminished SOX2 and elevated CDX2 expression compared to simple incomplete IM. CEACAM5 and TROP2 positivity in incomplete IM was similar to that of gastric adenomas and GC. Significant association was found between CEACAM5 and TROP2 positivity and histology of GC., Conclusions: These findings support the concept that incomplete IM is more likely associated with GC development. Overall, our study provides evidence of the heterogeneity of gastric IM and the distinct expression profiles of CEACAM5 and TROP2 in dysplastic incomplete IM. Our findings support the potential use of CEACAM5 and TROP2 as molecular markers for identifying individuals with a higher risk of GC development in the context of incomplete IM., (© 2024. The Author(s) under exclusive licence to The International Gastric Cancer Association and The Japanese Gastric Cancer Association.)

Intestinal metaplasia (IM) is a pre-malignant condition of the gastric mucosa associated with increased gastric cancer (GC) risk. Analyzing 1,256 gastric samples (1,152 IMs) across 692 subjects from a prospective 10-year study, we identify 26 IM driver genes in diverse pathways including chromatin regulation (ARID1A) and intestinal homeostasis (SOX9). Single-cell and spatial profiles highlight changes in tissue ecology and IM lineage heterogeneity, including an intestinal stem-cell dominant cellular compartment linked to early malignancy. Expanded transcriptome profiling reveals expression-based molecular subtypes of IM associated with incomplete histology, antral/intestinal cell types, ARID1A mutations, inflammation, and microbial communities normally associated with the healthy oral tract. We demonstrate that combined clinical-genomic models outperform clinical-only models in predicting IMs likely to transform to GC. By highlighting strategies for accurately identifying IM patients at high GC risk and a role for microbial dysbiosis in IM progression, our results raise opportunities for GC precision prevention and interception., Competing Interests: Declaration of interests P.T. has stock in Tempus Healthcare, previous funding from Kyowa Hakko Kirin and Thermo Fisher Scientific, and patents/other intellectual property through the Agency for Science and Technology Research, Singapore (all outside the submitted work). K.G.Y. is a co-inventor on patents “Serum MicroRNA Biomarker for the Diagnosis of Gastric Cancer” and “Methods Related to Real-Time Cancer Diagnostics at Endoscopy Utilizing Fiber-Optic Raman Spectroscopy”; a member of Scientific Advisory Board of MiRXES Pte Ltd. He has no stock or shares in the related companies. He has no conflicts of interest to disclose regarding this submitted work. R.S. has received honoraria from MSD, Eli Lilly, BMS, Roche, Taiho, Astra Zeneca, DKSH, and Ipsen; has advisory activity with Bristol Myers Squibb, Merck, Eisai, Bayer, Taiho, Novartis, MSD, GSK, DKSH, and Astellas; received research funding from Paxman Coolers, MSD, and Natera; and has received travel grants from Roche, Astra Zeneca, Taiho, Eisai, and DKSH., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: None

Background and Aims: Computer-assisted detection (CADe) is a promising technologic advance that enhances adenoma detection during colonoscopy. However, the role of CADe in reducing missed colonic lesions is uncertain. The aim of this study was to determine the miss rates of proximal colonic lesions by CADe and conventional colonoscopy., Methods: This was a prospective, multicenter, randomized, tandem-colonoscopy study conducted in 3 Asian centers. Patients were randomized to receive CADe or conventional white-light colonoscopy during the first withdrawal of the proximal colon (cecum to splenic flexure), immediately followed by tandem examination of the proximal colon with white light in both groups. The primary outcome was adenoma/polyp miss rate, which was defined as any adenoma/polyp detected during the second examination., Results: Of 223 patients (48.6% men; median age, 63 years) enrolled, 7 patients did not have tandem examination, leaving 108 patients in each group. There was no difference in the miss rate for proximal adenomas (CADe vs conventional: 20.0% vs 14.0%, P = .07) and polyps (26.7% vs 19.6%, P = .06). The CADe group, however, had significantly higher proximal polyp (58.0% vs 46.7%, P = .03) and adenoma (44.7% vs 34.6%, P = .04) detection rates than the conventional group. The mean number of proximal polyps and adenomas detected per patient during the first examination was also significantly higher in the CADe group (polyp: 1.20 vs .86, P = .03; adenoma, .91 vs .61, P = .03). Subgroup analysis showed that CADe enhanced proximal adenoma detection in patients with fair bowel preparation, shorter withdrawal time, and endoscopists with lower adenoma detection rate., Conclusions: This multicenter trial from Asia confirmed that CADe can further enhance proximal adenoma and polyp detection but may not be able to reduce the number of missed proximal colonic lesions. (Clinical trial registration number: NCT04294355.)., (Copyright © 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and study aims  We evaluated use of artificial intelligence (AI) assisted image classifier in determining the feasibility of curative endoscopic resection of large colonic lesion based on non-magnified endoscopic images Methods  AI image classifier was trained by 8,000 endoscopic images of large (≥ 2 cm) colonic lesions. The independent validation set consisted of 567 endoscopic images from 76 colonic lesions. Histology of the resected specimens was used as gold standard. Curative endoscopic resection was defined as histology no more advanced than well-differentiated adenocarcinoma, ≤ 1 mm submucosal invasion and without lymphovascular invasion, whereas non-curative resection was defined as any lesion that could not meet the above requirements. Performance of the trained AI image classifier was compared with that of endoscopists. Results  In predicting endoscopic curative resection, AI had an overall accuracy of 85.5 %. Images from narrow band imaging (NBI) had significantly higher accuracy (94.3 % vs 76.0 %; P  < 0.00001) and area under the ROC curve (AUROC) (0.934 vs 0.758; P  = 0.002) than images from white light imaging (WLI). AI was superior to two junior endoscopists in terms of accuracy (85.5 % vs 61.9 % or 82.0 %, P  < 0.05), AUROC (0.837 vs 0.638 or 0.717, P  < 0.05) and confidence level (90.1 % vs 83.7 % or 78.3 %, P  < 0.05). However, there was no statistical difference in accuracy and AUROC between AI and a senior endoscopist. Conclusions  The trained AI image classifier based on non-magnified images can accurately predict probability of curative resection of large colonic lesions and is better than junior endoscopists. NBI images have better accuracy than WLI for AI prediction.