Impact of annual case volume on colorectal endoscopic submucosal dissection outcomes in a large prospective cohort study.

OBJECTIVES: The adoption of colorectal endoscopic submucosal dissection (ESD) is still limited in the West. A recent randomized trial showed ESD is more effective and only slightly riskier than piecemeal endoscopic mucosal resection (EMR); reproducibility outside expert centers was questioned. We evaluated the results according to the annual case volume in a multicentric prospective cohort. METHODS: Between 09/2019 and 09/2022, colorectal ESD was consecutively performed at 13 participating centers classified as low-volume (LV), middle-volume (MV), and high-volume (HV). The main procedural outcomes were assessed. Multivariate and propensity score matching (PSM) analyses were performed. RESULTS: 3770 ESDs were included. HV centers treated larger and more often colonic lesions than MV and LV centers. En bloc, R0 and curative resection rates were 95.2%, 87.4%, and 83.2%, respectively, and were higher at HV than at MV and LV centers. HV centers achieved also a faster dissection speed. Delayed bleeding and surgery for complications rates were 5.4% and 0.8%, respectively, without significant differences. The perforation rate (overall: 9%) was higher at MV than at LV and HV centers. Lesion characteristics, but not volume center, were independently associated with both R1 resection and perforation. However, after PSM, R0 rates were significantly higher at HV than at LV centers, and perforation rates were significantly higher at MV than at HV centers. CONCLUSIONS: Colorectal ESD can be successfully implemented in the West, even in nonexpert centers. However, difficult lesions must still be referred to experts.

Management of perforations during endoscopic resection.

Despite the evolution in tools and techniques, perforation is still one of the most pernicious adverse events of therapeutic endoscopy with potentially huge consequences. As advanced endoscopic resection techniques are worldwide spreading, endoscopists must be ready to manage intraprocedural perforations. In fact, immediate endoscopic closure through a prompt diagnosis represents the first-line option, saving patients from surgery, long hospitalizations and worse outcomes. Traditional and novel endoscopic closure modalities, including clips, suturing devices, stents and vacuum therapy, are increasingly expanding the therapeutic armamentarium for closing these defects. Nevertheless, available literature on this topic is currently limited. In this review our goal is to give an overview on the management of perforations occurring during endoscopic resections, with particular attention to characteristics, advantages, disadvantages and new horizons of endoscopic closure tools.

Saline-immersion peroral endoscopic septotomy: a case report.

Video 1Saline-immersion peroral endoscopic septotomy.

Cold-snare endoscopic resection of non-ampullary duodenal adenomas: Systematic review and pooled-analysis.

BACKGROUND: Mirroring the experience with colonic resections, cold snare-based techniques have been recently proposed for non-ampullary duodenal lesions to reduce the risk of adverse events (AEs). As the duodenal wall is thinner and more vascularized than in the colon, electrocautery-related AEs are relevant issues in this setting. AIMS: We performed a systematic review with pooled-analysis to evaluate the efficacy and safety of this technique. METHODS: Electronic databases (Medline, Scopus, EMBASE) were searched up to January 2023. Full articles including patients with duodenal lesions resected by cold-snare technique were eligible. The adverse events (i.e., bleeding, perforation, stricture), complete resection, and recurrence rates were pooled using a random model. RESULTS: Eleven studies were eligible, providing data on 3137 lesions removed from 233 patients. The overall AE rate for cold snaring was 0.25% (95% CI, 0.19%-0.69%). Among the three studies comparing cold- and hot-snare approaches, procedure-related bleeding rate was significantly lower with cold approach (OR 1.21, 0.51-2.85; p = 0.66). The complete resection rate was 99.40% (95% CI, 98.60%-100%), with a residual/recurrence rate of 12.95% (95% CI, 4.75%-21.16%). On univariate meta-regression, lesion size significantly affected both the adverse events and recurrence risk. CONCLUSION: Cold-snare resection appears effective and extremely safe for resecting non-ampullary duodenal lesions.

Cold resection for colorectal polyps: where we are and where we are going?

INTRODUCTION: Endoscopic resection of colonic precancerous lesions has been demonstrated to significantly decrease colorectal cancer (CRC) incidence and mortality. Among resection techniques, cold snare polypectomy (CSP) has been shown as a highly feasible, effective and safe option and is widely used in clinical practice, being regarded as the first-line technique for removal of small and diminutive colorectal polyps. On the other hand, conventional hot snare polypectomy (HSP) and endoscopic mucosal resection (EMR), namely the gold standard treatments for larger polyps, may be occasionally associated to complications due to electrocautery injury. AREAS COVERED: To overcome these shortcomings of electrocautery-based resection techniques, in the last few years CSP has been increasingly assessed as a treatment option for additional indications, with a focus on nonpedunculated colorectal polyps ≥10 mm. EXPERT OPINION: This review aims to present current and widened indications of CSP discussing the latest findings from the most remarkable studies, with an insight into technical issues, novelties and potential advances in the near future.

Endoscopic resection of non-ampullary duodenal adenomas: Is cold snaring the promised land?

Due to the high risk of morbidity and mortality associated with surgical resection in this tract, endoscopic resection (ER) has taken the place of surgical resection as the first line treatment for non-ampullary duodenal adenomas. However, due to the anatomical characteristics of this area, which enhance the risk of post-ER problems, ER in the duodenum is particularly difficult. Due to a lack of data, no ER technique for superficial non-ampullary duodenal epithelial tumours (SNADETs) has yet been backed by strong, high-quality evidence; yet, traditional hot snare-based techniques are still regarded as the standard treatment. Despite having a favourable efficiency profile, adverse events during duodenal hot snare polypectomy (HSP) and hot endoscopic mucosal resection, such as delayed bleeding and perforation, have been reported to be frequent. These events are primarily caused by electrocautery-induced damage. Thus, ER techniques with a better safety profile are needed to overcome these shortcomings. Cold snare polypectomy, which has already been shown as a safer, equally effective procedure compared to HSP for treatment of small colorectal polyps, is being increasingly evaluated as a potential therapeutic option for non-ampullary duodenal adenomas. The aim of this review is to report and discuss the early outcomes of the first experiences with cold snaring for SNADETs.

What Is "Cold" and What Is "Hot" in Mucosal Ablation for Barrett's Oesophagus-Related Dysplasia: A Practical Guide.

Over the last two decades, endoscopic eradication therapy has been established as the therapeutic strategy of choice for patients with Barrett's oesophagus-related dysplasia and early oesophageal adenocarcinoma. With a multimodal approach, ablative therapies have been highly effective in achieving remarkable eradication rates of metaplastic epithelium with an acceptable adverse event rate. Among ablative techniques, radiofrequency ablation is currently considered as the first-line option as its efficacy and safety are strongly supported by relevant data. Nevertheless, radiofrequency ablation is costly, and not universally available, or applicable to every situation. Moreover, primary failure and recurrence rates are not negligible. In the last few years, cryotherapy techniques and hybrid argon plasma coagulation have been increasingly assessed as potential novel ablative therapies. Preliminary data have been promising and suggest that they may even have a role as first-line options, alternatively to radiofrequency ablation. The aim of this review is to provide a practical guide for the ablation of Barrett's oesophagus, with emphasis on the different ablative options.

Artificial Intelligence-Aided Endoscopy and Colorectal Cancer Screening.

Colorectal cancer (CRC) is the third most common cancer worldwide, with the highest incidence reported in high-income countries. However, because of the slow progression of neoplastic precursors, along with the opportunity for their endoscopic detection and resection, a well-designed endoscopic screening program is expected to strongly decrease colorectal cancer incidence and mortality. In this regard, quality of colonoscopy has been clearly related with the risk of post-colonoscopy colorectal cancer. Recently, the development of artificial intelligence (AI) applications in the medical field has been growing in interest. Through machine learning processes, and, more recently, deep learning, if a very high numbers of learning samples are available, AI systems may automatically extract specific features from endoscopic images/videos without human intervention, helping the endoscopists in different aspects of their daily practice. The aim of this review is to summarize the current knowledge on AI-aided endoscopy, and to outline its potential role in colorectal cancer prevention.

Artificial intelligence and inflammatory bowel disease: Where are we going?

Inflammatory bowel diseases, namely ulcerative colitis and Crohn's disease, are chronic and relapsing conditions that pose a growing burden on healthcare systems worldwide. Because of their complex and partly unknown etiology and pathogenesis, the management of ulcerative colitis and Crohn's disease can prove challenging not only from a clinical point of view but also for resource optimization. Artificial intelligence, an umbrella term that encompasses any cognitive function developed by machines for learning or problem solving, and its subsets machine learning and deep learning are becoming ever more essential tools with a plethora of applications in most medical specialties. In this regard gastroenterology is no exception, and due to the importance of endoscopy and imaging numerous clinical studies have been gradually highlighting the relevant role that artificial intelligence has in inflammatory bowel diseases as well. The aim of this review was to summarize the most recent evidence on the use of artificial intelligence in inflammatory bowel diseases in various contexts such as diagnosis, follow-up, treatment, prognosis, cancer surveillance, data collection, and analysis. Moreover, insights into the potential further developments in this field and their effects on future clinical practice were discussed.

Clinical features and management issues of NAFLD-related HCC: what we know so far.

INTRODUCTION: Nonalcoholic fatty liver disease (NAFLD) is replacing viral hepatitis as the leading cause of chronic liver disease and hepatocellular carcinoma (HCC) in many Western countries. NAFLD-associated HCC usually affects older patients with multiple comorbidities, frequently develops in the absence of cirrhosis, and is often diagnosed later with worse chance of survival. The worse prognosis is also due to limited surveillance strategies and a lower efficacy of standard treatments. AREAS COVERED: We evaluate the available literature to understand the current surveillance strategies and treatment limitations in the workup of NAFLD-associated HCC, focusing on the differences with HCC associated with other liver diseases. EXPERT OPINION: In this review we discuss epidemiology and risk factors for HCC in NAFLD patients and address key HCC surveillance and management issues. Although most data are still preliminary, the detection of non-cirrhotic NAFLD patients at increased risk for HCC and the potential adoption of novel screening tools could lead to accurate and suitable HCC surveillance and management strategies for NAFLD patients.

Technological advances in inflammatory bowel disease endoscopy and histology.

Accurate disease characterization is the pillar of modern treatment of inflammatory bowel disease (IBD) and endoscopy is the mainstay of disease assessment and colorectal cancer surveillance. Recent technological progress has enhanced and expanded the use of endoscopy in IBD. In particular, numerous artificial intelligence (AI)-powered systems have shown to support human endoscopists' evaluations, improving accuracy and consistency while saving time. Moreover, advanced optical technologies such as endocytoscopy (EC), allowing high magnification in vivo, can bridge endoscopy with histology. Furthermore, molecular imaging, through probe based confocal laser endomicroscopy allows the real-time detection of specific biomarkers on gastrointestinal surface, and could be used to predict therapeutic response, paving the way to precision medicine. In parallel, as the applications of AI spread, computers are positioned to resolve some of the limitations of human histopathology evaluation, such as interobserver variability and inconsistencies in assessment. The aim of this review is to summarize the most promising advances in endoscopic and histologic assessment of IBD.

Sphingosine 1-Phosphate Modulation in Inflammatory Bowel Diseases: Keeping Lymphocytes Out of the Intestine.

Inflammatory bowel diseases (IBDs) are chronic and disabling conditions that, uncontrolled, lead to irreversible bowel damage and associated comorbidities. Despite the new era of biological therapies, IBDs remain not curative. The treatment purpose is to induce endoscopic remission, reduce the progression of the disease and improve the quality of life. Optimal and early treatment could enable the prevention of their complications. Small molecules, administrated as oral agents, have the capacity of overcoming the limitations of biologic agents (i.e., parenteral administration, rapidity of action and primary and secondary non-responsiveness). Of special interest are results from the use of oral sphingosine 1-phosphate (S1P) receptor modulators (ozanimod, etrasimod, fingolimod and laquinimod), based on S1P activities to target lymphocyte recirculation in the mucosa, acting as immunosuppressive agents. Most S1P modulators are reported to be safe and effective in the treatment of both UC and CD. High and satisfactory rates of clinical remission as well as endoscopic improvement and remission can be achieved with these molecules. Safety alarms remain rather low, although the S1P binding to two of its G protein-coupled receptors, 2 and 3 (S1PR2 and S1PR3), may be associated with cardiovascular risks. Cost-effectiveness studies and head-to-head trials are needed to better define their place in therapy. This review summarizes these emerging data published by PubMed and EMBASE databases and from ongoing clinical trials on the safety and efficacy of selectivity of S1P modulators in the treatment of IBD.

Cross-Sectional Imaging Instead of Colonoscopy in Inflammatory Bowel Diseases: Lights and Shadows.

International guidelines recommend a treat-to-target strategy with a close monitoring of disease activity and therapeutic response in inflammatory bowel diseases (IBD). Colonoscopy (CS) represents the current first-line procedure for evaluating disease activity in IBD. However, as it is expensive, invasive and poorly accepted by patients, CS is not appropriate for frequent and repetitive reassessments of disease activity. Recently, cross-sectional imaging techniques have been increasingly shown as reliable tools for assessing IBD activity. While computed tomography (CT) is hampered by radiation risks, routine implementation of magnetic resonance enterography (MRE) for close monitoring is limited by its costs, low availability and long examination time. Novel magnetic resonance imaging (MRI)-based techniques, such as diffusion-weighted imaging (DWI), can overcome some of these weaknesses and have been shown as valuable options for IBD monitoring. Bowel ultrasound (BUS) is a noninvasive, highly available, cheap, and well accepted procedure that has been demonstrated to be as accurate as CS and MRE for assessing and monitoring disease activity in IBD. Furthermore, as BUS can be quickly performed at the point-of-care, it allows for real-time clinical decision making. This review summarizes the current evidence on the use of cross-sectional imaging techniques as cost-effective, noninvasive and reliable alternatives to CS for monitoring patients with IBD.

Comparing the number and relevance of false activations between 2 artificial intelligence computer-aided detection systems: the NOISE study.

BACKGROUND AND AIMS: Artificial intelligence has been shown to be effective in polyp detection, and multiple computer-aided detection (CADe) systems have been developed. False-positive (FP) activation emerged as a possible way to benchmark CADe performance in clinical practice. The aim of this study was to validate a previously developed classification of FPs comparing the performances of different brands of approved CADe systems. METHODS: We compared 2 different consecutive video libraries (40 video per arm) collected at Humanitas Research Hospital with 2 different CADe system brands (CADe A and CADe B). For each video, the number of CADe false activations, cause, and time spent by the endoscopist to examine the area erroneously highlighted were reported. The FP activations were classified according to the previously developed classification of FPs (the NOISE classification) according to their cause and relevance. RESULTS: In CADe A 1021 FP activations were registered across the 40 videos (25.5 ± 12.2 FPs per colonoscopy), whereas in CADe B 1028 were identified (25.7 ± 13.2 FPs per colonoscopy; P = .53). Among them, 22.9 ± 9.9 (89.8% in CADe A) and 22.1 ± 10.0 (86.0% in CADe B) were because of artifacts from the bowel wall. Conversely, 2.6 ± 1.9 (10.2% in CADe A) and 3.5 ± 2.1 (14% in CADe B) were caused by bowel content (P = .45). Within CADe A each false activation required .2 ± .9 seconds, with 1.6 ± 1.0 FPs (6.3%) requiring additional time for endoscopic assessment. Comparable results were reported within CADe B with .2 ± .8 seconds spent per false activation and 1.8 ± 1.2 FPs per colonoscopy requiring additional inspection. CONCLUSIONS: The use of a standardized nomenclature provided comparable results with either of the 2 recently approved CADe systems. (Clinical trial registration number: NCT04399590.).

IBD goes home: from telemedicine to self-administered advanced therapies.

INTRODUCTION: Major challenges have been posed by the coronavirus disease 2019 pandemic in the routine management of patients with inflammatory bowel disease (IBD). The need for constant monitoring of diseases activity and prompt adjustment of therapy have been balanced with the risk of contagion related to face-to-face consultations. Therefore, digital health initiatives have been pursued for safety reasons as vicarious instruments to avoid overcrowding of the IBD clinics. However, concerns and skepticism about the feasibility of digital health and telemedicine modalities limited their uptake in clinical practice in the pre-pandemic period. AREAS COVERED: We conducted a literature overview on the current state of the art and the potential future benefits deriving from the integration of telemedicine systems, home-based laboratory tests, and self-administered drugs into IBD daily practice. EXPERT OPINION: Digital health and telemedicine approaches at distance have been experimented as effective tools to avoid overcrowding of clinics and reduce risk from SARS-CoV2 exposure. Home-based point of care testing, such as fecal calprotectin and dried blood samples, might represent an effective method of remote monitoring of patients particularly when in-person visits are precluded. High expectations are placed on the use of self-administered advanced therapies, such as new subcutaneous formulation of biologics.