Large non-pedunculated colorectal polyps represent a heterogeneous group of lesions with variable malignant potential and technical complexity. Appropriate management requires careful lesion assessment, estimation of malignant risk and adoption of selective resection strategy with consideration to the patient, the lesion and technical challenges that may be encountered. Advances in endoscopic resection has meant that most colorectal polyps can be safely removed with an expanding role in the management of early colorectal cancer. Inappropriate lesion assessment and premature surgical referral continue to result in avoidable surgery and its associated morbidity. This review summarises the current evidence on techniques for the management of large non-pedunculated colorectal polyps, highlighting areas of uncertainty and priorities for future research.

BACKGROUND & AIMS:In Western populations, esophageal squamous high-grade dysplasia and early squamous cell carcinoma are usually detected incidentally and at a more advanced stage than in Asia. Many therefore fall outside traditional Japanese absolute criteria for endoscopic submucosal dissection and are referred directly for surgery. Endoscopic submucosal dissection is not routinely considered in this setting. METHODS:In a single-tertiary-center prospective cohort study over 92 months to April 2024, we evaluated long-term outcomes of endoscopic submucosal dissection for squamous high-grade dysplasia and early squamous cell carcinoma, comparing absolute criteria and outside criteria lesions. RESULTS:Seventy-five patients underwent endoscopic submucosal dissection (mean age, 72.9 ± 8.2 years; 62.7% female; median lesion size, 40 mm). Thirty-nine (52%) met absolute criteria and 36 (48%) outside criteria. Curative resection rates were higher for absolute criteria lesions (71.8% vs 19.4%), yet almost 1 in 5 outside criteria cases achieved cure without surgery. Median follow-up was 54 months (interquartile range, 34-75 months). Recurrence occurred in 12 of 75 patients (16%), and 15 patients (20%) died, including 7 from squamous cell carcinoma. In curative resections, 5-year overall survival and disease-specific survival were 95.5% and 100%, respectively. In noncurative resections (72.5% from the outside criteria group), 5-year overall survival and disease-specific survival were 61.4% and 81.4%, respectively. Overall survival improved to 87.5% among noncured patients receiving adjuvant therapy. CONCLUSIONS:Endoscopic submucosal dissection offers excellent procedural outcomes and provides definitive T-staging for esophageal squamous high-grade dysplasia and early squamous cell carcinoma in Western practice. In those meeting absolute criteria, the majority are cured and achieve excellent long-term overall survival. In the noncured, mostly outside criteria lesions in the elderly and comorbid, endoscopic submucosal dissection provides durable local disease control and facilitates organ preservation. Thus, endoscopic submucosal dissection should be considered at the forefront of therapeutic consideration. CLINICALTRIALS:gov, Number: NCT02305290.

Background:Endoscopic submucosal dissection (ESD) is a minimally invasive and effective treatment for large nonpedunculated colorectal polyps; however, it carries a relevant risk of adverse events (AEs), such as delayed bleeding, as well as postprocedural perforation (PPP) and postelectrocoagulation syndrome (PECS). Systematic defect closure may reduce these risks, but its preventive efficacy remains uncertain. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the efficacy of prophylactic clipping after colorectal ESD. Methods:Following PRISMA guidelines, we searched MEDLINE, Embase, and SCOPUS through to June 2025 for RCTs comparing prophylactic clipping vs. no clipping after colorectal ESD in adults. The primary outcome was clinically significant delayed bleeding; secondary outcomes included PPP and PECS, as well as subanalysis by location and size. Random-effects models were used to compute risk ratios (RRs) and 95%CIs. Results:Four RCTs from Asia including 684 patients were analyzed (336 with clipping, 348 controls). Prophylactic clipping significantly reduced clinically significant delayed bleeding risk (0.3% vs. 3.4%; RR 0.26, 95%CI 0.08-0.88). No significant differences were found for PPP (0.4% vs. 1.0%; RR 0.74; 95%CI 0.23-2.35) or PECS (12.2% vs. 11.8%; RR 1.06; 95%CI 0.74-1.52). Subgroup analyses by lesion size (>30 mm vs. <30 mm) and location (proximal vs. distal colon) were not significant. Conclusions:A 74% decrease in the risk of clinically significant delayed bleeding is achieved by prophylactic clipping after colorectal ESD, supporting its adoption in routine practice.

Background:Endoscopic resection (ER) of large (≥15 mm) duodenal laterally spreading lesions (D-LSLs) is now standard of care. Data on prevalence, risk factors, and management of strictures after ER of D-LSL are absent; we sought to evaluate this in a large tertiary referral cohort. Methods:A prospective cohort of ER-treated D-LSLs in an expert center was retrospectively analyzed. Strictures were considered "severe" if patients experienced obstructive symptoms, "moderate" if a standard gastroscope (diameter 9.9 mm) could not pass the stenosis, or "mild" if there was resistance on successful passage. When necessary, dilation was performed every 2-4 weeks until scope passage without resistance. Primary outcomes included stricture prevalence, risk factors, and management. Results:Over 193 months until February 2023, 246 lesions in 239 patients were included (median age 70 years [interquartile range (IQR) 63-77]; 51.5% male; median lesion size 35 mm [IQR 22.5-47.5]). Overall, 30 resections (12.2%) resulted in stricture (14 mild [46.7%], 4 moderate [13.3%], and 12 severe [40%]), and 18 (7.3%) required balloon dilation (median 2 sessions [IQR 0-6]). On multivariable analysis, post-ER defect circumference ≥80% was the strongest independent predictor of stricture formation (OR 60.2, 95%CI 17.5-254.2; P < 0.001). Incidence of stricture formation with ER defects of ≥80%, 60%-79%, and <60% was 72.2% (26/36), 12.5% (4/32), and 0% (0/178), respectively. All severe strictures occurred in ER defects ≥80%. Conclusions:ER defect circumference strongly predicted stricture formation following ER of D-LSLs. These findings can be used to guide informed consent and post-procedural care.

The prognosis of non-curative endoscopic submucosal dissection (ESD) for undifferentiated-type early gastric cancer (UD-EGC) remains unclear. This study aimed to identify risk factors for residual tumor, lymph node metastasis (LNM), and recurrence after non-curative ESD, and to define a potential low-risk subgroup suitable for active surveillance rather than additional surgery. This retrospective multicenter study included patients with non-curative ESD for UD-EGC from five institutions between 2017 and 2021. Patients were categorized into an additional surgery group or an observation group according to subsequent management. Clinicopathologic characteristics and survival outcomes were compared. Ninety-nine patients were analyzed, including 44 in the observation group and 55 in the additional surgery group. The median follow-up duration was 64 months. Six patients undergoing surveillance experienced recurrence within 12.0 to 37.3 months after ESD. Fourteen patients in the additional surgery group showed residual tumor or LNM. Vertical margin involvement independently predicted recurrence in the observation group, while ulceration and vertical margin involvement were independent predictors of residual tumor or LNM in surgical specimens or recurrence. Overall and disease-free survival were worse in the observation group. Disease-free survival in the observation group was associated with depth of invasion, lymphatic invasion, venous invasion, and resection margin status. Lesions with negative resection margins and no lymphovascular invasion meeting either (1) pT1a, UL0, > 2 cm, or (2) pT1a, UL1, ≤ 3 cm demonstrated excellent long-term outcomes without recurrence. Additional surgery remains standard after non-curative ESD for UD-EGC. However, a carefully selected low-risk subgroup may be appropriate candidates for close surveillance instead of further surgical intervention.

BACKGROUND:Peroral endoscopic myotomy (POEM) is an established treatment for achalasia, achieving >90% short-term clinical success. However, long-term durability remains less clear. This study evaluates POEM outcomes beyond 5 years in a multi-centre cohort. AIMS:This study evaluates POEM outcomes beyond 5 years in a multi-centre cohort. METHODS:Patients with achalasia who underwent POEM across four Australian tertiary centres (January 2014-January 2020) were prospectively enrolled. Eckardt scores were recorded pre-treatment and at multiple intervals up to ≥5 years after POEM. Primary outcome was clinical success at ≥5 years, defined as Eckardt score ≤3 without need for re-intervention. Secondary outcomes included risk factors for failure and management strategies. RESULTS:Of 221 eligible patients, 153 (69.2%) had ≥5-year follow-up data available, with median follow-up of 6.5 years (interquartile range (IQR) 5.6-7.6). Achalasia subtypes included type I (23.5%), type II (62.1%) and type III (14.4%). Among the patients, 52.3% were treatment-naïve; prior therapies included laparoscopic Heller myotomy (14.3%), botulinum toxin (17.0%) and pneumatic balloon dilation (30.7%). Clinical success at ≥5 years was observed in 118 (77.1%) patients. Median Eckardt scores improved from 8.0 (IQR 6.0-10.0) before POEM to 0.0 (IQR 0.0-1.0) at 3-6 months, 1.0 (IQR 0.0-2.0) at 2 years and 2.0 (IQR 0.0-3.0) at 5 years. Sustained success was associated with lower baseline Eckardt scores (P = 0.033). Prior lower oesophageal sphincter (LOS)-directed therapy predicted failure (odds ratio 3.80, P < 0.001). Age, achalasia subtype, myotomy characteristics and post-POEM endoscopy findings were not predictive. CONCLUSION:POEM provides durable symptom relief beyond 5 years for achalasia. Higher pre-POEM symptom burden and prior LOS-directed interventions are associated with reduced long-term success.