Accurate endoscopic characterization of colorectal lesions is essential to predict histology and select the best treatment strategy but remains very difficult. Instead of the recommended endoscopic characterization, many gastroenterologists routinely perform biopsies of the lesion to propose endoscopic resection with or without R0 intent. The aim of this study was to determine which of endoscopic characterization or biopsies, either targeted (TB) or non-targeted (NTB), is the most effective to determine the best treatment strategy for colorectal neoplasia > 2 cm. We prospectively assessed the best strategy between endoscopic characterization and targeted or non-targeted biopsies, so that the proposed resection technique offered a level of quality of tumor resection adapted to the definitive histology of the lesion on R0-resected specimen. 84 patients with 88 lesions were included. “Adequate treatment” was proposed by endoscopic characterization in 52.3 to 70.5

Aims ESD is the gold standard of treatment for large superficial colorectal lesions in Asia. In Western countries, it is struggling to establish itself as the reference treatment because of its technical difficulty. The aim of this study was to analyze 3 years after the creation of the prospective French ESD colorectal cohort (FECCO), the results of colorectal ESD, with focusing on comparison between colonic and rectal ESD.

Endoscopic submucosal dissection (ESD) is a reference method for the management of extensive lesions of the digestive tract. Its development extended the indications of ESD to lesions that were previously difficult to treat such as recurrences, lesions invading a diverticulum or the appendix, and submucosal lesions that may not be treatable by endoscopic mucosal resection [1] [2].

Background and Aims We aimed to compare the long-term outcomes of patients with high-risk T1 colorectal cancer (CRC) resected endoscopically who received either additional surgery or surveillance. Methods We used data from routine care to emulate a target trial aimed at comparing 2 strategies after endoscopic resection of high-risk T1 CRC: surgery with lymph node dissection (treatment group) versus surveillance alone (control group). All patients from 14 tertiary centers who underwent an endoscopic resection for high-risk T1 CRC between March 2012 and August 2019 were included. The primary outcome was a composite outcome of cancer recurrence or death at 48 months. Results Of 197 patients included in the analysis, 107 were categorized in the treatment group and 90 were categorized in the control group. From baseline to 48 months, 4 of 107 patients (3.7%) died in the treatment group and 6 of 90 patients (6.7%) died in the control group. Four of 107 patients (3.7%) in the treatment group experienced a cancer recurrence and 4 of 90 patients (4.4%) in the control group experienced a cancer recurrence. After balancing the baseline covariates by inverse probability of treatment weighting, we found no significant difference in the rate of death and cancer recurrence between patients in the 2 groups (weighted hazard ratio, .95; 95% confidence interval, .52-1.75). Conclusions Our study suggests that patients with high-risk T1 CRC initially treated with endoscopic resection may not benefit from additional surgery.

Background and study aims  The aim of this study was to validate the COlorectal NEoplasia Classification to Choose the Treatment (CONECCT) classification that groups all published criteria (including covert signs of carcinoma) in a single table. Patients and methods  For this multicenter comparative study an expert endoscopist created an image library (n = 206 lesions; from hyperplastic to deep invasive cancers) with at least white light Imaging and chromoendoscopy images (virtual ± dye based). Lesions were resected/biopsied to assess histology. Participants characterized lesions using the Paris, Laterally Spreading Tumours, Kudo, Sano, NBI International Colorectal Endoscopic Classification (NICE), Workgroup serrAted polypS and Polyposis (WASP), and CONECCT classifications, and assessed the quality of images on a web-based platform. Krippendorff alpha and Cohen's Kappa were used to assess interobserver and intra-observer agreement, respectively. Answers were cross-referenced with histology. Results  Eleven experts, 19 non-experts, and 10 gastroenterology fellows participated. The CONECCT classification had a higher interobserver agreement (Krippendorff alpha = 0.738) than for all the other classifications and increased with expertise and with quality of pictures. CONECCT classification had a higher intra-observer agreement than all other existing classifications except WASP (only describing Sessile Serrated Adenoma Polyp). Specificity of CONECCT IIA (89.2, 95 % CI [80.4;94.9]) to diagnose adenomas was higher than the NICE2 category (71.1, 95 % CI [60.1;80.5]). The sensitivity of Kudo Vi, Sano IIIa, NICE 2 and CONECCT IIC to detect adenocarcinoma were statistically different ( P  < 0.001): the highest sensitivities were for NICE 2 (84.2 %) and CONECCT IIC (78.9 %), and the lowest for Kudo Vi (31.6 %). Conclusions  The CONECCT classification currently offers the best interobserver and intra-observer agreement, including between experts and non-experts. CONECCT IIA is the best classification for excluding presence of adenocarcinoma in a colorectal lesion and CONECCT IIC offers the better compromise for diagnosing superficial adenocarcinoma.

Zenker’s diverticulum is a pulsion diverticulum developed in an area of weakness known as the Killian’s triangle. Flexible endoscopic treatment of this condition was first introduced in 1982 and is now the first line of treatment [1]. This technique involves the division of the septum of the diverticulum, by incision with a cutting device, in order to achieve the cricopharyngeal myotomy, with the objective to reduce the size of the diverticulum and improve the symptoms (dysphagia, regurgitation, and respiratory symptoms).

BACKGROUND:In France, it is mandatory that gastroenterology fellows have mastered the basic level of endoscopy by the end of training. The aim of this study was to assess improvement in the quality of fellows' endoscopy training in France during the last four years.METHODS:All fellows in France in training were eligible for participation. A 21-item questionnaire was sent out. The primary outcome was the completion by fourth year fellows of all the number of procedures recommended. Results were compared with those of a 2016 survey.RESULTS:Two-hundred-and-sixty-five fellows responded to the survey. The participation rate was 47.0%. The mean age was 27.3 ± 1.0 years and 56.4% were female. Access to theoretical courses (63.7% vs. 30.6%, p < 0.001) and simulation-based training (virtual reality simulator: 58.4% vs. 28.2%, p < 0.001, animal models: 29.4% vs. 17.2%, p < 0.001) was significantly higher in 2020. Although the number of procedures did not increase, significantly higher perception of skill acquisition in colonoscopy as well as diminished pressure to advance procedures were noted.CONCLUSION:Access to theoretical courses and simulation-based training and perceived acquisition of numerous skills has gotten better. However, the quality of training in endoscopy still needs improvement.

Climate change is a global issue. By changing our habits, we can tackle the climate emergency and build a sustainable world. Every effort can contribute to modify the future of our planet. In medicine, some disciplines have already integrated the concept of environmental effects of unused pharmaceutical products [1] [2] [3] [4] . In the endoscopic field, the green change is not yet a daily practice.

It is already common knowledge that endoscopic procedures are responsible for the production of large amounts of waste, mostly owing to the usage of a high number of disposable instruments [1]. Gastric peroral endoscopic myotomy (G-POEM) is a well-known procedure used for the treatment of refractory gastroparesis [2]. Like most submucosal endoscopic procedures, this technique requires the injection of a premixed methylene blue/glycerol solution into the submucosa, in order to raise a mucosal bleb and create the space to make a safe mucosal cut. This step is usually performed with a routine single-use sclerotherapy needle [2]; however, a DualKnife could also be used for the same purpose, allowing the use of one disposable injection needle to be spared.

Pancreatic ductal adenocarcinoma (PDAC) is expected to become the second leading cause of death from cancer by 2030. Despite intensive research in the field of therapeutics, the 5-year overall survival is approximately 8%, with only 20% of patients eligible for surgery at the time of diagnosis. The tumoral microenvironment (TME) of the PDAC is one of the main causes for resistance to antitumoral treatments due to the presence of tumor vasculature, stroma, and a modified immune response. The TME of PDAC is characterized by high stiffness due to fibrosis, with hypo microvascular perfusion, along with an immunosuppressive environment that constitutes a barrier to effective antitumoral treatment. While systemic therapies often produce severe side effects that can alter patients' quality of life, locoregional therapies have gained attention since their action is localized to the pancreas and can thus alleviate some of the barriers to effective antitumoral treatment due to their physical effects. Local hyperthermia using radiofrequency ablation and radiation therapy - most commonly using a local high single dose - are the two main modalities holding promise for clinical efficacy. Recently, irreversible electroporation and focused ultrasound-derived cavitation have gained increasing attention. To date, most of the data are limited to preclinical studies, but ongoing clinical trials may help better define the role of these locoregional therapies in the management of PDAC patients.

Background Endoscopic submucosal dissection (ESD) is potentially a curative treatment for T1 colorectal cancer under certain conditions. The aim of this study was to evaluate the feasibility and effectiveness of ESD for lesions with a suspicion of focal deep invasion. Methods In this retrospective multicenter study, consecutive patients with colorectal neoplasia displaying a focal (< 15 mm) deep invasive pattern (FDIP) that were treated by ESD were included. We excluded ulcerated lesions (Paris III), lesions with distant metastasis, and clearly advanced tumors (tumoral strictures). Results 124 patients benefited from 126 diagnostic dissection attempts for FDIP lesions. Dissection was feasible in 120/126 attempts (95.2 %) and, where possible, the en bloc and R0 resection rates were 95.8 % (115/120) and 76.7 % (92/120), respectively. Thirty-three resections (26.2 %) were for very low risk tumors, so considered curative, and 38 (30.2 %) were for low risk lesions. Noncurative R0 resections were for lesions with lymphatic or vascular invasion (LVI; n = 8), or significant budding (n = 9), and LVI + budding combination (n = 4). Conclusion ESD is feasible and safe for colorectal lesions with an FDIP <= 15 mm. It was curative in 26.6 % of patients and could be a valid option for a further 30.6 % of patients with low risk T1 cancers, especially for frail patients with co-morbidities.

For two decades, deep enteroscopy using instruments such as double-balloon systems (Fujifilm, Tokyo, Japan) has enabled resection of small-bowel polyps in patients with Peutz–Jeghers syndrome [1]. However, these techniques are time consuming, which has been a major limitation. Motorized spiral enteroscopy (MSE; Olympus Medical, Tokyo, Japan) is a recent advancement in this field; however, very limited data on the efficacy of MSE are available [2] [3]. In a recent European prospective study in patients with suspected small-bowel disease, MSE showed a diagnostic yield of 74 %, a total enteroscopy rate of 10 %, and a low rate of major adverse events (1.5 %) [2].

Background and aims:Endoscopic resection is the recommended staging and treatment modality for early gastric cancer (EGC). However, in Europe, data on long-term treatment outcomes and the occurrence of metachronous gastric cancer are lacking. Methods:Endoscopic resection for EGC was performed in 108 patients in 3 French referral centers. Resections were classified as eCuraA, B, C-1, or C-2 according to the new Japanese gastric cancer treatment guidelines and European guidelines. Patients who did not undergo secondary surgery and had follow-up data after 6 months were included in the analysis. Results:One hundred eight patients underwent endoscopic resection for EGC. Surgery was performed in 32 patients after endoscopic resection. Forty-five patients had follow-up visits at ≥6 months: 27 with an eCuraA resection, 1 with an eCuraB resection, 6 with an eCuraC-1 resection, and 11 with an eCuraC-2 resection. During a median follow-up time of 29.39 months, metachronous recurrence was observed in 12 patients (12/45; 26.7%) with a median period of 15.43 months (range, 7-44). Metastatic recurrence was observed in 3 patients (3/45, 6.7%), with a median period of 28.91 months (range, 7.52-28.91). Morbidity and mortality at day 30 after endoscopic resection were 2.8% (3/108) and 0.9% (1/108), respectively. Metachronous recurrences were diagnosed in 18.5% of the eCuraA group, 0% of the eCuraB group, 33.3% of the eCura C-1 group, and 45.5% of the eCura C-2 group; the differences were not statistically significant (P = .061). Conclusion:The rate of metachronous recurrence after endoscopic resection of early gastric cancer was very high, even after a curative resection. Close endoscopic surveillance is necessary to diagnose and treat metachronous gastric cancer.

Ligation is the recommended endoscopic treatment for acute esophageal variceal bleeding [1]. It can be challenging when associated with esophagitis. There is abundant evidence regarding the safety and efficacy of coil and glue embolization [2] [3] even in primary prophylaxis for gastric varices [4].

The management of pedunculated polyps can be challenging due to the bleeding risk and the technical difficulty in positioning the snare. In cases of a head diameter > 20 mm and/or stalk width > 10 mm, prevention of bleeding is necessary by injection of diluted adrenalin and/or mechanical hemostatic prevention, as recommended by the European Society of Gastrointestinal Endoscopy [1]. Mechanical prevention can hamper resection by causing difficulties in snare opening and placement. In addition to size, the nature of the polyp also influences the bleeding risk, and hamartomatous/juvenile polyps have a higher propensity to bleed [2].

Pancreatic ductal adenocarcinoma (PDAC) diagnosis accompanies a somber prognosis for the patient, with dismal survival odds: 5% at 5 years. Despite extensive research, PDAC is expected to become the second leading cause of mortality by cancer by 2030. Ultrasound (US) has been used successfully in treating other types of cancer and evidence is flourishing that it could benefit PDAC patients. High-intensity focused US (HIFU) is currently used for pain management in palliative care. In addition, clinical work is being performed to use US to downstage borderline resectable tumors and increase the proportion of patients eligible for surgical ablation. Focused US (FUS) can also induce mechanical effects, which may elicit an anti-tumor response through disruption of the stroma and can be used for targeted drug delivery. More recently, sonodynamic therapy (akin to photodynamic therapy) and immunomodulation have brought new perspectives in treating PDAC. The aim of this review is to summarize the current state of those techniques and share our opinion on their future and challenges.

With the broadening of indications for colonoscopy, colonic subepithelial lesions (SELs) are more frequently detected. Their incidence is about one in 300 colonoscopies. They appear as a small bulging lesion covered with normal mucosa [1]. Liposarcoma is one of the most common soft tissue sarcomas, yet it is an extremely rare disease. Less than 20 colonic liposarcomas have been described [2]. We report here the case of a 65-year-old man referred to our endoscopy unit for endoscopic submucosal dissection (ESD) of a large laterally spreading tumor of the right colon. During the surveillance endoscopy, a 3-mm SEL was found in the middle rectum, which at the time was thought to be a small neuroendocrine tumor. The mucosa covering the SEL was normal (▶Fig. 1, ▶Fig. 2). We decided to perform an ESD to do a complete removal of the suspect lesion on the hypothesis of a small neuroendocrine tumor (▶Video 1). After submucosal injection, a circumferential incision was made (▶Fig. 3). The double-clip traction technique was used to shorten the procedure duration (▶Fig. 4) [3]. Overall the resection lasted 14minutes. Two clips were placed to avoid delayed bleeding. Histology revealed a complete resection of a 3-mm well differentiated liposarcoma. The patient was referred to a specialized center. Computed tomography (CT) of the chest, abdomen, and pelvis revealed no lymph node or metastasis. The patient will be given no further treatment and will be monitored regularly by CT for the next 5 years. To our knowledge, this is the first ever case report showing the endoscopic appearance of an early well-differentiated liposarcoma and its complete resection with ESD leading to complete remission. This case emphasizes that ESD is surely the most appropriate technique to remove SELs with R0 margins, as the histological diagnosis may differ a lot between SELs. E-Videos

Aims Despite its undeniable carcinologic advantages, endoscopic submucosal dissection (ESD) has not replaced piecemeal endoscopic mucosal resection in Western countries because of the technical difficulty, long procedure duration, high complication rate, and steep learning curve. Differentiation of easy and difficult lesions would promote use of ESD. The objective of this study was to try to create a score that predict outcomes after colorectal ESD for large superficial lesions.