Liseth Rivero-Sánchez

A 34-year-old healthy man was referred for colonoscopy due to tenesmus and rectal bleeding in the absence of systemic or immunosuppressive conditions. Incomplete bowel preparation limited the examination, but rectal inspection revealed a well-demarcated erythematous lesion with a granular, micronodular surface and fibrinous areas. The mucosa appeared friable and bled with minimal contact. The differential diagnosis included infectious and inflammatory etiologies. Histologic analysis showed granulation tissue with moderate lymphoplasmacytic infiltration, and C-reactive protein (CRP) confirmed Herpes Simplex Virus type 2 (HSV-2). This case underscores the importance of considering sexually transmitted infections (STIs) such as HSV in the differential diagnosis of rectal bleeding, even in immunocompetent individuals.

Detection and management of recurrence after piecemeal endoscopic mucosal resection (p-EMR) of large colorectal polyps is crucial for preventing post-colonoscopy colorectal cancer. Colonoscopy assisted with artificial intelligence systems for lesion detection (CADe) has shown efficacy in identifying polyps, particularly small lesions (< 10 mm). Our aim was to evaluate sensitivity and negative predictive value of CADe compared with endoscopists in detecting recurrence after p-EMR. Sixty-six pseudo anonymized high-quality videos (25 with recurrence and 15 with previously clipped defects) of > 15 mm polyps post-EMR scars were assessed. Recurrence size was < 10 mm in 19 of 25 cases (76.0%). Six endoscopists—three experts and three non-experts—predicted recurrence (yes/no) with confidence level (high/low). The same videos were analyzed with CAD-e detection mode superimposed. The gold standard was histopathology. Endoscopists had higher sensitivity than CADe (96.0% vs 72.0%; P = 0.03). Experts performed better than non-experts in ruling out recurrence (specificity: 92.7% vs 58.5%; P = 0.001) and accuracy (92.4% vs 72.7%; P < 0.001). In non-clipped defects, endoscopists maintained higher sensitivity than CADe (95.0% vs 65.0%; P = 0.03). Concordance was moderate overall (Kappa 0.57) but substantial among experts (0.70) and when excluding clipped defects (0.61) Endoscopists outperformed CADe in interrogating post-EMR scars. Training CADe with images of post-polypectomy scars may further improve its performance.

Background Colorectal polypectomy is operator dependent, with variable rates of complete resection. The currently available assessment tools do not provide specific competency-based evaluation of provider technique. We aimed to validate the Global Polypectomy Assessment Tool (GPAT), a novel competency assessment tool for colorectal polypectomy. Methods GPAT was derived from the ESGE Curriculum for Training in endoscopic mucosal resection in the colon. Members of the curriculum taskforce plus three invited trainees and three medical students (collectively: the assessors) anonymously assessed nine endoscopic-view only polypectomy videos. The primary end point was the correlation of the assessors’ GPAT scores with a consensus-derived reference GPAT score per video. Secondary end points were the assessors’ subjective impression versus their GPAT score and interobserver agreement among assessors’ GPAT scores. Results 171 GPAT assessments by 19 assessors (consultant gastroenterologists [n = 10], trainee gastroenterologists [n = 4], consultant surgeons [n = 2], and medical students [n = 3]) were analyzed. Reference GPAT scores did not differ significantly from those of the assessors (73.1 % [95 %CI 64.6 %–81.6 %] vs. 69.3 % [95 %CI 64.9 %–81.2 %]; P = 0.47). There was moderate IOA in GPAT scores among gastroenterologists (intraclass correlation coefficient [ICC], 0.52 [moderate]) but not among nongastroenterologists (ICC 0.32 [poor]). GPAT correlated with assessors’ subjective impression of polypectomy quality (correlation coefficient 0.98 [95 %CI 0.90–1.00]; P < 0.001). Overall assessors’ qualitative usability scoring of GPAT was positive. Conclusions GPAT allows standardized scoring of polypectomies, with moderate IOA among gastroenterologists and correlation with subjective impressions of polypectomy quality. GPAT could standardize assessment of trainee polypectomy competency offering structured feedback on performance. ^‡ Joint first authors Article published online: 14 March 2025 © 2025. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Backgrounds Cold snare EMR (CS-EMR) in large flat nonpedunculated colonic lesions (LFNPCLs) is an alternative to the standard EMR procedure with a better safety profile, but scientific evidence on its efficacy is unavailable. This study aimed to compare the recurrence rate between the two techniques at 6 months. Secondary aims were comparison of the safety profile and procedure-related outcomes. Methods This was a noninferiority, multicenter, open-label, randomized controlled trial of consecutive large (≥ 20 mm) LFNPCLs without suspicious features of submucosal invasion. Results 229 patients were randomized to receive CS-EMR (n = 115) or EMR (n = 114). The median lesion size was 25 mm and 74.6 % were adenomas. The trial was stopped early by clinical consensus according to a safety monitoring board. At first surveillance colonoscopy (n = 220) the recurrence rate was significantly greater in the CS-EMR group than in the EMR group: 33.0 % vs. 16.2 % (P = 0.004) and 34.7 % vs. 14.8 % (P = 0.001) in the intention-to-treat and per-protocol analyses, respectively. According to the subgroup analysis, the recurrence rate was significantly greater after CS-EMR for LFNPCLs ≥ 30 mm (43.1 % vs. 18.2 %). There was no difference in the rate of adverse events. The use of clips was more common in the EMR group (52.6 % vs. 27.8 %). Conclusions The recurrence rate of LFNPCLs after CS-EMR was significantly greater than after the standard hot technique. A similar safety profile was found between groups.

Background Detection and treatment of recurrence after piecemeal endoscopic mucosal resection of nonpedunculated colorectal polyps are crucial for avoidance of post-colonoscopy cancer. Linked-color imaging (LCI) has demonstrated improved polyp detection but has never been assessed for evaluation of post-polypectomy scars. Our aim was to compare sensitivity and negative predictive value (NPV) between LCI and white-light endoscopy (WLE) for detection of post-polypectomy recurrence. Methods Patients undergoing surveillance colonoscopy after resection of lesions ≥15 mm were included in this prospective, single-center, randomized, crossover study. Each post-polypectomy scar underwent two examinations, one with LCI and the other with WLE, performed by two blinded endoscopists. Blue-light imaging (BLI) was then applied. A diagnosis of recurrence with a level of confidence was made for each modality and histopathology was the gold standard. Results 129 patients with 173 scars were included. Baseline patient, lesion, and procedural characteristics were similar in both arms. Recurrence was detected in 56/173 (32.4%), with 27/56 (48.2%) adenomas and 29/56 (51.8%) serrated lesions. LCI had greater sensitivity (96.4% [95%CI 87.8%–99.5%]) versus WLE (89.3% [95%CI 78.1%–95.9%]) and greater NPV (98.1% [95%CI 93.4%–99.8%] versus 94.6% [95%CI 88.7%–98.0%]). Paired concordance between modalities was 96.0%. In discordant cases, LCI identified four true-positive cases not detected by WLE and reclassified one false-positive of WLE. WLE reclassified two false positives of LCI without any increase in recurrence detection. Conclusions LCI was highly accurate and had greater ability than WLE to rule out recurrence on post-polypectomy scars after resection of large polyps.

Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3 A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4 Trained EMR practitioners should be familiar with the patient consent process for EMR. 5 The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6 Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7 A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8 A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9 A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10 Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11 Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document. ^* Although both ESGE and the Thieme Group adhere to a policy prohibiting publications by Russian authors in Endoscopy at this time, an exception has been made to include Dr. Kriazhov owing to the fact that his significant contribution to this Position Statement was made before Russia’s invasion of Ukraine. Article published online: 07 June 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany