Natural orifice translumenal endoscopic surgery (NOTES) is a unique emerging surgical concept expanding flexible endoscopy beyond the gut wall. The methods and technology growing from this concept may minimize trauma from surgical access to the peritoneal cavity by completely eliminating body surface incisions. Our colleagues at the Mayo Clinic have explored, over several years, the concept of using the submucosa as a working space for endoscopic interventions, such as resection of mucosal neoplasias and submucosal tumors, as well as for the acquisition of muscular tissue for etiologic analysis of motility disorders. The submucosal space can also be utilized as a protective tunnel preventing peritoneal soiling by using the free overlying mucosa, as a sealant flap, and permitting a safer offset entry into the peritoneal and thoracic cavities for NOTES. In the SEMF technique, the submucosal space is mechanically created by balloon dissection facilitated by either high‐pressure CO2 gas injection or chemically ‘softening’ the submucosal connective tissues. This article reviews and describes SEMF in detail along with applications involving in vivo porcine models.

Artificial intelligence (AI) has been attracting considerable attention as an important scientific topic in the field of medicine. Deep‐leaning (DL) technologies have been applied more dominantly than other traditional machine‐learning methods. They have demonstrated excellent capability to retract visual features of objectives, even unnoticeable ones for humans, and analyze huge amounts of information within short periods. The amount of research applying DL‐based models to real‐time computer‐aided diagnosis (CAD) systems has been increasing steadily in the GI endoscopy field. An array of published data has already demonstrated the advantages of DL‐based CAD models in the detection and characterization of various neoplastic lesions, regardless of the level of the GI tract. Although the diagnostic performances and study designs vary widely, owing to a lack of academic standards to assess the capability of AI for GI endoscopic diagnosis fairly, the superiority of CAD models has been demonstrated for almost all applications studied so far. Most of the challenges associated with AI in the endoscopy field are general problems for AI models used in the real world outside of medical fields. Solutions have been explored seriously and some solutions have been tested in the endoscopy field. Given that AI has become the basic technology to make machines react to the environment, AI would be a major technological paradigm shift, for not only diagnosis but also treatment. In the near future, autonomous endoscopic diagnosis might no longer be just a dream, as we are witnessing with the advent of autonomously driven electric vehicles.

Texture and color enhancement imaging (TXI) has been developed as an image-enhanced endoscopy technology. TXI mode2 enhances texture and brightness, and TXI mode1 also enhances color. This study aims to assess the color differences in squamous cell carcinoma (SCC) suspicious lesions in the pharynx and esophagus using white light imaging (WLI), TXI mode1, TXI mode2, and narrow-band imaging (NBI). A total of 59 SCC suspicious lesions from 30 patients were analyzed. The color differences (ΔE) between the lesion and the surrounding mucosa were calculated for each modality. The color value was assessed using the Commission Internationale d’Eclairage L*a*b* color space. The visibility of the lesion in each modality was evaluated and compared to that in the WLI by six endoscopists. The mean ΔE values in the WLI, TXI mode1, TXI mode2, and NBI were 11.6; 18.6; 14.3; and 17.2, respectively, and the ΔE values of TXI mode1, TXI mode2, and NBI were significantly higher than those of the WLI (p < 0.001). No lesions had worse visibility, and 62.5% (37/59) had improved visibility, as assessed by more than half of the endoscopists in TXI mode1. TXI mode1 can enhance color changes and improve the visibility of SCC suspicious lesions in the pharynx and esophagus, compared to WLI.

Objectives: We aimed to evaluate the efficacy of texture and color enhancement imaging (TXI), which allows the acquisition of brighter images with enhanced color and surface structure in colorectal polyp detection compared to white light imaging.Methods: Patients who underwent colonoscopy with repeated ascending colon observation using TXI and white light imaging between August 2020 and January 2021 were identified in three institutions. The outcomes included the mean number of adenomas detected per procedure (MAP), adenoma detection rate (ADR), and ascending colonic adenoma miss rate (Ac‐AMR). Logistic regression was used to determine the effects of the variables on the outcomes.Results: We included 1043 lesions from 470 patients in the analysis. The MAP, ADR, flat polyp detection rate, and Ac‐AMR in TXI and white light imaging were 1.5% (95% confidence interval 1.3–1.6%) vs. 1.0% (0.9–1.1%), 58.2% (51.7–64.6%) vs. 46.8% (40.2–53.4%), 66.2% (59.8–72.2%) vs. 49.8% (43.2–56.4%), and 17.9% (12.1–25.2%) vs. 28.2% (20.0–37.6%), respectively. TXI, age, withdrawal time, and endoscopy type were identified as significant factors affecting the MAP and the ADR using multivariate regression analysis.Conclusions: Our study indicates that TXI improve the detection of colorectal neoplastic lesions. However, prospective randomized trials are required to confirm these findings.

In this study, we evaluated the technical feasibility of mucosal approximation of large ulcers via an endoscopic suturing system after endoscopic submucosal dissection (ESD), assessed the durability of these sutures, and compared this technique with serosal apposition of full-thickness gastric wall defects using the same device. Post-ESD ulcers were closed with mucosal apposition in 7 pigs, and endoscopic full-thickness resection (EFTR) defects were closed with serosal apposition in 3 pigs. Pigs recovered for 1 week; they were then euthanized and necropsies were performed. Primary defect closure was achieved in 85.7% of the post-ESD closures and in 100% of the post-EFTR closures (p = 0.67). All pigs survived for 1 week. At necropsy, sutures had loosened in the post-ESD animals, although only minor deformity of the ulcer edges was observed in all repaired post-ESD ulcers. Meanwhile, all of the post-EFTR defect closures were sustained for 1 week. Primary closure of post-therapeutic defects can be accomplished using the device. Inverted serosal apposition provides a more durable and reliable repair than everted mucosal apposition.