The endoscopic resection of gastrointestinal tract lesions embraces different types of techniques, ranging from conventional polypectomy/endoscopic mucosal resection (EMR) to the field of third-space endoscopy, including endoscopic submucosal dissection (ESD), full-thickness resection and peroral endoscopic myotomy (POEM). Parallelly, the advent of underwater techniques has served as an add-on for both basic and advanced procedures, since its first report in 2012. We aimed to provide a comprehensive update on the state of the art about the feasibility of underwater basic and advanced techniques for GI endoscopy. Underwater EMR (U-EMR) has proved effective and safe in treating > 10 mm sessile or flat or all-size recurrent colonic lesions. Conversely, although data show good effectiveness and safety for <10 mm lesions, it is preferred when high-grade dysplasia is suspected, favouring cold snare polypectomy for all other cases. Moreover, promising data are emerging regarding the feasibility of U-ESD for difficult-to-resect colonic lesions. U-EMR represents a standard of care for treating < 25 mm superficial non-ampullary duodenal epithelial tumours. Data regarding oesophageal, gastric and ampullary lesions remains limited to small cohorts. Finally, using water immersion for POEM has shown a reduction in procedure time compared to the CO₂ insufflation technique for vessel coagulation, albeit in a single-centre experience. Based on these results, U-EMR has become a standard for treating intermediate-size colonic and non-ampullary duodenal lesions, as highlighted also in the European Society of Gastrointestinal Endoscopy guidelines. Promising results have been shown in third-space endoscopy studies, even though further prospective studies are awaited to standardise the technique for both ESD and POEM.

Factors affecting the quality of bowel preparation for colonoscopy in the elderly are not fully known, and current guidelines provide no specific recommendations. This study aimed to assess the difference in bowel cleansing in young and elderly patients and evaluate predictors of bowel cleansing in the elderly. We retrospectively reviewed a prospective cohort of 1289 patients performing colonoscopy after a 1-, 2-, or 4-L PEG-based preparation. All 1289 were included in the analysis. Overall, 44.6% of patients were aged ≥65 years. Cleansing success (CS) was achieved in 77.3% and 70.3% of patients aged <65 years and ≥65 years, respectively. At multivariable analysis, split regimen (OR = 2.43, 95% CI = 1.34–4.38; p = 0.003), adequate cleansing at previous colonoscopy (OR = 2.29, 95% CI = 1.14–4.73; p = 0.02), tolerability score (OR = 1.29, 95% CI = 1.16–1.44; p < 0.001), a low-fiber diet for at least 3 days (OR = 2.45, 95% CI = 1.42–4.24; p = 0.001), and colonoscopy within 5 h after the end of preparation (OR = 2.67, 95% CI = 1.28–5.56; p = 0.008) were independently associated with CS in the elderly. Combining a low-fiber diet for at least 3 days, split preparation, and colonoscopy within 5 h allowed a CS rate above 90% and should always be encouraged. A 1-L PEG-ASC preparation was also associated with greater high-quality cleansing of the right colon and may be preferred.

Background: Endoscopic submucosal dissection (ESD) is an advanced technique that can become more challenging in the presence of submucosal fibrosis. Predicting the grade of fibrosis is important in order to identify technically difficult ESD. Aims and Methods: Our study aimed to derive and validate a prediction model to determine the preoperative degree of submucosal fibrosis in colorectal tumours undergoing ESD. A predictive model was developed to derive the probability of an increasing submucosal fibrosis in the derivation cohort and then externally validated. Results: 309 patients (age: 68 ± 10.9 years) underwent colorectal ESD between January 2016 and June 2020. F0, F1, and F2 fibroses were reported in 196 (63.4%), 70 (22.6%), and 43 (13.9%) cases, respectively. R0 resection was found in 266 (87%) lesions. At multivariable analysis in the derivation cohort, lesion morphology (OR = 0.37 and CI = 0.14–0.97 for LST-NG vs. 0-Is; OR = 0.29 and CI = 0.1–0.87 for the LST mixed type vs. 0-Is; and OR = 0.32 and CI = 0.1–1.03 for LST-G vs. 0-Is) and increasing size (OR = 1.02 and CI = 1.01–1.04 for a 1 mm increase) were significantly associated with an increasing degree of fibrosis. The model had fair discriminating ability in the derivation group (AUROC = 0.61 and CI = 0.52–0.69 for F1–F2 vs. F0 fibroses; AUROC = 0.61 and CI = 0.45–0.77 for F2 vs. F0–F1 fibroses) and in the validation group (AUROC = 0.71 and CI = 0.59–0.83 for F1–F2 vs. F0 fibroses; AUROC = 0.65 and CI = 0.52–0.77 for F2 vs. F0–F1 fibroses). Conclusions: Our findings introduce a new tool for the stratification of ESD technical difficulty based on lesion size and morphological characteristics which could become crucial during the procedure’s planning process.

Endoscopic submucosal dissection (ESD) in colorectal lesions is demanding, and a significant rate of non-curative procedures is expected. We aimed to assess the rate of residual lesion after a piecemeal ESD resection, or after an en bloc resection but with positive horizontal margins (local-risk resection—LocRR), for colorectal benign neoplasia. A retrospective multicenter analysis of consecutive colorectal ESDs was performed. Patients with LocRR ESDs for the treatment of benign colorectal lesions with at least one follow-up endoscopy were included. A cohort of en bloc resected lesions, with negative margins, was used as the control. A total of 2255 colorectal ESDs were reviewed; 352 of the ESDs were “non-curative”. Among them, 209 were LocRR: 133 high-grade dysplasia and 76 low-grade dysplasia. Ten cases were excluded due to missing data. A total of 146 consecutive curative resections were retrieved for comparison. Compared to the “curative group”, LocRRs were observed in lengthier procedures, with larger lesions, and in non-granular LSTs. Recurrence was higher in the LocRR group (16/199, 8% vs. 1/146, 0.7%; p = 0.002). However, statistical significance was lost when considering only en bloc resections with positive horizontal margins (p = 0.068). In conclusion, a higher rate of residual lesion was found after a piecemeal ESD resection, but not after an en bloc resection with positive horizontal margins.

Background: An extensive body of evidence regarding artificial intelligence (AI) in gastroenterology is currently available, but the transition of these technologies to the bedside is still in progress. This national survey aims to assess the perceptions of AI among gastroenterologists in Italy. Methods: A total of 320 Italian gastroenterologists and trainees in gastroenterology were invited to answer a web-based survey. A sub-group analysis between the two categories was performed. Results: Data from 150 respondents were analyzed. Of these, 67.3% were gastroenterologists and 32.7% trainees. Notably, 99.3% reported familiarity with AI in gastroenterology, with 49.3% currently using AI tools, indicating high levels of awareness and current use. Participants expressed low concerns regarding reliability on a 0-to-10-point scale (median = 4), legal and ethical issues (median = 5), and data protection (median 5), whereas regulatory concerns were moderate (median = 6), representing a key concern. Subgroup analysis revealed that male gastroenterologists had a higher understanding of AI (median = 7) compared to females (median 6, p = 0.036). Additionally, older gastroenterologists showed greater ease of use in AI endoscopy tools (median 8 vs. 7, p = 0.040) and raised more regulatory concerns (median 7 vs. 6, p = 0.036). Conclusions: The data from this survey show that Italian gastroenterologists have high-level awareness and a favorable perception of AI systems, with a good diffusion of AI tools across the national territory and reasonable concerns about regulatory issues, raising attention on international AI regulations.

Endoscopic submucosal dissection (ESD) has emerged as the standard treatment for colorectal lesions. Considering aging of the global population, we aimed to assess effectiveness and safety of colorectal ESD in patients aged ≥ 80 years compared with those aged 65 to 79 years in a large Western cohort.We retrospectively enrolled patients aged > 64 years undergoing colorectal ESD, classifying them into a very elderly group (VE-Group, aged > 80 years) and elderly group (E-Group, 65–79 years). Procedure outcomes and safety were compared between the VE-Group and E-Group and between patients with comorbidities and those who were healthy (1-CM-Group and H-Group).A total of 980 patients were included (269; 27.5% in the VE-Group and 711; 72.5% in the E-Group). En-bloc, R0, and oncological curative resection rates did not differ, nor did intra-procedure or post-procedure adverse events (AEs). Delirium occurrence was registered in VE-group [6 (2.2%) in VE-Group vs 1 (0.1%) in E-Group; P = 0.001; OR = 16.2, (95%CI:1.9–135.2)]. The 1-CM-Group had a higher rate of intra-procedure bleeding (P = 0.001), delayed perforation (P = 0.03), fever onset (P < 0.001), and systemic infections (P = 0.02) compared with the H-Group. Having one or more comorbidities was associated with increased overall AEs (P < 0.001; OR 2.3, 95% CI 1.5–3.6).Colorectal ESD is feasible in elderly patients. Physicians should consider delirium a possible AE in patients older than age 80 years. These findings, which bridge the gap between Asian and Western clinical data, underscore the importance of tailored pre-procedure and post-procedure assessments in a global clinical context.