One of the major procedural risks of third space endoscopy techniques is represented by intraprocedural bleeding.1 A clear strategy to reduce the risk of intraprocedural bleeding remains elusive, since current guidelines do not suggest a standardised approach, and existing practice consists of the direct coagulation of the designed vessels during submucosal dissection.2 Bleeding episodes can lengthen or complicate these procedures, by obstructing clear visualisation of the structures or resulting in the application of excessive electrocoagulation current.3 In some of these cases, complete haemostasis is not achievable, and the use of additional haemostatic devices, such as coagulation forceps, is required. However, these forceps present with some limitations, requiring the exchange of the device, slowing procedures and increasing the costs. In addition, by applying soft coagulation current, it may result in an unpredictable risk of deep mural injuries.4

Colorectal cancer (CRC) prevention depends on effective colonoscopy; yet variability in adenoma detection rates (ADRs) and missed lesions remain significant hurdles. Artificial intelligence-powered computer-aided detection (CADe) systems offer promising advancements in enhancing polyp detection. This review examines the role of CADe in improving ADR and reducing adenoma miss rates (AMRs) while addressing its broader clinical implications. CADe has demonstrated consistent improvements in ADRs and AMRs; largely by detecting diminutive polyps, but shows limited efficacy in identifying advanced adenomas or sessile serrated lesions. Challenges such as operator deskilling and the need for enhanced algorithms persist. Combining CADe with adjunctive techniques has shown potential for further optimizing performance. While CADe has standardized detection quality; its long-term impact on CRC incidence and mortality remains inconclusive. Future research should focus on refining CADe technology and assessing its effectiveness in reducing the global burden of CRC.

Impedance and voltage of monopolar currents are directly related. By replacing air with saline solution, a change in behavior of these currents are achieved in endoscopy, resulting in a desired coagulation effect. However, the underlying electrophysical mechanisms of this effect remain poorly explained. This investigation assessed the relationship between the electrical parameters and the surrounding environment for three high-voltage monopolar coagulation currents commonly used for therapeutic endoscopy. Six consecutive applications per setting and per environment were performed with dissection knife on porcine kidney. When transitioning from air to saline immersion, a 99% decrease in impedance was observed for all current settings tested (Air_Range: 4400–8150 Ω, Saline_Range: 64–71 Ω; p < 0.01 for all settings). This resulted in a 52-78% reduction in peak voltage (Air_Range: 920–1165 V, Saline_Range: 257–499 V; p < 0.01 for all settings), and a 237-2030% increase in power delivered (Air_Range: 3–19 W, Saline_Range: 50–117 W; p < 0.01 for all settings). The dramatic decrease in impedance results in a sharp reduction of voltage, explaining the coagulation effect observed when passing from air to saline-immersion therapeutic endoscopy.

ESD is a preferred technique for en bloc resection of large (≥2 cm) non-pedunculated colorectal polyps or adenomas, offering high R0 resection and low recurrence rates.1 2 However, its adoption in Western countries remains limited due to technical complexity, long procedure times and associated adverse events.3 Underwater ESD, which replaces CO₂ insufflation with a saline-filled environment, has been proposed to enhance visualisation, traction and submucosal dissection, improving procedural outcomes.4–6 Additionally, saline impedance allows prophylactic underwater vessel coagulation when swift coagulation (effect: 4.0; electrosurgical generator: VIO3, Erbe Elektromedizin GmbH) is applied, improving submucosal vessel sealing to reduce intraprocedural bleeding.7–10

Risk factors for hepatic immune-related adverse events (HIRAEs) in patients with advanced/unresectable hepatocellular carcinoma (HCC) treated with immune checkpoint inhibitors (ICIs) are unclear. We investigated: (i) clinical and morpho-pathological predictors of HIRAEs in 27 pretreatment tumor specimens, including surrogate biomarkers of the HCC immune class (based on intratumoral tertiary lymphoid structures, and glutamine synthase, CD3, and CD79 expression); and (ii) the relationship between HIRAE onset and subsequent treatment outcomes. Fifty-eight patients were included—20 (34%) received ICIs alone, and 38 (66%) received ICIs plus targeted agents as first- or further-line treatment. After a median time of 0.9 months (range, 0.4–2.7), nine patients (15.5%) developed grade ≥ 3 hepatitis, which was significantly associated with higher baseline ALT levels (p = 0.037), and an infectious HCC etiology (p = 0.023). ICIs were safely resumed in six out of nine patients. Time to treatment failure (TTF) was not significantly different in patients developing grade ≥ 3 hepatitis vs. lower grades (3.25 vs. 3.91 months, respectively; p = 0.81). Biomarker surrogates for the HCC immune class were not detected in patients developing grade ≥ 3 hepatitis. Grade ≥ 3 hepatitis has a benign course that does not preclude safe ICI reintroduction, without any detrimental effect on TTF.