This meta-analysis of randomized controlled trials (RCTs) aimed to compare the risk of recurrence and adverse events (AEs) between cold snare polypectomy (CSP) and hot endoscopic mucosal resection (H-EMR) for large nonpedunculated colorectal polyps (LNPCPs).A systematic search of Medline, Embase, and Cochrane Library databases until August 2024 was performed for studies comparing recurrence, bleeding, and perforation rates between CSP and H-EMR for LNPCPs ≥15 mm. A random-effects meta-analysis, with heterogeneity measured with I2, was conducted to generate pooled risk ratios (RRs) with 95%CIs.Four RCTs comprising 1516 LNPCPs (766 CSP and 750 H-EMR) in 1442 patients were included in the quantitative analysis. CSP demonstrated a higher recurrence risk at first surveillance colonoscopy than H-EMR in the pooled analysis (22.6% vs. 10.8%; RR 1.98; 95%CI 1.22–3.21; P = 0.02; moderate certainty evidence), corresponding to a number needed to harm of 9. Regarding AEs, CSP demonstrated a 67% reduced risk of delayed bleeding (1.2% vs. 3.9%; RR 0.33; 95%CI 0.12–0.89; P = 0.03; high certainty evidence), corresponding to a number needed to treat of 37. Although CSP appeared to reduce the risk of intraprocedural bleeding (10.0% vs. 19.8%; RR 0.30, 95%CI 0–52 256, P = 0.42), the wide confidence interval from the random-effects model included 1. There were no intraprocedural or delayed perforations in the CSP group.CSP has nearly double the recurrence risk of H-EMR for LNPCPs; however, its superior safety profile may make it a preferable option for patients where procedural safety is prioritized over radicality, such as those with extensive co-morbidities.

Local full‐thickness resection techniques for rectal cancer are limited by lesion size, location, or poor margin delineation. We aimed to evaluate the feasibility of endoscopic knife‐assisted full‐thickness resection (kFTR) guided by the pocket‐detection method (PDM) for deeply invasive rectal cancer.Consecutive posterior‐lateral rectal lesions suspected of deep submucosal invasion treated at a tertiary care center from February to October 2024 were retrospectively included. kFTR guided by PDM involved creating a submucosal pocket to detect and isolate the suspected invasive component (muscle‐retracting sign), followed by muscularis propria incision and full‐thickness resection.Technical success, accuracy of detecting deep submucosal invasion, and en‐bloc resection rates were 100%. The median procedure time was 141.5 [IQR 123.7–179.5] minutes and the median hospitalization was 1 [IQR 1–7] day. No adverse events occurred. Histopathology showed R1‐vertical margin in patient 1 (pT2 adenocarcinoma) and R0 resection in patients 2, 3, and 4 (pT1bsm3) after refinement of the procedure to include a ≥3 mm muscularis propria margin around the suspected invasive component. There was no recurrence at the first endoscopic follow‐up of patients 1, 2, and 4. Patient 3 was sent to surgical low anterior resection due to multiple high‐risk histological features. The previous kFTR did not impair surgery (no residual rectal carcinoma and 1/17 positive lymph nodes).Endoscopic kFTR guided by the PDM may be a feasible organ‐preserving treatment for the detection and resection of deeply invasive posterior rectal cancer. Future studies are needed to ascertain whether rectal kFTR could represent a viable alternative to conventional surgical local excision techniques.

This study aimed to determine the accuracy of the muscle-retracting sign (MRS) for the detection of deep submucosal invasion (SMI) in early rectal cancer. In this prospective observational single-center study, consecutive rectal lesions that underwent endoscopic resection using the pocket-detection method (PDM) between August 2023 and March 2025 were included. Directionality of the initial submucosal dissection targeted any morphologic or surface vascular pattern at risk of deep SMI to attempt MRS identification. Histopathology was the reference standard for MRS diagnostic accuracy in detecting deep SMI. 38 rectal lesions (median size 30 mm [interquartile range 20]) were included. The PDM for detection of the MRS was successful in all cases, with MRS positivity in 15/38 cases (39.5%). Deep SMI was confirmed in 15/38 cases (39.5%). The accuracy of MRS positivity for deep SMI detection was 84.2% (95%CI 69.6%–92.6%), with a sensitivity of 80.0% (95%CI 54.8%–92.9%), specificity of 87.0% (95%CI 67.9%–95.5%), positive likelihood ratio of 6.13, negative likelihood ratio of 0.23, and area under the receiver operating characteristic curve of 0.83 (95%CI 0.71–0.96). The rate of R0 resection was 92.1% (35/38). The MRS detected using the PDM demonstrated moderate-to-high accuracy for the prediction of deep SMI in early rectal cancer. This finding may allow the precise selection of an endoscopic resection strategy based on invasion depth for the minimally invasive treatment of early rectal cancer.

Endoscopic resection can be challenging for large nonpedunculated colorectal polyps (LNPCPs) around the appendiceal orifice. Factors predicting failure of endoscopic mucosal resection (EMR) include deep invasion of the appendiceal orifice and >50% involvement of the appendiceal orifice. In contrast, patients with a previous appendectomy are often able to undergo complete resection using EMR for LNPCPs that completely cover the prior appendiceal orifice [1]. Unfortunately, it is often difficult to tell upfront which of these factors is present in a given LNPCP. Other options include full-thickness resection, which carries a 25% risk of acute appendicitis and is not suitable for large lesions [2]. Surgery may also be considered, but an extended appendectomy is often insufficient for lesions extending into the cecum. More extensive surgery, such as ileocecal resection or right hemicolectomy, carry significant risks, including 20% morbidity and 0.5% mortality [3]. This case series ([Video 1]) demonstrates endoscopic submucosal dissection (ESD) for peri-appendiceal LNPCPs showing type 3a, 1, and 3 lesions according to Toyonaga’s classification [3]. Other studies have described the ESD technique for LNPCPs of the appendiceal orifice using both traction-assisted and nontraction methods [3] [4] [5]. However, none have described a combined approach using multipoint traction with saline immersion. In this case series, multipoint traction, using a multiband system ([Fig. 1]), is applied to lift the appendix and expose the submucosal plane between the appendiceal mucosa and muscularis propria ([Video 1]) for precise dissection. Saline immersion is used intermittently to improve visualization and access to the dissection plane ([Fig. 2]). In contrast to EMR, even lesions with deep invasion into the appendiceal orifice can be fully resected using this ESD-based technique as the caudal appendiceal margin can be visualized and the depth of mucosal incision within the appendix completely controlled. Furthermore, lesions fully encircling the orifice can also be completely removed. In conclusion, using traction-assisted ESD with intermittent saline immersion, the skilled practitioner can avoid the pitfalls of EMR while avoiding the excess risks of full-thickness resection and laparoscopic surgery. Endoscopy_UCTN_Code_TTT_1AQ_2AD_3AD Article published online: 20 February 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Objective Operator technical skill is recognised as a critical determinant of surgical outcomes. However, no equivalent recognition for quality of endoscope tip manipulation (tip-control) exists. We aimed to create an ex-vivo snare tip soft coagulation (STSC) model to objectively quantify endoscopist tip-control. Method This prospective interventional study was conducted at Ghent University Hospital. Participants applied STSC to a training model simulating four endoscopic mucosal resection (EMR) defects on a slice of ham. Accuracy (correct/total-hits) and speed (correct-hits/s) were assessed from a video by a single-blinded rater using a web-based scoring system. Results 22 endoscopists participated. Interventional endoscopists demonstrated significantly higher accuracy (87.0%) and speed (0.184 correct-hits/s) compared with trainees (74.5%, 0.106 correct-hits/s; both p<0.001) and non-interventional consultants (77%, 0.141 correct-hits/s; p5 years of endoscopic experience did not have better tip-control (accuracy 88.0%(p=0.07), speed 0.132 hits/s (p=0.36)) when compared with those with ≤4 years of experience. Conclusion This inexpensive ex vivo STSC simulation model effectively quantified endoscopic tip-control, correlating with endoscopist expertise and clinical profiles. The model could support the shift towards competency-based education, potentially improving patient outcomes. Trial registration number NCT05660317.