Main Recommendations: 1 ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1–2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2 ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3 ESGE recommends CSP, to include a clear margin of normal tissue (1–2 mm) surrounding the polyp, for the removal of small polyps (6–9 mm).Strong recommendation, high quality of evidence. 4 ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10–19 mm in size.Strong recommendation, high quality of evidence. 5 ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6 ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7 Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8 ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9 ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10 ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11 ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.

Quality markers and patient experience should be implemented to ensure standardization of practice across upper gastrointestinal (UGI) endoscopy procedures. The set benchmarks ensure high quality procedures are delivered and linked to measurable outcomes. In 2016, the European Society of Gastrointestinal Endoscopy (ESGE), via its Quality Improvement Committee’s UGI Working Group, set a first list of performance measures, including major (key) and minor performance indicators. This paper provides an update on those performance measures, considering the latest literature. Patients referred for a UGI endoscopy should have an appropriate indication and be fasting for ≥ 2 hours for liquids and ≥ 6 hours for solids. For a diagnostic UGI endoscopy, patients should have an allocated time slot of ≥ 20 minutes; adequate reporting should include a mucosal visibility score according to one of the available standardized and validated scales; adequate photodocumentation should include relevant normal anatomical landmarks and all abnormal findings; adequate inspection should include the esophagus, stomach, and duodenum, and should last ≥ 7 minutes from intubation to extubation; adequate terminology should include the description of any abnormal finding according to the available standardized and validated classifications. For patients with nondysplastic Barrett’s esophagus (BE) undergoing surveillance UGI endoscopy, an adequate inspection should take ≥ 1 minute/cm of circumferential extent of Barrett’s epithelium and include the use of chromoendoscopy (acetic acid and/or virtual); biopsies should be taken according to the Seattle protocol. Adequate inspection for a diagnostic UGI endoscopy in patients with a history of ear, nose, and throat, or lung tumors treated with curative intent should include the use of virtual chromoendoscopy. Adequate diagnostic UGI endoscopy for patients evaluated for their risk of gastric cancer should include biopsies taken according to the ESGE management of precancerous conditions and lesions in the stomach (MAPS) guideline. Adequate safety after a therapeutic UGI endoscopy should be assessed by monitoring the incidence of complications. Patients undergoing a diagnostic UGI endoscopy should have their experience measured using a validated scale, to promote a patient-centered and quality-driven environment. Patients with nondysplastic BE or gastric precancerous conditions in an endoscopic surveillance program should be monitored for guideline interval adherence.

Underwater endoscopic mucosal resection (U-EMR) has been recently described as an alternative to endoscopic mucosal resection (EMR) for flat colorectal polyps. However, the real applications remain unclear due to the lack of comparative studies. a multi-centric prospective study was performed from November 2016 to December 2017. All lesions larger than 15 mm that were resected with both techniques were included in the study. The samples were matched using the size, morphology, site and access (SMSA) score as a reference. The efficacy, efficiency and adverse events rates were compared. a total of 162 resections were collected (112 EMR and 50 U-EMR) with an average size of 25 mm. U-EMR achieved better results for the en bloc resection rate (49 vs 62%; p = 0.08) and there were no cases of an incomplete resection (10.7 vs 0%; p = 0.01). U-EMR was faster than EMR and there were no differences in the adverse events rate. Furthermore, U-EMR tended to achieve better results in terms of recurrence. Performing the resection in emersion appeared to prevent the cautery artefact, especially in sessile serrated adenomas. in the real clinical practice, U-EMR and EMR are equivalent in terms of efficacy and safety. Furthermore, U-EMR may be a feasible approach to prevent cautery artefact, allowing an accurate pathologic assessment.

ConstitutionalMLH1methylation (epimutation) is a rare cause of Lynch syndrome. Low-level methylation (≤ 10%) has occasionally been described. This study aimed to identify low-level constitutionalMLH1epimutations and determine its causal role in patients withMLH1-hypermethylated colorectal cancer.Eighteen patients withMLH1-hypermethylated colorectal tumors in whomMLH1methylation was previously undetected in blood by methylation-specific multiplex ligation-dependent probe amplification (MS-MLPA) were screened forMLH1methylation using highly sensitive MS-melting curve analysis (MS-MCA). Constitutional methylation was characterized by different approaches.MS-MCA identified one patient (5.6%) with low-levelMLH1methylation (~ 1%) in blood and other normal tissues, which was confirmed by clonal bisulfite sequencing in blood. The patient had developed three clonally related gastrointestinalMLH1-methylated tumor lesions at 22, 24, and 25 years of age. The methylated region in normal tissues overlapped with that reported for other carriers of constitutionalMLH1epimutations. Low-levelMLH1methylation and reduced allelic expression were linked to the same genetic haplotype, whereas the opposite allele was lost in patient’s tumors. Mutation screening ofMLH1and other hereditary cancer genes was negative.Herein, a highly sensitive MS-MCA-based approach has demonstrated its utility for the identification of low-level constitutionalMLH1epigenetic mosaicism. The eventual identification and characterization of additional cases will be critical to ascertain the cancer risks associated with constitutionalMLH1 epigenetic mosaicism.