European Society Of Gastrointestinal Endoscopy Research Articles

A comprehensive examination of small-bowel capsule endoscopy in Spanish centers to meet European Society of Gastrointestinal Endoscopy standards.

Background and study aims In 2019, the European Society of Gastrointestinal Endoscopy (ESGE) created a working group to develop technical and quality standards for small-bowel capsule endoscopy (SBCE) to improve the daily practice of endoscopy services. They developed 10 quality parameters, which have yet to be tested in a real-life setting. Our study aimed to evaluate the accomplishment of the quality standards in SBCE established by the ESGE in several Spanish centers. Materials and methods An online survey of 11 multiple-choice questions related to the ESGE performance measures was sent to Spanish centers with experience in SBCE. In order to participate and obtain reliable data, at least 100 questionnaires had to be answered per center because that is the minimum number established by ESGE. Results 20 centers participated in the study, compiling 2049 SBCEs for the analysis. Only one of 10 performance measures (cecal visualization) reached the minimum standard established by the ESGE. In five of 10 performance measures (Indication, lesion detection rate, terminology, and retention rate) the minimum standard was nearly achieved. Conclusions Our study is the first multicenter study regarding SBCE quality performance measures in a real setting. Our results show that the minimum standard is hardly reached in most procedures, which calls into question their clinical applicability in real life. We suggest performing similar studies in other countries to evaluate whether there is a need for quality improvement programs or a need to reevaluate the minimum and target values published so far.

A31 DYSPLASIA IN COLONIC POLYPS: PREPARING FOR A RESECT AND DISCARD STRATEGY IN CANADA

Abstract Background While diminutive colorectal polyps have a negligible cancer risk, current management involves resecting and submitting all polyps for histological assessment. This is a substantial burden and cost to the healthcare system. The European Society of Gastrointestinal Endoscopy (ESGE) has recommended a “resect-and-discard strategy” without histological evaluation as an acceptable strategy when high-confidence endoscopic characterization of colorectal polyps is achieved. However, a resect and discard strategy has not been adopted yet in Canada. Aims The objective of this study was to determine the prevalence and characteristics of polyps removed at our center based on size. Methods We retrospectively reviewed colonoscopies and pathology reports at Kingston Health Sciences Center from January to December 2020. Based on the pathology report, polyps were classified as diminutive (1-5mm), small (6-9mm) or large (ampersand:003E or = 10mm). We recorded histology and the presence of high-grade dysplasia (HGD) or cancer. Results Out of 2218 colonoscopies, 2945 polyps were removed. 1703 (57.8%) polyps were diminutive with only two (0.1%) having focal HGD and none having cancer. 699 (23.7%) polyps were classified as small with three (0.4%) having HGD and none having cancer. The large polyp group had 543 (18.4%) polyps, of which 87 (16%) showed HGD and 15 (2.8%) exhibited cancer. The specific histologic findings are shown in Table 1. Endoscopy reports specifically mentioned concern of dysplasia in one out of the five polyps with HGD in the diminutive and small groups. Conclusions As expected, most polyps were either diminutive or small (81.5%). Neither of these groups had cancer and only 5 had HGD. Adopting a resect and discard strategy at our center for diminutive polyps has the potential for significant cost savings with negligible risk of missing a high-risk polyp. The next steps would involve assessing optical diagnosis sensitivity and specificity for diminutive and small polyps. Histological characterization of polyps within each size range Funding Agencies None

Position statement on how can we can implement the Greendeal in our gastrointestinal and gastrointestinal endoscopy department in Belgium.

The importance to reach the target to be carbon net zero by 2050, as presented by the European Commission in the European Green Deal, cannot be overestimated. In a current endoscopy world, where single use has found its place and techniques are constantly evolving, it will be a challenge to reach these goals. How can we reconcile this evolution to a carbon neutral status by 2050 without compromising patients care, clinical standards and training needs? The European Society of Gastrointestinal Endoscopy (ESGE) together with the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) recently published a position statement (1) whereas in the UK there is the work from the green endoscopy group (2) in line with the strategy of the British Society of Gastroenterology (BSG) on sustainability (3). In Flanders, a project called "greendeal in duurzame zorg" had its kick off in March 2023 (4) so it is about time that we in Belgium, as gastroenterologists, start with tangible actions to a more sustainable daily practice. We wrote this position statement in cooperation with the Vlaamse Vereniging voor Gastro-Enterologie (VVGE), the Société royale belge de Gastro-entérologie (SRBGE) and the Belgian Society of Gastrointestinal Endoscopy (BSGIE). We will also work together in the coming years to continue to motivate our members to work on these initiatives and to co-opt new projects within the framework of the greendeal.

Perspectives and awareness of endoscopy healthcare professionals on sustainable practices in gastrointestinal endoscopy: results of the LEAFGREEN survey.

Gastrointestinal (GI) endoscopy is one of healthcare's main contributors to climate change. We aimed to assess healthcare professionals' attitudes and the perceived barriers to implementation of sustainable GI endoscopy. The LEAFGREEN web-based survey was a cross-sectional study conducted by the European Society of Gastrointestinal Endoscopy (ESGE) Green Endoscopy Working Group. The questionnaire comprised 39 questions divided into five sections (respondent demographics; climate change and sustainability beliefs; waste and resource management; single-use endoscopes and accessories; education and research). The survey was available via email to all active members of the ESGE and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) in March 2023. 407 respondents participated in the survey (11% response rate). Most participants (86%) agreed climate change is real and anthropogenic, but one-third did not consider GI endoscopy to be a significant contributor to climate change. Improvement in the appropriateness of endoscopic procedures (41%) and reduction in single-use accessories (34%) were considered the most important strategies to reduce the environmental impact of GI endoscopy. Respondents deemed lack of institutional support and knowledge from staff to be the main barriers to sustainable endoscopy. Strategies to reduce unnecessary GI endoscopic procedures and comparative studies of single-use versus reusable accessories were identified as research priorities. In this survey, ESGE and ESGENA members acknowledge climate change as a major threat to humanity. Further improvement in sustainability beliefs and professional attitudes, reduction in inappropriate GI endoscopy, and rational use of single-use accessories and endoscopes are critically required.

P926 Improved standards of colonoscopy for Inflammatory Bowel Disease through implementation of key performance measures - A quality improvement initiative

Abstract Background Improving the quality of colonoscopy in inflammatory bowel disease is expected to improve clinical outcomes for patients. The European Society of Gastrointestinal Endoscopy (ESGE) recently published key performance measures for IBD colonoscopy assessment. This study aimed to assess the impact of implementing key performance measures and assess for sustainable improvement through a multimodal education intervention. Methods A baseline retrospective analysis was performed in patients with established IBD between June and August of 2022 at a tertiary hospital. The key performance measures included 1) pre-procedure metrics including indication, consent, and safety checklist (target of 100%) and 2) bowel preparation score, photo-documentation, disease activity scores, adequate biopsies, use of high-definition endoscopy and chromoendoscopy. There were six proceduralists involved and data was collected from electronic medical records including endoscopy and histopathology results. The ESGE performance measures were used to set minimum standards and we have adopted overall standards for our unit based on the ECCO and SCENIC consensus guidelines. Over 12 months, proceduralists and endoscopy nursing staff were engaged with educational interventions including didactic teaching for one hour and diagrammatic reminders in the endoscopy suites of the ESGE key performance measures. A post-implementation analysis was conducted at 1 year from baseline, from August to November of 2023. Results Baseline standards showed suboptimal performance in the use of disease activity scores and chromoendoscopy. Educational interventions were implemented and after 12 months, a repeat analysis of 50 consecutive patients showed significant improvement in all performance measures (see Table 1). Conclusion Quality metrics are important and underrecognised components in colonoscopy for IBD patients and form an integral part of improving patient care. Our study demonstrated that the implementation of the ESGE key performance measures is effective in improving the quality of colonoscopy assessment in IBD patients, identifying areas requiring further development and increasing the dysplasia detection rate. Acknowledging quality attrition over time, we recognise that regular teaching and education are required in addressing the challenge of sustainable long-term improvement.

[Gastroenterology and hepatology: what's new in 2023].

2023 has been marked by numerous advancements in the fields of hepatology, liver transplantation, gastroenterology, and interventional endoscopy. These developments hold the promise of changing our daily practice while enhancing the diagnosis and treatment of various hepatic and gastroenterological conditions. Additionally, the European Association for the Study of the Liver (EASL) has issued recommendations for the management of hepatitis delta, acute-on-chronic liver failure, liver diseases of pregnancy, and intrahepatic cholangiocarcinoma. Risankizumab was approved by Swiss Authorities for patients with Crohn's disease and dupilumab was approved for patients with eosinophilic esophagitis. The European Society of Gastrointestinal Endoscopy (ESGE) has revised its recommendations regarding Barrett's esophagus.

Curriculum for diagnostic endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in diagnostic endoscopic ultrasound (EUS). This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in diagnostic EUS. This curriculum is set out in terms of the prerequisites prior to training; the recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice. 1:  Trainees should have achieved competence in upper gastrointestinal endoscopy before training in diagnostic EUS. 2:  The development of diagnostic EUS skills by methods that do not involve patients is advisable, but not mandatory, prior to commencing formal training in diagnostic EUS. 3:  A trainee's principal trainer should be performing adequate volumes of diagnostic EUSs to demonstrate maintenance of their own competence. 4:  Training centers for diagnostic EUS should offer expertise, as well as a high volume of procedures per year, to ensure an optimal level of quality for training. Under these conditions, training centers should be able to provide trainees with a sufficient wealth of experience in diagnostic EUS for at least 12 months. 5:  Trainees should engage in formal training and supplement this with a range of learning resources for diagnostic EUS, including EUS-guided fine-needle aspiration and biopsy (FNA/FNB). 6:  EUS training should follow a structured syllabus to guide the learning program. 7:  A minimum procedure volume should be offered to trainees during diagnostic EUS training to ensure that they have the opportunity to achieve competence in the technique. To evaluate competence in diagnostic EUS, trainees should have completed a minimum of 250 supervised EUS procedures: 80 for luminal tumors, 20 for subepithelial lesions, and 150 for pancreaticobiliary lesions. At least 75 EUS-FNA/FNBs should be performed, including mostly pancreaticobiliary lesions. 8:  Competence assessment in diagnostic EUS should take into consideration not only technical skills, but also cognitive and integrative skills. A reliable valid assessment tool should be used regularly during diagnostic EUS training to track the acquisition of competence and to support trainee feedback. 9:  A period of supervised practice should follow the start of independent activity. Supervision can be delivered either on site if other colleagues are already practicing EUS or by maintaining contacts with the training center and/or other EUS experts. 10:  Key performance measures including the annual number of procedures, frequency of obtaining a diagnostic sample during EUS-FNA/FNB, and adverse events should be recorded within an electronic documentation system and evaluated.

Performance of European and American Societies of Gastrointestinal Endoscopy Guidelines for Prediction of Choledocholithiasis in Patients with Acute Biliary Pancreatitis.

Background and Objectives: Up to one-third of patients with acute biliary pancreatitis also present with choledocholithiasis. Guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and the American Society for Gastrointestinal Endoscopy (ASGE) for investigating suspected choledocholithiasis suggest endoscopic retrograde cholangiopancreatography in patients with high-likelihood (ESGE)/high-probability (ASGE) predictors and endoscopic ultrasound in those with intermediate-likelihood (ESGE)/intermediate-probability (ASGE) predictors. Although both guidelines are similar, they are not identical. Furthermore, these algorithms were mainly developed from cohorts of patients without pancreatitis and are therefore poorly validated in a subset of patients with acute pancreatitis. We aimed to assess the performance of the ESGE and ASGE algorithms for the prediction of choledocholithiasis in patients with acute biliary pancreatitis. Materials and Methods: This was a retrospective analysis of 86 consecutive patients admitted to a tertiary referral centre in the year 2020 due to acute biliary pancreatitis. Results: Choledocholithiasis was confirmed in 29/86 (33.7%) of patients (13 with endoscopic retrograde cholangiopancreatography and 16 with endoscopic ultrasound). All 10/10 (100%) ESGE high-likelihood and 14/19 (73.7%) ASGE high-probability patients had choledocholithiasis. Only 19/71 (26.8%) patients with ESGE intermediate likelihood and 15/67 (22.4%) with ASGE intermediate probability had choledocholithiasis. Only 8/13 (61.5%) patients with the ASGE high-probability predictor of dilated common bile duct plus bilirubin > 68.4 µmol/mL had choledocholithiasis. Since this predictor is not considered high likelihood by ESGE, this resulted in a superior specificity of the European compared to the American guideline (100% vs. 91.2%). Following the American instead of the European guidelines would have resulted in five unnecessary endoscopic retrograde cholangiopancreatographies and five unnecessary endoscopic ultrasound examinations. Conclusions: This retrospective analysis suggests that the European guidelines may perform better than the American guidelines at predicting choledocholithiasis in the setting of acute pancreatitis. This was because dilated common bile duct plus bilirubin > 68.4 µmol/mL was not a reliable predictor for persistent bile duct stones.

Endoscopic stenting of a tumor of the rectosigmoid junction

Annotation. Obturational obstruction of the large intestine of tumor genesis belongs to acute surgical pathology and the issue of operative tactics in this case is extremely important in emergency surgery. The current trend in the treatment of complicated colorectal cancer is to carry out radical surgical interventions with the formation of primary anastomoses and compliance with basic oncological principles. However, carrying out such interventions under adverse conditions, including neglected oncological processes, the presence of severe concomitant pathologies, late hospitalization, instability and uncompensated indicators of the patient's homeostasis, leads to a high risk of developing various postoperative complications and postoperative mortality. Therefore, the use of endoscopic methods of restoring the patency of the large intestine with the help of stents is becoming widely used. Endoscopic colonic stenting is one of the modern, promising methods of treatment for patients with intestinal obstruction. It is characterized by minimal invasiveness, and a significantly lower frequency of post-surgery complications and mortality. According to the recommendations of the European Society of Gastrointestinal Endoscopy, colonic stenting is used for patients with clinical symptoms and radiological signs of tumor obstruction of the colon without signs of perforation; installation of a stent for compensation of homeostasis systems, for comprehensive preoperative preparation (if necessary, with the use of chemotherapy or X-ray therapy). The article presents the results of our own clinical observation of an endoscopic colonic stenting case as a method of symptomatic treatment of colonic obstruction in a patient with colorectal cancer and severe concomitant diseases. We analyzed the peculiarities of using colonic stents and determined the importance of mastering this method for proctologists and oncoproctologists.

Training in basic gastrointestinal endoscopic procedures: a European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement.

This ESGE Position Statement provides structured and evidence-based guidance on the essential requirements and processes involved in training in basic gastrointestinal (GI) endoscopic procedures. The document outlines definitions; competencies required, and means to their assessment and maintenance; the structure and requirements of training programs; patient safety and medicolegal issues. 1:  ESGE and ESGENA define basic endoscopic procedures as those procedures that are commonly indicated, generally accessible, and expected to be mastered (technically and cognitively) by the end of any core training program in gastrointestinal endoscopy. 2:  ESGE and ESGENA consider the following as basic endoscopic procedures: diagnostic upper and lower GI endoscopy, as well as a limited range of interventions such as: tissue acquisition via cold biopsy forceps, polypectomy for lesions ≤ 10 mm, hemostasis techniques, enteral feeding tube placement, foreign body retrieval, dilation of simple esophageal strictures, and India ink tattooing of lesion location. 3:  ESGE and ESGENA recommend that training in GI endoscopy should be subject to stringent formal requirements that ensure all ESGE key performance indicators (KPIs) are met. 4:  Training in basic endoscopic procedures is a complex process and includes the development and acquisition of cognitive, technical/motor, and integrative skills. Therefore, ESGE and ESGENA recommend the use of validated tools to track the development of skills and assess competence. 5:  ESGE and ESGENA recommend incorporating a multimodal approach to evaluating competence in basic GI endoscopic procedures, including procedural thresholds and the measurement and documentation of established ESGE KPIs. 7:  ESGE and ESGENA recommend the continuous monitoring of ESGE KPIs during GI endoscopy training to ensure the trainee's maintenance of competence. 9:  ESGE and ESGENA recommend that GI endoscopy training units fulfil the ESGE KPIs for endoscopy units and, furthermore, be capable of providing the dedicated personnel, infrastructure, and sufficient case volume required for successful training within a structured training program. 10:  ESGE and ESGENA recommend that trainers in basic GI endoscopic procedures should be endoscopists with formal educational training in the teaching of endoscopy, which allows them to successfully and safely teach trainees.

A machine learning-based choledocholithiasis prediction tool to improve ERCP decision making: a proof-of-concept study.

Previous studies demonstrated limited accuracy of existing guidelines for predicting choledocholithiasis, leading to overutilization of endoscopic retrograde cholangiopancreatography (ERCP). More accurate stratification may improve patient selection for ERCP and allow use of lower-risk modalities. A machine learning model was developed using patient information from two published cohort studies that evaluated performance of guidelines in predicting choledocholithiasis. Prediction models were developed using the gradient boosting model (GBM) machine learning method. GBM performance was evaluated using 10-fold cross-validation and area under the receiver operating characteristic curve (AUC). Important predictors of choledocholithiasis were identified based on relative importance in the GBM. 1378 patients (mean age 43.3 years; 61.2% female) were included in the GBM and 59.4% had choledocholithiasis. Eight variables were identified as predictors of choledocholithiasis. The GBM had accuracy of 71.5% (SD 2.5%) (AUC 0.79 [SD 0.06]) and performed better than the 2019 American Society for Gastrointestinal Endoscopy (ASGE) guidelines (accuracy 62.4% [SD 2.6%]; AUC 0.63 [SD 0.03]) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines (accuracy 62.8% [SD 2.6%]; AUC 0.67 [SD 0.02]). The GBM correctly categorized 22% of patients directed to unnecessary ERCP by ASGE guidelines, and appropriately recommended as the next management step 48% of ERCPs incorrectly rejected by ESGE guidelines. A machine learning-based tool was created, providing real-time, personalized, objective probability of choledocholithiasis and ERCP recommendations. This more accurately directed ERCP use than existing ASGE and ESGE guidelines, and has the potential to reduce morbidity associated with ERCP or missed choledocholithiasis.

HPB O03 ERCPs and Biliary Stenting for Ductal Stone Disease: A Call for a National Database

Abstract Background According to the European Society of Gastrointestinal Endoscopy, in the context of complicated biliary stone disease, plastic stenting of the biliary tree via endoscopic retrograde cholangiopancreatography (ERCP) temporarily provides drainage of a blocked or infected biliary system. However, there is high mortality and morbidity associated with long-term endoprostheses; cholangitis as one of the main complications. Therefore, plastic stenting should only be used for a period of up to 6 months, according to latest guidelines. Our aim was to compare Trust practice with international recommendations, identifying potential causes for prolonged stent placement in patients with choledocholithiasis, and to discuss possible solutions. Methods Patients who underwent an ERCP across a 3-year period from NHS secure server records were identified, with further analysis of patients undergoing plastic biliary stent insertion. Results Of the 1118 ERCPs performed, 281 underwent plastic stenting for choledocholithiasis. Some patients were not suitable for cholecystectomy, so stents were accepted as the ceiling of care. 29 had stents in situ for over 6 months, while waiting for surgery. Of the 75 who had proceeded to cholecystectomy, 57 subsequently had stents removed in the trust. 18 still had plastic stents in situ. 5 had stents removed elsewhere, one of whom developed cholangitis and sepsis, requiring removal of the infected stent at a tertiary centre. Two patients were no longer fit for removal, and two had spontaneously passed their stents. Conclusions Retained biliary stents is not a rarity. There are many factors leading to delays, including long waiting lists for surgery, lack of requests to the endoscopy department and patient choice. Extrapolation of this single-trust audit would suggest that many sites are not meeting international guidelines for the duration of indwelling plastic stents. We suggest the implementation of a national database to monitor all patients with biliary endoprostheses to reduce morbidity associated with retained stents. We also recommend that incidents where harm is caused by plastic stents remaining in situ for greater than six months be treated as a Never Event.

Device-assisted enteroscopy performance measures in the United Kingdom: DEEP-UK quality improvement project.

Device-assisted enteroscopy (DAE) has become a well-established diagnostic and therapeutic tool for the management of small-bowel pathology. We aimed to evaluate the performance measures for DAE across the UK against the quality benchmarks proposed by the European Society of Gastrointestinal Endoscopy (ESGE). We retrospectively collected data on patient demographics and DAE performance measures from electronic endoscopy records of consecutive patients who underwent DAE for diagnostic and therapeutic purposes across 12 enteroscopy centers in the UK between January 2017 and December 2022. A total of 2005 DAE procedures were performed in 1663 patients (median age 60 years; 53% men). Almost all procedures (98.1%) were performed for appropriate indications. Double-balloon enteroscopy was used for most procedures (82.0%), followed by single-balloon enteroscopy (17.2%) and spiral enteroscopy (0.7%). The estimated depth of insertion was documented in 73.4% of procedures. The overall diagnostic yield was 70.0%. Therapeutic interventions were performed in 42.6% of procedures, with a success rate of 96.6%. Overall, 78.0% of detected lesions were marked with a tattoo. Patient comfort was significantly better with the use of deep sedation compared with conscious sedation (99.7% vs. 68.5%; P<0.001). Major adverse events occurred in only 0.6% of procedures. Performance measures for DAE in the UK meet the ESGE quality benchmarks, with high diagnostic and therapeutic yields, and a low incidence of major adverse events. However, there is room for improvement in optimizing sedation practices, standardizing the depth of insertion documentation, and adopting marking techniques to aid in the follow-up of detected lesions.

Strategy for post-polypectomy colonoscopy surveillance: focus on the revised Korean guidelines

Background: The risk of metachronous advanced neoplasia is linked to the presence of polyps on initial colonoscopy. Consequently, it is crucial to establish an appropriate colonoscopy surveillance period post-polypectomy.Current Concepts: The US Multi-Society Task Force, the European Society of Gastrointestinal Endoscopy, and the British Society of Gastroenterology revised their respective foreign guidelines in the 2020s. In Korea, a revised edition of post-polypectomy colonoscopic surveillance was announced in 2022, with the following risk factors: (1) adenoma ≥10 mm in size; (2) 3 to 5 (or more) adenomas; (3) tubulovillous or villous adenoma; (4) adenoma containing high-grade dysplasia; (5) traditional serrated adenoma; (6) sessile serrated lesions containing any grade of dysplasia; (7) serrated polyps of at least 10 mm in size; and (8) 3 to 5 (or more) sessile serrated lesions. In these guidelines, suitable surveillance periods are suggested for each risk factor.Discussion and Conclusion: The evidence supporting the best practices for post-polypectomy colonoscopy surveillance has strengthened, helping to support both close follow-up for some populations and less intense follow-up for others.

Summary and comparison of recently updated post-polypectomy surveillance guidelines.

Recently, updated guidelines for post-polypectomy surveillance have been published by the U.S. Multi-Society Task Force (USMSTF), the British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland/Public Health England (BSG/ACPGBI/PHE), the European Society of Gastrointestinal Endoscopy (ESGE), the Japan Gastroenterological Endoscopy Society (JGES), and the Korean Multi-Society Taskforce Committee. This review summarizes and compares the updated recommendations of these 5 guidelines. There are some differences between the guidelines for the recommended post-polypectomy surveillance intervals. In particular, there are prominent differences between the guidelines for 1-4 tubular adenomas < 10 mm with low-grade dysplasia (nonadvanced adenomas [NAAs]) and tubulovillous or villous adenomas. The USMSTF, JGES, and Korean guidelines recommend colonoscopic surveillance for patients with 1-4 NAAs and those with tubulovillous or villous adenomas, whereas the BSG/ACPGBI/PHE and ESGE guidelines do not recommend endoscopic surveillance for such patients. Surveillance recommendations for patients with serrated polyps (SPs) are limited. Although the USMSTF guidelines provide specific recommendations for patients who have undergone SPs removal, these are weak and based on very lowquality evidence. Future studies should examine this topic to better guide the surveillance recommendations for patients with SPs. For countries that do not have separate guidelines, we hope that this review article will help select the most appropriate guidelines as per each country's healthcare environment.

First report from the International Evaluation of Endoscopic classification Japan NBI Expert Team: International multicenter web trial.

Narrow-band imaging (NBI) contributes to real-time optical diagnosis and classification of colorectal lesions. The Japan NBI Expert Team (JNET) was introduced in 2011. The aim of this study was to explore the diagnostic accuracy of JNET when applied by European and Japanese endoscopists not familiar with this classification. This study was conducted by 36 European Society of Gastrointestinal Endoscopy (ESGE) and 49 Japan Gastroenterological Endoscopy Society (JGES) non-JNET endoscopists using still images of 150 lesions. For each lesion, nonmagnified white-light, nonmagnified NBI, and magnified NBI images were presented. In the magnified NBI, the evaluation area was designated by region of interest (ROI). The endoscopists scored histological prediction for each lesion. In ESGE members, the sensitivity, specificity, and accuracy were respectively 73.3%, 94.7%, and 93.0% for JNET Type 1; 53.0%, 64.9%, and 62.1% for Type 2A; 43.9%, 67.7%, and 55.1% for Type 2B; and 38.1%, 93.7%, and 85.1% for Type 3. When Type 2B and 3 were considered as one category of cancer, the sensitivity, specificity, and accuracy for differentiating high-grade dysplasia and cancer from the others were 59.9%, 72.5%, and 63.8%, respectively. These trends were the same for JGES endoscopists. The diagnostic accuracy of the JNET classification was similar between ESGE and JGES and considered to be sufficient for JNET Type 1. On the other hand, the accuracy for Types 2 and 3 is not sufficient; however, JNET 2B lesions should be resected en bloc due to the risk of cancers and JNET 3 can be treated by surgery due to its high specificity.

Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2:  ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3:  ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4:  ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5:  ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6:  ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7:  ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8:  ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9:  ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B:  ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C:  ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D:  ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E:  ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11:  After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.

Piecemeal Resection for Large Colorectal Adenomas Remains Essential in 2022: A Single-Center Experience in a Tertiary French Center.

Colorectal lesions measuring greater than 20 mm are unsuitable for en bloc endoscopic mucosal resection (EMR): piecemeal EMR (PM-EMR) and endoscopic submucosal dissection (ESD) are needed. The European Society of Gastrointestinal Endoscopy (ESGE) recommends ESD only for microinfiltrative lesions, although Japanese teams perform en bloc ESD for all lesions. We report the outcomes obtained in our endoscopy unit for these lesions and assess the hybrid "knife-assisted piecemeal EMR" (KAPM-EMR) technique. The main aim was to assess the short-term outcomes (C1). The secondary objectives were to evaluate the long-term results (C2), adverse event rate and management of recurrence. We retrospectively analyzed data from patients treated by PM-EMR, KAPM-EMR and ESD for a colorectal lesion measuring greater than 20 millimeters using prospective inclusion over four years. Data from 167 patients (median age: 70) with a median follow-up of 15.1 months were analyzed after excluding 95 patients. A total of 131 lesions were removed by PM-EMR, 24 by KAPM-EMR and 12 by ESD; 146/167 (87.4%) patients were considered in remission at C1. Recurrence was treated by endoscopy in 20/21 patients (95%); 86/89 (96.6%) were in remission at C2. A total of 16/167 patients developed adverse events, all of whom except one were endoscopically managed. KAPM-EMR was associated with a higher perforation risk (p=0.037). No differences in postoperative bleeding were found among the three groups (p=0.576). Piecemeal resection remains an effective and safe technique for large colorectal adenomas. KAPM-EMR may be useful but should be applied with caution due to the risk of perforation.

SP7.7 Evaluation of predictive models of common bile duct stones and the use of biliary investigations

Abstract Aims This study identifies clinical, biochemical and radiological factors that may predict CBD stones prior to cholecystectomy to reduce costs and delays of non-indicated biliary imaging. Method Retrospective data of patients underwent cholecystectomy over 6 months was collected, including first presentations, liver function tests (LFTs), and imaging. Data was tested against guidelines from European Society of Gastrointestinal Endoscopy (ESGE, 2019), American Society of Gastrointestinal Endoscopy (ASGE, 2019) and literature models (Gurusamy-2015, Isherwood-2014). Results 322 included patients had LFTs and US scans in first presentations with symptomatic gall stones. 52 of them had repeated biliary imaging (US, MRCP or CT) without showing any new findings in 92% of cases. 118 patients had MRCP prior to cholecystectomy, with only 22 cases of confirmed CBD stones. After applying the above-mentioned guidelines and predictive values, new criteria, combining cut-off values of 30 µmol/L for bilirubin and 180 IU/L for Alkaline phosphatase, showed the highest sensitivity (72.73%) and specificity (81.25%), while maintaining high positive predictive value (PPV) (46.99%) and accuracy (79.66%). (Table 1) Conclusion Using clinical and radiological findings to guide the need for definitive biliary imaging, commonly MRCP, can reduce unnecessary radiological investigations and costs. Our new suggested combined cut-off values of Bilirubin and ALP can complement the clinical judgement.

Capsule Endoscopy for the Diagnosis of Suspected Small Bowel Bleeding

   This review discusses the role of capsule endoscopy in diagnosing suspected small bowel bleeding and compares guidelines of the European Society of Gastrointestinal Endoscopy (ESGE), the American College of Gastroenterology (ACG), the American Society for Gastrointestinal Endoscopy (ASGE), the Canadian Association of Gastroenterology (CAG), and the consensus document of 4 Japanese medical societies. European and North American experts recommend capsule endoscopy as a first-line diagnostic modality for suspected small bowel bleeding without life-threatening signs in adult patients when ileocolonoscopy and esophagogastroduodenoscopy failed to be informative. Japanese experts, on the contrary, prefer cross-sectional imaging “from the chest to the pelvis” and consider capsule endoscopy as an alternative.