Standardised training for endoscopic mucosal resection of large non-pedunculated colorectal polyps to reduce recurrence (*STAR-LNPCP study): a multicentre cluster randomised trial.

OBJECTIVE: Endoscopic mucosal resection (EMR) is the preferred treatment for non-invasive large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs) but is associated with an early recurrence rate of up to 30%. We evaluated whether standardised EMR training could reduce recurrence rates in Dutch community hospitals. DESIGN: In this multicentre cluster randomised trial, 59 endoscopists from 30 hospitals were randomly assigned to the intervention group (e-learning and 2-day training including hands-on session) or control group. From April 2019 to August 2021, all consecutive EMR-treated LNPCPs were included. Primary endpoint was recurrence rate after 6 months. RESULTS: A total of 1412 LNPCPs were included; 699 in the intervention group and 713 in the control group (median size 30 mm vs 30 mm, 45% vs 52% size, morphology, site and access (SMSA) score IV, 64% vs 64% proximal location). Recurrence rates were lower in the intervention group compared with controls (13% vs 25%, OR 0.43; 95% CI 0.23 to 0.78; p=0.005) with similar complication rates (8% vs 9%, OR 0.93; 95% CI 0.64 to 1.36; p=0.720). Recurrences were more often unifocal in the intervention group (92% vs 76%; p=0.006). In sensitivity analysis, the benefit of the intervention on recurrence rate was only observed in the 20-40 mm LNPCPs (5% vs 20% in 20-29 mm, p=0.001; 10% vs 21% in 30-39 mm, p=0.013) but less evident in ≥40 mm LNPCPs (24% vs 31%; p=0.151). In a post hoc analysis, the training effect was maintained in the study group, while in the control group the recurrence rate remained high. CONCLUSION: A compact standardised EMR training for LNPCPs significantly reduced recurrences in community hospitals. This strongly argues for a national dedicated training programme for endoscopists performing EMR of ≥20 mm LNPCPs. Interestingly, in sensitivity analysis, this benefit was limited for LNPCPs ≥40 mm. TRIAL REGISTRATION NUMBER: NTR7477.

Effect of optical diagnosis training on recognition and treatment of submucosal invasive colorectal cancer in community hospitals: a prospective multicenter intervention study.

BACKGROUND: Recognition of submucosal invasive colorectal cancer (T1 CRC) is difficult, with sensitivities of 35 %-60 % in Western countries. We evaluated the real-life effects of training in the OPTICAL model, a recently developed structured and validated prediction model, in Dutch community hospitals. METHODS: In this prospective multicenter study (OPTICAL II), 383 endoscopists from 40 hospitals were invited to follow an e-learning program on the OPTICAL model, to increase sensitivity in detecting T1 CRC in nonpedunculated polyps. Real-life recognition of T1 CRC was then evaluated in 25 hospitals. Endoscopic and pathologic reports of T1 CRCs detected during the next year were collected retrospectively, with endoscopists unaware of this evaluation. Sensitivity for T1 CRC recognition, R0 resection rate, and treatment modality were compared for trained vs. untrained endoscopists. RESULTS: 1 year after e-learning, 528 nonpedunculated T1 CRCs were recorded for endoscopies performed by 251 endoscopists (118 [47 %] trained). Median T1 CRC size was 20 mm. Lesions were mainly located in the distal colorectum (66 %). Trained endoscopists recognized T1 CRCs more frequently than untrained endoscopists (sensitivity 74 % vs. 62 %; mixed model analysis odds ratio [OR] 2.90, 95 %CI 1.54-5.45). R0 resection rate was higher for T1 CRCs detected by trained endoscopists (69 % vs. 56 %; OR 1.73, 95 %CI 1.03-2.91). CONCLUSION: Training in optical recognition of T1 CRCs in community hospitals was associated with increased recognition of T1 CRCs, leading to higher en bloc and R0 resection rates. This may be an important step toward more organ-preserving strategies.

Limited wedge resection for T1 colon cancer (LIMERIC-II trial) - rationale and study protocol of a prospective multicenter clinical trial.

BACKGROUND: The sole presence of deep submucosal invasion is shown to be associated with a limited risk of lymph node metastasis. This justifies a local excision of suspected deep submucosal invasive colon carcinomas (T1 CCs) as a first step treatment strategy. Recently Colonoscopy-Assisted Laparoscopic Wedge Resection (CAL-WR) has been shown to be able to resect pT1 CRCs with a high R0 resection rate, but the long term outcomes are lacking. The aim of this study is to evaluate the safety, effectiveness and long-term oncological outcomes of CAL-WR as primary treatment for patients with suspected superficial and also deeply-invasive T1 CCs. METHODS: In this prospective multicenter clinical trial, patients with a macroscopic and/or histologically suspected T1 CCs will receive CAL-WR as primary treatment in order to prevent unnecessary major surgery for low-risk T1 CCs. To make a CAL-WR technically feasible, the tumor may not include > 50% of the circumference and has to be localized at least 25 cm proximal from the anus. Also, there should be sufficient distance to the ileocecal valve to place a linear stapler. Before inclusion, all eligible patients will be assessed by an expert panel to confirm suspicion of T1 CC, estimate invasion depth and subsequent advise which local resection techniques are possible for removal of the lesion. The primary outcome of this study is the proportion of patients with pT1 CC that is curatively treated with CAL-WR only and in whom thus organ-preservation could be achieved. Secondary outcomes are 1) CAL-WR's technical success and R0 resection rate for T1 CC, 2) procedure-related morbidity and mortality, 3) 5-year overall and disease free survival, 4) 3-year metastasis free survival, 5) procedure-related costs and 6) impact on quality of life. A sample size of 143 patients was calculated. DISCUSSION: CAL-WR is a full-thickness local resection technique that could also be effective in removing pT1 colon cancer. With the lack of current endoscopic local resection techniques for > 15 mm pT1 CCs with deep submucosal invasion, CAL-WR could fill the gap between endoscopy and major oncologic surgery. The present study is the first to provide insight in the long-term oncological outcomes of CAL-WR. TRIAL REGISTRATION: CCMO register (ToetsingOnline), NL81497.075.22, protocol version 2.3 (October 2022).

Intuitive understanding of the connection between Pancharatnam-Berry optical beam deflectors and polarization volume holograms.

An approximate beam propagation method is proposed as an intuitive simulation of the optics of Pancharatnam-Berry phase and polarization volume hologram devices. Using this method, the connection between and polarization properties of these two types of devices are made clear.

Full-color optical combiner with good imaging quality and a wide angle of incident light acceptance.

This work demonstrates a full-color optical image combiner for augmented reality head-up displays. In this device, the angle of the incident light of the computer-generated image reflected by it can vary over a large range. It achieves improved performance by using a combination of polarization interference filters (PIFs), quarter-wave retarders (QWRs), and polarization volume holograms (PVHs). The details for an example design and its performance are presented.

Dynamic correction of astigmatism.

For the correction of defocus and astigmatism, mechanical approaches are well known, but there is a need for a non-mechanical, electrically tunable optical system that could provide both focus and astigmatism power correction with an adjustable axis. The optical system presented here is composed of three liquid-crystal-based tunable cylindrical lenses that are simple, low cost, and having a compact structure. Potential applications of the concept device include smart eyeglasses, virtual reality (VR)/ augmented reality (AR) head-mounted displays (HMDs), and optical systems subject to thermal or mechanical distortion. Details of the concept, design method, numerical computer simulations of the proposed device, as well as characterization of a prototype, are provided in this work.

Full-Thickness Scar Resection After R1/Rx Excised T1 Colorectal Cancers as an Alternative to Completion Surgery.

INTRODUCTION: Local full-thickness resections of the scar (FTRS) after local excision of a T1 colorectal cancer (CRC) with uncertain resection margins is proposed as an alternative strategy to completion surgery (CS), provided that no local intramural residual cancer (LIRC) is found. However, a comparison on long-term oncological outcome between both strategies is missing. METHODS: A large cohort of patients with consecutive T1 CRC between 2000 and 2017 was used. Patients were selected if they underwent a macroscopically complete local excision of a T1 CRC but positive or unassessable (R1/Rx) resection margins at histology and without lymphovascular invasion or poor differentiation. Patients treated with CS or FTRS were compared on the presence of CRC recurrence, a 5-year overall survival, disease-free survival, and metastasis-free survival. RESULTS: Of 3,697 patients with a T1 CRC, 434 met the inclusion criteria (mean age 66 years, 61% men). Three hundred thirty-four patients underwent CS, and 100 patients underwent FTRS. The median follow-up period was 64 months. CRC recurrence was seen in 7 patients who underwent CS (2.2%, 95% CI 0.9%-4.6%) and in 8 patients who underwent FTRS (9.0%, 95% CI 3.9%-17.7%). Disease-free survival was lower in FTRS strategy (96.8% vs 89.9%, P = 0.019), but 5 of the 8 FTRS recurrences could be treated with salvage surgery. The metastasis-free survival (CS 96.8% vs FTRS 92.1%, P = 0.10) and overall survival (CS 95.6% vs FTRS 94.4%, P = 0.55) did not differ significantly between both strategies. DISCUSSION: FTRS after local excision of a T1 CRC with R1/Rx resection margins as a sole risk factor, followed by surveillance and salvage surgery in case of CRC recurrence, could be a valid alternative strategy to CS.

Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new endoscopic approach.

BACKGROUND: The risk of lymph node metastasis associated with deep submucosal invasion should be balanced against the mortality and morbidity of total mesorectal excision (TME). Dissection through the submucosa hinders radical deep resection, and full-thickness resection may influence the outcome of completion TME. Endoscopic intermuscular dissection (EID) in between the circular and longitudinal part of the muscularis propria could potentially provide an R0 resection while leaving the rectal wall intact. METHODS: In this prospective cohort study, the data of patients treated with EID for suspected deep submucosal invasive rectal cancer between 2018 and 2020 were analyzed. Study outcomes were the percentages of technical success, R0 resection, curative resection, and adverse events. RESULTS: 67 patients (median age 67 years; 73 % men) were included. The median lesion size was 25 mm (interquartile range 20-33 mm). The rates of overall technical success, R0 resection, and curative resection were 96 % (95 %CI 89 %-99 %), 81 % (95 %CI 70 %-89 %), and 45 % (95 %CI 33 %-57 %). Only minor adverse events occurred in eight patients (12 %). CONCLUSION: EID for deep invasive T1 rectal cancer appears to be feasible and safe, and the high R0 resection rate creates the potential of rectal preserving therapy in 45 % of patients.

Compensator design for polarization state management in waveguide displays based on polarization volume gratings.

In this work, we focus on the polarization state management in optical devices using optical elements based on circular polarization. As an example, we point out the issue in a waveguide display using circular polarization optical elements as input/output couplers, where the polarization state of the light can change as it propagates in the waveguide due to total internal reflection (TIR). This has a negative effect on the waveguide output coupler efficiency, image uniformity, and the polarization multiplexing capability. To address this problem, we discussed two different methods to compensate the polarization state change. With the compensator applied to correct the polarization state change in the waveguide, the optical elements based on circular polarization can be used with their advantages as input/output couplers for waveguide displays.

Closer look at transmissive polarization volume holograms: geometry, physics, and experimental validation.

In this work, we took a closer look at transmissive polarization volume holograms (T-PVH) to provide clarifications on their geometry, physics, and optical responses by finite-difference time-domain (FDTD) simulation and experimental validation. First, we introduced the four possible geometries of T-PVH and simulated their optical responses in terms of diffraction efficiency, polarization selectivity, and polarization output. It is shown that the configuration we called "Slanted T-PVH (B-θ/D-θ+90)," where the director is perpendicular to the Bragg planes, has the advantageous property of maintaining circular output polarization states. For this configuration, a detailed simulation of spectral, angular, and polarization responses was completed. Finally, we validated the FDTD simulation results of the Slanted T-PVH (B-θ/D-θ+90) structures with experiments.

Large area liquid crystal lenses for correction of presbyopia.

Presbyopia is the failure of the eye lens to accommodate. The widely used presbyopia correction method involves wearing bi/trifocal or progressive glasses, which limits the field of view due to division of lens area into sections of different optical power. A large aperture focus tunable liquid crystal lens has the potential to correct human eye accommodation failure and provide a wide field of view. In this paper, we present characterization and demonstration of a segmented phase profile liquid crystal lens, which has the characteristics of a large area (diameter: 20 mm), being flat and thin (<2 mm), and having continuous focus tunability (1.5 D to 0 D), fast response time (<500 ms), low operating voltage (<5 V), and on-axis diffraction-limited performance (for a 5mm aperture). Considering all these properties, our lens provides performance details of an approach for presbyopia correction. We have tested the minimum resolution and visual acuity of 20 subjects using the designed lens and compared the results with a reference glass lens of the same optical power.

Design of a large aperture, tunable, Pancharatnam phase beam steering device.

Replacing mechanical optical beam steering devices with non-mechanical electro-optic devices has been a long-standing desire for applications such as space-based communication, LiDAR and autonomous vehicles. While promising progress has been achieved to non-mechanically deflect light with high efficiency over a wide angular range, significant limitations remain towards achieving large aperture beam steering with a tunable steering direction. In this paper, we propose a unique liquid crystal based Pancharatnam Phase Device for beam steering which can provide both tunability and a fast response times in a format scalable to large apertures. This architecture employs a linear array of phase control elements to locally control the orientation of the liquid crystal director into a cycloidal pattern to deflect transmitted light. The PCEs are comprised of a fringe field switching electrode structure that can provide a variable in-plane electric field. Detailed modeling of the proposed design is presented which demonstrates that such a device can achieve a high degree of uniformity as it rotates the LC molecules over the 180 ° angular range required to create a Pancharatnam phase device.

High-efficiency, tunable, fringe-field switching-mode beam steering based on a liquid crystal Pancharatnam phase.

We have fabricated, characterized, and analyzed a recently proposed non-mechanical beam steering device based on the Pancharatnam-Berry phase in a liquid crystal. The architecture of our proposed device employs a linear array of phase control elements (PCEs) to locally control the orientation of the liquid crystal director into a cycloidal pattern to deflect transmitted light. The PCEs are comprised of a fringe-field switching electrode structure that can provide a variable in-plane electric field. Detailed optimization of the director configuration is in a good agreement with experimental results showing that the half-wave retardation condition has been uniformly achieved across the aperture. Moreover, efficiency simulations using a finite-difference time-domain algorithm verify a high beam steering efficiency for the proposed device.

Polarization-independent fast optical shutter with high transmission.

In this work, we designed a fast cholesteric shutter by switching the director between homeotropic and transient planar states. It is polarization independent, has sub-millisecond response time, high transmission in homeotropic state, and is highly reflective in the transient planar state. We also developed a driving waveform to achieve a long dark state of the device. The device has potential to be applied in the optics and display industries, for applications that could include augmented reality, head-up displays, transparent OLED displays, and smart windows.

"Achromatic limits" of Pancharatnam phase lenses.

Lenses based on the Pancharatnam phase have the advantage of being thin and inexpensive. Unfortunately, their optical effect is strongly wavelength dependent, and their applications generally are limited by the requirement of a monochromatic source. However, low-power lenses based on the Pancharatnam phase can be considered for applications over the visible range. In this paper, we provide intuitive "limits" for the lens power, below which these devices can be considered for use with the eye and visible light imaging applications.

Design of a large aperture tunable refractive Fresnel liquid crystal lens.

A large aperture tunable lens based on liquid crystals, which is considered for near-to-eye applications, is designed, built, and characterized. Large liquid crystal lenses with high quality are limited by very slow switching speeds due to the large optical path difference (OPD) required. To reduce the switching time of the lens, the thickness is controlled through the application of several phase resets, similar to the design of a Fresnel lens. A main point of the paper is the design of the Fresnel structure to have a minimal effect on the image quality. Our modeling and experimental results demonstrate that minimal image degradation due to the phase resets is observable when the segment spacing is chosen by taking into account human eye resolution. Such lenses have applications related to presbyopia and, in virtual reality systems, to solve the well-known issue of accommodation-convergence mismatch.

Design of a sensitive uncooled thermal imager based on a liquid crystal Fabry-Perot interferometer.

Microbolometers are the dominant technology for uncooled thermal imaging; however, devices based on a direct retardation measurement of a liquid crystal (LC) transducer pixel have been shown to have comparable sensitivity. In this paper, an approach for increasing LC transducer sensitivity utilizing an etalon structure is considered. A detailed design for an LC resonant cavity between dielectric mirrors is proposed and the performance is evaluated numerically. The measured quantity is the transmission of a visible wavelength through the etalon, which requires no thermal contact with the IR sensor. Numerical and analytical calculations that consider a 470 nm thick LC pixel demonstrate that the change in transmitted intensity with temperature is 26 times greater in the device based on a resonant structure than in a device based on a direct retardation measurement. Finally, the paper discusses how the dielectric mirror materials, dimensions of the resonant cavity structure, and expected process tolerances affect the sensitivity of the device.

High-efficiency large-angle Pancharatnam phase deflector based on dual-twist design.

We have previously shown through simulation that an optical beam deflector based on the Pancharatnam (geometric) phase can provide high efficiency with up to 80° deflection using a dual-twist structure for polarization-state control [Appl. Opt.54, 10035 (2015)]. In this report, we demonstrate that its optical performance is as predicted and far beyond what could be expected for a conventional diffractive optical device. We provide details about construction and characterization of a ± 40° beam-steering device with 90% diffraction efficiency based on our dual-twist design at a 633nm wavelength.

Flexoelectric in-plane switching (IPS) mode with ultra-high-transmittance, low-voltage, low-frequency, and a flicker-free image.

The demands for a power-saving mode for displaying static images are ubiquitous not only in portable devices but also in price tags and advertising panels. At a low-frequency driving in liquid crystal displays (LCDs) for low-power consumption, the flexoelectric effect arises even in calamitic liquid crystals and the optical appearance of this physical phenomenon is found to be unusually large, being noticed as an image-flickering. Although the inherent integrated optical transmittance of in-plane switching (IPS) mode is relatively lower than that of fringe-field switching (FFS) mode, the IPS mode shows no static image-flickering but an optical spike (the so-called optical bounce), at the transient moment between signal positive and negative frames. Here, we demonstrate an IPS mode using negative dielectric anisotropy of liquid crystals (Δε < 0) and fine-patterned electrodes (the width w of and the space l between electrodes ≤ 3 µm) with reduced operation voltage (up to 40.7% to a conventional FFS mode with Δε < 0), reduced optical bounce (up to 4.4%. to a conventional FFS mode with Δε < 0) and enhanced transmittance (up to 32.1% to a conventional IPS mode with Δε > 0). We believe the result will contribute not only to the scientific understanding of the optical appearance of flexoelectric effect but also pave the way for engineering of a superior low-power consumption LCD.