Cold Vs Hot Snare Endoscopic Resection of Large Nonpedunculated Colorectal Polyps: Randomized Controlled German CHRONICLE Trial.

BACKGROUND & AIMS: Endoscopic mucosal resection (EMR) is standard therapy for nonpedunculated colorectal polyps ≥20 mm. It has been suggested recently that polyp resection without current (cold resection) may be superior to the standard technique using cutting/coagulation current (hot resection) by reducing adverse events (AEs), but evidence from a randomized trial is missing. METHODS: In this randomized controlled multicentric trial involving 19 centers, nonpedunculated colorectal polyps ≥20 mm were randomly assigned to cold or hot EMR. The primary outcome was major AE (eg, perforation or postendoscopic bleeding). Among secondary outcomes, major AE subcategories, postpolypectomy syndrome, and residual adenoma were most relevant. RESULTS: Between 2021 and 2023, there were 396 polyps in 363 patients (48.2% were female) enrolled for the intention-to-treat analysis. Major AEs occurred in 1.0% of the cold group and in 7.9% of the hot group (P = .001; odds ratio [OR], 0.12; 95% CI, 0.03-0.54). Rates for perforation and postendoscopic bleeding were significantly lower in the cold group, with 0% vs 3.9% (P = .007) and 1.0% vs 4.4% (P = .040). Postpolypectomy syndrome occurred with similar frequency (3.1% vs 4.4%; P = .490). After cold resection, residual adenoma was found more frequently, with 23.7% vs 13.8% (P = .020; OR, 1.94; 95% CI, 1.12-3.38). In multivariable analysis, lesion diameter of ≥4 cm was an independent predictor for major AEs (OR, 3.37) and residual adenoma (OR, 2.47) and for high-grade dysplasia/cancer for residual adenoma (OR, 2.92). CONCLUSIONS: Cold resection of large, nonpedunculated colorectal polyps appears to be considerably safer than hot EMR; however, at the cost of a higher residual adenoma rate. Further studies have to confirm to what extent polyp size and histology can determine an individualized approach. German Clinical Trials Registry (Deutsches Register Klinischer Studien), Number DRKS00025170.

Reducing scope 3 carbon emissions in gastrointestinal endoscopy: results of the prospective study of the 'Green Endoscopy Project Würzburg'.

OBJECTIVE: Carbon emissions generated by gastrointestinal endoscopy have been recognised as a critical issue. Scope 3 emissions are mainly caused by the manufacturing, packaging and transportation of purchased goods. However, to our knowledge, there are no prospective data on the efficacy of measurements aimed to reduce scope 3 emissions. DESIGN: The study was performed in a medium-sized academic endoscopy unit. Manufacturers of endoscopic consumables were requested to answer a questionnaire on fabrication, origin, packaging and transport. Based on these data, alternative products were purchased whenever possible. In addition, staff was instructed on how to avoid waste. Thereafter, the carbon footprint of each item purchased was calculated from February to May 2023 (intervention period), and scope 3 emissions were compared with the same period of the previous year (control period). RESULTS: 26 of 40 companies answered the questionnaire. 229 of 322 products were classified as unfavourable. A switch to alternative items was possible for 47/229 items (20.5%). 1666 endoscopies were performed during the intervention period compared with 1751 examinations during the control period (-4.1%). The number of instruments used decreased by 10.0% (3111 vs 3457). Using fewer and alternative products resulted in 11.5% less carbon emissions (7.09 vs 8.01 tons of carbon equivalent=tCO2 e). Separation of waste led to a reduction of 20.1% (26.55 vs 33.24 tCO2e). In total, carbon emissions could be reduced by 18.4%. CONCLUSION: Use of fewer instruments per procedure, recycling packaging material and switching to alternative products can reduce carbon emissions without impairing the endoscopic workflow.

Direct comparison of multiple computer-aided polyp detection systems.

BACKGROUND AND STUDY AIMS: Artificial intelligence (AI)-based systems for computer-aided detection (CADe) of polyps receive regular updates and occasionally offer customizable detection thresholds, both of which impact their performance, but little is known about these effects. This study aimed to compare the performance of different CADe systems on the same benchmark dataset. METHODS: 101 colonoscopy videos were used as benchmark. Each video frame with a visible polyp was manually annotated with bounding boxes, resulting in 129 705 polyp images. The videos were then analyzed by three different CADe systems, representing five conditions: two versions of GI Genius, Endo-AID with detection Types A and B, and EndoMind, a freely available system. Evaluation included an analysis of sensitivity and false-positive rate, among other metrics. RESULTS: Endo-AID detection Type A, the earlier version of GI Genius, and EndoMind detected all 93 polyps. Both the later version of GI Genius and Endo-AID Type B missed 1 polyp. The mean per-frame sensitivities were 50.63 % and 67.85 %, respectively, for the earlier and later versions of GI Genius, 65.60 % and 52.95 %, respectively, for Endo-AID Types A and B, and 60.22 % for EndoMind. CONCLUSIONS: This study compares the performance of different CADe systems, different updates, and different configuration modes. This might help clinicians to select the most appropriate system for their specific needs.

Artificial intelligence-based polyp size measurement in gastrointestinal endoscopy using the auxiliary waterjet as a reference.

BACKGROUND: Measurement of colorectal polyp size during endoscopy is mainly performed visually. In this work, we propose a novel polyp size measurement system (Poseidon) based on artificial intelligence (AI) using the auxiliary waterjet as a measurement reference. METHODS: Visual estimation, biopsy forceps-based estimation, and Poseidon were compared using a computed tomography colonography-based silicone model with 28 polyps of defined sizes. Four experienced gastroenterologists estimated polyp sizes visually and with biopsy forceps. Furthermore, the gastroenterologists recorded images of each polyp with the waterjet in proximity for the application of Poseidon. Additionally, Poseidon's measurements of 29 colorectal polyps during routine clinical practice were compared with visual estimates. RESULTS: In the silicone model, visual estimation had the largest median percentage error of 25.1 % (95 %CI 19.1 %-30.4 %), followed by biopsy forceps-based estimation: median 20.0 % (95 %CI 14.4 %-25.6 %). Poseidon gave a significantly lower median percentage error of 7.4 % (95 %CI 5.0 %-9.4 %) compared with other methods. During routine colonoscopies, Poseidon presented a significantly lower median percentage error (7.7 %, 95 %CI 6.1 %-9.3 %) than visual estimation (22.1 %, 95 %CI 15.1 %-26.9 %). CONCLUSION: In this work, we present a novel AI-based method for measuring colorectal polyp size with significantly higher accuracy than other common sizing methods.

The influence of computer-aided polyp detection systems on reaction time for polyp detection and eye gaze.

BACKGROUND: Multiple computer-aided systems for polyp detection (CADe) have been introduced into clinical practice, with an unclear effect on examiner behavior. This study aimed to measure the influence of a CADe system on reaction time, mucosa misinterpretation, and changes in visual gaze pattern. METHODS: Participants with variable levels of colonoscopy experience viewed video sequences (n = 29) while eye movement was tracked. Using a crossover design, videos were presented in two assessments, with and without CADe support. Reaction time for polyp detection and eye-tracking metrics were evaluated. RESULTS: 21 participants performed 1218 experiments. CADe was significantly faster in detecting polyps compared with participants (median 1.16 seconds [99 %CI 0.40-3.43] vs. 2.97 seconds [99 %CI 2.53-3.77], respectively). However, the reaction time of participants when using CADe (median 2.90 seconds [99 %CI 2.55-3.38]) was similar to that without CADe. CADe increased misinterpretation of normal mucosa and reduced the eye travel distance. CONCLUSIONS: Results confirm that CADe systems detect polyps faster than humans. However, use of CADe did not improve human reaction times. It increased misinterpretation of normal mucosa and decreased the eye travel distance. Possible consequences of these findings might be prolonged examination time and deskilling.

A video based benchmark data set (ENDOTEST) to evaluate computer-aided polyp detection systems.

BACKGROUND AND AIMS: Computer-aided polyp detection (CADe) may become a standard for polyp detection during colonoscopy. Several systems are already commercially available. We report on a video-based benchmark technique for the first preclinical assessment of such systems before comparative randomized trials are to be undertaken. Additionally, we compare a commercially available CADe system with our newly developed one. METHODS: ENDOTEST consisted in the combination of two datasets. The validation dataset contained 48 video-snippets with 22,856 manually annotated images of which 53.2% contained polyps. The performance dataset contained 10 full-length screening colonoscopies with 230,898 manually annotated images of which 15.8% contained a polyp. Assessment parameters were accuracy for polyp detection and time delay to first polyp detection after polyp appearance (FDT). Two CADe systems were assessed: a commercial CADe system (GI-Genius, Medtronic), and a self-developed new system (ENDOMIND). The latter being a convolutional neuronal network trained on 194,983 manually labeled images extracted from colonoscopy videos recorded in mainly six different gastroenterologic practices. RESULTS: On the ENDOTEST, both CADe systems detected all polyps in at least one image. The per-frame sensitivity and specificity in full colonoscopies was 48.1% and 93.7%, respectively for GI-Genius; and 54% and 92.7%, respectively for ENDOMIND. Median FDT of ENDOMIND with 217 ms (Inter-Quartile Range(IQR)8-1533) was significantly faster than GI-Genius with 1050 ms (IQR 358-2767, p = 0.003). CONCLUSIONS: Our benchmark ENDOTEST may be helpful for preclinical testing of new CADe devices. There seems to be a correlation between a shorter FDT with a higher sensitivity and a lower specificity for polyp detection.

Frame-by-Frame Analysis of a Commercially Available Artificial Intelligence Polyp Detection System in Full-Length Colonoscopies.

INTRODUCTION: Computer-aided detection (CADe) helps increase colonoscopic polyp detection. However, little is known about other performance metrics like the number and duration of false-positive (FP) activations or how stable the detection of a polyp is. METHODS: 111 colonoscopy videos with total 1,793,371 frames were analyzed on a frame-by-frame basis using a commercially available CADe system (GI-Genius, Medtronic Inc.). Primary endpoint was the number and duration of FP activations per colonoscopy. Additionally, we analyzed other CADe performance parameters, including per-polyp sensitivity, per-frame sensitivity, and first detection time of a polyp. We additionally investigated whether a threshold for withholding CADe activations can be set to suppress short FP activations and how this threshold alters the CADe performance parameters. RESULTS: A mean of 101 ± 88 FPs per colonoscopy were found. Most of the FPs consisted of less than three frames with a maximal 66-ms duration. The CADe system detected all 118 polyps and achieved a mean per-frame sensitivity of 46.6 ± 26.6%, with the lowest value for flat polyps (37.6 ± 24.8%). Withholding CADe detections up to 6 frames length would reduce the number of FPs by 87.97% (p < 0.001) without a significant impact on CADe performance metrics. CONCLUSIONS: The CADe system works reliable but generates many FPs as a side effect. Since most FPs are very short, withholding short-term CADe activations could substantially reduce the number of FPs without impact on other performance metrics. Clinical practice would benefit from the implementation of customizable CADe thresholds.

Evolution of endoscopic vacuum therapy for upper gastrointestinal leakage over a 10-year period: a quality improvement study.

BACKGROUND: Endoscopic vacuum therapy (EVT) is an effective treatment option for leakage of the upper gastrointestinal (UGI) tract. The aim of this study was to evaluate the clinical impact of quality improvements in EVT management on patients' outcome. METHODS: All patients treated by EVT at our center during 2012-2021 were divided into two consecutive and equal-sized cohorts (period 1 vs. period 2). Over time several quality improvement strategies were implemented including the earlier diagnosis and EVT treatment and technical optimization of endoscopy. The primary endpoint was defined as the composite score MTL30 (mortality, transfer, length-of-stay > 30 days). Secondary endpoints included EVT efficacy, complications, in-hospital mortality, length-of-stay (LOS) and nutrition status at discharge. RESULTS: A total of 156 patients were analyzed. During the latter period the primary endpoint MTL30 decreased from 60.8 to 39.0% (P = .006). EVT efficacy increased from 80 to 91% (P = .049). Further, the need for additional procedures for leakage management decreased from 49.9 to 29.9% (P = .013) and reoperations became less frequent (38.0% vs.15.6%; P = .001). The duration of leakage therapy and LOS were shortened from 25 to 14 days (P = .003) and 38 days to 25 days (P = .006), respectively. Morbidity (as determined by the comprehensive complication index) decreased from 54.6 to 46.5 (P = .034). More patients could be discharged on oral nutrition (70.9% vs. 84.4%, P = .043). CONCLUSIONS: Our experience confirms the efficacy of EVT for the successful management of UGI leakage. Our quality improvement analysis demonstrates significant changes in EVT management resulting in accelerated recovery, fewer complications and improved functional outcome.

Telemetric capsule-based upper gastrointestinal tract - blood detection - first multicentric experience.

INTRODUCTION: Risk stratification in upper gastrointestinal bleeding (UGIB) currently relies on clinical parameters and risk scores. HemoPill® acute (Ovesco Endoscopy, Tuebingen, Germany) is a pill-shaped, orally administered sensor capsule for real-time blood detection. The aim of this study was to evaluate the system in clinical routine. MATERIAL AND METHODS: Sixty-one consecutive patients in whom the HemoPill® had been used at 12 international hospitals between July 2019 and March 2020 were retrospectively analysed. Indications for application were the clinical suspicion of UGIB, small bowel bleeding, of rebleeding after hemostasis. Primary endpoints were technical success and bleeding detection/exclusion. Secondary endpoints included adverse events and change of clinical course. RESULTS: The capsule was used in 45 (73%) patients with UGIB, in 12 (20%) patients with small bowel bleeding and in four (7%) patients for exclusion of rebleeding. Technical success was 98%. 35/60 (58%) cases were capsule-positive and among these, endoscopy showed bleeding in 20/35 (57%) cases. None of the 25 capsule-negative patients rebled. Emergency endoscopy could be avoided in 18/25 (72%) cases. Serious adverse events did not occur. CONCLUSION: HemoPill®-based blood detection is feasible and safe. Negative capsule results might 'downgrade' the need for urgent endoscopy.

The over-the-scope grasper (OTSG).

BACKGROUND : Endoscopic removal of foreign bodies, coagulated blood, or necrotic debris is sometimes challenging and time-consuming, partly because of inadequate endoscopic instruments. Therefore, new devices are needed to overcome the current limitations. METHODS : The over-the-scope grasper (OTSG) is a new grasping tool that can be attached to any standard gastroscope. It has been developed for endoscopic removal of larger particles. We present retrospective data on five patients who were treated using the device for various indications, including necrosectomy, bolus impaction, and removal of blood clots. RESULTS : In two patients, the OTSG was used through a lumen-apposing metal stent for direct endoscopic necrosectomy after severe pancreatitis. The other patients had a massive blood clot in the esophagus after endoscopic submucosal dissection, or aphagia due to large meat chunks clogging the esophagus. The OTSG was used with technical success in all of the patients and without any procedure-associated complications. CONCLUSION : The OTSG appears to be a useful device for endoscopic removal of larger particles, blood clots, or necrotic debris. Preliminary experience shows that the device is effective and easy to use.

Endoscopic full thickness resection vs. transanal endoscopic microsurgery for local treatment of rectal neuroendocrine tumors - a retrospective analysis.

PURPOSE: Local treatment of small well-differentiated rectal neuroendocrine tumors (NETs) is recommended by current guidelines. However, although several endoscopic methods have been established, the highest R0 rate is achieved by transanal endoscopic microsurgery (TEM). Since a recently published study about endoscopic full thickness resection (eFTR) showed a R0 resection rate of 100%, the aim of this study was to evaluate both methods (eFTR vs. TEM). METHODS: We retrospectively analyzed all patients with rectal NET treated either by TEM (1999-2018) or eFTR (2016-2019) in two tertiary centers (University Hospital Wuerzburg and Ulm). We analyzed clinical, procedural, and histopathological outcomes in both groups. RESULTS: Twenty-eight patients with rectal NET received local treatment (TEM: 13; eFTR: 15). Most tumors were at stage T1a and grade G1 or G2 (in the TEM group two G3 NETs were staged T2 after neoadjuvant chemotherapy). In both groups, similar outcomes for en bloc resection rate, R0 resection rate, tumor size, or specimen size were found. No procedural adverse events were noted. Mean procedure time in the TEM group was 48.9 min and 19.2 min in the eFTR group. CONCLUSION: eFTR is a convincing method for local treatment of small rectal NETs combining high safety and efficacy with short interventional time.

Klotho and phosphate are modulators of pathologic uremic cardiac remodeling.

Cardiac dysfunction in CKD is characterized by aberrant cardiac remodeling with hypertrophy and fibrosis. CKD is a state of severe systemic Klotho deficiency, and restoration of Klotho attenuates vascular calcification associated with CKD. We examined the role of Klotho in cardiac remodeling in models of Klotho deficiency-genetic Klotho hypomorphism, high dietary phosphate intake, aging, and CKD. Klotho-deficient mice exhibited cardiac dysfunction and hypertrophy before 12 weeks of age followed by fibrosis. In wild-type mice, the induction of CKD led to severe cardiovascular changes not observed in control mice. Notably, non-CKD mice fed a high-phosphate diet had lower Klotho levels and greatly accelerated cardiac remodeling associated with normal aging compared with those on a normal diet. Chronic elevation of circulating Klotho because of global overexpression alleviated the cardiac remodeling induced by either high-phosphate diet or CKD. Regardless of the cause of Klotho deficiency, the extent of cardiac hypertrophy and fibrosis correlated tightly with plasma phosphate concentration and inversely with plasma Klotho concentration, even when adjusted for all other covariables. High-fibroblast growth factor-23 concentration positively correlated with cardiac remodeling in a Klotho-deficient state but not a Klotho-replete state. In vitro, Klotho inhibited TGF-ß1-, angiotensin II-, or high phosphate-induced fibrosis and abolished TGF-ß1- or angiotensin II-induced hypertrophy of cardiomyocytes. In conclusion, Klotho deficiency is a novel intermediate mediator of pathologic cardiac remodeling, and fibroblast growth factor-23 may contribute to cardiac remodeling in concert with Klotho deficiency in CKD, phosphotoxicity, and aging.

Kelp forest community structure and demography in Kongsfjorden (Svalbard) across 25 years of Arctic warming.

The Arctic archipelago of Svalbard is a hotspot of global warming and many fjords experience a continuous increase in seawater temperature and glacial melt while sea-ice cover declines. In 1996/1998, 2012-2014, and 2021 macroalgal biomass and species diversity were quantified at the study site Hansneset, Kongsfjorden (W-Spitsbergen) in order to identify potential changes over time. In 2021, we repeated the earlier studies by stratified random sampling (1 × 1 m2, n = 3) along a sublittoral depth transect (0, 2.5, 5, 10, and 15 m) and investigated the lower depth limits of dominant brown algae between 3 and 19 m. The maximum fresh weight (FW) of all seaweeds was 11.5 kg m-2 at 2.5 m and to 99.9% constituted of kelp. Although biomass distribution along the depth transect in 2021 was not significantly different compared to 2012/2013, the digitate kelp community (Laminaria digitata/Hedophyllum nigripes) had transformed into an Alaria esculenta-dominated kelp forest. Consequently, a pronounced shift in kelp forest structure occurred over time as we demonstrate that biomass allocation to thallus parts is kelp species-specific. Over the past decade, kelp demography changed and in 2021 a balanced age structure of kelps (juveniles plus many older kelp individuals) was only apparent at 2.5 m. In addition, the abundances and lower depth limits of all dominant brown algae declined noticeably over the last 25 years while the red algal flora abundance remained unchanged at depth. We propose that the major factor driving the observed changes in the macroalgal community are alterations in underwater light climate, as in situ data showed increasing turbidity and decreasing irradiance since 2012 and 2017, respectively. As a consequence, the interplay between kelp forest retreat to lower depth levels caused by coastal darkening and potential macroalgal biomass gain with increasing temperatures will possibly intensify in the future with unforeseen consequences for melting Arctic coasts and fjord ecosystem services.

Positive resection margins in Crohn's disease are a relevant risk factor for postoperative disease recurrence.

Postoperative disease recurrence in Crohn's disease represents a relevant issue despite recent advancements in surgical and medical therapies. Additional criteria are necessary to improve the identification of patients at risk and to enable selective therapeutic approaches. The role of resection margins on disease recurrence remains unclear and general recommendations are lacking. A single-center retrospective analysis was performed including all patients who received ileocecal resection due to Crohn's disease. Resection margins were analyzed by two independent pathologists and defined by histopathological criteria based on previous consensus reports. 158 patients were included for analysis with a median follow up of 35 months. While postoperative morbidity was not affected, positive resection margins resulted in significantly increased rates of severe endoscopic recurrence at 6 months (2.0% versus 15.6%, p = 0.02) and overall (4.2% versus 19.6%, p = 0.001), which resulted in significantly increased numbers of surgical recurrence (0% versus 4.5%, p = 0.04). Additionally, positive margins were identified as independent risk factor for severe endoscopic disease recurrence in a multivariate analysis. Based on that, positive margins represent an independent risk factor for postoperative endoscopic and surgical disease recurrence. Prospective studies are required to determine whether extended resection or postoperative medical prophylaxis is beneficial for patients with positive resection margins.

The Role of Specialized Instruments for Advanced Endoscopic Resections in Gastrointestinal Disease.

INTRODUCTION: Advanced endoscopic therapy techniques have been developed and have created alternative treatment options to surgical therapy for several gastrointestinal diseases. This work will focus on new endoscopic tools for special indications of advanced endoscopic resections (ER), especially endoscopic submucosal dissection (ESD), which were developed in our institution. This paper aims to analyze these specialized instruments and identify their status. METHODS: Initially, the technical process of ESD was analyzed, and the following limitations of the different endoscopic steps and the necessary manipulations were determined: the problem of traction-countertraction, the grasping force needed to pull on tissue, the instrument tip maneuverability, the limited angulation/triangulation, and the mobility of the scope and instruments. Five instruments developed by our team were used: the Endo-dissector, additional working channel system, external independent next-to-the-scope grasper, 3D overtube working station, and over-the-scope grasper. The instruments were used and applied according to their special functions in dry lab, experimental in vivo, and clinical conditions by the members of our team. RESULTS: The Endo-dissector has a two-fold function: (1) grasping submucosal tissue with enough precision and strength to pull it off the surrounding mucosa and muscle, avoiding damage during energy application and (2) effectively dividing tissue using monopolar energy. The AWC system quickly fulfills the lack of a second working channel as needed to complete the endoscopic task on demand. The EINTS grasper can deliver a serious grasping force, which may be necessary for a traction-countertraction situation during endoscopic resection for lifting a larger specimen. The 3D overtube multifunctional platform provides surgical-like work with bimanual-operated instruments at the tip of the scope, which allows for a coordinated approach during lesion treatment. The OTSG is a grasping tool with very special features for cleaning cavities with debris. CONCLUSIONS: The research and development of instruments with special features can solve unmet needs in advanced endoscopic procedures. The latter may help to increase indications for the endoscopic resections of gut lesions in the future.

Wnt/ß-catenin modulating drugs regulate somatostatin receptor expression and internalization of radiolabelled octreotide in neuroendocrine tumor cells.

BACKGROUND: Differentiated neuroendocrine tumors (NETs) express somatostatin receptors (SSTRs), targets for therapy with either unlabeled or radioactively labeled somatostatin analogs (SSA). Associated with worse prognosis, dedifferentiated NET loose SSTR expression, which may be linked to deregulation of Wnt/ß-catenin signaling on an intracellular level. The aim of the present study was to investigate the effect of Wnt/ß-catenin signaling pathway alterations on SSTR expression and its function in NET. METHODS: The NET cell lines BON-1 and QGP-1 were incubated with the Wnt-inhibitors 5-aza-2'-deoxycytidine (5-aza-CdR), Quercetin, or Niclosamide, or the Wnt activator lithium chloride (LiCl). Expression of SSTR1, SSTR2, and SSTR5 was determined by quantitative RT-PCR (qRT-PCR), immunocytomicroscopy and western blot. Changes in the Wnt pathway were analyzed by qRT-PCR of selected target genes and the TaqMan Array Human WNT Pathway. Receptor-associated function was determined by measuring the cellular uptake of [125I-Tyr3] octreotide. RESULTS: The mRNAs of SSTRs 1-5 were expressed in both cell lines. Wnt inhibitors caused downregulation of Wnt target genes, while 5-aza-CdR had the highest inhibitory effect. LiCl lead to an upregulation of Wnt genes, which was more marked in QGP-1 cells. SSTR expression increased in both cell lines upon Wnt inhibition. All three Wnt inhibitors lead to a marked increase in the specific uptake of [125I-Tyr3]octreotide, with 5-aza-CdR showing the greatest effect (increase by more than 50% in BON-1 cells), while a decreased uptake of [125I-Tyr3]octreotide was seen upon activation of Wnt signaling by LiCl. CONCLUSIONS: We demonstrate here that Wnt signaling orchestrates SSTR expression and function in a preclinical NET model. Wnt inhibition increases [125I-Tyr3]octreotide uptake offering an opportunity to enhance the efficacy of SSTR-targeted theranostic approaches.

Development and evaluation of a deep learning model to improve the usability of polyp detection systems during interventions.

BACKGROUND: The efficiency of artificial intelligence as computer-aided detection (CADe) systems for colorectal polyps has been demonstrated in several randomized trials. However, CADe systems generate many distracting detections, especially during interventions such as polypectomies. Those distracting CADe detections are often induced by the introduction of snares or biopsy forceps as the systems have not been trained for such situations. In addition, there are a significant number of non-false but not relevant detections, since the polyp has already been previously detected. All these detections have the potential to disturb the examiner's work. OBJECTIVES: Development and evaluation of a convolutional neuronal network that recognizes instruments in the endoscopic image, suppresses distracting CADe detections, and reliably detects endoscopic interventions. METHODS: A total of 580 different examination videos from 9 different centers using 4 different processor types were screened for instruments and represented the training dataset (519,856 images in total, 144,217 contained a visible instrument). The test dataset included 10 full-colonoscopy videos that were analyzed for the recognition of visible instruments and detections by a commercially available CADe system (GI Genius, Medtronic). RESULTS: The test dataset contained 153,623 images, 8.84% of those presented visible instruments (12 interventions, 19 instruments used). The convolutional neuronal network reached an overall accuracy in the detection of visible instruments of 98.59%. Sensitivity and specificity were 98.55% and 98.92%, respectively. A mean of 462.8 frames containing distracting CADe detections per colonoscopy were avoided using the convolutional neuronal network. This accounted for 95.6% of all distracting CADe detections. CONCLUSIONS: Detection of endoscopic instruments in colonoscopy using artificial intelligence technology is reliable and achieves high sensitivity and specificity. Accordingly, the new convolutional neuronal network could be used to reduce distracting CADe detections during endoscopic procedures. Thus, our study demonstrates the great potential of artificial intelligence technology beyond mucosal assessment.

Kono-S Anastomosis in Crohn's Disease: A Retrospective Study on Postoperative Morbidity and Disease Recurrence in Comparison to the Conventional Side-To-Side Anastomosis.

INTRODUCTION: The rates of postoperative recurrence following ileocecal resection due to Crohn's disease remain highly relevant. Despite this fact, while the Kono-S anastomosis technique initially demonstrated promising results, robust evidence is still lacking. This study aimed to analyze the short- and long-term outcomes of the Kono-S versus side-to-side anastomosis. METHODS: A retrospective single-center study was performed including all patients who received an ileocecal resection between 1 January 2019 and 31 December 2021 at the Department of Surgery at the University Hospital of Wuerzburg. Patients who underwent conventional a side-to-side anastomosis were compared to those who received a Kono-S anastomosis. The short- and long-term outcomes were analyzed for all patients. RESULTS: Here, 29 patients who underwent a conventional side-to-side anastomosis and 22 patients who underwent a Kono-S anastomosis were included. No differences were observed regarding short-term postoperative outcomes. The disease recurrence rate postoperatively was numerically lower following the Kono-S anastomosis (median Rutgeert score of 1.7 versus 2.5), with a relevantly increased rate of patients in remission (17.2% versus 31.8%); however, neither of these results reached statistical significance. CONCLUSION: The Kono-S anastomosis method is safe and feasible and potentially decreases the severity of postoperative disease remission.

Over-the-scope-grasper: A new tool for pancreatic necrosectomy and beyond - first multicenter experience.

BACKGROUND: Endoscopic treatment of pancreatic necrosis can be challenging and time-consuming because sticky necrotic debris is sometimes difficult to remove. The over-the-scope-grasper, a new tool that has recently become available for this purpose, might also be useful for other indications. However, clinical data on the efficacy and safety of this new device are lacking. AIM: To evaluate the technical success and safety of the device in a multicenter setting. METHODS: The over-the-scope-grasper was used in nine selected endoscopic centers between November 2020 and October 2021 for appropriate indications. Overall, 56 procedures were included in the study. We retrospectively evaluated procedural parameters of all endoscopic interventions using a predefined questionnaire, with special respect to technical success, indications, duration of intervention, type of sedation, and complications. In the case of pancreatic necrosectomy, the access route, stent type, number of necrosis pieces removed, and clinical handling were also recorded. RESULTS: A total of 56 procedures were performed, with an overall technical success rate of 98%. Most of the procedures were endoscopic pancreatic necrosectomies (33 transgastric, 4 transduodenal). In 70% of the procedures, access to the necrotic cavity was established with a lumen apposing metal stent. The technical success of pancreatic necrosectomy was 97%, with a mean of 8 pieces (range, 2-25 pieces) of necrosis removed in a mean procedure time of 59 min (range, 15-120 min). In addition, the device has been used to remove blood clots (n = 6), to clear insufficiency cavities before endoluminal vacuum therapy (n = 5), and to remove foreign bodies from the upper gastrointestinal tract (n = 8). In these cases, the technical success rate was 100%. No moderate or severe/fatal complications were reported in any of the 56 procedures. CONCLUSION: These first multicenter data demonstrate that the over-the-scope-grasper is a promising device for endoscopic pancreatic necrosectomy, which is also appropriate for removing foreign bodies and blood clots, or cleaning insufficiency cavities prior to endoluminal vacuum therapy.