Navigating the learning landscape: comprehensive training in third space endoscopy - training, techniques, and practical recommendations

Third space endoscopy (TSE), including ESD, POEM, or STER are advanced procedures requiring precise endoscopic control and tissue recognition. Despite its increasing adoption, evidence-based curricula, and standardized training protocols for TSE are lacking. This review explores training methods, cognitive skills, and technical proficiency requirements for endoscopists performing TSE, with a primary emphasis on POEM. Generally, it seems wise to recommend a step-up approach to TSE training, starting with ex-vivo models or POEM simulators; mechanical and virtual reality (VR) simulators are commonly used during early training. Preclinical training involving ex-vivo and live animal models is suggested to prepare trainees for safe and effective procedures. Studies suggest varying numbers of procedures for training, with approximately 20–40 cases needed before a first plateau is achieved in terms of complications and speed. The duration of on-patient clinical training varies depending on prior experience. Mentorship programs, workshops, and case discussions may facilitate dynamic knowledge transfer. In addition, adverse event management is a crucial aspect of any TSE training program. Existing evidence supports the use of preclinical models and emphasizes the importance of specialized training programs for TSE in alignment with our proposed step-up training approach. This review outlines practical recommendations for the theoretical knowledge and technical skills required before commencing TSE training, covering clinical understanding, diagnostic and outcome assessment, procedural requirements, and the role of mentorship programs

Role of artificial intelligence in diagnosing Barrett’s esophagus-related neoplasia

Barrett’s esophagus is associated with an increased risk of adenocarcinoma. Thorough screening during endoscopic surveillance is crucial to improve patient prognosis. Detecting and characterizing dysplastic or neoplastic Barrett’s esophagus during routine endoscopy are challenging, even for expert endoscopists. Artificial intelligence-based clinical decision support systems have been developed to provide additional assistance to physicians performing diagnostic and therapeutic gastrointestinal endoscopy. In this article, we review the current role of artificial intelligence in the management of Barrett’s esophagus and elaborate on potential artificial intelligence in the future

Artificial intelligence in the management of barrett’s esophagus and early esophageal adenocarcinoma

Esophageal adenocarcinoma is increasing in incidence and is the most common subtype of esophageal cancer in Western societies. The stepwise progression of Barrett´s metaplasia to high-grade dysplasia and invasive adenocarcinoma provides an opportunity for screening and surveillance. There are important unresolved issues, which include (i) refining the definition of the screening population in order to avoid unnecessary invasive diagnostics, (ii) a more precise prediction of the (very heterogeneous) individual progression risk from metaplasia to invasive cancer in order to better tailor surveillance recommendations, (iii) improvement of the quality of endoscopy in order to reduce the high miss rate for early neoplastic lesions, and (iv) support for the diagnosis of tumor infiltration depth in order to guide treatment decisions. Artificial intelligence (AI) systems might be useful as a support to better solve the above-mentioned issues

Endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma: long-term follow-up in a Western center

Background/Aims Endoscopic submucosal dissection (ESD) has been established as a treatment modality for superficial esophageal squamous cell carcinoma (ESCC). Long-term follow-up data are lacking in Western countries. The aim of this study was to analyze long-term survival in a Western center. Methods Patients undergoing ESD for ESCC were included. The analysis was performed retrospectively using a prospectively collected database. Results R0 resection rate was 96.7% (59/61 lesions in 58 patients). Twenty-seven patients (46.6%) fulfilled the curative resection criteria (M1/M2) (group A), 11 patients (19.0%) had M3 lesions without lymphovascular invasion (LVI) (group B), and 20 patients (34.5%) had lesions with submucosal invasion or LVI (group C). Additional treatment was recommended after non-curative resection. It was not performed in 20/31 patients (64.5%), mainly because of comorbidities (75%). Twenty-nine out of 58 (50.0%) patients died during a mean follow-up of 3.7 years. Death was related to ESCC in 17.2% (5/29) of patients. The disease-specific survival rate after curative resection was 100%. Overall survival rates after 5 years were 61.5%, 63.6% and 28.1% for groups A, B, and C, respectively. The overall survival was significantly worse after non-curative resection (p=0.038). Conclusions Non-curative resection is frequent after ESD for ESCC in Western patients. The long-term prognosis is limited and mainly determined by comorbidity. Early diagnosis and pre-interventional assessments need to be improved

Evaluation of the ESGE recommendations for COVID-19 pre-endoscopy risk-stratification in a high-volume center in Germany

Background and study aims The European Society of Gastrointestinal Endoscopy (ESGE) has defined COVID-19 infection prevention and control strategies within the endoscopy unit. These include pre-endoscopic questionnaire-based risk-stratification as well as pre-procedure viral testing. Real-life data on the effectiveness of these measures are presented here. Patients and methods Data from the outpatient endoscopic unit of the University Hospital Augsburg between July 1, 2020 and December 31, 2020 including the second pandemic wave were reviewed retrospectively. All patients were assessed with a pre-endoscopic risk-stratification questionnaire as well as viral testing using an antigen point-of-care test (Ag-POCT) in conjunction with a standard polymerase chain reaction (PCR) test. Highly elective procedures were postponed. The theoretically expected number of SARS-CoV-2-positive patients was simulated and compared with the actual number. In addition, endoscopy staff was evaluated with a rapid antibody test to determine the number of infections among the personnel. Results In total, 1029 procedures, 591 questionnaires, 591 Ag-POCTs, and 529 standard PCR tests were performed in 591 patients. 247 procedures in 142 patients were postponed. One Ag-POCT was positive but with a negative PCR test, while one PCR test was positive but with a negative Ag-POCT. This was lower than the theoretically expected number of COVID-19-positive patients (n = 15). One of 43 employees (2.3 %) in the outpatient endoscopy unit was seropositive. Conclusions Pre-endoscopic risk management including questionnaire-based risk stratification and viral testing seems to be an effective tool in combination with personal protective equipment for SARS-CoV-2 infection prevention and control within the endoscopy unit even in a high-prevalence setting