Long-term outcomes of EUS-guided balloon-occluded gastrojejunostomy bypass for malignant gastric outlet obstruction (with video).
Gastrointestinal endoscopy
BACKGROUND AND AIMS:EUS-guided gastroenterostomy (EUS-GE) is a minimally invasive technique for gastric outlet obstruction (GOO). EUS-guided balloon-occluded gastrojejunostomy bypass (EPASS) aims to improve stent deployment and minimize migration in EUS-GE. In this study, we evaluated the long-term outcomes of EPASS. METHODS:We retrospectively analyzed 37 patients (mean age, 71 years; 21 men) with symptomatic, nonrefractory GOO who had undergone EPASS. RESULTS:EPASS achieved a 94.6% technical success rate (35/37), including 2 cases of stent misdeployment. The mean procedure time was 27.3 minutes, with a double-balloon tube insertion time of 10.4 minutes. Initial GOO scores improved from .43 to 2.14 and 2.60 at 7 and 28 days after EPASS, respectively. The clinical success rate was 89.2%. The rate of adverse events, including fever and abdominal pain, was 16.2%. The mean overall survival after EPASS was 193.5 days, with no stent occlusion or migration (100% patency). CONCLUSIONS:EPASS demonstrated safety and reliability in EUS-GE, offering a viable option for symptomatic malignant GOO treatment. (Clinical trial registration number: UMIN000011608.).
10.1016/j.gie.2024.07.006
Efficacy of cold piecemeal EMR of medium to large adenomas compared with sessile serrated lesions.
Gastrointestinal endoscopy
BACKGROUND AND AIMS:There is growing evidence for the role of cold piecemeal EMR (C-EMR) in the treatment of colorectal lesions ≥10 mm. However, it is unclear if C-EMR is equally efficacious for all histologic subtypes and sizes. This retrospective study compares the efficacy and safety of C-EMR in the resection of medium (10-19 mm) and large (≥20 mm) serrated and adenomatous lesions. METHODS:A retrospective analysis was performed of Paris IIa colonic lesions resected by using a C-EMR technique over a 3.5-year period at our center. RESULTS:C-EMR was performed for 242 lesions in 151 patients. Lesion size ranged between 10 and 50 mm, with a median size of 20 mm. Ninety-five polyps were adenomatous, with 147 sessile serrated lesions (SSLs). At 6-month surveillance colonoscopy, the combined recurrence rate was 6.2%. Adenomas ≥20 mm showed a higher rate of recurrence (16.1%) compared with large SSLs (4.1%), medium adenomas (3.0%), and medium SSLs (1.4%). There were no adverse events reported after C-EMR. CONCLUSIONS:C-EMR seems to be less effective for the resection of large adenomas compared with medium adenomas or large SSLs. C-EMR is equally safe for all lesion sizes and histology.
10.1016/j.gie.2024.08.008
Colonoscopy quality measures and adherence to follow-up guidelines among endoscopists participating in a U.S. endoscopy registry.
Gastrointestinal endoscopy
BACKGROUND AND AIMS:Colonoscopy screening can substantially reduce colorectal cancer incidence and mortality. Colonoscopies may achieve maximum benefit when they are performed with high quality and accompanied by follow-up recommendations that adhere to clinical guidelines. This study aimed to determine to what extent endoscopists met targets for colonoscopy quality from 2016 through 2019 (the most recent years before the COVID-19 pandemic). METHODS:We examined measures of colonoscopy quality and recommended follow-up intervals in the GI Quality Improvement Consortium, a large nationwide endoscopy registry. The analysis included >2.5 million outpatient screening colonoscopies in average-risk adults aged 50 to 75 years. RESULTS:At least 90% of endoscopists met performance targets for adequate bowel preparation, cecal intubation rate, and adenoma detection rate. However, nonadherence to guidelines for follow-up intervals was common. For patients with no colonoscopy findings, 12.0% received a follow-up interval recommendation of ≤5 years instead of the guideline-recommended 10 years. For patients with 1 to 2 small tubular adenomas, 13.5% received a follow-up interval recommendation of ≤3 years instead of the guideline-recommended 5 to 10 years. For patients with small sessile serrated polyps, 30.7% received a follow-up interval recommendation of ≤3 years instead of the guideline-recommended 5 years. Some patients with higher risk findings received a follow-up interval recommendation of ≥5 years instead of the guideline-recommended 3 years, including 18.2% of patients with advanced serrated lesions. CONCLUSIONS:Additional attention may be needed to achieve more consistent adherence to guidelines for colonoscopy follow-up recommendations.
10.1016/j.gie.2024.07.027
Adenoma detection rate and tolerability of 2 ultra-low-volume bowel preparations in screening: a noninferiority randomized controlled trial.
Gastrointestinal endoscopy
BACKGROUND AND AIMS:The adenoma detection rate (ADR), recognized as a surrogate marker for colorectal cancer (CRC) incidence and mortality reduction, is closely linked to the efficacy of bowel cleansing. However, there is a dearth of evidence examining the impact on ADR when using 2 distinct very-low-dose bowel cleansing products. This study sought to compare ADR in an immunochemical fecal occult blood test (iFOBT)-based organized screening program by using 1 L of polyethylene glycol plus ascorbate (1L-PEGA) versus sodium picosulfate with magnesium citrate (SPMC), both administered in a split-dose regimen. METHODS:We conducted a comparative, parallel, randomized, noninferiority, and low-intervention clinical trial targeting individuals from a population CRC screening program aged 50 to 69 years with a positive iFOBT result scheduled for a workup colonoscopy in the morning. Participants were randomized to either 1L-PEGA or SPMC for bowel cleansing. The main outcome was ADR, whereas secondary outcomes were bowel preparation quality, safety, tolerability, and satisfaction. RESULTS:A total of 1002 subjects, 501 were included in each group. There were no differences between groups with respect to pooled ADR (SPMC, 56.5% [95% CI, 52.1-60.8]; 1L-PEGA, 53.7% [95% CI, 49.3-58.0]; relative risk, .95 [95% CI, .85-1.06]); therefore, SPMC demonstrated noninferiority in ADR compared with 1L-PEGA (difference, 2.8%; 2-sided 95% lower confidence limit, -3.4). In addition, there were no significant differences in mean lesions regardless of size and location between arms. Bowel preparation favored 1L-PEGA (96.2% vs 89.2%, P < .001), whereas SPMC exhibited significantly higher safety and tolerability, as shown by fewer nonserious treatment-emergent adverse events. CONCLUSIONS:SPMC emerged as a noninferior laxative compared with 1L-PEGA concerning ADR. Despite the superior bowel preparation quality associated with 1L-PEGA, the safety, tolerability, and overall satisfaction of participants were higher with SPMC. (Clinical trial registration number: EudraCT: 2019-003186-18.).
10.1016/j.gie.2024.07.007
Prospective, randomized controlled study evaluating a double-balloon interventional endoscopic platform for colorectal endoscopic submucosal dissection (with video).
Gastrointestinal endoscopy
BACKGROUNDS AND AIMS:Endoscopic submucosal dissection (ESD) can be challenging and time-consuming. A double-balloon interventional platform (DBIP) was designed to assist with navigation, stabilization, traction, and device delivery during complex colorectal polypectomy. We compared traditional ESD (T-ESD) with DBIP-assisted ESD (DBIP-ESD) in a prospective, randomized trial. METHODS:Patients with colorectal polyps ≥2 cm were randomly assigned (1:1) to DBIP-ESD or T-ESD. The primary study endpoint was the mean total procedure time difference between groups. Secondary endpoints were intraprocedural time points, en bloc resection rate, procedure cost, adverse events, and 3-month assessment. A sample size of 200 subjects for ≥80% power was calculated. Interim analysis for early study termination was planned at 70% enrollment if the primary endpoint was met (P ≤ .05). RESULTS:One hundred forty-seven patients were enrolled between February 2019 and February 2020. Seven patients dropped out, and the interim analysis was performed on 140 patients (71 DBIP-ESD, 69 T-ESD). Demographics, comorbidities, and lesion size, location, and classification were similar between groups. The mean procedure time decreased with DBIP-ESD (88.6 ± 42.7 minutes) versus T-ESD (139.5 ± 83.2 minutes; difference of ∼51 minutes [36.5%]; P < .001], with procedural savings of $610.16 (11.4%) per patient after DBIP cost. The DBIP increased dissection speed by 49.0% (15.1 ± 8.0 vs 7.7 ± 6.6 cm/h, P < .001). En bloc resection was superior with the addition of DBIP (97.2% vs 87.0%, P = .030). The mean navigation time with DBIP-ESD for sutured defect closure decreased by 7.7 minutes (P < .001). There were no adverse events in the DBIP-ESD group. CONCLUSIONS:DBIP-ESD decreased the total procedure time, improved the en bloc resection rate, and facilitated sutured defect closure, making DBIP a promising and cost-effective tool to improve colorectal ESD adoption. (Clinical trial registration number: NCT03846609.).
10.1016/j.gie.2024.07.001
Contaminated duodenoscopes in ERCP: sensitivity of detection and risk of underdetection.
Gastrointestinal endoscopy
BACKGROUND AND AIMS:Periodic duodenoscope cultures are essential to timely detect contamination, but their sensitivity remains unknown. This study aims to determine the sensitivity of duodenoscope cultures and to estimate the prevalence of contaminated duodenoscope use. METHODS:We combined duodenoscope microbiologic surveillance data from March 2015 to June 2022 with usage data to evaluate patient exposure to duodenoscopes contaminated with microorganisms of gut or oral origin (MGO). We identified duodenoscopes with repeated species-level contamination within a year and used molecular typing to confirm genetic relatedness. Genetically related microorganisms over multiple duodenoscope cultures of a single duodenoscope indicated a period of sustained contamination, and a cluster was defined as overlapping periods of sustained contamination between different duodenoscopes. If microorganisms were not available for molecular analysis, we marked the period as unconfirmed. A sample was defined as false negative if it did not show the target microorganism(s) in a period of sustained contamination. We used 3 scenarios to hypothesize about contaminated use and culture sensitivity. RESULTS:We included 556 duodenoscope cultures with 185 (33.3%) contaminated with MGO. The total usage of duodenoscopes was 5226. We identified 1 period of sustained contamination, 6 unconfirmed periods, and 2 clusters. Depending on our scenario assumptions, the percentage of contaminated use varied from 12.3% to 23.7% and culture sensitivity ranged from 82.2% to 98.9%. CONCLUSIONS:Limited sensitivity of duodenoscope cultures leads to improper clearance of duodenoscopes for clinical use, increasing risks of outbreaks. The applicability of a single culture to end a duodenoscope's quarantine should be re-evaluated.
10.1016/j.gie.2024.08.004
Development and validation of a machine learning-based, point-of-care risk calculator for post-ERCP pancreatitis and prophylaxis selection.
Gastrointestinal endoscopy
BACKGROUND AND AIMS:A robust model of post-ERCP pancreatitis (PEP) risk is not currently available. We aimed to develop a machine learning-based tool for PEP risk prediction to aid in clinical decision making related to periprocedural prophylaxis selection and postprocedural monitoring. METHODS:Feature selection, model training, and validation were performed using patient-level data from 12 randomized controlled trials. A gradient-boosted machine (GBM) model was trained to estimate PEP risk, and the performance of the resulting model was evaluated using the area under the receiver operating curve (AUC) with 5-fold cross-validation. A web-based clinical decision-making tool was created, and a prospective pilot study was performed using data from ERCPs performed at the Johns Hopkins Hospital over a 1-month period. RESULTS:A total of 7389 patients were included in the GBM with an 8.6% rate of PEP. The model was trained on 20 PEP risk factors and 5 prophylactic interventions (rectal nonsteroidal anti-inflammatory drugs [NSAIDs], aggressive hydration, combined rectal NSAIDs and aggressive hydration, pancreatic duct stenting, and combined rectal NSAIDs and pancreatic duct stenting). The resulting GBM model had an AUC of 0.70 (65% specificity, 65% sensitivity, 95% negative predictive value, and 15% positive predictive value). A total of 135 patients were included in the prospective pilot study, resulting in an AUC of 0.74. CONCLUSIONS:This study demonstrates the feasibility and utility of a novel machine learning-based PEP risk estimation tool with high negative predictive value to aid in prophylaxis selection and identify patients at low risk who may not require extended postprocedure monitoring.
10.1016/j.gie.2024.08.009
Management and outcomes of antithrombotic therapy in EUS-guided gallbladder drainage.
Gastrointestinal endoscopy
BACKGROUND AND AIMS:EUS-guided gallbladder drainage (EUS-GBD) is increasingly used for the management of gallbladder disease in patients at high risk for cholecystectomy. These patients often have underlying medical comorbidities requiring anticoagulation and/or antiplatelet therapy. We evaluated the safety, management, and outcomes of EUS-GBD in patients being treated with antithrombotic therapy (ATT). METHODS:We performed a retrospective study of patients undergoing EUS-GBD between 2018 and 2023 within Geisinger Health System. Outcomes were analyzed between patients previously on ATT but held for the procedure compared with no ATT. Primary outcomes were bleeding within 48 hours and 30 days. Secondary outcomes were risk of thrombotic events, length of stay, and 30-day mortality. RESULTS:Of 177 patients undergoing EUS-GBD, 118 patients were on ATT. No statistical difference was found for EUS-GBD-related bleeding for patients on ATT compared with no ATT within 48 hours (.9% vs 0%, P > .999) or within 30 days (3.5% vs 0%, P = .302). Overall, 5 patients (2.9%) had bleeding related to the EUS-GBD procedure. There was no difference between the groups for secondary outcomes: thrombotic events (2.5% vs 3.4%), length of stay (7 days vs 5 days), and 30-day mortality (11% vs 10.2%). CONCLUSIONS:Patients undergoing EUS-GBD who require ATT did not have any immediate or delayed increased risk of bleeding, thrombotic events, length of stay, or mortality when the medication was appropriately held.
10.1016/j.gie.2024.08.003
EUS-guided hepaticojejunostomy in patients with history of total gastrectomy: a multicenter retrospective feasibility study (with video).
Gastrointestinal endoscopy
BACKGROUND AND AIMS:EUS-guided hepaticogastrostomy (EUS-HGS) is an effective biliary drainage technique for patients with altered anatomy or duodenal strictures. EUS-guided hepaticojejunostomy (EUS-HJS) can be used to create a fistula between the left hepatic duct and the jejunum in patients with a history of total gastrectomy. No specific data on this technique have been published. The aim of this study was to assess the feasibility and safety of EUS-HJS in patients with a history of total gastrectomy. METHODS:This retrospective multicenter study included all adult patients who underwent EUS-HJS at 3 tertiary French centers and 1 tertiary Swiss center between May 2011 and February 2023. The primary outcome was clinical success, which was defined as the disappearance of pruritus, jaundice, and/or cholangitis. An improvement in bilirubin >30% within the first week and/or bilirubin normalization within 1 month after the procedure were also considered indicators of clinical success. Secondary outcomes were technical success, rate of adverse events, need for endoscopic revision, possibility of resuming anticancer treatment, median survival, and technical differences compared with EUS-HGS. RESULTS:Twenty-one patients with history of complete gastrectomy who underwent EUS-HJS were included. Technical success was achieved in 100% of patients (95% confidence interval [CI], 85-100). Clinical success was achieved in 80% of patients (95% CI, 58-92). The incidence of recorded adverse events was 33% (95% CI, 17-55), with cholangitis being the most frequent adverse event. Seven patients (39%) were able to benefit from anticancer treatment after the procedure. Median survival time was 6 months (interquartile range, 1.5-12). CONCLUSIONS:EUS-HJS is an effective and feasible procedure for patients whose anatomy has been altered by total gastrectomy.
10.1016/j.gie.2024.07.011
Prospective, single-arm multicenter, international, observational postmarket study to assess the safety and efficacy of a triangulation platform for treating patients requiring endoscopic gastroplasty.
Gastrointestinal endoscopy
BACKGROUND AND AIMS:Gastric restriction techniques have recently emerged as minimally invasive bariatric procedures. Endoscopic sutured gastroplasty (ESG) with the Endomina (Endo Tools Therapeutics, Gosselies, Belgium) triangulation platform proved to be safe and effective for the treatment of class I and II obesity in prospective studies. In this registry, we aimed to further assess on a larger scale the safety and efficacy of the procedure in routine practice with a dedicated device. METHODS:This was a multicenter, observational, prospective post-market study including patients with obesity undergoing Endomina ESG. The primary safety outcome was the occurrence of serious adverse device effects (SADEs) at 12 months. The primary efficacy outcome was the technical success defined by completing the procedure without premature abortion owing to technical issues. The rates of procedure-related adverse events, weight loss outcomes, and quality of life changes were collected. RESULTS:A total of 142 patients underwent ESG in 3 centers from July 2020 to March 2023. Of these, 67 (mean body mass index, 38.5 ± 6.3 kg/m) reached at least 12 months of follow-up up to October 2022. Technical success was 100%. No SADEs occurred. Seven mild procedure-related adverse events were reported overall. Mean percentage of excess weight loss and total body weight loss at 12 months' follow-up were 48.5% ± 38.6 and 15.3% ± 10.6, respectively (n = 67). Improved quality of life was observed following ESG. CONCLUSIONS:ESG is safe and effective, thus offering a satisfactory therapeutic option for a wide range of obese patients on a large scale.
10.1016/j.gie.2024.06.041
Comparison of flexible endoscopic needle-knife septotomy and peroral endoscopic myotomy for treatment of Zenker's diverticulum.
Gastrointestinal endoscopy
BACKGROUND AND AIMS:Treatment of Zenker's diverticulum (ZD) has evolved from flexible endoscopic septotomy (FES) to peroral endoscopic myotomy for ZD (Z-POEM). In this study, we compare the efficacy and safety of flexible endoscopic needle-knife septotomy (FENKS) and Z-POEM for symptomatic ZD. METHODS:Consecutive patients at a single institution who underwent endoscopic ZD treatment by FENKS or Z-POEM were identified. Demographics, clinical characteristics, procedure technique, technical and clinical success, and adverse events (AEs) within 30 days were reviewed and compared between the 2 groups. AEs were classified by the AGREE classification. Baseline and postprocedure Dakkak and Bennett (DB) scores were reported at 6, 12, and 24 months. Clinical success (DB score ≤1) was assessed by per-protocol (PP) and intention-to-treat analyses (ITT). RESULTS:Sixty patients (55% men; mean age, 72 ± 12 years) underwent FENKS (n = 21) or Z-POEM (n = 39) between 2016 and 2023. Baseline clinical characteristics were similar, and overall technical success was 98.3%. Clinical success by PP and ITT analyses at 6, 12, and 24 months after each intervention were similar between both groups. The FENKS group had a higher prevalence (29% vs 5%, P = .018) and severity (P = .032) of AEs and were more likely to be hospitalized after treatment (71% vs 33%, P = .007). During a median follow-up of 18 months, reintervention was required for 5 cases (10%), 2 (9%) in the FENKS and 3 (7.6%) in the Z-POEM group (P = 1.0) a mean 7.6 ± 4.4 months after initial therapy. CONCLUSIONS:Treatment of ZD with Z-POEM appears to be safer than FENKS with similar short and midterm clinical success.
10.1016/j.gie.2024.08.035
Use of artificial intelligence improves colonoscopy performance in adenoma detection: a systematic review and meta-analysis.
Gastrointestinal endoscopy
BACKGROUND AND AIMS:Artificial intelligence (AI) is increasingly used to improve adenoma detection during colonoscopy. This meta-analysis aimed to provide an updated evaluation of computer-aided detection (CADe) systems and their impact on key colonoscopy quality indicators. METHODS:We searched the EMBASE, PubMed, and MEDLINE databases from inception until February 15, 2024, for randomized control trials (RCTs) comparing the performance of CADe systems with routine unassisted colonoscopy in the detection of colorectal adenomas. RESULTS:Twenty-eight RCTs were selected for inclusion involving 23,861 participants. Random-effects meta-analysis demonstrated a 20% increase in adenoma detection rate (risk ratio [RR], 1.20; 95% confidence interval [CI], 1.14-1.27; P < .01) and 55% decrease in adenoma miss rate (RR, 0.45; 95% CI, 0.37-0.54; P < .01) with AI-assisted colonoscopy. Subgroup analyses involving only expert endoscopists demonstrated a similar effect size (RR, 1.19; 95% CI, 1.11-1.27; P < .001), with similar findings seen in analysis of differing CADe systems and healthcare settings. CADe use also significantly increased adenomas per colonoscopy (weighted mean difference, 0.21; 95% CI, 0.14-0.29; P < .01), primarily because of increased diminutive lesion detection, with no significant difference seen in detection of advanced adenomas. Sessile serrated lesion detection (RR, 1.10; 95% CI, 0.93-1.30; P = .27) and miss rates (RR, 0.44; 95% CI, 0.16-1.19; P = .11) were similar. There was an average 0.15-minute prolongation of withdrawal time with AI-assisted colonoscopy (weighted mean difference, 0.15; 95% CI, 0.04-0.25; P = .01) and a 39% increase in the rate of non-neoplastic resection (RR, 1.39; 95% CI, 1.23-1.57; P < .001). CONCLUSIONS:AI-assisted colonoscopy significantly improved adenoma detection but not sessile serrated lesion detection irrespective of endoscopist experience, system type, or healthcare setting.
10.1016/j.gie.2024.08.033
Efficacy and safety of gastric peroral endoscopic myotomy across different etiologies of gastroparesis: systematic review and meta-analysis.
Gastrointestinal endoscopy
BACKGROUND AND AIMS:Gastric peroral endoscopic myotomy (G-POEM) is an emerging treatment for refractory gastroparesis. Although its efficacy and safety have been analyzed in previous systematic reviews and meta-analyses, no studies have compared its effectiveness based on etiology. Our study aims to evaluate the efficacy and safety of G-POEM by etiologies of gastroparesis. METHODS:We conducted a comprehensive search in major databases until October 2023, focusing on the efficacy and safety of G-POEM by etiology. Our primary outcome was clinical success based on etiology, with an additional subgroup analysis on Gastroparesis Cardinal Symptom Index (GCSI) scores before and after G-POEM based on etiology using standard meta-analysis methods and the random-effects model. Heterogeneity was assessed using I statistics. RESULTS:In our analysis of 15 studies (7 retrospective, 8 prospective) involving 982 patients (mean patient age, 50.81 years; mean follow-up, 21 months), postsurgical conditions were the most common etiology in G-POEM (290 cases), followed by idiopathic factors (287 cases) and diabetes (286 cases). Subgroup analysis revealed pooled clinical success rates of 65% (95% confidence interval [CI], 51-77; I = 46%) for diabetes, 70% (95% CI, 46-86; I = 73%) for postsurgical conditions, and 60% (95% CI, 41-77; I = 68%) for idiopathic etiologies. Our research also indicated that G-POEM significantly improved GCSI scores: 1.7 (95% CI, -.01 to 3.5; P = .052) for diabetes, 1.34 (95% CI, -.07 to 2.62; P = .038) for postsurgical conditions, and 1.5 (95% CI, .36-2.75; P = .01) for idiopathic patients. CONCLUSIONS:Based on this meta-analysis, G-POEM is effective and safe for treating refractory gastroparesis irrespective of the etiology, with significant improvements in clinical success rates and GCSI scores.
10.1016/j.gie.2024.08.024
Tunneled or pocket creation method versus conventional endoscopic submucosal dissection for gastric lesions: a systematic review and meta-analysis.
Gastrointestinal endoscopy
BACKGROUND AND AIMS:Tunneled endoscopic submucosal dissection (T-ESD) and pocket creation-method ESD (PCM-ESD) are considered to have technical advantages over conventional ESD (C-ESD). However, data comparing these techniques for ESD of gastric lesions are limited. METHODS:PubMed and Cochrane databases were reviewed for relevant studies from their inceptions to October 31, 2023. Studies comparing T-ESD or PCM-ESD (T/PCM-ESD) with C-ESD for gastric lesions were included. The primary outcomes were dissection speed and en-bloc resection. Secondary outcomes were R0 resection, recurrence, perforation, and post-ESD bleeding. A random effects meta-analysis was conducted. RESULTS:Eight observational studies (359 patients with T/PCM-ESD, 670 patients with C-ESD) were included. T/PCM-ESD was associated with a significantly faster dissection speed (mean difference, 4.42 mm/min; 95% confidence interval [CI], 2.05-6.79; I = 79%). There were no significant differences between the groups in terms of en-bloc resection (risk ratio [RR], 1.01; 95% CI, 1.00-1.03; I = 0%), R0 resection (RR, 1.03; 95% CI, 0.99-1.07; I = 0%), and recurrence (RR, 0.73; 95% CI, 0.14-3.84; I = 0%). Although T/PCM-ESD was associated with a significantly lower risk of perforation (RR, 0.21; 95% CI, 0.06-0.80; I = 0%), post-ESD bleeding rates were not significantly different. CONCLUSIONS:T/PCM-ESD facilitates faster and safer gastric ESD than C-ESD, with similar en-bloc resection, R0 resection, and recurrence rates. A future randomized controlled control trial is required.
10.1016/j.gie.2024.06.034