Introduction

Computer-aided detection (CADe) systems have gained attention for their use in colonoscopy, with growing evidence of increased adenoma detection rates (ADR). However, results remain inconsistent, and debate regarding their usefulness continues, including their impact on serrated lesion (SL) detection and performance across varying levels of endoscopist expertise. Given that CADe is used as a real-time assistive tool, it is crucial to confirm its efficacy in lesion detection before considering long-term outcomes.

Aims & Methods

We conducted a multinational, multicenter randomized controlled trial in the Asia-Pacific (Project CAD/NCCH2217; jRCT1032230396) to assess the efficacy of CADe in improving lesion detection during colonoscopy performed as part of colorectal cancer (CRC) screening [1]. We enrolled asymptomatic individuals aged 50–79 years undergoing either primary screening colonoscopy or colonoscopy following a positive fecal immunochemical test (FIT), who had not received colonoscopy in the past 5 years. Participants were randomly assigned (1:1) to the CADe group (colonoscopy with CADe assistance) or the standard group (colonoscopy without CADe) using a minimization method to balance age, sex, colonoscopy indication, endoscopist experience, and country/region. In the CADe group, approved CADe devices were used in accordance with each country's regulations, including EndoBRAIN-EYE, ENDO-AID, CAD EYE, and WISE VISION. All procedures were performed by endoscopists with experience of ≥500 colonoscopies. The primary endpoint was adenoma detection rate (ADR). Secondary endpoints included adenomas per colonoscopy (APC), advanced ADR (AADR), sessile serrated lesion detection rate (SSLDR), sessile serrated lesions per colonoscopy (SSLPC), scope withdrawal time, and the resection rate of non-neoplastic lesions. Planned sample size was 1400 cases (one-sided α = 0.05, 80% power).

Results

Of the 1,399 participants enrolled between December 28, 2023, and March 6, 2025, 1,373 were included in the full analysis set (688 and 685 in the CADe and standard groups, respectively). In both groups, the proportions of primary screening and post-FIT colonoscopies were 75% and 25%, respectively. No differences were observed between the CADe and standard groups in ADR (54.7% vs. 53.9%; odds ratio [OR] 1.04; 95% confidence interval [CI], 0.83–1.30, one-sided p=0.38), APC (1.17 vs. 1.24; risk ratio [RR], 0.94; 95% CI, 0.81–1.09), or AADR (5.5% vs. 7.6%; OR, 0.71; 95% CI, 0.46–1.10). The CADe group showed higher SSLDR (9.0% vs. 6.0%; OR, 1.55; 95% CI, 1.03–2.33) and SSLPC (0.11 vs. 0.07; RR, 1.65; 95% CI, 1.09–2.50). Subgroup analysis based on endoscopist experience demonstrated a higher SSLDR in the CADe group among those with 500–4,999 (10.1% vs. 5.4%) and 5,000–9,999 (11.9% vs. 3.6%) prior colonoscopies, but not among those with experience of ≥10,000 procedures (7.0% vs. 7.5%). There was no difference between groups in the non-neoplastic lesion resection rate (14.7% vs. 13.4%; OR, 1.11; 95% CI, 0.82–1.50), and the median scope withdrawal time in cases without polypectomy was 9 minutes in both groups.

Conclusion

CADe assistance did not improve adenoma detection where high ADR was already achieved with standard colonoscopy. Nevertheless, it enhanced SSL detection, except among highly experienced endoscopists, without prolonging withdrawal time or increasing unnecessary polypectomies. While our findings do not overstate the efficacy of CADe, they support a reasonable and practical role for its use in improving colonoscopy quality in CRC screening.

References

1. Sekiguchi M, et al. Protocol for a multicenter randomized controlled trial to assess the usefulness of computer-aided detection systems for colonoscopy in colorectal cancer screening in the Asia-Pacific region (project CAD/NCCH2217). Jpn J Clin Oncol. 2025; 55: 837-40.

Disclosure

The authors have no conflict of interest related with this study.

Introduction

Post-procedural pancreatitis (PPP) is the most common adverse event associated with endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) using a lumen-apposing metal stent is emerging as a promising approach for managing malignant distal biliary obstruction (MDBO), offering the potential to lower the risk of PPP. We compared the outcomes of EUS-CDS with ERCP when used as the primary modality for biliary decompression.

Aims & Methods

This was a multicenter randomized controlled study, enrolling consecutive patients admitted for obstructive jaundice due to malignant distal biliary obstruction with dilated common bile duct (CBD>15mm). Patients were randomly allocated to receive EUS-CDS or ERCP for primary biliary drainage. This was a superiority trial with post-procedural acute pancreatitis (abdominal pain, elevation in pancreatic enzymes, and hospitalisation) as primary outcome. Other outcomes included technical success, clinical success, adverse events, 6-months stent patency rate, and overall survival. Analyses were performed according to intention-totreat principles.

Results

Between April 2021 and October 2023, 220 patients were enrolled in the study (EUS-CDS group: 111; ERCP group: 109). EUS-CDS group showed a lower risk for post-procedural acute pancreatitis (1.8% in EUS-CDS group vs 7.3% in ERCP group; RR: 0.25, 95%CI 0.07-0.88). Technical success was achieved in 94.6% in EUS-CDS group vs 78.9% ERCP group (p value: <0.001), in a mean procedural time of 13.5+11.6 minutes, and 24.7+14.9 minutes, respectively (p value: <0.001). No differences were found in other adverse events, clinical success, stent patency, or overall mortality

Conclusion

EUS-CDS is superior to ERCP in reducing post-procedural acute pancreatitis risk, without significantly affecting the overall risk of adverse events. Additionally EUS-CDS showed improved technical success, and comparable clinical efficacy. These results support the use of EUS-CDS as the potential preferred primary approach in patients with dilated CBD (NCT04099862).

Introduction

Endoscopic Submucosal Dissection (ESD) is the best endoscopic technique that enables en bloc resection of superficial colorectal neoplasms.Despite its effectiveness, ESD is not very widespread in Western countries due to technical complexity, long procedure times, and a steep learning curve. These barriers have created a significant gap in adoption and outcomes between Eastern and Western centers. Underwater ESD (U-ESD) has been introduced to simplify the procedure. This study aimed to evaluate the effectiveness of U-ESD versus conventional gas-based ESD (G-ESD) in a Western center, focusing on procedural efficiency and safety.

Aims & Methods

This is a single-center, prospective randomized controlled trial conducted at Fondazione Campus Bio-Medico in Rome between December 2024 and April 2025.Forty patients with non-pedunculated colorectal lesions were randomly assigned in a 1:1 ratio to undergo either Underwater ESD (U-ESD) or conventional ESD with insufflation of Carbon Dioxide (CO2) (G-ESD).The primary outcome was total procedure time. Secondary outcomes included dissection speed, en bloc and R0 resection rates, use of hemostatic forceps, and the incidence of adverse events such as delayed bleeding, perforation, and post-ESD coagulation syndrome (PECS).

Results

A total of 40 patients referred to our endoscopic unit for ESD between December 2024 and April 2025. The mean size of the colorectal lesions was 57.4 mm and 40.7 mm in the U-ESD and G-ESD groups. The location of the lesions was in the rectum in 15% and 55% of the U-ESD and C-ESD groups, respectively; in the right side of the colon in 35% and 20% of the U-ESD and G-ESD groups, respectively. The morphology of LST was classified as LST-nongranular in 20 % and 25% of the U-ESD and G-ESD groups, respectively; as LST granular in 60% and 35% of the U-ESD and G-ESD groups, respectively. Fibrosis (grade 1 and 2) was present in 45% and 30% of the U-ESD and G-ESD groups, respectively. The mean total procedure time was shorter in the U-ESD group compared with the G-ESD group (53.3 ±33 minutes vs 78.7 ± 25.6 minutes; mean difference,–25.4 minutes; P=0.009).Mean dissection speed was faster in the U-ESD group compared with the G-ESD group (42 ± 26.3 mm2/min vs 13.3 ± 8 mm2/min; mean difference, 28.7 mm2/min; P= 0.001). En bloc and R0 resection rates in both groups were 100%. The use of a hemostatic forceps was significantly lower in U-ESD compared G-ESD (40% vs 90%, P= 0.001). Delayed bleeding occurred in only one patient in G-ESD group and was managed successfully by endoscopic clipping. No perforations occurred in either group. PECS was noted in only one patient in the G-ESD group.

Conclusion

UESD has shown a significantly shorter procedure time and faster dissection speed compared with GESD. These both empower the possibility of considering U-ESD as the preferred colorectal ESD method for colorectal lesions.