Background Delayed bleeding (DB) after endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) remains a significant clinical problem. This study aimed to evaluate the safety and efficacy of a new gel hemostatic powder (GHP) for the prevention of DB in high-risk patients. Methods A prospective, multicentric, open-label study was conducted at seven Belgian hospitals from 2023 to 2024 in patients undergoing EMR or ESD for lesions over 20 mm with high risk of DB (either anticoagulant or P2Y12RA treated, or undergoing duodenal EMR). The Nexpowder GHP preventive spray was applied to the resected area at the end of the procedure. The primary outcome was the rate of DB within 4 weeks post-procedure. Secondary outcomes included safety, procedure duration, post-procedural pain, and incidence of adverse events. Results Fifty patients were enrolled in the study and treated with endoscopic resection followed by GHP application. The observed DB rate was 22% (11/50), higher than the literature-reported rate of 16%. The hypothesized reduction in DB below 5% was not achieved ( p = 0.2472). DB was most common in rectal ESD ( n = 3/5; 60%) and duodenal EMR ( n = 6/20; 30%). DB typically occurred within the first 10 days post-procedure (median onset 7d). On univariate analysis, the only factor associated with DB risk was lesion size ( p = 0.042). No adverse events related to the use of the GHP were reported. Conclusion In this prospective study, GHP demonstrated limited efficacy for the prevention of DB in high-risk patients, with a 22% observed DB rate. Lesion size and location were key predictors of DB.
Background and study aims Esophageal stricture is a common complication after extensive endoscopic submucosal dissection (ESD) for superficial esophageal cancer, requiring multiple interventions with substantial medical costs. Endoscopic conical cap dilatation is a novel, minimally invasive technique invented by Jinfeng Zhou, but its efficacy and safety compared to conventional endoscopic balloon dilatation remain unclear. Patients and methods We conducted a retrospective case-control study involving patients who developed esophageal strictures after ESD and underwent either endoscopic conical cap dilatation ( n = 32) or endoscopic balloon dilatation ( n = 64) between January 2020 and December 2024. The primary outcome was the stricture recurrence rate within 12 months. Secondary outcomes included technical success rate, number of dilatation sessions, procedure time, dysphagia improvement (Eckardt score), and complication rates. Results The endoscopic conical cap dilatation group had a significantly lower 12-month recurrence rate (22.6% vs. 56.7%, P = 0.002) and required fewer dilatation sessions (median 3 [2-4] vs. 5 [3-7], P < 0.001). Technical success rates were comparable (96.9% vs. 93.8%, P = 0.572). Procedure time was shorter in the endoscopic conical cap dilatation group (median 2 min [1-3] vs. 6 min [3-8], P < 0.001). Both groups showed significant Eckardt score improvement at 1 month ( P < 0.001), with no between-group difference ( P = 0.326). Complication rates were low (3.1% vs. 4.7%, P = 0.725), with no perforations in the endoscopic conical cap dilatation group. Conclusions This single-center retrospective cohort shows endoscopic conical cap dilatation yields promising preliminary results for post-ESD esophageal strictures, with lower recurrence, fewer sessions and shorter procedures and comparable safety versus balloon dilation. Further large randomized studies are required to confirm these findings.
Background and Study Aims Biliary obstruction caused by food is a little known and rarely reported long-term complication of endoscopic sphincterotomy (ES). This retrospective study aimed to characterize patients diagnosed with this condition between 2012 and 2025 and to assess the outcomes of surgical therapy. Patients and Methods Patients were selected who were diagnosed with symptomatic duodenobiliary reflux of food (DBR-F) after earlier ES and who all underwent hepaticojejunostomy with partial resection or ligation of the common bile duct (CBD). DBR-F was diagnosed by pathologic examination of material extracted from the CBD during episodes of biliary obstruction. Data were assessed retrospectively using the hospital electronic patient record system. Long-term outcomes and satisfaction with treatment were also evaluated using a questionnaire. Results We identified 12 patients who had undergone multiple ERCPs for "stone" or "sludge" removal (presurgery median 9, IQR 7.3-10) with microscopic proof of DBR-F. Patients presented with (episodic) abdominal pain, often associated with cholangitis. Liver abscesses were diagnosed in two cases. The median diagnostic delay was 3.3 years. Medical (antibiotics, ursodeoxycholic acid) and endoscopic (repeat sphincterotomy, stenting) treatment were ineffective. Surgical complications were observed in 4/12 (33%) patients. Long-term patient satisfaction after surgery was excellent in 9/10 evaluable patients. Conclusions This single-center series suggests that DBR-F is a long-term complication of ES that must be more prevalent than is suggested by anecdotal literature. This diagnosis should be considered when patients present with recurrent "stones" or "sludge" after previous ES. In selected patients with recurrent significant symptoms associated with DBR-F, surgical therapy is an effective option.
Background and Study Aims Esophagectomy is the standard treatment for superficial esophageal squamous cell carcinoma (ESCC) but carries substantial morbidity. Endoscopic submucosal dissection (ESD) followed by adjuvant chemoradiotherapy (CRT) is an organ-preserving alternative, but its oncologic efficacy in T1aM3 disease with lymphovascular invasion (LVI) and in T1b disease remains uncertain. We compared ESD+CRT with esophagectomy for these lesions. Patients and Methods Medline, Embase, and Google Scholar were searched through June 2024 (PROSPERO CRD42024593581). Primary endpoints were the risk differences (RDs) between esophagectomy and ESD+CRT for 3-year disease-free survival (3y-DFS), 3-year overall survival (OS-3y), and 5-year OS (OS-5y); the secondary endpoint was serious adverse events (SAEs). Cumulative DFS and OS were estimated by Kaplan-Meier analysis and compared with the log-rank test. Results Six retrospective studies (16 centers; 306 patients treated 2002-2021; ESD+CRT n = 170, esophagectomy n = 136) were included; mean follow-up was 49.8 and 53.1 months, respectively. Baseline age, LVI, and tumor depth were comparable. Three-year DFS was similar between groups (86.4% vs. 92.6%; RD 0.92, 95% CI 0.85-1.00), as was OS at 3 years (RD -0.02, 95% CI -0.08 to 0.45) and 5 years (RD -0.09, 95% CI -0.18 to 0.01). SAEs were significantly less frequent with ESD+CRT than with esophagectomy (RD 0.55, 95% CI 0.35-0.86; p = 0.009). Conclusions In selected superficial ESCC, ESD+CRT achieved DFS and OS comparable to esophagectomy while significantly reducing SAEs. These retrospective data support ESD+CRT as a viable organ-preserving option, particularly for patients at high surgical risk.
Background and Study Aims A papilla located on the left wall of a periampullary diverticulum creates a mechanically unfavourable axis for biliary cannulation that is not readily corrected from the conventional endoscopist position. We describe the Extreme Anticlockwise Bileduct Cannulation Diverticulum (ABCD) technique, where "Extreme" qualifies the degree of anticlockwise rotation applied-an endoscopist-repositioning manoeuvre designed to address this constraint without additional instrumentation. Patients and Methods Following observations in two index cases, the technique was adopted pre-emptively in consecutive patients with a confirmed left-wall periampullary papilla. Twenty-four patients were prospectively enrolled between July 2021 and February 2026. The endoscopist repositioned to the patient's head end and applied extreme anticlockwise duodenoscope rotation to realign the instrument axis. The primary outcome was successful biliary cannulation. Adverse events were graded using the Cotton consensus criteria. Results Successful biliary cannulation was achieved in 23/24 patients (95.8%), all within 5 min of adopting the repositioned stance. Primary guidewire cannulation was achieved in 20/24 (83.3%); the remaining three required needle-knife fistulotomy, performed from the same repositioned stance. Trainees were involved in 22 cases and cannulated independently in 16 (72.7%). Then, 3 of 24 patients (12.5%) experienced post-sphincterotomy bleeding, graded as AGREE Grade I. No post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis or other major complications were observed. Conclusions The Extreme ABCD technique is a simple, equipment-independent repositioning strategy for ERCP in left-wall periampullary diverticular anatomy. In this prospective series, it was associated with a high rate of biliary cannulation without rescue accessories and was feasible in a supervised training environment. Multicentre evaluation is warranted.
Purpose Percutaneous drainage is the standard nonsurgical treatment for liver abscess. Recent retrospective studies suggest that endoscopic ultrasound (EUS)-guided drainage may be an effective and safe alternative. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of EUS-guided drainage as a stand-alone approach and in comparison, with percutaneous drainage. Methods PubMed, EMBASE, and Cochrane databases were searched from inception through November 2025. The primary outcome was clinical success; secondary outcomes included technical success, total adverse events, and abscess relapse. Sensitivity analyses using a treatment-arm continuity correction were performed to address zero-event cells. Results Eleven studies were included (EUS, n = 186; percutaneous drainage, n = 325). In single-arm studies, pooled technical and clinical success rates with EUS were both 1.00 (95% CI, 0.95-1.00 and 0.99-1.00, respectively). Pooled total adverse event and relapse rates were 0.02 (95% CI, 0.00-0.12) and 0.00 (95% CI, 0.00-0.01), respectively. Comparative studies showed no significant differences between EUS and percutaneous drainage in technical success (RR 1.00, 95% CI, 0.83-1.19) or clinical success (RR 1.02, 95% CI, 0.86-1.22). EUS was associated with a significantly lower risk of total adverse events (RR 0.34, 95% CI, 0.15-0.76), while relapse rates were similar (RR 0.83, 95% CI, 0.30-2.33). Sensitivity analyses yielded consistent findings across all outcomes. Conclusion EUS-guided drainage is an effective and safe treatment for liver abscesses primarily involving the left hepatic and caudate lobes. Although EUS was associated with a lower risk for adverse events, larger comparative studies are needed to define its role in right lobe abscesses.
Background and aims Severe submucosal fibrosis presents a major challenge during endoscopic resection (ER) of large colorectal polyps, often precluding standard endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). This challenge is particularly relevant in elderly or comorbid patients when procedural safety is paramount. We describe the safety and efficacy of the novel Polyp Excision with Thermal Ablation and avuLsion (PETAL) technique, a staged hybrid approach combining wide-field EMR, thermal ablation, and avulsion. Methods This retrospective cohort study included consecutive patients undergoing PETAL for benign-appearing colorectal polyps ≥20 mm with severe fibrosis between January 2015 and December 2024. Primary outcomes included adverse events and recurrence at follow-up. Secondary outcomes included eradication rates and the need for surgery. Results Sixty-nine patients were included (median age, 71 years; 38% ASA III-IV; 20% on antithrombotics). The median lesion size was 50 mm, with 13.0% recurrent lesions. Delayed bleeding occurred in 2.9%, with no perforations or deep mural injuries. Follow-up data were available for 61 patients (88%), with median duration 40 months. Recurrence at first follow-up was 45.9%, but typically small and amenable to repeat endoscopic therapy. Cumulative eradication rates were 91.1% and 98.2% at the second and third follow-ups, respectively. One patient required surgery. Conclusions PETAL is a safe and effective strategy for large colorectal polyps with severe fibrosis, achieving high rates of eventual eradication despite frequent early recurrence. Its staged, low-risk profile makes it particularly suitable for elderly or comorbid patients and may represent an alternative to higher-risk techniques such as ESD and full-thickness resection.
Background and study aims: Clipping is a simple conventional closure technique for gastric endoscopic submucosal dissection (ESD) defects. This study evaluated the technical feasibility and stability of mucosal defect closure using a novel hooking-jaw clip. In addition, we assessed the safety outcomes compared with a non-closure group. Patients and methods: This single-center retrospective pilot study assessed technical success (complete closure, ≥ 90% area reduction) and closure stability during second-look endoscopy (SLE) on postoperative day 1 in 41 patients. We compared the secondary outcomes with a non-closure group using propensity score matching (PSM) (n = 41 per group). Secondary outcomes included incidences of delayed bleeding and frequency of hemostatic interventions during SLE. Results: Hooking-jaw clip-closure achieved technical success in 92.7% (38/41) of patients; partial closure (50%–89% area reduction) occurred in 7.3% (3/41), and no closure failure (<50%) occurred. The median closure time was 10.0 minutes. Closure remained stable in 87.8% (36/41) of patients at SLE. After PSM, the delayed bleeding rate was 0.0% (0/41) in the closure group and 4.9% (2/41) in the non-closure group (P = 0.494). The closure group required a lower rate of hemostatic interventions during SLE (24.4% [10/41] vs. 58.5% [24/41]; P = 0.003). Conclusions: Hooking-jaw clip-assisted closure of gastric ESD defects is technically feasible and maintains stability. Closing reduced the frequency of hemostatic interventions during SLE. Given current guidelines that conditionally recommend omitting routine SLE, stable closure provides a physical rationale to support this practice. Future trials should evaluate this strategy for high-risk populations.
Background and aims Gastrointestinal telangiectasias are a recognised manifestation of hereditary haemorrhagic telangiectasia (HHT), but data on their nature and distribution throughout the entire gastrointestinal tract are limited. We aimed to evaluate gastrointestinal disease manifestations using pan-enteric video capsule endoscopy (VCE) and to assess its applicability in a non-selected group of patients with HHT. Methods In this cross-sectional study, patients aged ≥50 years with confirmed HHT residing in the Region of Southern Denmark were invited to undergo pan-enteric VCE. Telangiectatic lesions were recorded according to anatomic location and lesion burden. Feasibility outcomes included patient acceptance, completion rate, mucosal visibility and transit times. Associations between active gastrointestinal bleeding and haemoglobin concentration were analysed using multivariable linear regression. Results Of 52 eligible patients, 28 underwent VCE. One examination was lost due to technical failure, leaving 27 recordings available for analysis. Telangiectatic lesions were identified in 96.3% of evaluable examinations and were predominantly located in the stomach (74%) and the proximal small bowel (81.5%). Active bleeding was observed in 14.8% of patients, only in the upper gastrointestinal tract, and was independently associated with lower haemoglobin concentrations (β -2.84 g/dL, 95% CI -4.69 to -1.00; p = 0.004). Seven examinations (25.9%) were incomplete, and colonic mucosal visibility was frequently suboptimal. No capsule retention or procedure-related complications occurred. Conclusion Pan-enteric VCE demonstrated widespread gastrointestinal involvement in HHT, predominantly in the proximal gastrointestinal tract. Although active bleeding was infrequent, it was associated with lower haemoglobin levels. Practical limitations suggest that the role of pan-enteric VCE in routine evaluation of HHT requires further clarification.
Background Workflow interruptions are common in procedural medicine and may increase cognitive load, stress, and the risk of errors. While interruptions and flow disruptions have been studied in surgical settings, little is known about workflow interruptions in endoscopic environments. Objective evaluation of workflow interruptions requires a reliable measurement tool. This study aimed to develop a structured observation tool for recording workflow interruptions during endoscopic procedures and to evaluate its interrater reliability. Methods A structured tally-based observation tool for recording workflow interruptions was developed in an iterative process, and interruptions were categorized into predefined domains. Three independent observers underwent structured training and calibration. A predefined subset of endoscopic procedures was observed simultaneously by two independent observers. Interrater reliability was assessed using intraclass correlation coefficients (ICC) and Bland–Altman analysis. Results A total of 35 procedures were scheduled for double observation, and 33 procedures were included in the final interrater reliability analysis. Interrater reliability for the total number of interruptions was excellent for both observer pairs (ICC 0.995 for A-B and 0.995 for A-C). Reliability across interruption domains ranged from good to excellent. Bland–Altman analysis demonstrated small mean differences with narrow limits of agreement and no relevant systematic bias. Conclusion This methodological study demonstrates that workflow interruptions during endoscopic procedures can be measured reliably using a structured tally-based observation tool. The instrument provides a standardized methodological framework for future studies investigating workflow processes and workflow-focused interventions in endoscopy.
Background and study aim Biliary plastic stents are widely used for biliary drainage but are prone to dysfunction and causing cholangitis. The aim of this study was to identify the risk factors for early post-ERCP cholangitis in patients with biliary plastic stents, assess clinical impact, and evaluate changes in bile composition associated with indwelling stents. Patients and methods We conducted a prospective, longitudinal observational study including consecutive patients with native papilla who underwent endoscopic retrograde cholangiopancreatography (ERCP) with biliary plastic stent placement at a tertiary referral center. Bile was aspirated at index ERCP prior to contrast injection and processed for microbiologic and chemical analysis. A follow-up procedure was scheduled at 3 months when we retrieved the stent for patency analysis and obtained a new bile sample. The primary outcome was early cholangitis after the index procedure (<3 months). Secondary outcomes included bile culture positivity, bile composition changes, stent occlusion degree, and cholangitis-related mortality. Multivariable binary logistic regression was used to identify independent predictors of early cholangitis, with results expressed as odds ratios (ORs) with 95% confidence intervals. Results A total of 159 patients were included, with malignant strictures accounting for 84.4% of indications. Complete follow-up was available for 136 patients, of whom 47 (34.6%) developed early cholangitis after a median of 32.5 days. On multivariable analysis, a positive bile culture at index ERCP was the only independent predictor of early cholangitis (OR 4.71, 95% CI 1.69-13.17). Degree of stent occlusion, stent characteristics, and bile duct obstruction severity were not associated with cholangitis. Seven deaths were directly attributable to cholangitis. Conclusions Early cholangitis after biliary plastic stenting is frequent and associated with positive bile cultures at index ERCP. Bile culture obtained at stent placement may help identify patients at increased risk of early cholangitis.
Backgrounds and study aim Placement of a self-expandable metallic stent (SEMS) has become a common practice for obstructive colorectal cancer. However, the safety and efficacy of systemic chemotherapy after SEMS placement remain unclear. Patients and methods This multicenter retrospective cohort study was conducted by the Japan Colonic Stent Safe Procedure Group across Japan to investigate the SEMS-related complications and clinical outcomes of chemotherapy in patients with unresectable obstructive colorectal cancer. Results A total of 289 patients were included in the study. The median duration from SEMS placement to chemotherapy initiation was 11 days (range, 6-21 days). SEMS-related complications occurred in 30.1% of the patients, with the most common complications being perforation (8.7%; 95% CI, 5.9-12.5A%), re-obstruction (19.4%), and migration (20.8%). Among the patients with stent migration, 30% required additional intervention. The median progression-free survival (PFS) was 9.2 months (95% confidence interval [CI], 7.5-10.9 months), and the median overall survival (OS) was 17.3 months (95% CI, 14.1-20.5 months). No significant difference in perforation rate was observed with or without bevacizumab use (14.5% vs. 7.3%, P < 0.107). Factors influencing survival outcomes included the number of metastatic organs, presence of perforation, and performance of primary tumor resection (PTR). Survival analyses showed that patients who underwent PTR had significantly better PFS and OS; however, this result should be interpreted with caution due to potential selection bias and immortal time bias inherent in the retrospective design. Conclusions This multicenter retrospective study demonstrated that while chemotherapy after SEMS placement is generally feasible, clinicians should remain vigilant for complications like perforation, migration, and re-obstruction.
Introduction Underwater endoscopic mucosal resection (uEMR) technique has gained popularity for removal of large non-pedunculated colorectal polyps (LNPCPs) due to high en-bloc resection rates and lower recurrence rates. However, there is no information regarding outcomes of uEMR for giant colorectal polyps. Therefore, we aimed to evaluate the outcomes of uEMR for giant colorectal polyps across multiple centers in North America. Methods We conducted a multicenter retrospective study of adults with giant colorectal polyps undergoing uEMR between January 2019 and November 2025. Giant colorectal polyps were defined as LNPCPs ≥40 mm. Primary outcomes were technical success and rate of recurrent adenoma. Secondary outcomes were severe adverse events (SAEs) and predictors of technical success, recurrence, and SAEs. Results A total of 137 polyps, with mean polyp size 47.6 mm were included. Majority of the lesions were located in right colon (61%, n = 83) with the most common histopathology being high-grade dysplasia (HGD) (31.4%, n = 43). Technical success was achieved in 90.5% ( n = 124) with en-bloc resection rate of 11.7% ( n = 16). Polyp fibrosis (OR: 0.08) and HGD (OR: 0.15) were independent predictors of inability to achieve technical success. Of 92 (67.1%) patients with follow-up, recurrent polyp was present in 8.7% ( n = 8). SAEs were noted in 9.5%, consisting of delayed bleeding (9.5%, n = 13), while no delayed perforation or post polypectomy syndrome was noted. Discussion Our study demonstrates that uEMR is technically feasible for the removal of giant colorectal polyps with an acceptable safety profile and recurrence rate.
Introduction Colorectal cancer is a major global health concern, with colonoscopy as the gold standard for detection and prevention. Accurate localization of findings remains challenging, limiting reporting objectivity and completeness, which can be supported by artificial intelligence (AI). We present an AI system that identifies the appendiceal orifice, ileocecal valve, and flexures, enabling automated colon segment localization. Methods The AI was trained on 7264 manually annotated images from 991 patients and internally evaluated on 1238 images from 215 patients. Performance was assessed using accuracy, sensitivity, specificity, and F1-score. External validation was conducted on 78 public videos. The impact on standardized reporting was evaluated on 14 videos recorded in a different external clinic that did not contribute training data. These were independently evaluated by two expert endoscopists who reached a consensus that was used as the gold standard for flexure detection. Results On the internal image test set, the AI achieved 94.5% accuracy, 76.7% sensitivity, 97.0% specificity, and 0.79 F1-score. In external validation on videos from a public dataset, the AI identified 91.7% of cecum segments and 66% of flexures, with 81.4% detected within 30 s of annotation. AI integration improved flexure identification in the external video dataset from the second clinic, increasing detected flexures by 53.8% and videos with both flexures identified by 133.3%. Conclusions The AI reliably detects key anatomical landmarks, supporting colon segment localization. Its integration into reporting pipelines could enhance lesion localization, improve report completeness, and reduce documentation workload.
