Main recommendations:BENIGN BILIARY STRICTURES. Main recommendations:1: ESGE suggests temporary insertion of multiple plastic stents (MPSs) to treat postcholecystectomy benign biliary strictures. A fully covered self-expandable metal stent (FCSEMS) can be considered in these patients when the stricture is located >2 cm distally from the main hepatic confluence or for patients who are noncompliant with repeated endoscopic retrograde cholangiopancreatographies (ERCPs). Main recommendations:2: ESGE suggests treating anastomotic biliary strictures following liver transplantation with either MPSs or temporary insertion of an FCSEMS when located >2 cm distally from the main hepatic confluence. Main recommendations:3: ESGE suggests treating biliary strictures secondary to chronic pancreatitis with temporary insertion (6-12 months) of an FCSEMS. Main recommendations:4: ESGE suggests using balloon dilation alone for high grade biliary strictures secondary to primary sclerosing cholangitis. There is no added benefit of stenting following balloon dilation, and stenting may increase the risk of adverse events. Main recommendations:5: ESGE suggests avoiding the insertion of uncovered SEMSs (USEMSs) for the drainage of extrahepatic biliary obstruction of unconfirmed etiology. Main recommendations:DISTAL MALIGNANT BILIARY STRICTURES. Main recommendations:6: ESGE recommends the endoscopic placement of a 10-mm diameter SEMS for preoperative biliary drainage (PBD) of extrahepatic malignant biliary obstruction (MBO). Main recommendations:7: ESGE recommends the endoscopic placement of a 10-mm diameter SEMS for neoadjuvant biliary drainage of extrahepatic pathologically confirmed MBO. Main recommendations:8: ESGE recommends endoscopic over surgical or percutaneous biliary drainage for primary decompression of inoperable, extrahepatic MBO. Main recommendations:HILAR MALIGNANT BILIARY STRICTURES. Main recommendations:9: ESGE recommends ERCP over percutaneous transhepatic biliary drainage (PTBD) for PBD in hilar malignant obstruction. Main recommendations:10: ESGE suggests palliative drainage of malignant hilar strictures by means of ERCP for Bismuth types I-II. For Bismuth III-IV, ERCP or a combination of ERCP with endoscopic ultrasound-guided biliary drainage (EUS-BD) is preferable over primary PTBD. Complementary drainage using PTBD might be required in some cases. Main recommendations:11: ESGE suggests obtaining drainage of more than 50%, and ideally 70% or more, of the viable nonatrophic liver volume for palliative drainage of proven malignant Bismuth II-IV strictures, using a multimodal approach (EUS-BD/PTBD if needed, as complementary methods to ERCP). Main recommendations:12: ESGE suggests using either plastic stents or USEMSs for palliative drainage of proven malignant hilar obstruction. ESGE suggests a plastic stent when the optimal drainage strategy has not been defined. ESGE suggests using a USEMS in expert centers to reduce the need for revisional procedures based on the patient's expected survival and the likelihood of achieving complete biliary drainage. Main recommendations:MALIGNANT BILIARY STRICTURE IN CASES OF FAILED OR UNFEASIBLE ERCP. Main recommendations:13: ESGE recommends EUS-BD over PTBD in cases of malignant biliary stricture following failed or unfeasible ERCP.In patients with distal stricture, ESGE suggests using EUS-guided hepaticogastrostomy (EUS-HGS) where a duodenal stricture is present, and either EUS-HGS or EUS-guided choledochoduodenostomy where there is no duodenal stricture.ESGE suggests using PTBD when EUS-BD fails or is not feasible.
BACKGROUND AND AIMS:Clinically significant portal hypertension (CSPH) is the main driver of hepatic decompensation, and its early identification allows timely initiation of preventive therapies. Hepatic Venous Pressure Gradient (HVPG) is the current gold standard for assessing portal hypertension (PH), but it may underestimate PH in conditions with a presinusoidal component. Endoscopic ultrasound-guided portal pressure gradient (EUS-PPG) enables direct measurement of portal pressure and may overcome these limitations. We evaluated the prognostic performance of EUS-PPG compared with HVPG for predicting hepatic decompensation in patients with suspected CSPH. APPROACH AND RESULTS:This preliminary exploratory analysis of the ongoing prospective EVADIPP study included 90 patients who underwent paired HVPG and EUS-PPG measurements and were followed for decompensation. Mean EUS-PPG and HVPG values were 13.8 ± 5.8 mmHg and 8.9 ± 4.8 mmHg, respectively, with poor overall agreement (ICC 0.08, 95% CI -0.08 to 0.24). Agreement remained poor in porto-sinusoidal vascular disorder (PSVD), slight in metabolic dysfunction-associated steatotic liver disease, and substantial in alcohol- and viral-related liver disease. During follow-up, 28 patients (31%) developed decompensation; no events occurred among patients with EUS-PPG<10 mmHg, whereas 60.7% had HVPG <10 mmHg. In multivariable analysis, EUS-PPG (HR 1.19, 95% CI 1.10-1.30; p<0.001) and albumin were independently associated with decompensation. EUS-PPG demonstrated better discrimination than HVPG (C-index 0.78 vs 0.56), and time-dependent ROC analysis identified an optimal threshold of 12 mmHg. CONCLUSIONS:EUS-PPG is independently associated with hepatic decompensation and showed better prognostic discrimination than HVPG in this exploratory cohort.
BACKGROUND:Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) and related EUS-guided anastomoses are increasingly used for gastric outlet obstruction and other complex gastrointestinal scenarios, but indications, technical standards, and peri-procedural care remain heterogeneous. METHODS:An international panel of 66 experts (i-EUS) developed statements using a structured modified Delphi process. Literature searches were performed up to 30 April 2025. Comparative PICO-framed questions with extractable evidence underwent structured evidence synthesis and GRADE assessment, whereas procedural, technical, and organizational statements were classified as consensus based. Consensus was predefined as ≥85% agreement. RESULTS:Of 25 draft statements, 20 reached consensus and 5 did not. Six endorsed statements were GRADE-based and 14 were consensus-based. For malignant gastric outlet obstruction, EUS-GE was recommended over duodenal stenting because of greater durability and fewer reinterventions and suggested over surgical bypass because of comparable efficacy and fewer overall adverse events. Consensus-based statements addressed expert-centre requirements, supervised training, catheter-based target-loop distension, freehand LAMS deployment, fluoroscopy availability, antithrombotic management, refeeding, post-procedural imaging, recurrent obstruction, and misdeployment. Conditional recommendations addressed LAMS diameter selection, selected benign gastric outlet obstruction, EDGE/EDGI in Roux-en-Y gastric bypass, and malignant afferent limb syndrome. No formal recommendation was issued for peritoneal carcinomatosis, routine tracheal intubation, antibiotic prophylaxis, EDEE in non-RYGB anatomy, or EUS-guided colo-enterostomy. CONCLUSIONS:These i-EUS recommendations provide a practical framework for EUS-GE and related anastomoses in expert settings. The evidence base remains limited, and prospective comparative studies are needed to refine patient selection, training requirements, and long-term outcomes.
Background:Colonoscopy quality and diagnostic outcomes in Lynch syndrome have historically been heterogeneous. Following the introduction of the Lynch syndrome Bowel Cancer Screening Programme (BCSP), we assessed colonoscopy quality and diagnostic yield in Lynch syndrome using the National Endoscopy Database (NED), comparing outcomes between BCSP and non-BCSP providers. Methods:We performed a cross-sectional analysis of UK Lynch syndrome colonoscopies from NED between June 2024 and June 2025. Colonoscopy quality indicators and endoscopic detection rates for polyp (PDR) and advanced neoplasia (eANDR; polyps ≥10 mm or cancer; histopathology linkage was unavailable) were calculated and compared between BCSP and non-BCSP providers. Factors associated with neoplasia detection were identified using logistic regression. Results:Among 3196 colonoscopies, most were performed in England (90.2%), with 34.1% undertaken within BCSP. Overall colonoscopy quality was high: 97.6% were complete, 89.0% had adequate bowel preparation, and 96.3% had adequate tolerance. BCSP procedures demonstrated higher rates of completion (98.5% vs. 97.1%; P = 0.02) and adequate bowel preparation (92.7% vs. 86.7%; P < 0.001) than non-BCSP colonoscopies. PDR and eANDR were 46.8% and 4.7%, respectively, and were higher in BCSP than non-BCSP procedures (PDR 53.7% vs. 43.3%; eANDR 5.7% vs. 3.9%). Higher polyp detection was associated with increasing age (odds ratio [OR] 1.03, 95%CI 1.03-1.04), male gender (OR 1.48, 95%CI 1.26-1.73), BCSP status (OR 1.50, 95%CI 1.28-1.77), adequate bowel preparation (OR 1.81, 95%CI 1.40-2.34), and England nation (OR 1.99, 95%CI 1.22-3.36). Conclusions:Our NED evaluation demonstrated high colonoscopy performance in Lynch syndrome, with superior quality and endoscopic yield in BCSP procedures, supporting national integration of surveillance to establish Lynch syndrome-specific quality benchmarks.
BACKGROUND:The optimal self-expandable metallic stent (SEMS) choice for endoscopic drainage of unresectable extrahepatic malignant biliary obstruction (MBO) with endoscopic retrograde cholangiopancreatography (ERCP) remains unclear due to limited randomized controlled trial (RCT) evidence. Prior meta-analyses have relied on observational data, introducing heterogeneity and bias. To overcome these limitations, an RCT-only network meta-analysis (NMA) was performed to evaluate the efficacy and safety of SEMS types. METHODS:A literature search was conducted to identify RCTs assessing fully covered SEMS (FCSEMS), partially covered SEMS (PCSEMS), and/or uncovered SEMS (UCSEMS) for ERCP drainage of unresectable extrahepatic MBO. Study outcomes included recurrent biliary obstruction (RBO), specific causes of RBO, overall survival (OS), and adverse events (AEs). A frequentist NMA was performed to estimate hazard ratios (HRs) and incidence rate ratios (IRRs) with their 95% confidence intervals and overall P-scores. RESULTS:Ten RCTs (1,659 patients) were included. There were no significant differences in time to RBO, incidence of any RBO, or OS between stent types. UCSEMS had the lowest rates of stent migration, tumor overgrowth, and sludge occlusion, whereas FCSEMS most effectively prevented tumor ingrowth. AE rates were similar across groups; however, only FCSEMS, but not PCSEMS, had significantly higher rates of acute cholecystitis than UCSEMS in patients with an intact gallbladder. CONCLUSION:There were no differences in RBO, OS, or AE excluding acute cholecystitis between each SEMS type, although each type has its advantages and disadvantages. FCSEMS was associated with a higher risk of acute cholecystitis, emphasizing careful patient selection, particularly regarding gallbladder status.
BACKGROUND AND STUDY AIMS:Post-endoscopy upper gastrointestinal cancer (PEUGIC) is an emerging quality metric, but varying definitions complicate benchmarking. We characterized PEUGIC rates and outcomes by anatomical site and coded high-risk condition (HRC) status in a large US cohort. PATIENTS AND METHODS:Retrospective cancer-first cohort study of 14,814 patients with upper gastrointestinal cancer (UGIC) from a multicenter database (2016-2024). Detected UGIC was diagnosed within 6 months of EGD. PEUGIC was defined as UGIC diagnosed 6-36 months after a non-diagnostic EGD. The primary outcome was the PEUGIC rate by cancer type (esophageal [EC], gastric [GC], duodenal [DC]) and HRC status. Secondary outcomes included 3-year overall survival. RESULTS:The overall PEUGIC rate was 9.4% (EC 9.6%, GC 8.6%, DC 10.7%). Rates were higher with HRC (18.2%) versus without HRC (5.0%, P < .001). PEUGIC rate without HRC plateaued (4.1-5.1% in 2022-2024), while PEUGIC rate with HRC for EC (16.8%) and GC (14.4%) decreased over time. In exploratory analysis, PEUGIC was associated with better survival versus Detected UGIC for EC (adjusted hazard ratio [aHR] 0.82, 95% CI 0.67-0.99) and GC (aHR 0.77, 0.62-0.96), and PEUGIC with HRC was associated with lower mortality versus PEUGIC without HRC for EC (aHR 0.51, 0.36-0.74) and GC (aHR 0.50, 0.34-0.73). CONCLUSIONS:One in 10 upper GI cancer patients had a prior non-diagnostic endoscopy within 3 years. PEUGIC rates varied by anatomical site and HRC status, suggesting site- and HRC-stratified benchmarks may better capture endoscopic performance than aggregate metrics.
