The proliferation of advanced endoscopic resection techniques has provided a minimally invasive alternative to esophagectomy and revolutionized outcomes for patients with early-stage esophageal adenocarcinoma (EAC). This paradigm shift and the resulting research data on clinical and histologic determinants of treatment outcome have highlighted the heterogeneity of outcomes within EAC staged as T1 by invasion depth. Multidisciplinary cancer care teams are now routinely facing difficult decisions regarding the management of high-risk T1 EAC to balance the risk of long-term lymph node (LNM) or distant metastasis against the risks of surgical resection. In this review, we summarize the current state of knowledge regarding the staging and risk stratification of T1 EAC, with particular attention to features that contribute to a higher risk of LNM and cancer mortality. We review recent clinical trial data on positioning the use of endoscopic resection (cap-assisted or submucosal dissection) versus surgical resection in high-risk T1 EAC patients and describe adjunctive techniques to further improve risk stratification and treatment. Finally, we explore emerging and future directions, such as artificial intelligence and advanced biomarker analysis to further aid decision-making and enhance patient outcomes.
Background and Aims Acute upper gastrointestinal (UGI) bleeding is a potential life-threatening medical emergency among the elderly. There are limited data on the presentation, management, and outcomes of nonvariceal UGI bleeding (NVUGIB) in the elderly from India. We aimed to study clinical presentation, endoscopic findings, and outcomes in elderly patients with acute nonvariceal UGI bleeding. Methods In this retrospective study, we analyzed data from elderly patients (>= 60 years) who presented with acute nonvariceal UGI bleeding at our tertiary care center between 2020 and 2023. Patient demographics, clinical presentation, comorbidities, medication history, laboratory parameters, endoscopic findings, and therapeutic interventions were recorded. Risk stratification was performed using AIMS65 and Complete Rockall scores. Primary outcomes studied were rebleeding and in-hospital mortality rates. Results Of the 623 patients who had acute nonvariceal UGI bleed, 445 patients aged < 60 years were excluded. Among 178 elderly patients (mean age: 69.83 +/- 7.36 years, 83.1% males), hematemesis was the predominant presentation (34.8%). Antiplatelet use was noted in 40.4% of patients. Gastric ulcer was the most common endoscopic finding (42.7%), followed by duodenal ulcer (21.3%). Early endoscopy (within 24 hours) was performed in 82.5% of patients, and endoscopic therapy was required in 34.8% of patients. The Complete Rockall score indicated moderate risk (3-7) in 79.2% of patients. The rebleeding and in-hospital mortality rates were 5% and 1.1%, respectively. Conclusion Our study showed that gastric ulcer was the most common cause of acute NVUGIB in the elderly, and hematemesis being the most common presentation. The predominance of low-risk peptic ulcers and the administration of early endoscopic intervention could have contributed to favorable outcomes, despite the majority of patients falling into moderate-risk categories. Future prospective studies with longer follow-up periods and multiple centers would be valuable to validate these findings.
Antireflux mucosal ablation (ARMA) has emerged as a novel endoscopic therapy for gastroesophageal reflux disease (GERD), aiming to augment the gastroesophageal junction through mucosal scarring. However, recent randomized controlled trials (RCTs) have reported conflicting results, raising questions regarding its true clinical utility. In this news and views, we will discuss two recently published RCTs analyzing the efficacy and safety of ARMA in the management of GERD.
Background and Aims Endoscopic ultrasound (EUS)-guided drainage is now the preferred first-line treatment for walled-off pancreatic necrosis (WON). Necrotic tissue can be removed either at the time of initial drainage (immediate necrosectomy) or later, using a step-up approach if patients fail to improve. However, the optimal timing of necrosectomy remains unclear. We performed a systematic review and meta-analysis of randomized controlled trials to compare immediate versus step-up necrosectomy following EUS-guided drainage of WON. Methods We systematically searched PubMed/MEDLINE, Embase, and Cochrane CENTRAL from inception through March 2026 for randomized controlled trials comparing immediate necrosectomy during index drainage with a step-up (on-demand) approach. The primary outcome was reintervention-free clinical success (RFCS), defined as resolution of the collection without the need for additional procedures. Secondary outcomes included overall treatment success, adverse events (disease- and procedure-related), number of necrosectomy sessions, length of hospital stay, and mortality. A random-effects meta-analysis was performed using risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs). Results Four randomized controlled trials, including 215 patients, were analyzed. Reintervention-free clinical success was significantly lower in the immediate necrosectomy group compared with the step-up approach (RR 0.07, 95% CI 0.02-0.25; I (2) = 0%). Overall treatment success, adverse events, and mortality were similar between the two strategies. However, immediate necrosectomy was associated with a substantially higher procedural burden, reflected by a greater number of necrosectomy sessions. These findings were consistent across sensitivity analyses. Conclusions Performing necrosectomy at the time of initial EUS-guided drainage does not improve clinical outcomes and significantly reduces the likelihood of achieving success without additional interventions. A step-up approach, reserving necrosectomy for selected patients who do not improve after drainage, appears to be the more appropriate strategy. Future research should focus on identifying predictors of necrosectomy requirement to support a more individualized treatment approach.
Objective Appropriate lower threshold of hemoglobin or platelet counts to effectively perform endoscopic procedure in patients with portal hypertension has not been well studied. The objective of the study was to determine the safety and efficacy of endoscopic procedure in portal hypertensive patients with severe anemia or thrombocytopenia. Materials and Methods This study was a retrospective analysis of consecutive portal hypertension patients, who underwent upper gastrointestinal endoscopy. Follow-up period was 1 month after endoscopy. After collecting clinical, biochemical, and endoscopic data, patients were divided into two groups. Group A (n = 58, platelet counts < 50 & times; 10(9) cells/L or hemoglobin level < 7 g/dL) and Group B (n = 43, platelet counts >= 50 (& times;10(9) cells/L and hemoglobin >= 7 g/dL). Immediate complication, hospital stays, rebleeding, rehospitalization, and mortality were compared in both groups. Statistical Analysis Comparisons of quantitative data between the two groups were done using independent sample t-test or Mann-Whitney U test. Qualitative data were expressed as percentage and analyzed using Kruskal-Wallis test. Multivariate analysis was used to determine the independent predictors of rehospitalization and death. p-Value of less than 0.05 was taken as significant. Results Immediate complication (1.7: 2.3%, p = 0.95), rebleeding (6.9%: 2.3%, p = 0.41), and death rate (3.4:6.9%, p = 0.65) were similar in group A and B. Rehospitalization rate (17.2:9.3%, p < 0.001) and hospital stay (5.87 +/- 1.86 vs. 4.97 +/- 1.92 days, p = 0.02), respectively, were significantly higher in group A than B, but these were more attributable to severity of liver disease rather than low platelets or hemoglobin level. Conclusion Diagnostic and therapeutic endoscopic procedure was safe and effective in severely low anemic thrombocytopenic patients. Prolonged hospital stay and higher rehospitalization were more attributable to the severity of liver disease rather than severe anemia or thrombocytopenia.
Objective One of the commonly encountered complications of hepatic hydatid cysts is cystobiliary communication, which is observed in 2% to 42% of cases. Presentations can range from nonspecific mild symptoms to jaundice, biliary colic, cholangitis, liver abscesses, pancreatitis, sepsis, and organ failure, often necessitating surgical intervention. Preoperative endoscopic drainage, in such cases, is intended to achieve biliary decompression in the presence of cholangitis, remove hydatid elements within the bile duct, and reduce the chances of postoperative biliary fistulae. The role of endoscopic management as a therapeutic option resulting in complete resolution is less reported. We describe our experience regarding the feasibility and outcome of an alternative method. Materials and Methods This is a retrospective, single-center, case series of three patients with hepatic hydatid ruptured into the biliary tract, who presented with cholangitis. All three patients underwent endoscopic treatment consisting of endoscopic sphincterotomy, nasocystic biliary drainage, and biliary stenting. Results At a median follow-up of 18 months, imaging and cholangiography revealed a complete cure in all three patients. There were no complications related to the procedure. Conclusion Endoscopic drainage can be a modality of definitive treatment for intrabiliary ruptured hepatic hydatid cysts in select groups of patients, thus avoiding the need for surgical interventions.
Background Multiple prognostic scoring systems exist for risk stratification in non-variceal upper gastrointestinal bleeding (NVUGIB) but the optimal tool remains unclear. This study compared six scoring systems for predicting clinical outcomes in NVUGIB. Materials and Methods This single-center retrospective analysis of 303 acute NVUGIB patients compared Glasgow Blatchford score (GBS), AIMS65, MAP(ASH), age, blood tests and comorbidities (ABC), H3B2, and Nagoya university score (N-score) at admission. Discriminative performance was assessed using area under the receiver operating characteristic curve (AUROC) analysis against clinical outcomes. Binary logistic regression was performed to identify predictors of endoscopic intervention and blood transfusion. Results MAP(ASH) achieved the highest accuracy for mortality (AUROC 0.917). For rebleeding, MAP(ASH) was also superior (AUROC 0.795) followed by GBS (AUROC 0.773). However, for endoscopic intervention, H3B2 demonstrated the best performance (AUROC 0.736), followed by N-score (AUROC 0.731). For blood transfusion, GBS (AUROC 0.877) and MAP(ASH) (AUROC 0.864) were superior. Multivariate analysis identified hematemesis as an independent predictor of endoscopic intervention and pulse rate as one of the strong predictors for the need of blood transfusion. Conclusions MAP(ASH), ABC, and AIMS65 perform well for mortality risk assessment, while GBS and MAP(ASH) are best for predicting transfusion requirements. All pre-endoscopy scores have only moderate accuracy for predicting rebleeding and need for endoscopic intervention.
Objectives Peroral endoscopic esophageal myotomy (POEM) has become a primary therapeutic modality for Achalasia. PreciseSECT is a newly developed electrosurgical current mode with proposed advantages over standard modes in the POEM procedure. Methods A total of 52 patients diagnosed with achalasia were randomized to undergo POEM performed using either PreciseSECT mode or Spray coag mode for submucosal tunneling. An ERBE VIO3 generator and Hybridknife were used in all procedures. The primary outcome was submucosal dissection duration, while secondary outcomes included total procedure duration, adverse events, and clinical success. Results Technical success occurred in all patients. Submucosal tunneling duration (17 min [8-41] vs. 15.5 [7-76], p = 0.5), submucosal tunneling speed (0.64 cm/min [0.21-1.5] vs. 0.73 [0.2-1.43], p = 0.34), and total procedure duration (44 min [27-77] vs. 38.5 [21-130], p = 0.19) were similar in PreciseSECT and Spray coag groups, respectively. Bleeding requiring change to a coagrasper (1 [0-3] vs. 0 [0-1], p = 0.01) and the need to change the electrosurgical mode to coagulate non-bleeding vessels (3 [0-9] vs. 1 [0-5], p = 0.002) were higher in the PreciseSECT group. However, the occurrence of type 1 mucosal injury was higher in the Spray coag group (7.7 vs. 34.6%, p = 0.05). Conclusion Using a hybrid knife, Spray coag mode is associated with a higher incidence of mucosal injury. In contrast, PreciseSECT mode is associated with a more frequent need to switch accessories to coagulate bleeding vessels, as well as a more frequent need to change to another mode to coagulate non-bleeding vessels. Both modes seem to have similar submucosal dissection speeds.
Colorectal cancer is a major global public health concern since it is the second most prevalent cause of cancer-related mortality worldwide. Early rectal neoplasia requires treatment strategies that ensure oncologic safety while preserving rectal function and quality of life. Transanal minimally invasive surgery (TAMIS) has traditionally served as a standard local excision technique, whereas endoscopic submucosal dissection (ESD) has emerged as a less invasive alternative capable of achieving en bloc resection of large, non-pedunculated rectal lesions. In this news and views, we will discuss the recently published DSETAMIS trial, which compares ESD and TAMIS for early rectal cancer.
Disconnected pancreatic duct syndrome (DPDS) often complicates acute necrotizing pancreatitis (ANP) and can result in persistent external pancreatic fistulae (EPFs), leading to significant morbidity. Traditional surgical approaches are effective, but are associated with a high risk. Endoscopic ultrasound (EUS)-guided tractogastrostomy has emerged as a minimally invasive technique to internalize EPF by creating a physiological drainage route into the stomach. This study evaluated the efficacy, safety, and technical variations of EUS-guided tractogastrostomy for DPDS-related EPF. We retrospectively analyzed 21 patients with persistent EPF secondary to DPDS who underwent EUS-guided tractogastrostomy using different techniques: Direct tract puncture, artificial fluid collection creation, wire localization, water instillation, double-scope, direct percutaneous catheter drainage (PCD) puncture, EUS-guided pancreatogastrostomy (EUS-PG), and interventional radiologist-guided rendezvous approach. The outcomes included technical success, fistula closure, complications, and follow-up data. Technical and clinical success was achieved in all patients (100%). Complete EPF closure occurred in all the patients within 3 months. Minor complications included abdominal pain (n = 4), minor bleeding (n = 1), and stent migration (n = 3, 14.28%). No major adverse events or recurrences were reported over the 6-month follow-up period. EUS-guided tractogastrostomy is a safe, effective, and minimally invasive procedure for internalizing EPF in DPDS with promising clinical outcomes.
Objectives Esophageal ectopic sebaceous gland (EESG) is a rare lesion that can be challenging to differentiate from other upper gastrointestinal endoscopic findings. The origin of EESG remains debated, with hypotheses ranging from embryologic misplacement to metaplasia of esophageal epithelium or glands. The aim of our study is to further investigate the clinicopathological features and pathogenesis of EESG. Materials and Methods Our study systematically reviewed 87 cases reported in the literature and analyzed an additional 21 cases from our institution. Demographic data (gender, age), lesion location, endoscopic features, and clinical presentations were summarized. Additionally, immunohistochemical staining for androgen receptor (AR), Kiel 67 (Ki-67), and cytokeratin 14 (CK14) was performed on nine cases. Statistical Analysis A normality test was conducted to determine whether the age distribution of male and female patients followed a normal distribution. Correlation coefficients and principal component analysis (PCA) were applied to further analyze the characteristics of case onset. Results The estimated prevalence of EESG was approximately 0.105 parts per thousand. Lesions were more frequent in males than in females (nearly 2:1 ratio) and predominantly occurred in middle-aged and elderly individuals (mean age: 56.9 years). Most lesions were located in the middle and/or lower esophagus in both genders (99.6% variance explained by PCA). Endoscopically, EESG presented as distinctive "whitehead acne-like" structures with protrusions corresponding to sebaceous duct openings. Immunohistochemistry showed positive AR expression in all cases (9/9, 100%). Ki-67 and CK14 expression patterns indicated a close association between ectopic lesions and the basal layer of the esophageal squamous epithelium. Conclusion EESG typically presents after puberty with a male predominance. Given that sebaceous glands are androgen-responsive, androgens are likely involved in lesion development. The anatomical proximity of ectopic lesions to the basal layer of the squamous epithelium supports the hypothesis that pubertal androgens may drive aberrant differentiation of basal stem cells toward sebaceous gland lineage.
Pancreatic cystic lesions (PCLs), increasingly being detected via advanced imaging, pose diagnostic and management challenges due to their varying malignant potential. This review explores recent advances in endoscopic ultrasound (EUS) for PCL evaluation. PCLs are classified as neoplastic (e.g., intraductal papillary mucinous neoplasms [IPMNs], mucinous cystic neoplasms [MCNs]) or nonneoplastic (e.g., serous cystic neoplasms), with IPMNs and MCNs carrying higher malignancy risks (16–60% and 10–17%, respectively). Conventional EUS offers high-resolution imaging, outperforming computed tomography/magnetic resonance imaging in detecting high-risk features, though operator dependency limits reproducibility. Contrast-enhanced EUS enhances vascularity assessment, achieving 97% sensitivity for identifying high-grade dysplasia. Detective flow imaging EUS detects microvasculature without contrast, showing promise but requiring further validation. EUS-guided needle-based confocal laser endomicroscopy provides real-time histopathology, with 98% sensitivity for mucinous PCLs. EUS-guided sulfur hexafluoride pancreatography differentiates IPMNs with 96.6% accuracy. EUS-guided fine-needle aspiration and biopsy (FNB) improve diagnostic yield, with FNB offering 87% accuracy. Through-the-needle biopsy achieves 80 to 90% sensitivity for mucinous cysts, enhanced by molecular analysis (e.g., KRAS mutations). Artificial intelligence (AI) boosts EUS accuracy to 98.5% for cyst differentiation, reducing operator variability. Therapeutically, EUS-guided chemoablation and radiofrequency ablation offer minimally invasive options, with alcohol-free protocols improving safety (67% resolution). Challenges include complication risks and nonstandardized protocols and surveillance. Future directions involve AI integration, multiomics, and standardized protocols to optimize personalized PCL management, minimizing overtreatment while prioritizing high-risk lesions.
Solid pancreatic mass lesions pose a substantial diagnostic challenge, especially in resource-limited settings. Endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA) and fine-needle biopsy (EUS-FNB) are both widely utilized, yet comparative data on their performance under constrained conditions remain limited. In this prospective, randomized, single-center pilot study, patients with suspected solid pancreatic lesions were randomized to undergo either EUS-FNA (n = 20) or EUS-FNB (n = 21). Diagnostic accuracy, sensitivity, specificity, sample cellularity, technical success, adverse events, and total cost (needle + pathological processing) were assessed. Forty-one patients were randomized. Diagnostic accuracy was slightly higher in the FNB group (95.2%) compared to the FNA group (90%). Sensitivity was similar for FNB (92.9%) and FNA (92.3%), but specificity was greater with FNB (100% vs. 85.7%). Technical success was 100% in both arms, with only minor adverse events reported. Most samples demonstrated moderate to high cellularity in both arms. The estimated cost per procedure was INR 22,200 for FNA and INR 27,400 for FNB. EUS-FNB demonstrated slightly improved diagnostic yield but was expensive compared to FNA. In resource-limited settings, EUS-FNA offers a cost-effective and reliable first-line diagnostic option. Larger multicenter studies are needed to guide context-appropriate needle selection strategies.
Objective Percutaneous endoscopic gastrostomy (PEG) tube placement is a common gastrointestinal procedure that provides nutrition, fluids, and medications to patients with inadequate oral intake. A substantial proportion of patients undergoing PEG tube placement are frail. This study compares mortality, morbidity, and 30-day hospital readmission rates between frail and nonfrail patients undergoing PEG tube placement. Materials and Methods We conducted a retrospective analysis using data from the National Readmission Database for 2018 to 2020. The study included all patients aged >= 18 years who underwent PEG tube placement. Patients were stratified into two groups based on frailty, defined using the Johns Hopkins Adjusted Clinical Groups Frailty Indicator. Primary outcomes were mortality and all-cause 30-day readmission rates. Secondary outcomes included length of stay (LOS), total hospitalization charges, and inpatient complications such as sepsis and aspiration pneumonia.Statistical Analysis A multivariate regression model was used to estimate clinical outcomes between the two cohorts after adjusting for potential confounders. Results A total of 419,313 patients underwent PEG tube placement, among whom 278,564 (66.43%) were frail. Frail patients had higher mortality ( p = 0.003), longer LOS, and higher all-cause readmission rates than nonfrail patients. Rates of gastric perforation and intraprocedural puncture/laceration were lower in frail patients. The most common causes of 30-day readmission were sepsis (53.14%), pneumonitis due to inhalation of food and vomit (15.55%), gastrostomy malfunction (6.13%), acute kidney failure (3.38%), and pneumonia, unspecified organism (3.97%). Independent predictors of all-cause readmission included frailty, age, Charlson Comorbidity Index, hospital bed size, and insurance, all statistically significant. Conclusion Frail patients undergoing PEG tube placement have higher mortality, morbidity, and readmission burden. These findings highlight the need for caution when performing PEG tube placement in frail patients. Further research is warranted to validate these findings.
Objectives Eosinophilic esophagitis (EoE) is an emerging chronic immune-mediated esophageal disease characterized by eosinophilic infiltration of the esophageal mucosa. In India, the prevalence and predictors of EoE in patients presenting with gastroesophageal reflux symptoms remain inadequately explored. This article determines the prevalence of EoE in adult patients with esophageal symptoms and identifies potential clinical, endoscopic, and hematologic predictors of EoE. Materials and Methods A prospective observational study was conducted at a tertiary care gastroenterology outpatient clinic between April 2023 and December 2024. Consecutive adult patients presenting with esophageal symptoms underwent esophagogastroduodenoscopy with targeted esophageal biopsies. Histopathological examination for mucosal eosinophilia (>= 15 eosinophils per high-power field) was performed. Demographic, clinical, hematologic, and endoscopic parameters were analyzed to identify predictors of EoE. Results Among 350 screened patients, 4 (1.14%) were diagnosed with EoE. EoE patients were predominantly male with a mean age of 39.6 +/- 4.2 years and had a higher prevalence of allergic history (75%) compared with non-EoE subjects (5.2%, p = 0.003). Nonresponse to proton-pump inhibitors (PPIs) was significantly associated with EoE (p = 0.001). Peripheral absolute eosinophil counts were elevated in EoE cases (median 410/mm(3)) compared with non-EoE cases (median 162/mm(3), p = 0.02). Endoscopic features such as esophageal rings and linear furrows were noted in some EoE cases. Multivariate analysis identified allergy history and PPI nonresponsiveness as significant independent predictors of EoE. Conclusion The prevalence of EoE among Indian adults with esophageal symptoms is low (1.14%). However, a personal history of allergy, elevated peripheral eosinophil count, and poor response to PPI therapy are significant predictors of EoE. Early recognition of these factors can facilitate targeted biopsy and accurate diagnosis of EoE in clinical practice.
Background and Objectives Serrated epithelial change (SEC) is an increasingly recognized histologic finding in patients with inflammatory bowel disease (IBD) and may be associated with an increased risk of colorectal dysplasia. SEC is defined as colonic mucosa with goblet cell-rich epithelium and serrated crypt architecture without basal crypt distortion or dysplasia. This study aimed to characterize the clinical, endoscopic, and histologic features of SEC in IBD patients and determine the incidence of associated dysplasia. Materials and Methods A retrospective single-center study was conducted at a tertiary referral hospital. IBD patients with histologically confirmed SEC from colonic biopsies between January 1, 2015 and December 31, 2024 were identified via pathology database searches. Patients without follow-up colonoscopy or flexible sigmoidoscopy were excluded. Clinical, endoscopic, and histologic data were extracted from electronic records. Descriptive statistics were used to summarize demographics, endoscopic findings, and histologic data. Median values were reported for age and follow-up time; mean values described disease duration. Results Twenty-six IBD patients (16 Crohn's disease, 10 ulcerative colitis) with SEC were analyzed (14 males; median age 58 years). Mean disease duration was 15 years, with a median follow-up of 24.5 months. The estimated prevalence of SEC was . A total of 30 SEC specimens were identified, most commonly located in the cecum (30%), rectum (23.3%), and transverse colon (16.7%). SEC presented as nodular or polypoid lesions in 60% of cases and was detected by high-definition white light endoscopy in 61.5% of patients. Multifocal SEC occurred in 19.2% of patients. Endoscopic and histologic inflammations were present in approximately half of the cases. Only one patient (3.8%) developed low-grade dysplasia adjacent to SEC. Conclusion SEC was predominantly observed in patients with long-standing IBD as polypoid or nodular lesions proximal to the splenic flexure and associated with mucosal inflammation. A solitary case of colorectal dysplasia was observed. Larger prospective studies are needed to clarify SEC's role in colorectal carcinogenesis and to guide dysplasia surveillance strategies in IBD.
Recent advancements in endoscopic technology have established endoscopic ultrasonography (EUS) as a valuable tool for gastroenterologists. The integration of complementary imaging techniques, such as contrast enhancement and elastography, has significantly enhanced the capabilities of EUS. EUS-guided elastography (EUS-E) is an innovative imaging modality that improves the diagnostic accuracy of standard B-mode EUS by measuring the mechanical properties of tissues, particularly their elasticity or stiffness. These measurements are indicative of pathological changes and can aid in differentiating benign from malignant tissues. By combining elastography with EUS, it is now possible to assess tissue stiffness in organs such as the liver, pancreas, and lymph nodes. This approach not only aids in differential diagnosis but also enables the identification of the most accurate areas for EUS-guided tissue acquisition. EUS-E is performed using two main techniques: strain elastography and shear wave elastography, each with distinct advantages and limitations. This article provides an in-depth review of EUS-E, including its principles, techniques, clinical applications, and inherent limitations.
