We report the case of a 20-year-old woman with a complex type “D” pancreaticobiliary maljunction and recurrent pancreatitis who underwent surgical resection with Roux-en-Y reconstruction. Fourteen years later, magnetic resonance cholangiopancreatography (MRCP) revealed dilation of the common bile duct with associated stones. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy was performed to confirm the MRCP findings and facilitate stone removal; this procedure also demonstrated an incomplete pancreas divisum. Given the complex postoperative anatomy and the long-standing history of inflammation, direct cholangioscopy was used to inspect the biliary epithelium, clarify the anatomy, and enable selective cannulation. In this setting, ERCP combined with direct cholangioscopy represented a reliable approach for the postoperative management of maljunction, offering a minimally invasive option for surveillance while improving anatomical assessment and guiding subsequent management.
Polypoid lesions at colorectal endoscopic submucosal dissection (ESD) scars are often interpreted as local tumor recurrence, although benign scar-related changes, such as polypoid nodule scar (PNS), have been reported in the colorectum in rare cases. We report the case of a 66-year-old man who developed recurrent polypoid lesions at a sigmoid colon ESD scar after curative resection of an intramucosal adenocarcinoma. Despite repeated endoscopic treatment, the lesions recurred; however, histopathologic examination consistently demonstrated granulation tissue with regenerative epithelial hyperplasia and no dysplasia or malignancy. Subsequent surveillance colonoscopies showed spontaneous resolution, with no recurrence during long-term follow-up. This case highlights the importance of recognizing benign PNS lesions to avoid unnecessary aggressive endoscopic or surgical intervention.
Background : To report a single center experience with percutaneous necresectomy (PN) to treat a variety of complex fluid collections. Methods : A retrospective review of patients that underwent PN between 2019 and 2024 was performed in a single tertiary medical center. Clinical indications, PN technique, outcomes and complications were recorded. Twenty-nine patients underwent PN using peel-away sheaths and a combination of mechanical techniques. Nineteen patients had wall-off necrosis after necrotizing pancreatitis, 2 pancreatic leaks, 3 necrotic colon cancers, 3 necrotic liver collections, 1 fat necrosis after pelvic fracture and 1 a splenic abscess with fistula to the colon after splenic artery embolization. Results : The number of PN sessions varied from 1 to 7 (mean 1.7). Successful removal of necrotic material was obtained in all patients, 22 patients had the drains removed. Two out of three with necrotic tumors failed to have the drains removed. Two patients with NP died of multiorgan failure with drains in place. One major complication occurred in a liver collection patient with erosion of the portal vein by a large bore drain requiring placement of a stent graft. Associated fistulas with biliary (n = 2) or gastrointestinal (n = 6) tracts were embolized as part of the treatment in 6 patients. Conclusion : PN is a very useful technique for the treatment of complex fluid collections associated with different clinical scenarios. Higher failure rates were seen in patients with necrotic tumors.
Double balloon enteroscopy (DBE) with argon plasma coagulation (APC) is an effective treatment for small bowel gastrointestinal bleeding but is not thoroughly studied in patients with hereditary hemorrhagic telangiectasia (HHT). We conducted a study of HHT patients who underwent DBE at an academic referral center from 2011-2021. Fourteen patients underwent 26 DBEs; median age was 57; most were on antifibrinolytic or antiangiogenic therapy. Most scopes identified > 20 arteriovenous malformations (AVMs); 34.6% of DBEs reported > 100 AVMs. Nearly all lesions were treated with APC. No post-procedure adverse events occurred in this cohort. Patients who had their procedures at the HHT Center and those with 21-100 AVMs required less blood transfusions in the year following DBE. DBE-directed therapy was found to be safe in HHT patients; it may be especially helpful when performed in an HHT Center (likely due to improved interdisciplinary care) or in those with 21-100 AVMs.
Background: Gastric peroral endoscopic myotomy (G-POEM) has shown promising results in improving gastroparesis (GP) symptoms and quality-of-life (QoL). However, a proportion of patients either fail to respond to initial G-POEM or later experience symptom recurrence after an initial period of improvement. G-POEM revision has been proposed as a management option, but data regarding its safety and feasibility remain limited. Methods: Prospectively enrolled patients who underwent initial G-POEM followed by a G-POEM revision at a single high-volume institution were included. Evaluations were conducted at baseline and at 6 months after both the initial procedure and the revision. Validated tools were used to assess outcomes, including the Gastroparesis Cardinal Symptom Index (GCSI), the Patient Assessment of Gastrointestinal Disorders Symptom Severity Index (PAGI-SYM), and the 36-Item Short Form Survey (SF-36). Additionally, results of 4-hour solid-phase gastric emptying scans (GES) were recorded. Clinical success was defined as improvement in GCSI scores by >= 1 point after G-POEM revision compared to the baseline prior to the initial G-POEM. Results: Fourteen patients were included. The mean total GCSI score improved from 3.5 (+/- 0.8) at baseline prior to initial G-POEM to 2.4 (+/- 1.5) at 6 months after G-POEM revision (P = 0.047). The average PAGI-SYM total score significantly improved from 3.2 (+/- 0.9) at baseline to 2.2 (+/- 1.3) at 6 months after revision (P = 0.008). The mean SF-36 QoL total score and the mean 4-hour gastric retention on GES demonstrated improvement trends but did not reach statistical significance. Clinical success was achieved in 50.0% of patients who underwent G-POEM revision. No adverse events were reported. Conclusion: G-POEM revision resulted in meaningful symptom improvement for GP patients with primary failure or recurrent symptoms after initial G-POEM, without associated adverse events. Further studies are needed to better characterize patient phenotypes most likely to benefit from revision G-POEM. Copyright (c) 2026, Society of Gastrointestinal Intervention.
Endoscopic resection has advanced substantially over the past six decades, with the advent of endoscopic polypectomy, endoscopic mucosal resection (EMR), and subsequently advanced endoscopic resection techniques such as endoscopic submucosal dissection (ESD) and endoscopic full thickness resection (EFTR). As endoscopic resection techniques become increasingly adopted, they have become favored as first-line therapy over surgical resection in the management of superficial neoplasms throughout the upper and lower gastrointestinal tract. ESD has become increasingly incorporated into standard endoscopic practice in the United States. However, the adoption of ESD has been highly variable and many practitioners in the United States have faced significant challenges both in ESD training as well as starting an independent practice focused on ESD and endoscopic resection. In this narrative review, we discuss the current landscape of ESD training in the United States, with a particular focus on how to start a practice in endoscopic resection.
Gastroesophageal reflux disease (GERD) is a very common gastrointestinal disorder worldwide. Lifestyle interventions and medical therapy remain the first-line treatment for GERD, while surgical interventions are considered the gold standard for patients who are refractory to or who prefer alternatives to medical therapy. Endoscopic anti-reflux therapies have emerged to address the treatment gap between medical management and surgical intervention. In this review, the most prominent endoscopic techniques are discussed. Transoral incisionless fundoplication has the most robust data with respect to both short- and long-term clinical efficacy. Emerging techniques, including anti-reflux mucosectomy, resection and plication, and ablation procedures, have shown promise; however, further research is required to refine these techniques, determine the durability of symptom relief, and optimize patient selection.
Background: Transoral incisionless fundoplication (TIF) is an effective treatment for gastroesophageal reflux disease. As a technically demanding endoscopic procedure, TIF has a measurable learning curve that may influence procedural performance and outcomes. This study evaluates the learning curve associated with TIF and its impact on clinical outcomes. Methods: This is a retrospective study of patients who underwent TIF procedures at a tertiary center from January 2018 to December 2021. Proficiency was defined as reliably achieving a procedure length <= 45 minutes. Patient symptoms and procedure-related adverse events occurring up to two months were collected. Results: A total of 68 patients underwent 77 consecutive TIF procedures (67.6% female), with procedural proficiency achieved after 12 cases. After adjustment for body mass index, American Society of Anesthesiologists class, and Hill grade, Hill grade and procedure duration were not associated with the number of fasteners used (P = 0.475 and P = 0.091, respectively). Mean fastener use increased significantly over time, from 18.3 +/- 3.8 in the first tertile to 28.0 +/- 4.8 in the final tertile (Holm-adjusted P < 0.001). Immediate abdominal pain was reported by 28% of patients and was associated with increased fastener use (odds ratio 1.13 per fastener; 95% confidence interval 1.02-1.24). Among 29 patients with follow-up endoscopy, 62.1% had an intact wrap, with no association between fastener number and wrap integrity (P = 0.534). Conclusion: TIF has a defined learning curve, with proficiency achieved after 12 procedures. Operator experience influenced technical execution without compromising wrap integrity, supporting the safe adoption of TIF in experienced centers. Copyright (c) 2026, Society of Gastrointestinal Intervention.
Zenker’s diverticulum (ZD) is a pulsion-type hypopharyngeal pseudodiverticulum that develops through Killian’s triangle. The treatment of symptomatic ZD of variable sizes involves cricopharyngeal myotomy. Endoscopic techniques, particularly flexible endoscopic septotomy and Zenker’s per-oral endoscopic myotomy, have become preferred treatment options compared with traditional surgery. Both endoscopic procedures provide comparable efficacy, an acceptable adverse event profile, and promising durability. However, recurrence remains possible, and retreatment using the same modality is both feasible and safe. Given the broad range of clinical presentations and the heterogeneity in treatment response, an optimal “one size fits all” solution for symptomatic ZD is still lacking, and the most appropriate intervention will continue to depend on patient preference within the context of local expertise.
Subepithelial lesions of the gastrointestinal tract are masses with an overlying layer of normal mucosa, most frequently found in the stomach and often detected incidentally. They may originate from the submucosa, muscularis mucosa, or muscularis propria and encompass a broad differential diagnosis. Endoscopic ultrasound provides important diagnostic information and lesion characterization, enabling risk stratification and guiding the selection of resection technique where indicated. Management is determined by malignancy risk, lesion size, and patient-specific factors. While observation is appropriate in many asymptomatic cases involving small lesions, resection is indicated for larger lesions (> 2 cm), symptomatic cases, inconclusive pathology results, and/or when the presence of a lesion confers significant psychological or financial burden to the patient. Recent advancements in endoscopic resection techniques have expanded treatment options beyond surgery, enabling minimally invasive and organ-sparing approaches. Techniques include endoscopic submucosal resection with cap- or ligation-assisted resection and underwater endoscopic mucosal resection for lesions primarily involving the submucosa. Larger or deeper lesions are addressed through endoscopic full-thickness resection, which can be categorized into exposed and nonexposed methods. Each has technical considerations, including closure strategies, size limitations, and complication risks. Exposed endoscopic full-thickness resection offers high en bloc resection rates but carries a risk of perforation, whereas nonexposed tunneling techniques are preferred in anatomically challenging regions such as the esophagus. Device-assisted resection using full-thickness resection devices presents a promising “one-stop” solution for selected subepithelial lesions but may be limited by lesion size and device constraints. Optimal management requires a multidisciplinary, patient-centered approach informed by lesion characteristics, advanced resection expertise, and the available technology.
Background : This study aimed to evaluate the safety and effectiveness of percutaneous transhepatic biliary drainage (PTBD) following failed endoscopic retrograde cholangiopancreatography (ERCP) in patients with distal malignant biliary obstruction (DMBO). Methods : This cross-sectional study included 68 patients with DMBO who underwent PTBD at two tertiary hospitals between January 2019 and December 2024. Indications, procedural techniques, safety, and effectiveness were assessed according to the Society of Interventional Radiology guidelines. The study endpoint was defined as either the first follow-up visit or death. A post-procedural reduction in total bilirubin level of ≥ 20% from the pre-procedural value was considered significant. Catheter positioning, configuration, and side-hole modification were individualized based on cholangiographic findings and specific treatment objectives. Results : The mean age of the patients was 64.5 ± 15.2 years, with an average follow-up duration of 4.52 ± 1.05 months. The mean pre-procedural total bilirubin level was 13.81 ± 7.88 mg/dL. Technical success was achieved in all cases (100%), with 44.1% of patients receiving internal-external drainage. A significant reduction in serum total bilirubin was observed in 85.3% of patients, with an average reduction of 6.36 ± 0.87 mg/dL (P < 0.001). Following PTBD, 48.5% of patients became eligible for curative treatment and/or chemotherapy, while 17.64% underwent biliary stent placement for palliative care. The rates of major and minor in-hospital complications were 5.88% and 2.94%, respectively. Conclusion : PTBD is a safe and effective therapeutic option for managing DMBO after failed ERCP, demonstrating high technical and clinical success rates as well as a low complication rate.
Background : Foreign body (FB) ingestion in the upper gastrointestinal (GI) tract is a common clinical emergency globally, with risk profiles influenced by local dietary practices. In Eastern China, ingestion of sharp-edged jujube seeds represents a unique epidemiological concern. This study aimed to characterize the clinical features, endoscopic outcomes, and complication profiles associated with upper GI FB ingestion in this regional population. Methods : A retrospective study was conducted involving 642 adult patients who underwent endoscopic evaluation for suspected upper GI FB ingestion at Qilu Hospital, Shandong University (2015-2023). Data on FB types, anatomical locations, demographics, procedural outcomes, and complications were analyzed. Complications were categorized by severity into minor (erosion), moderate (ulceration/bleeding), and major (perforation/infection). Statistical significance was established at P < 0.05. Results : Among the 642 patients, 514 (80.06%) had confirmed FB ingestion. Jujube seeds were the most common FB (n = 269; 52.33%), followed by fish bones (n = 74; 14.39%) and other animal bones (n = 68; 13.22%). The upper esophagus was the predominant location for FB lodgment (n = 374; 72.76%). Endoscopic removal was successful in all confirmed FB cases (100%). Complications occurred in 395 patients (76.84%), primarily minor (mucosal erosion, 43.8%) and moderate (ulceration/bleeding, 42.6%). Major complications (perforation/infection) accounted for 13.67%, aligning with international standards. Jujube seeds were associated with the highest complication rate (49.07%). Conclusion : Endoscopic intervention remains highly effective for FB removal from the upper GI tract. However, sharp-edged FBs such as jujube seeds carry a significant complication burden, underscoring the need for early intervention, risk stratification, and public health initiatives targeting modifiable dietary risk factors.
