Background The uncertainty regarding its long-term effectiveness and perforation rates sometimes reaching 4% have led centers to abandon pneumatic dilatation (PD). We evaluated the efficacy and safety of a treatment strategy based on stepwise pneumatic dilations (30, 35 ± 40 mm) in real-world practice among patients with achalasia. Methods This was a retrospective study including consecutive, treatment naive, achalasia patients treated with PD at a single center. The study was based on a prospectively maintained database. The primary endpoint was the rate of clinical remission, defined as an Eckardt score < 3 at the end of follow-up. Results We included 132 patients with achalasia between 2018 and 2023. Achalasia was classified as type I in 44 patients (33%), type II in 83 patients (63%), and type III in 5 patients (4%). Ninety-nine patients (75%) underwent a series of two dilations at 30 and 35 mm, 7 patients (5%) underwent a single 30-mm dilation, and 26 patients (20%) received three dilations at 30, 35, and then 40 mm. The clinical success rate at the first 3-month follow-up was 88%, with no statistically significant difference between subtypes. The median follow-up duration was 40 months. At the end of follow-up, 66 patients (65%) were in clinical remission without additional treatment. Three of the 317 procedures (1%) were complicated by perforation. Discussion Pneumatic dilation provides sustained symptomatic improvement in 65% of patients, with a severe complication rate of 1%. It therefore remains a valuable option to treat achalasia, particularly for frail patients.

Aim: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are the two main techniques used for endoscopic resection of superficial rectal tumours. The aim of this study was to compare the outcomes of ESD and EMR in treating superficial rectal tumours. Method: A retrospective observational study was conducted at two French centres including all patients treated with ESD or EMR for superficial rectal tumours. The primary outcome was the rate of local recurrence at the first follow-up endoscopy after endoscopic resection. Secondary outcomes included the curative resection rate, procedure duration, length of hospital stay, complication rates and the need for additional surgery. Results: A total of 254 patients were included, 159 treated with ESD and 95 treated with EMR. The local recurrence rate at the first follow-up endoscopy was 8.6% and was significantly lower in the ESD group than in the EMR group (4.3% vs. 16.9%; p = 0.005). The rates of en bloc and histologically complete resections were higher in the ESD group (88.1% vs. 42.7% and 85.5% vs. 38.9%, respectively; p < 0.001), while the curative resection rate was 90.6% in the EMR group and 92.5% in the ESD group (p = 0.59). Mostly due to poor histoprognostical criteria, 6.0% of patients underwent additional surgery (6.3% vs. 5.2% in the ESD vs. EMR group, respectively; p = 0.73). Conclusion: ESD demonstrated higher rates of en bloc, R0 resection than EMR, translating into significantly lower rates of local recurrence at the first follow-up endoscopy.

BACKGROUND:Clinically significant delayed bleeding (CSDB) is the most common complication after colorectal endoscopic submucosal dissection (ESD). The Limoges Bleeding Score (LBS) was developed to identify high-risk patients. The efficacy of prophylactic clipping in reducing CSDB remains debated. This study assessed the effectiveness of complete clip closure in preventing CSDB after colorectal ESD. METHODS:A retrospective analysis of prospectively collected data from 10 centers (2019-2022) was conducted. ESD-treated epithelial colorectal lesions were included. Patients were categorized into closure and non-closure groups, and compared using propensity score matching (PSM) based on LBS factors (age > 75, lesion > 50 mm, American Society of Anesthesiologists III-IV, rectal location, anticoagulant/antiplatelet use). Subgroup analyses focused on anticoagulant use and high-risk patients (LBS 5-8). Environmental impact was estimated based on a representative sample. RESULTS:Among 3142 patients (1199 closure, 1943 non-closure), 216 (6.9 %) developed CSDB, with no difference between groups (closure: 7.2 % vs. non-closure: 6.9 %; P = 0.66). PSM analysis (944 matched cases) confirmed no statistically significant difference in CSDB (7.7 % vs. 5.7 %, respectively; P = 0.10). Subgroup analyses in patients on anticoagulants and at high risk showed no significant differences between the two groups (P = 0.39 and P = 0.73, respectively). Mean waste and carbon footprint was 283.2 g and 2.9 kg carbon dioxide equivalents, respectively, for single-use clips per closure (clip-to-lesion ratio: 0.8 clips/cm). CONCLUSIONS:Prophylactic clipping did not significantly reduce CSDB following colorectal ESD, even in high-risk patients. Given its environmental impact and technical challenges, routine closure should be reconsidered.

INTRODUCTION:The diagnosis and localization of insulinomas remain challenging. Imaging with contrast-enhanced CT, PET with somatostatin analogs, MRI, and endoscopic ultrasonography is often inconclusive. GLP1 receptor radioligands can specifically target insulinomas. A recent multicenter trial reported the superior performance of 68 Ga-NODAGA-Exendin-4 (EX) PET/CT for the detection of benign insulinomas. PATIENTS AND METHODS:Fifty EX-PET/CTs (individually authorized by the French Medicine Agency) were performed on 44 patients with a suspected sporadic insulinoma, based on biochemistry and clinical signs, but without a target lesion identified by imaging. A composite reference standard was based on postsurgical histology and/or follow-up data over 6-45 months after the EX-PET/CT. RESULTS:The examination-based EX-PET/CT positivity rate was 62% (31/50), equivocal 0. Positive EX-PET/CTs were confirmed by the outcomes of all 29 EX-guided resections (PPV 100%), including 2 re-operations following partial resection. Furthermore, the suspected diagnosis of an insulinoma was abandoned in 12 patients after 14 of 19 negative EX-PET/CTs. Suspicion of occult insulinoma remained in 5 patients. EX-PET/CT performed similarly well in patients treated by antihypoglycemic drugs and/or younger than 18 years. Since no extra-pancreatic EX abnormal foci were observed, the EX-PET/CT field-of-view to the upper abdomen should be sufficient. Only 1 patient experienced symptomatic hypoglycemia after EX injection. CONCLUSIONS:In cases of suspected insulinomas with nondiagnostic imaging, the performance of EX-PET/CT for the detection of nonmalignant sporadic insulinomas was excellent, with a 29/50 (58%) rate of major impact on patients' management. A negative EX-PET/CT appears to be a confident predictor to rule out the presence of sporadic insulinoma.

BACKGROUND:For large non-pedunculated rectal polyps, en bloc resection via endoscopic submucosal dissection (ESD) is typically recommended due to presumed higher risk of submucosal invasive cancer (SMIC) compared with the colon; however, data on cancer risk by location remain controversial. OBJECTIVE:Using the French ESD registry, we compared SMIC rates in large non-pedunculated colorectal polyps in the rectum versus colon. Procedural outcomes were also compared. DESIGN:From September 2019 to September 2022, all large non-pedunculated polyps resected by ESD in 13 centres were included. Oncological and procedural outcomes were analysed using propensity score matching (PSM) and inverse probability weighting, accounting for relevant influencing factors. A subgroup analysis was performed on cases from the three largest centres, where such polyps were exclusively treated with ESD. RESULTS:Among 3770 lesions, 3310 were analysed. Rectal lesions were larger (56.0 (40; 75) mm vs 47.0 (37; 62) mm), more often granular (80.0% vs 59.4%) and mixed nodular (54.0% vs 32.5%) (p<0.001). After PSM, submucosal cancer rates were not significantly different between rectal and colonic lesions of similar size and morphology (9.8% vs 8.9%, p=0.52). En bloc (97.7% vs 97.3%, p=0.757) and R0 resection rates (89.7% vs 89.5%, p=0.937) were also comparable. Perforation (5.5% vs 7.9%, p=0.057) and surgery for complications (0.1% vs 1.1%, p=0.051) showed a non-significant trend towards higher rates in colonic procedures. Subgroup analysis from the three centres exclusively performing ESD for large non-pedunculated polyps confirmed these findings. CONCLUSION:In our multicentre registry, large non-pedunculated polyps do not show a higher prevalence of SMIC in the rectum compared with colon, when adjusted for relevant factors such as size and morphology. Therefore, risk features, rather than location, should guide the choice of resection technique. Technical outcomes were comparable between rectal and colonic ESD, with a trend for higher complication rates in the colon. TRIAL REGISTRATION NUMBER:NCT04592003.

BACKGROUND:Gastric adenoma is widely acknowledged as a premalignant lesion that can progress to gastric adenocarcinoma. The distinctions among subtypes of gastric adenomas have been infrequently explored in existing literature. AIM:To assess the subtype-specific risk factors and outcomes of endoscopic resection (ER) for gastric adenomas. METHODS:This is a retrospective cohort study. Among 162 patients who underwent ER for gastric lesions larger than 10 mm between 2017 and 2022, 79 patients with gastric adenomas were included. Hyperplastic polyps (n = 37) and subepithelial lesions (n = 46) were excluded. Logistic regression and survival analyses were conducted. RESULTS:The 79 patients (mean age 68.1 years; 65% male) had adenoma subtypes: 62% intestinal, 29% foveolar, 8% pyloric, and 1% oxyntic. The mean follow-up was 26 months. Intestinal adenoma was strongly linked to a family history of gastric adenocarcinoma and atrophic gastritis (P < 0.001); foveolar adenoma was significantly associated with intestinal metaplasia (P < 0.001). Pyloric adenomas had the largest polyp size (P < 0.001). Recurrence rates were 8%, 17%, and 17% for the respective subtypes (P = 0.07), with no significant difference in the meantime to recurrence (P = 0.8). Independent predictors of recurrence after ER included a family history of gastric adenocarcinoma, active Helicobacter pylori infection, polyp size ≥ 30 mm, presence of > 3 polyps and Paris 0-IIc morphology (P < 0.001). CONCLUSION:This study identifies distinct risk factor profiles for different subtypes of gastric adenomas and independent recurrence predictors post-ER, underscoring the importance of subtype-specific tailored risk assessment and surveillance strategies.

Background and study aims We aimed to identify risk factors and salvage technique for technical failures of endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) and evaluate the short and long-term consequences in patients with biliary obstruction. Patients and methods This retrospective multicenter study included EUS-CDS from 2018 to 2024. Cases were defined as technical failure and classified as follow: type1 (digestive-flange mispositioned), type2 (biliary-flange mispositioned), type3 (stent deployment failure), type4 (catheter-LAMS through the bile duct), and type5 (others). Controls were successful EUS-CDS in the same center and period. The primary endpoint was to to identify risk factors for failure. Secondary endpoints were to describe the endoscopic rescue techniques to evaluate immediate and long-term consequences. Results Technical failures occurred in 7% (95%CI[5;9]). In 23 centers, 296 patients were included (53% male, 71±16 years): 100 cases (type1 [26%], type2 [41%], type3 [11%], type4 [6%], and type5 [16%]) and 196 controls. Risk factors in multivariate analysis for technical failures included CBD diameter ≤15mm, duodenal stenosis, Wired technique and low operator experience (≤10 LAMS). Endoscopic salvage was successful in 77% of cases, with 53% using a covered metal stent and 22% using a new LAMS. Early failures were mild in 50% of cases, but 12% resulted in death within 30 days. Immediate endoscopic salvage reduced severe clinical adverse event (p<0.00001) and increased success rates (p<0.0004). Conclusions EUS-CDS failures are not rare and are severe in half of the cases. Recognizing risk factors, identifying failures during the procedure, and knowing endoscopic salvage methods are crucial.

BACKGROUND AND AIMS:Endoscopy makes a significant contribution to the carbon footprint of healthcare. A randomized trial (RESECT-COLON) demonstrated that endoscopic submucosal dissection (ESD) decreases the recurrence rate of large adenomas (>25 mm) vs piecemeal endoscopic mucosal resection (P-EMR), reducing the need for follow-up colonoscopy. We aimed to compare the carbon footprint of those 2 strategies. METHODS:Devices used for both procedures were collected prospectively for each of the 359 patients. P-EMR and ESD were assessed using the life cycle assessment, evaluating 4 parameters: endoscopes and disposable medical products, electricity consumption, anesthetic products, and patient transport. The carbon footprint of the follow-up was simulated in both arms with different scenarios. We performed a post hoc analysis of the carbon footprint of these 2 strategies over 18 months. RESULTS:Carbon footprint of a single P-EMR procedure was 63.5 kg carbon dioxide equivalent (CO2e) vs 73.2 kg CO2e for ESD (half for patient transport). Including follow-up in local centers, P-EMR generates 93.5 kg CO2e and ESD 76.3 kg CO2e, corresponding to an absolute reduction of 17 kg CO2e (18%) per procedure for ESD. Simulating a strategy of P-EMR resection and follow-up both performed in local centers, the global impact with 18 months follow-up would be 67.3 kg CO2e, favoring P-EMR over ESD. CONCLUSIONS:ESD strategy for lesions over 25 mm could reduce the environmental impact by reducing the associated follow-up colonoscopies and transports of patients. If P-EMR could be performed in local centers with similar quality, results would be in favor of local P-EMR.

Digestive endoscopy is a highly dynamic medical discipline, with the recent adoption of new endoscopic procedures. However, comprehensive guidelines on the role of antibiotic prophylaxis in these new procedures have been lacking for many years. The Guidelines Commission of the French Society of Digestive Endoscopy (SFED) convened in 2023 to establish guidelines on antibiotic prophylaxis in digestive endoscopy for all digestive endoscopic procedures, based on literature data up to September 1, 2023. This article summarizes these new guidelines and describes the literature review that fed into them.

Background and study aims: Laparoscopic approach of perihilar cholangiocarcinoma (PHC) is still challenging. We report the original use of a endoscopic hepaticogastrostomy (EHG) for definite biliary drainage in order to avoid biliary reconstruction. Patients and methods: A 70-year-old man presenting with jaundice was referred for resection of a Bismuth type IIIa PHC. Repeated endoscopic retrograde cholangiopancreatography failed to drain the future liver remnant, enabling only right anterior liver section drainage. EHG was performed three weeks before surgery. A hepatogastric anastomosis was created, placing a half-coated self-expanding endoprosthesis between biliary duct of segment 2 and the lesser gastric curvature. Results: A laparoscopic right hepatectomy extended to segment 1, common bile duct, and hepatic pedicle lymphadenectomy was performed. The left hepatic duct was sectioned and ligated downstream to the biliary confluence of segment 2-3 and 4 allowing exclusive biliary flow through the EHG. The patient was disease free at 12 months, postoperative outcomes were uneventful except three readmissions for acute cholangitis due to prosthesis obstruction. Conclusions: EHG may be used as definite biliary drainage technique in laparoscopic PHC resection, at the expense of prosthesis obstruction and cholangitis.

INTRODUCTION:The adoption of colorectal endoscopic submucosal dissection (ESD) is still limited in the West. A recent randomized trial showed that ESD is more effective and only slightly riskier than piecemeal endoscopic mucosal resection; reproducibility outside expert centers was questioned. We evaluated the results according to the annual case volume in a multicentric prospective cohort. METHODS:Between September 2019 and September 2022, colorectal ESD was consecutively performed at 13 participating centers classified as low volume (LV), middle volume (MV), and high volume (HV). The main procedural outcomes were assessed. Multivariate and propensity score matching analyses were performed. RESULTS:Three thousand seven hundred seventy ESDs were included. HV centers treated larger and more often colonic lesions than MV and LV centers. En bloc , R0, and curative resection rates were 95.2%, 87.4%, and 83.2%, respectively, and were higher at HV than at MV and LV centers. HV centers also achieved a faster dissection speed. Delayed bleeding and surgery for complications rates were 5.4% and 0.8%, respectively, without significant differences. The perforation rate (overall: 9%) was higher at MV than at LV and HV centers. Lesion characteristics, but not volume center, were independently associated with both R1 resection and perforation. However, after propensity score matching, R0 rates were significantly higher at HV than at LV centers, and perforation rates were significantly higher at MV than at HV centers. DISCUSSION:Colorectal ESD can be successfully implemented in the West, even in nonexpert centers. However, difficult lesions must still be referred to experts.

Intrahepatic cholangiocarcinoma (iCCA) is the second most common malignant primary liver cancer. iCCA may develop on an underlying chronic liver disease and its incidence is growing in relation with the epidemics of obesity and metabolic diseases. In contrast, perihilar cholangiocarcinoma (pCCA) may follow a history of chronic inflammatory diseases of the biliary tract. The initial management of CCAs is often complex and requires multidisciplinary expertise. The French Association for the Study of the Liver wished to organize guidelines in order to summarize the best evidence available about several key points in iCCA and pCCA. These guidelines have been elaborated based on the level of evidence available in the literature and each recommendation has been analysed, discussed and voted by the panel of experts. They describe the epidemiology of CCA as well as how patients with iCCA or pCCA should be managed from diagnosis to treatment. The most recent developments of personalized medicine and use of targeted therapies are also highlighted.

Lumen-apposing metal stents (LAMS) were initially developed to drain perigastric pancreatic necrotic collections and perform endoscopic necrosectomy.