Background:Biliary cannulation during endoscopic retrograde cholangiopancreatography (ERCP) remains a critical yet challenging step, particularly in patients with a naïve papilla. The European Society of Gastrointestinal Endoscopy (ESGE) proposed a stepwise algorithm to guide cannulation strategies, but its real-world applicability and outcomes have not been systematically evaluated. This study aimed to assess the effectiveness and safety of ESGE algorithm-guided biliary cannulation during ERCP in a multicenter Italian cohort. Methods:This was a prospective observational study conducted across 11 Italian centers. Consecutive patients undergoing ERCP with naïve papilla were enrolled. Cannulation strategies were categorized based on adherence to the ESGE algorithm. Results:A total of 1435 patients were included and 1086 (75.7%) procedures adhered to the ESGE algorithm. Compared with nonadherence, adherence to the ESGE algorithm resulted in significantly higher biliary cannulation success (98.6% vs. 78.8%; P < 0.001) and shorter procedure duration (median 21 vs. 35 minutes; P < 0.001). Among difficult cannulation cases, success remained higher in the ESGE adherence group (93.1% vs. 78.8%; P < 0.001). At multivariable analyses, factors significantly associated with successful cannulation were adherence to the ESGE algorithm, prone position, degree of ERCP difficulty, and use of short guidewire. Rates of post-ERCP pancreatitis were comparable overall, but moderate-to-severe pancreatitis and perforation were less frequent in the ESGE adherence group. Conclusions:Adherence to the ESGE cannulation algorithm was feasible and was associated with higher cannulation success during ERCP.

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.

EUS-guided gallbladder drainage (EUS-GBD) has proved to be highly safe and effective in patients with acute cholecystitis at high surgical risk. These findings stimulated the search for populations outside the acute setting, where EUS-GBD performed electively could become a valid therapeutic option. This is a retrospective, multicenter, study involving patients who underwent elective endoscopic gallbladder treatment (EEGBT) in nine referral centers. All patients had a benign gallbladder disease and were judged to be at high surgical risk, with an indication to undergo cholecystectomy. EUS-GBD was performed using LAMSs and followed by intra-gallbladder lithotripsy when necessary. Primary outcome was adverse events (AE) rate; secondary outcomes included technical and clinical success rates and need for additional intracholecystic procedures. Forty-nine patients (mean age 78.7 ± 12.3 years, M/F 22/27) underwent EEGBT over a 2-year period. All patients had ASA score ≥ 3, and a Charlson Comorbidity Index ≥ 5 was present in 71

BACKGROUND:Laparoscopic cholecystectomy is the standard treatment for acute cholecystitis (AC), but some patients are unfit for (immediate) surgery. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS) is increasingly used in this population. OBJECTIVE:This multicenter cohort study aimed to evaluate practice patterns in EUS-GBD across Western centers and to identify factors that influence outcomes. DESIGN:We retrospectively analyzed data from patients undergoing EUS-GBD for AC across 18 centers. Patient-related, procedural and outcome data were collected. The primary outcomes of interest were LAMS-related adverse events (AEs), recurrent biliary disease, recurrent acute cholecystitis, and all-cause mortality. Time-to-event analyses were performed using center-stratified Cox proportional hazards and Fine-Gray competing-risk models to identify LAMS procedural factors associated with clinical outcomes. RESULTS:We included 496 patients with a median follow-up of 176 days (IQR 44-569). Technical and clinical success rates of EUS-GBD were 98.2% and 93.5%, respectively. LAMS-related AEs and recurrent biliary disease occurred in 11.1% and 18.8% of patients, respectively. Transduodenal access was associated with a lower cumulative incidence of LAMS-related AEs compared with transgastric access (SHR 0.42, 95% CI 0.23-0.76, p = 0.004) and lower rates of recurrent biliary disease and recurrent acute cholecystitis during follow-up. Larger LAMS diameters (> 10 mm) were associated with a lower risk of recurrent acute cholecystitis and all-cause mortality. No association between coaxial DPPS placement and improved long-term outcomes could be demonstrated after competing-risk adjustment. Among patients undergoing interval cholecystectomy (N = 46), LAMS-related conversion from laparoscopy to laparotomy occurred in 3 cases (6.5%). CONCLUSIONS:In this large cohort study, transduodenal access route and choice of a large (> 10 mm) LAMS diameter were associated with improved outcomes of EUS-GBD. EUS-GBD may be a feasible option as a bridge to laparoscopic cholecystectomy, with limited risk of conversion to laparotomy. The findings of our study require prospective validation.

Metastases to the pancreas (PM), although rare, have been increasingly identified in recent years, especially among high-volume pancreatic centers. They are often asymptomatic and incidentally detected during follow-up examinations, even several years after the treatment of the primary tumor. In this scenario, endoscopic ultrasound (EUS) has emerged as a crucial diagnostic tool for PM, being capable of providing a detailed morphological characterization and safe and effective tissue acquisition for cytohistological examination. The aim of our study was to extensively review the current evidence concerning the role of EUS in the diagnosis of PM, specifically focusing on its morphological features, contrast-enhancement patterns, and tissue acquisition techniques.

ABSTRACT The management of complex gastrointestinal defects (CGDs), such as fistulas, leaks, and anastomotic dehiscence, remains challenging. Over‐the‐scope suturing (OTSS) systems provide effective closure, but their application is limited to specific anatomical sites. The X‐Tack through‐the‐scope suturing (TTSS) system offers a minimally invasive alternative for CGD closure without requiring scope withdrawal. This case series evaluated patients who underwent TTSS closure for CGDs ≤25 mm at our center. All patients were assessed through computed tomography and multidisciplinary board discussion before endoscopic treatment. Endoscopic closure was performed using the X‐Tack system, applying a figure‐of‐8 or zig‐zag pattern depending on defect characteristics. Follow‐up included clinical and laboratory assessments at seven days and during long‐term observation. Thirteen patients underwent TTSS closure, achieving a 100% technical success rate. Clinical and laboratory remission at seven days was observed in 76.9% of cases, with a sustained clinical remission in 76.9% after a median follow‐up of 2.5 months. The procedure was effective even in challenging anatomical locations, including post‐surgical anastomotic leaks and narrow lumens. TTSS using the X‐Tack system is a safe and effective approach for small CGD closure, particularly in difficult anatomical sites.

The endoscopic removal of colorectal polyps is a key skill for endoscopists and is considered an essential strategy for preventing colorectal cancer. This document focuses on the therapeutic phase of screening colonoscopy, providing indications on the appropriate treatment for all types of superficial colorectal lesions. Various polypectomy techniques are described and, moreover, recommendations about diagnosis and periprocedural management of antithrombotic therapy are given, in particular in the subgroup of small lesions.

Pancreatic ductal adenocarcinoma (PDAC) presents a unique challenge for researchers due to its late diagnosis caused by vague symptoms and lack of early detection markers. Additionally, PDAC is characterized by an immunosuppressive microenvironment (TME), making it a difficult tumor to treat. While γδ T cells have shown potential for anti-tumor activity, conflicting studies exist regarding their effectiveness in pancreatic cancer. This study aims to explore the hypothesis that the PDAC TME hinders the anti-tumor capabilities of γδ T cells through blockade of cytotoxic functions. For this reason, we chose to enroll PDAC treatment-naive patients to avoid the possibility of therapy modifying the TME. By flow cytometry, our research findings indicate that the presence of γδ T cells among CD45+ cells in tumor tissue is lower compared to CD66+ cells, but higher than in blood. Circulating Vδ1 T cells exhibit a terminal effector memory phenotype (TEMRA) more than Vδ2 T cells. Interestingly, Vδ1 and Vδ2 T cells appear to be more prevalent at different stages of tumor development. In our in vitro culture using conditioned medium derived from Patient-derived organoids ;(PDOs), we observed a shift in expression markers in γδ T cells of healthy individuals toward an activation and exhaustion phenotype, as confirmed by scRNA-seq analysis extracted from a public database. A deeper understanding of γδ T cells in PDAC could be valuable for developing novel therapies aimed at mitigating the impact of the pancreatic tumor microenvironment on this cell population.

Aims The aim of the study was to confirm the long-term efficacy and safety of duodenal uncovered self-expandable metallic stent (SEMS) in malignant gastric outlet obstruction (GOO).

Aims ERCP is considered the first-line treatment for several biliary and pancreatic diseases and is technically demanding in patients with surgically altered anatomy (SAA) like gastrectomy or Rou-ex-Y reconstruction. Afferent loop (AL) intubation, selective biliary or pancreatic cannulation and sphincterotomy are the main issues especially for the absence of available and dedicated devices.

Aims Cholecystectomy is one of the most common surgical procedure performed nowadays (ie, 750,000 cases a year in the United States) and bile duct injury presents a formidable challenge for physicians that requires a prompt treatment in order to avoid chronic cholestasis, recurrent cholangitis, and secondary biliary cirrhosis. Post-cholecystectomy biliary strictures (PCBS) occurring in 0–0.6% of laparoscopic cholecystectomy cases. Endoscopic retrograde cholangiography (ERC) with multiple plastic biliary stents placed sequentially and side-by-side (multistenting – MPs), is a minimally invasive alternative to surgery with good outcome, also in post-transplant biliary stricture [1].