EUS-guided gastroenterostomy (EUS-GE) is rapidly emerging as a pivotal procedure in the management of gastric outlet obstruction due to its advantages over historical comparators such as surgical gastroenterostomy and endoscopic placement of gastroduodenal stents. The ability to create a stable surgical-range connection between 2 lumens, distant from the tumor, with the minimally invasive nature of an endoscopic procedure, offers high clinical efficacy, acceptable safety, and low recurrence rates. However, widespread adoption is impeded by the steep learning curve and lack of standardized methodologies. Like other interventional EUS procedures, EUS-GE utilizes lumen apposing metal stents. Unlike drainage procedures, the target in EUS-GE is a mobile structure with a virtual resting caliber that needs to be distended to create the connection, making misdeployment a significant drawback. This comprehensive illustrated technical review dissects the general and specific technical principles of EUS-GE covering the equipment, scene, settings, and endoscopic signs of correct and incorrect placement. It provides a deeper insight into the wireless simplified EUS-GE technique, the EUS-guided double-balloon-occluded gastrojejunostomy bypass, and the direct technique. Through pragmatic tips, expert advice, and elucidative step-by-step videos, a systematic roadmap for mastering this intricate procedure is presented. By addressing common challenges and providing troubleshooting strategies, this review aims to demystify EUS-GE, equipping practitioners with the tools to achieve reproducible and optimal outcomes.

EUS-guided radiofrequency ablation (EUS-RFA) has gained recognition in the last decade as a preferred alternative method for pancreatic neuroendocrine tumors (PNETS) where surgical resection is contraindicated. However, clinical outcomes of EUS-RFA for PNETS have not been well studied due to variability in procedure techniques and lack of data from good-quality studies. In this meta-analysis, we aim to study the pooled clinical outcomes of EUS-RFA in patients with PNETS. We searched multiple electronic databases and conference proceedings from inception through Jan 2024. The clinical outcomes studied were pooled technical success, clinical success, and adverse events. We also performed a subgroup analysis based on the sample size of the studies. Standard meta-analysis methods were employed using the random-effects model, and heterogeneity was studied by I 2 statistics. We analyzed 11 studies, which included 7 prospective and 4 retrospective studies involving 345 patients (55.3% females with a mean age of 58.73 ± 3.01 years) having a mean tumor size of 13.87 ± 0.82 cm and a mean duration follow-up of 13.36 months. Technical was assessed on per session basis, defined by EUS-guided access to PNETs along with the completion of the planned ablation procedure. Clinical success was defined as symptom resolution in functional lesions or complete ablation/disappearance or absence of imaging (cross-sectional or EUS) enhancement in nonfunctional lesions upon follow-up. The pooled technical success rate of EUS-RFA for PNETS was 97.6% (confidence interval 93.3%-99.2%; I 2 = 0%), and the pooled clinical success rate was 88.2% (76.3%-94.6%; I 2 = 74%). The pooled overall adverse event rate associated with EUS-RFA for PNETS was 19.6% (15.3%-24.9%; I 2 = 0%). The pooled rates of pancreatitis, bleeding, perforation, infection, and abdominal pain associated per procedure were as follows: 9.1% (6.2%-13.2%; I 2 = 0%); 4.0% (1.9%-8.2%; I 2 = 0%); 2.3% (1.0%-5.4%; I 2 = 0%); 2.3% (1.0%-5.4%; I 2 = 0%) and 8.8% (5.4%-14.1%; I 2 = 0%), respectively. There were no reported deaths with EUS-RFA. Due to the presence of small sample-size studies, subgroup analysis based on patient sample size of number (N) >20 and (N) <20 was performed. The pooled clinical success rate for studies with N >20 was 90.6% (68.1%-97.7%), whereas for studies with N <20 was 83.0% (69.3%-91.4%). On meta-analysis of EUS-RFA for PNETS, the overall technical success was 97.6%, the clinical success rate was 88.2%, and the overall adverse events was 19.6%. A key finding of this study was the pooled pancreatitis rate of 9.1%. Future studies are warranted to study methods aimed at pretreatment prophylactic measures to prevent this significant adverse event.

Superficial nonampullary duodenal epithelial tumors (SNADETs) present significant challenges in endoscopic management due to their unique anatomic and histologic features, including thin muscularis propria, abundant vasculature, and Brunner glands. In this study, we aim to evaluate the efficacy and safety of underwater endoscopic mucosal resection (U-EMR) compared with conventional endoscopic mucosal resection (C-EMR) in treating SNADETs ≤20 mm. A systematic search was performed in PubMed, Web of Science, Scopus, and Embase from inception to June 1, 2025. Risk of bias assessment was performed by using the Newcastle-Ottawa scale for cohort studies. Data analysis was conducted using R version 4.2.2 (2022-10-31) and RStudio version 2022.07.2 (2009 to 2022, RStudio, Inc.). Outcomes included clinical success defined as no local recurrence detected on endoscopy after 3 to 6 months of follow-up. Findings from 11 studies involving 1465 patients indicate that U-EMR demonstrates a significantly higher clinical success rate (OR: 2.68, 95% CI: 1.58-4.55; P =0.0003, I2 =0%) and reduced procedure time (MD: -2.74, 95% CI: -5.05 to -0.44; P =0.0198, I2 =96.1%) compared with C-EMR, while showing no statistically significant differences in en bloc resection (OR: 1.42, 95% CI: 0.80-2.53; P =0.2297, I2 =60.2%), R0 resection rates (OR: 1.12, 95% CI: 0.69-1.83; P =0.6477, I2 =61.7%), delayed bleeding, intraoperative perforation, or recurrence rates between the 2 techniques. Despite the comparable safety profiles, the study suggests that U-EMR may offer practical advantages in clinical settings, particularly in terms of efficiency and procedural success; U-EMR is positioned as a potential approach for managing SNADETs.

Background:Colectomy with ileorectal anastomosis (IRA) or proctocolectomy with ileal pouch-anal anastomosis (IPAA) are the 2 standard prophylactic surgical options for patients with familial adenomatous polyposis (FAP). We aimed to compare the functional and long-term outcomes of IRA and IPAA among FAP patients. Methods:We searched large databases to identify studies evaluating the functional outcomes of prophylactic surgical modalities for FAP. The primary outcomes of interest were the functional outcomes of IRA with IPAA, including fecal incontinence, fecal urgency, use of pads for defecation, and use of antidiarrheal drugs. Secondary outcomes included the social outcomes of the 2 procedural modalities, early postoperative adverse events, and long-term adverse events. Results:Compared with IPAA, FAP patients who underwent IRA had a lower frequency of fecal incontinence (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.41-0.76; P<0.001), but were more likely to have fecal urgency (OR 1.53, 95%CI 1.08-2.15; P=0.02). There was no difference in the use of pads and antidiarrheals between the 2 groups (OR 0.55, 95%CI 0.27-1.11; P=0.09; and OR 0.83, 95%CI 0.57-1.22; P=0.35, respectively). Moreover, there was no difference in social outcomes or perioperative adverse events (OR 1.19, 95%CI 0.53-2.68; P=0.68; and OR 0.73, 95%CI 0.50-1.06; P=0.10, respectively). Lastly, IRA had lower long-term complications than IPAA (OR 0.78, 95%CI 0.63-0.97; P=0.03). Conclusion:IRA has better functional outcomes regarding fecal incontinence, a better prophylactic intervention profile, and fewer long-term complications.

Endoscopic submucosal dissection (ESD) is widely used to treat esophageal cancer. Traction-assisted ESD (TA-ESD) has shown promising outcomes, potentially offering better clinical results than conventional ESD (C-ESD). This study compares the efficacy and safety of C-ESD versus TA-ESD in esophageal cancer treatment. We conducted a meta-analysis of six studies involving 694 patients comparing clinical outcomes between the two techniques. Mean dissection time was similar between TA-ESD and C-ESD (71.48 vs 72.02 minutes, p = 0.4). TA-ESD yielded a larger resected area (32.49 cm2 vs 25.05 cm2, p < 0.05). TA-ESD had higher curative resection rates, 52.5% (CI = 42.4-62.4; I2 = 97.8%), compared to C-ESD, 36.6% (CI = 25.4-49.5; I2 = 98.2%); RR 1.46 (CI = 1.15-1.84; p = 0.0018). En-bloc resection rates were 96.9% (CI = 90.9-98.7; I2 = 19.3%) and 96.8% (CI = 82.5-99.5; I2 = 74.6%) with TA-ESD and C-ESD, respectively; RR 1.01 (CI = 0.96-1.09; p = 0.68). R0 resection rates with TA-ESD and C-ESD were 86.6% (CI = 62.3-96.2; I2 = 89.5%) and 77.6% (CI = 42.9-94.1; I2 = 95%), respectively; RR 1.11 (CI = 0.81-1.51; p = 0.28). Total adverse events with TA-ESD and C-ESD were 0.9% (CI = 0.2-3.6; I2 = 0%) and 4.1% (CI = 2.0-8.2; I2 = 95.9%), respectively; RR 0.08 (CI = 0.004-1.36; p = 0.08). Stricture development was more common with TA-ESD, 35.4% (CI = 24.3-48.4; I2 = 96.1%), compared to C-ESD, 19.5% (CI = 11.3-31.6; I2 = 97.5%); RR 1.33 (CI = 1.08-1.65; p = 0.0079). Perforation rates were lower with TA-ESD, 2.0% (CI = 0.5-7.2; I2 = 51.9%), compared to C-ESD, 3.6% (CI = 0.7-17.2; I2 = 85%), with RR 0.55 (CI = 0.32-0.94; p = 0.03). TA-ESD demonstrated higher curative resection rates with larger resected area and lower perforation rates. However, it is associated with a higher risk of stricture formation. Further studies and cost-effective analysis are warranted to determine the optimal treatment approach.

Background:The heterogeneity of inflammatory bowel disease (IBD) and its unpredictable course have always been a challenge for gastroenterologists, with regard to predicting the disease response using endoscopic techniques. Machine learning (ML) models have shown some early promise in predicting treatment response in IBD patients. Methods:We conducted a systematic review of studies investigating the application of ML to predict treatment response and remission in IBD patients. We used the CHARMS checklist for data extraction. Bias was assessed with the PROBAST tool. Results:We included in our review 6 studies that evaluated numbers of IBD patients ranging from 67 to 3004. ML models demonstrated low to moderate predictive accuracy for treatment response and remission (area under the receiver operating characteristic curve: 0.489-0.811; sensitivity: 0.46-0.96; specificity: 0.56-0.98). The studies that utilized ML models with more input variables performed better. Furthermore, only 2 studies performed external validation, and half of the studies demonstrated a substantial risk of bias due to missing data/overfitting, and variability in outcome definition. Conclusions:ML models show considerable promise in predicting treatment outcomes and remission in IBD. However, given the substantial bias in studies so far, future studies should use a standardized methodology, external validation, and an interpretable broader input variable.

Malignant gastric outlet obstruction is a frequent complication of advanced pancreatic and gastric antral malignancies requiring palliative intervention. EUS-guided gastroenterostomy (EUS-GE) has emerged as an alternative to enteral stent placement (ESP), but comparative evidence remains limited. We conducted a pairwise and reconstructed individual patient data meta-analysis of randomized controlled trials and cohort studies comparing EUS-GE with duodenal stent placement in adults with malignant gastric outlet obstruction. Systematic searches of PubMed, Web of Science, Scopus, and the Cochrane Library were performed from inception through November 15, 2025. Stent-related failure was the primary outcome and was analyzed as a time-to-event endpoint using reconstructed individual patient data from published Kaplan-Meier curves. Secondary outcomes included technical success, clinical success, overall survival, length of hospital stay, and adverse events. Random-effects models were applied using hazard ratios and risk ratios (RRs) with 95% confidence intervals (CIs). Ten studies comprising 1359 patients were included. EUS-GE was associated with a significantly lower rate of stent-related failure compared with duodenal stenting (hazard ratio, 0.57; 95% CI, 0.45-0.73; P < 0.001). Technical success was slightly lower with EUS-GE (RR, 0.98; 95% CI, 0.97-1.00; P = 0.028), whereas clinical success was significantly higher than ESP (RR, 1.13; 95% CI, 1.08-1.19; P < 0.001). Overall survival, length of hospital stay, and rates of adverse events were comparable between groups. EUS-GE was associated with lower stent-related failure rates and higher clinical success compared with enteral stenting, with similar survival and safety outcomes. Despite slightly lower technical success rates, EUS-GE remains a durable palliative option in experienced centers, while ESP remains appropriate for short-term palliation.

Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used to treat pancreaticobiliary diseases, but can be technically challenging, leading to occasional unsuccessful attempts. While repeat ERCP is one option in these cases, data on the effectiveness and safety of this practice remain limited. Thus, we conducted a systematic review and meta-analysis to assess outcomes of repeat ERCP after initial unsuccessful attempt. MEDLINE, Embase, and CENTRAL were searched on February 28, 2025. We included randomized trials and observational studies reporting on outcomes of repeat ERCP following an initial unsuccessful attempt, with the primary outcome being technical success of cannulation, and secondary outcomes including adverse events (AEs). Random-effects models were used to pool data, and heterogeneity was assessed through the I2 statistic. A total of 22 studies involving 1514 patients with a median age of 62 years were included. The majority of studies were conducted at a single center (86.4

Acute cholecystitis affects ∼200,000 individuals annually in the United States, with laparoscopic cholecystectomy as the gold standard treatment. However, in high-risk surgical candidates, alternative drainage methods are necessary. Percutaneous transhepatic gallbladder drainage (PT-GBD) has traditionally served as the primary alternative intervention, offering rapid decompression, but is limited by a negative impact on the patient's quality of life, the risk of long-term or even permanent tube placement, adverse events, and high recurrence rates. Endoscopic approaches, such as endoscopic transpapillary gallbladder drainage (ET-GBD) and, more recently, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), have emerged as viable alternatives to PT-GBD. EUS-GBD, first introduced in 2007, offers technical and clinical outcomes comparable to PT-GBD with fewer adverse events, shorter hospital stays, and lower rates of recurrence. The introduction of lumen-apposing metal stents (LAMS) has revolutionized EUS-GBD, simplifying deployment and enabling subsequent internal gallbladder access, which allows additional interventions such as cholecystoscopy and stone removal. EUS-GBD is now supported by international guidelines, and 1 device has achieved FDA approval for the management of acute cholecystitis in nonsurgical candidates. Proper patient selection is essential, guided by multidisciplinary evaluation, with EUS-GBD contraindicated in specific scenarios such as gallbladder perforation, coagulopathy, and large-volume ascites. Technical considerations include choice of access site (transgastric versus transduodenal), stent type, and procedural route [direct (freehand) or wire-guided]. Postprocedural care and stent management remain variable and nonstandardized. Emerging data suggest that interval cholecystectomy can still be performed safely after EUS-GBD. As adoption of EUS-GBD with LAMS expands, structured training and standardization of practice are crucial to optimizing outcomes.

INTRODUCTION:Gastroparesis (GP) is a chronic gastrointestinal motility disorder that imposes a substantial clinical and economic burden. For patients with refractory GP, gastric peroral endoscopic myotomy (G-POEM) and botulinum toxin injection (BTI) are emerging therapies with differing efficacy profiles and procedural costs. Given these differences, we evaluated the cost-effectiveness of G-POEM versus BTI for refractory GP. METHODS:We conducted a cost-effectiveness analysis using a decision tree model informed by randomized trial data from a US health care system perspective over 3- and 12-month time horizons. Procedural costs, adverse events, and repeat BTI sessions were incorporated. Quality-adjusted life-years (QALYs) were estimated from the Gastrointestinal Quality of Life Index (GIQLI) and from Short Form-12 (SF-12) scores. Cost-effectiveness was assessed using incremental cost-effectiveness ratios (ICERs) at a willingness-to-pay (WTP) threshold of $100,000/QALY. RESULTS:The base-case analysis was modeled on a 48.1-year-old patient with refractory GP-defined as persistent symptoms despite 6 months of medical therapy and a GP Cardinal Symptom Index score >2. At 3 months, G-POEM was associated with higher costs and marginally greater effectiveness than BTI (ICER $288,341/QALY), making BTI the cost-effective strategy in the short term. At 12 months, incorporating repeat BTI, G-POEM became the cost-effective option, with BTI yielding an ICER of $334,046/QALY relative to G-POEM. Sensitivity analyses identified clinical success rates and procedural costs as primary cost-effectiveness drivers. At 12 months, the cost-effectiveness acceptability curve showed G-POEM was cost-effective in most simulations at lower WTP thresholds, with BTI favored only at thresholds near $335,000/QALY. CONCLUSION:While BTI is more cost-effective in the short term, the cumulative costs of repeat sessions make G-POEM the more economically favorable strategy over 12 months. Improving clinical success rate by optimizing patient selection and refining procedural techniques could further improve cost-effectiveness profiles.