Background and aims: Cricopharyngeal bar-related dysphagia predominantly affects elderly patients with significant comorbidity, in whom surgical myotomy carries substantial risk. Cricopharyngeal per-oral endoscopic myotomy (C-POEM) is an endoscopic alternative; however, data in elderly populations remain limited. We evaluated the feasibility, safety, and efficacy of C-POEM in patients aged ≥70 years. Methods: This prospective study included patients aged ≥70 years who underwent C-POEM between March 2023 and October 2025. Symptoms assessed using the Sydney Swallow Questionnaire (SSQ) at baseline, 4–6 weeks, and 3 months. Objective outcomes measured using EndoFLIP-derived distensibility index (DI) before C-POEM and 3 and 12 months post C-POEM. Technical success, clinical success, adverse events, length of stay were recorded. Results: Twelve patients (median age 79 years, IQR 76.5–83.3; median Charlson Comorbidity Index 6, (IQR 5–7) underwent C-POEM. Technical success was 100%. Clinical success was observed in all patients at 3 months; sustained at 12 month follow up. Median SSQ improved from 897 (IQR 686–1103) to 60 (IQR 20–269; p=0.001), and median UES DI improved from 1.6 (IQR 1.4–2.0) to 4.3 mm²/mmHg (IQR 3.6–5.2; p=0.001). Median length of stay was 3 days (IQR 2–4.5). No procedure-related major adverse events were observed. At a median follow-up of 55 weeks, symptomatic improvement was sustained. Conclusions: In this elderly cohort, C-POEM was feasible, safe, and associated with significant symptomatic and physiological improvement. These findings support C-POEM as a promising option for cricopharyngeal bar-related dysphagia in elderly patients. Larger comparative studies are required to define its role relative to established therapies.

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: Acute GI bleeding (AGIB) can be associated with significant mortality. Topical endoscopic hemostatic powders (TEHPs) have become established as one of the endoscopic treatment modalities for AGIBs. There is no dedicated consensus on the role of TEHPs in the GIB algorithm. Objective: We aimed to develop expert-led consensus statements to provide guidance on the use of TEHPs in AGIBs. Design: A team of 15 experts in the field of acute AGIB from 8 countries was recruited to construct consensus statements on the use of TEHPs. A first meeting was held to define statements. Using the RAND/UCLA appropriateness method, they voted on statements by combining expert collective judgment and best available evidence in a 2-round voting process. Statements were rated on a 9-point interval scale (1 to 9). Four statistical methods were used to delineate statements that satisfied all criteria of appropriateness. For a statement to be considered appropriate, it had to meet all statistical definitions of appropriateness showing consensus agreement. Results: Following round 2, 11 final statements were scored as appropriate, reaching overall consensus. Key recommendations include that TEHPs are effective in achieving hemostasis in malignancy-related GIBs, can be used as “salvage” therapy for nonvariceal GIBs and can be used as a bridge to definitive nonendoscopic therapy. Conclusion: We present a dedicated international consensus statement aimed at providing guidance to clinicians on best practice use of TEHPs in patients with AGIBs. There was consensus among the panel on the need for future trials to compare the use of different hemostatic powders in patients presenting with GIB.

Background: Patients with inflammatory bowel disease (IBD) have an increased risk of colorectal cancer. Endoscopic surveillance is recommended but is challenging due to the presence of active inflammation, flat dysplasia and inflammatory pseudopolyposis. CAD-EYE, an artificial intelligence (AI) powered endoscopic module by FUJIFILM, optically characterises lesions in real time. The aim of this study was to evaluate the accuracy of CAD-EYE in IBD surveillance. Methods: Ninety-seven lesions were identified from 38 patients with IBD, undergoing surveillance at a single centre. Non-magnified, still images of lesions identified during the procedure were captured, followed by characterisation by CAD-EYE as neoplastic or hyperplastic (non-neoplastic) prior to resection. Inflammatory pseudopolyps were imaged and only resected based on the physician’s discretion. Images of lesions identified were characterised by two expert IBD clinicians. The accuracy of CAD-EYE was assessed for all lesions (composite of histology for resected lesions and expert-verified non-resected pseudopolyps). For the resected lesions, the accuracy of CAD-EYE was compared to expert characterisation. Results: CAD-EYE correctly characterised 92/97 lesions (94.8%) with a sensitivity of 80.0%, specificity of 97.6%, positive predictive value of 85.7% and negative predictive value of 96.4% for neoplastic lesions. For resected lesions, diagnostic accuracy was similar between CAD-EYE (93.0%) and expert characterisation (88.4%), with no statistically significant differences in sensitivity. Conclusion: CAD-EYE demonstrated its utility in IBD surveillance with excellent accuracy in the characterisation of lesions, including inflammatory pseudopolyps. Larger studies are required to confirm these findings, particularly for flat dysplasia.

Three-dimensional (3D)-printed models have been extensively applied in operative planning and medical education to directly visualize anatomical structures and gain tactile experiences. Although studies are available on the use of 3D printing technology in the gastrointestinal tract, there is a lack of detailed analyses of its current applications, particularly in the context of 3D-printed gastrointestinal tract models for surgical planning and education. Therefore, this systematic review aims to analyze the current application of 3D printing technology in gastrointestinal tract diseases, focusing on the techniques, materials, anatomical structures, and the impact of its use. A systematic search was conducted across the PubMed/Medline, Scopus, and Embase databases adhering to the PRISMA 2020 protocols. A total of 25 articles were identified as eligible for review. The findings revealed that 3D-printed gastrointestinal tract models can enhance technical skills, knowledge, and confidence in performing gastrointestinal surgery or other procedures in a risk-free environment. However, most studies (76%) were limited by their small sample size, with only 1–3 models printed, and lacked comparative analysis. The influence of this procedure on actual patients was not followed up; hence, the impact of this simulator on clinical practice outcomes remains unknown. Most of the 3D-printed models were designed for a single procedure, limiting their widespread application. Future research should focus on developing more realistic printed materials to accurately simulate real organs, including large sample sizes; comparing 3D-printed models with other simulators or other visualization modalities such as virtual reality and mixed reality; and investigating their impact on actual gastrointestinal procedures.

Abstract Background Patients with inflammatory bowel disease (IBD) have an increased risk of developing dysplasia and colorectal cancer. Endoscopic surveillance is recommended, however, key quality performance metrics for surveillance are lacking. The aim of this study was to perform a systematic review and meta-analysis of the prevalence of dysplasia in patients undergoing IBD surveillance in the era of high-definition colonoscopy, in order to determine a target dysplasia detection rate (DDR) which can be used as a quality measure. Methods The trial protocol was registered with PROSPERO (CRD42024537521). An extensive search was performed of Medline, EMBASE, Web of Science and Cochrane Library databases to identify all prospective published studies (randomised controlled trials (RCT), observational cohort studies and crossover/tandem studies) of patients undergoing IBD dysplasia surveillance using high-definition colonoscopes. Several surveillance modalities were included (high-definition white light, dye spray chromoendoscopy, virtual chromoendoscopy, full spectrum endoscopy, autofluorescence and endomicroscopy with chromoendoscopy). Two reviewers independently evaluated studies for eligibility and methodological quality. All variables of interest were collected on a standardised form. A random-effects model was used to calculate an estimate of the pooled prevalence of dysplasia defined as the dysplasia detection rate. An estimate of the pooled prevalence of cancer was also determined. A sub-group analysis was performed, by surveillance modality, for all non-crossover/tandem studies where data was available. Results Twenty-five studies (11 RCT, 8 tandem/crossover studies and 6 observational cohort studies) were included, from a total of 3029 abstracts screened. For the calculation of dysplasia and cancer prevalence rates, a total of 4136 patients (55.2% male), mean age 49.4 years and mean disease duration 16.5 years met inclusion criteria. The pooled dysplasia detection rate was 16.5% (95% CI, 14% to 19%). (Figure 1). The pooled cancer detection rate was 0.1% (95% CI, 0 to 0.2%). Subgroup analysis by surveillance modality demonstrated similar pooled dysplasia detection rates with slight differences in mean procedural withdrawal times. (Table 1). Conclusion This is the first study that attempts to measure dysplasia detection rates in a systematic fashion in patients undergoing IBD surveillance colonoscopy in the high-definition colonoscopy era. The pooled dysplasia detection rate was 16.5% and cancer detection rate was 0.1%. We propose a conservative estimate dysplasia detection rate of 14% (the lower confidence limit in our study) as a target quality metric for IBD surveillance.

Introduction:Image enhanced endoscopy (IEE) can augment the detection of colorectal cancer (CRC) and its precursor lesions, potentially reducing incidence and mortality. Early data on texture and color enhancement imaging (TXI) support its use for neoplasia screening. This study aimed to systematically review and perform a meta-analysis to assess the impact of TXI on colonic adenoma detection. Methods:The systematic review and meta-analysis followed PRISMA guidelines. Studies comparing TXI with white light imaging (WLI) were eligible for inclusion. Searches were conducted through relevant databases and major conferences up to July 1, 2024. The primary outcome was ADR, with secondary outcomes including polyp detection rate (PDR), mean number of adenomas per patient (MAP), and size, location, morphology, and withdrawal time. Results:From 1270 results, 4 studies were included in the meta-analysis (n = 5481). TXI significantly increased ADR compared to WLI (55.8% vs. 47.8%, RR 1.24, p < 0.001), PDR (63.7% vs. 54.7%, RR 1.23, p < 0.001), and MAP (mean difference 0.41, p = 0.005). and improved detection of proximal lesions (MD 0.21, 95% CI [0.15-0.27], p < 0.001, I 2 = 0%). Pooled withdrawal times were not different between groups, with no differences between endoscopist experience or quality of bowel preparation, where reported. Sub-analysis further demonstrated superiority of TXI, with an absolute difference in ADR of 14.2%. Conclusion:TXI significantly improves ADR, PDR, and MAP compared to WLI, highlighting its potential to enhance CRC screening efficacy without impact from user experience, bowel prep, or withdrawal times. TXI is a useful and practical adjunct to enhance the detection of colonic neoplasia.

Quality standards for upper gastrointestinal (UGI) endoscopy are required to identify key quality indicators that are relevant to Australasian endoscopic practice and local patient populations. Such standards will promote equitable access to high-quality UGI endoscopy for appropriate indications across Australia and Aotearoa New Zealand. The Gastroenterological Society of Australia (GESA) Endoscopy Faculty's quality of UGI endoscopy working group conducted a review of published guidelines on quality standards in UGI endoscopy. A literature search was performed using the MEDLINE database, with further references sourced from bibliographies of published papers. Recommendations from international guidelines and available evidence were reviewed, and their relevance to the Australian clinical context was assessed. The working group then formulated a position statement on quality assurance in UGI endoscopy in Australian practice. A further iterative process involving the Endoscopy Guidance Group for New Zealand (EGGNZ) and the Royal Australasian College of Surgeons (RACS) culminated in the final recommendations for practice in Australia and Aotearoa New Zealand. The recommendations in this position statement are categorized into preprocedural, intraprocedural, and postprocedural. As UGI endoscopy examines several anatomical structures and is performed for a wider range of indications than colonoscopy, disease-specific intraprocedural recommendations for common benign and premalignant conditions of the UGI tract are also presented. This GESA initiative was undertaken in collaboration with the RACS and endorsed by GESA, RACS, the Royal Australasian College of Physicians, and EGGNZ, membership of which includes the New Zealand Society of Gastroenterology, the New Zealand Association of General Surgeons, and other local endoscopy stakeholders.

Dear Editor, Small extracellular vesicles(sEVs)are membranous nanovesicles involved in intercellular communication that carry distinct cell-derived molecular cargo.1 We previously characterised sEVs from human non-malignant pancreatic duct cells(HPDE,hTERT-HPNE)and from PDAC cells(AsPC-1,BxPC-3 and MIA PaCa-2)2 and identified protein cargo-specific to cancer-associated sEVs.2 Among the proteins uniquely expressed in cancer sEVs but not in those from non-malignant cells,we focused on SLC5A3,also known as SMIT1(sodium-coupled Myo-inositol transporter-1).

Pancreatic ductal adenocarcinoma (PDAC) is among the most aggressive malignancies, with dismal survival rates. Cannabinoids have shown anticancer properties in various cancers, including PDAC. This study aimed to evaluate the anticancer effects of cannabinoids, individually and in combination, and to elucidate their mechanisms of action in a murine PDAC model (KPC mice, KRASWT/G12D/TP53WT/R172H/Pdx1-Cre+/+) that mimics human disease. Additionally, the study explored the potential link between cannabinoid action, gut microbiota modulation, and bile acid (BA) metabolism. PDAC cell lines and KPC mice were treated with delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), either as monotherapy or in combination. Faecal pellets, caecal contents, plasma, and tissues were collected at the survival endpoint for analysis. BA profiling was performed using mass spectrometry, and the faecal microbiota was characterised by sequencing the V3-V4 region of the 16S rRNA gene. While CBD and THC synergistically reduced cell viability in PDAC cell lines, only CBD monotherapy improved survival in KPC mice. Extended survival with CBD was accompanied by changes in gut microbiota composition and BA metabolism, suggesting a possible association. Notably, the effects of CBD were different from those observed with THC alone or in combination with CBD. The study highlights a distinct role for CBD in altering BA profiles, suggesting these changes may predict responses to cannabidiol in PDAC models. Furthermore, the findings propose that targeting BA metabolism could offer a novel therapeutic strategy for PDAC.

Barrett's Esophagus (BE) is a key precursor to esophageal adenocarcinoma that requires quality management to improve patient outcomes. This article explores current evidence-based practices in the diagnosis, surveillance, and endoscopic treatment of BE, with a focus on quality indicators including biopsy protocols, dysplasia detection techniques, and adherence to surveillance intervals. We examine emerging technologies, such as image-enhanced endoscopy and artificial intelligence, with emphasize on the importance of training, audit, and standardization in clinical practice. By aligning care with established quality benchmarks, clinicians can enhance the early detection and prevention of neoplastic progression in patients with BE.

INTRODUCTION:The performance of a high quality esophagogastroduodenoscopy (EGD) is dependent on the mucosal cleanliness. Recently, the Polprep: Effective Assessment of Cleanliness in EGD (PEACE) scale was created to assess the degree of mucosal cleanliness during EGD. The aim of this study was to validate this scoring system in a cohort of international endoscopists. METHODS:In total, 39 EGD videos, with different degrees of mucosal cleanliness were retrieved from a previously conducted prospective trial. All experts rated the cleanliness of the mucosa on each video using the PEACE scale. To evaluate agreement of all scores (0-3), intraclass correlation coefficient 2.1 was used. The agreement on adequate (scores 2 and 3) and inadequate (scores 0 and 1) cleanliness was assessed using kappa values. RESULTS:Videos evaluating esophagus, stomach, and duodenum cleanliness were reviewed by 16 endoscopists. The PEACE scores demonstrated good agreement (intraclass correlation coefficient 0.82, 95% CI 0.75-0.89), especially for esophagus (0.84; 95% CI 0.71-0.95) and stomach (0.81; 95% CI 0.69-0.91), while agreement was moderate for the duodenum (0.69; 95% CI 0.51-0.87). The agreement was similar between Eastern (0.86; 95% CI 0.79-0.92) and Western experts (0.80; 95% CI 0.72-0.88). Similarly, agreement regarding adequate cleanliness was comparable between Eastern (0.70; 95% CI 0.55-0.85) and Western (0.74; 95% CI 0.64-0.84) endoscopists being overall 0.75 (95% CI 0.65-0.85). DISCUSSION:The PEACE scoring system is a simple and reliable scale to assess the cleanliness during EGD. The score is now validated among international experts with high concordance, justifying its use in clinical practice.

There is growing interest in establishing quality indicators (QIs) for endoscopic screening and surveillance in Barrett's esophagus (BE). QIs are objective, measurable, and evidence‐based metrics that are applicable in a health‐care setting to monitor a process and identify key performance indicators (KPIs) to achieve defined goals. In the Barrett's endoscopy setting, QIs can offer a standardized approach to monitor and maintain high‐quality endoscopy for BE screening and surveillance that will allow measuring performance of an endoscopist as an individual, a group, or a facility. Since BE is an endoscopically identifiable premalignant condition with histological corroboration, adherence to QIs is paramount for the early and accurate detection of dysplasia and neoplasia. It is the holy grail for BE screening and surveillance. Although several suggested QIs for Barrett's endoscopy exist, issues remain in determining the most appropriate ones. These issues include inconsistent use of terminology, unclear definitions, and a scarcity of studies linking these QIs with relevant patient outcomes, making it difficult for clinicians to understand the concept and clinical importance. Hence, there is an urgent need to determine what should constitute appropriate QIs for Barrett's endoscopy, clearly define items used in the QIs, and identify ways to measure these KPIs. Ultimately, well‐defined and validated QIs will contribute to clinically effective, safe, timely, and patient‐focused care. In this review, we summarize recent literature and discuss four proposed QIs: (i) neoplasia detection rate; (ii) postendoscopy Barrett's neoplasia; (iii) Barrett's inspection time; and (iv) adherence to the Seattle biopsy protocol.

AbstractBackground and AimEndoscopic submucosal dissection (ESD) has become the treatment of choice for many superficial gastric neoplasms. Clinical outcomes are increasingly comparable between Japanese and Western series; however, data are lacking on the validity of risk stratification tools in Western cohorts. We aimed to evaluate clinical outcomes, explore risk stratification, and compare our data with published Western series.MethodsWe conducted a retrospective, observational cohort study in a single tertiary referral center over a 13‐year period. Primary outcomes were rates of en bloc, complete (R0) and curative resection. Secondary outcomes included adverse events, recurrence, metachronous lesions, eCura grades, and ESGE criteria. A comparative analysis was performed with existing published series from Western centers.ResultsTotally 112 patients were included in the study cohort. 50.9% were male, 87.5% Caucasian, and median age was 75.5 years (IQR 14.3 years). Lesions were predominantly antral (36.6%) or body (35.7%); median size 20 mm (IQR 15 mm). Rates of en bloc, R0 resection, and curative resection were 96.4%, 89.3%, and 78.6% (identical between eCura and ESGE), respectively. Adverse events occurred in 5.8%, recurrence in 0%, and metachronous lesions in 9.9%. Our data compared favorably with a review existing Western series, which illustrates increasing adoption of ESD and stable outcomes over time.ConclusionESD represents a safe and effective method of treatment for gastric neoplasia in the Western setting. This study highlights the potential for excellent outcomes in a single center with a heterogeneous patient cohort and supports the use of eCura in guiding post procedural management.

Background & aimsCharacterization of visible abnormalities in Barrett esophagus (BE) patients can be challenging, especially for unexperienced endoscopists. This results in suboptimal diagnostic accuracy and poor inter-observer agreement. Computer-aided diagnosis (CADx) systems may assist endoscopists. We aimed to develop, validate and benchmark a CADx system for BE neoplasia.MethodsThe CADx system received pretraining with ImageNet with consecutive domain-specific pretraining with GastroNet which includes 5 million endoscopic images. It was subsequently trained and internally validated using 1,758 narrow-band imaging (NBI) images of early BE neoplasia (352 patients) and 1,838 NBI images of non-dysplastic BE (173 patients) from 8 international centers. CADx was tested prospectively on corresponding image and video test sets with 30 cases (20 patients) of BE neoplasia and 60 cases (31 patients) of non-dysplastic BE. The test set was benchmarked by 44 general endoscopists in two phases (phase 1: no CADx assistance; phase 2: with CADx assistance). Ten international BE experts provided additional benchmark performance.ResultsStand-alone sensitivity and specificity of the CADx system were 100% and 98% for images and 93% and 96% for videos, respectively. CADx outperformed general endoscopists without CADx assistance in terms of sensitivity (p=0.04). Sensitivity and specificity of general endoscopist increased from 84% to 96% and 90 to 98% with CAD assistance (p<0.001), respectively. CADx assistance increased endoscopists’ confidence in characterization (p<0.001). CADx performance was similar to Barrett experts.ConclusionCADx assistance significantly increased characterization performance of BE neoplasia by general endoscopists to the level of expert endoscopists. The use of this CADx system may thereby improve daily Barrett surveillance.