Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an alternative treatment of acute cholecystitis, though there is limited literature on its use in surgically altered anatomy. A 64-year-old woman with gastric adenocarcinoma and Billroth II reconstruction presented with clinical signs and symptoms of acute cholecystitis, cholestatic liver function tests, and an hepatobiliary iminodiacetic acid scan supporting the diagnosis of acute calculous cholecystitis. She was deemed a nonsurgical candidate due to medical comorbidities; therefore, EUS-GBD was pursued. Our case highlights technical modifications to EUS-GBD to navigate challenges in Billroth II anatomy and supports the addition of this technique for high-risk surgical patients.

Background: Gastric peroral endoscopic myotomy (G-POEM) is an effective, minimally invasive treatment for refractory gastroparesis. However, limited data exists on its performance by early-career endoscopists (1-3 years post-advanced endoscopy training). This multicenter study assessed the technical and clinical outcomes of G-POEM performed by early-career endoscopists, providing insight into their procedural efficacy and safety.Methods: This retrospective study analyzed patients who underwent G-POEM performed by early-career endoscopists across multiple US centers. Patient demographics, procedural characteristics, and follow-up data were collected. Primary outcomes included technical success and clinical response (defined as a >= 1-point improvement in the Gastroparesis Cardinal Symptom Index [GCSI]). Secondary outcomes included adverse events, hospital length of stay, and the need for reintervention.Results: A total of 103 patients (mean age 48.9 +/- 15.2 years; 75.5% female) underwent G-POEM by seven early-career endoscopists. Gastroparesis etiologies included idiopathic (36.9%), diabetes (32%), and post-transplant (13.6%). Technical success was 100%, and clinical response was 73.8%, with comparable efficacy between severe-to-very-severe and mild-to-moderate cases (79% vs 69.2%; P = .26). 23.3% of patients were discharged in the same day as the procedure and the mean hospital stay was 1.22 +/- 0.59 days. Adverse events were minimal, with no major complications. Nine patients (8.7%) required reintervention.Conclusions: G-POEM performed by early-career endoscopists is safe and effective, with high technical success and clinical response rates. Comparable efficacy was observed across gastroparesis severity levels. Larger studies are needed to further evaluate outcomes and guide training and practice.

Background and Aims: The application of endoscopic suturing has revolutionized defect closures. Conventional over-the-scope suturing necessitates removal of the scope, placement of the device, and reinsertion. A single channel, single sequence, through-the-scope suturing device has been developed to improve this process. This study aims to describe the efficacy, feasibility, and safety of a through-the-scope suturing device for gastrointestinal defect closure. Methods: This was a retrospective multicenter study involving 9 centers of consecutive adult patients who underwent suturing using the X-Tack Endoscopic HeliX Tacking System (Apollo Endosurgery). The primary outcomes were technical success and long-term clinical success. Secondary outcomes included adverse events, recurrence, and reintervention rates. Results: In all, 56 patients (mean age 53.8, 33 women) were included. Suturing indications included fistula repair (n=22), leak repair (n=7), polypectomy defect closure (n=12), peroral endoscopic myotomy (POEM) site closure (n=7), perforation repair (n=6), and ulcers (n=2). Patients were followed at a mean duration of 74 days. Overall technical and long-term clinical success rates were 92.9% and 75%, respectively. Both technical and clinical success rates were 100% for polypectomies, POEM-site closures, and ulcers. Success rates were lower for the repair of fistulas (95.5% technical, 54.5% clinical), leaks (57.1%, 28.6%), and perforations (100%, 66.7%). No immediate adverse events were noted. Conclusion: This novel, through-the-scope endoscopic suturing system, is a safe and feasible method to repair defects that are ≤3 cm. The efficacy of this device may be better suited for superficial defects as opposed to full-thickness defects. Larger defects will need more sutures and probably a double closure technique to provide a reinforcement layer.

Background: Endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) is frequently used to obtain core samples of solid lesions. Here, we describe and evaluate a novel hydrostatic stylet (HS) technique designed to optimize core sample acquisition, reporting diagnostic yield, efficacy, and safety relative to the conventional stylet slow-pull (SP) technique. Methods: A novel HS technique was developed and validated retrospectively. Consecutive patients who underwent EUS-FNB with core biopsy of solid lesions through either the HS or SP technique between January 2020 and April 2022 were included. Exclusion criteria included cystic lesions, nonlesional liver biopsies, and specimens sent for cytologic analysis only. Patient and lesion characteristics, number of passes, sample adequacy, and adverse events were compared between the two techniques. Results: A total of 272 patients were included with 138 in the HS group and 134 in the SP group. Lesion size and anatomic distribution were similar in both groups. Compared with the SP approach, the HS technique demonstrated significantly higher sample adequacy (97.8% vs 83.6%, P < 0.001), higher sensitivity (97.1% vs 89.7%, P = 0.03), and lower mean number of passes (1.2 vs 3.3, P < 0.001). Rates and severity of adverse events in the HS group were comparable to the SP group and existing literature. Similar associations were observed in pancreatic and nonpancreatic lesion subanalyses. Conclusions: The novel HS technique demonstrated excellent biopsy sample adequacy and diagnostic yield while requiring fewer passes to obtain diagnostic specimens compared with a conventional EUS-FNB approach. Further prospective evaluation is needed to confirm these pilot findings and optimize EUS-FNB acquisition techniques.

Obesity and its associated comorbid conditions have been increasing globally. Endoscopic bariatric and metabolic therapies (EBMTs) were initially designed to replicate bariatric surgery physiology for those who are not or choose not to be surgical candidates. Now, newer procedures target the complicated pathophysiology underlying obesity and its comorbidities. EBMT has been categorized based on its therapeutic target (stomach or small intestine), but innovations have expanded to include extraintestinal organs including the pancreas. Gastric EBMTs, namely space-occupying balloons, gastroplasty with suturing or plication, and aspiration therapy, are primarily used for weight loss. Small bowel EBMTs are designed to cause malabsorption, epithelial endocrine remodeling, and other changes to intestinal physiology to ultimately improve the metabolic comorbidities of obesity rather than induce weight loss alone. These include duodenal mucosal resurfacing, endoluminal bypass sleeves, and incisionless anastomosis systems. Extraluminal or pancreatic EBMT is aimed to restore the production of normal pancreatic proteins that are involved in the progression of type 2 diabetes. This review discusses the current and new technologies of metabolic bariatric endoscopy, their pros and cons, and areas for future research.

Obesity is a complex disease process, which often requires multifactorial, patient-tailored strategies for effective management. Treatment options include lifestyle optimization, pharmacotherapy, endobariatrics, and bariatric metabolic endoscopy. Obesity-based interventions can be challenging in patient populations with severe obesity, particularly post-gastric bypass. We report the case of a non-surgical patient with a failed remote open gastric bypass, who underwent an endoscopic small bowel diversion procedure, resulting in partial caloric diversion, via the creation of an EUS-guided jejunocolostomy (EUS-JC). The procedure is an extension of prior reported EUS-guided and magnet-based small bowel bypass procedures, in this case, for the purposes of weight loss (Kahaleh et al., 1; Jonica et al. Gastrointest Endosc. 97(5):927-933, 2; Machytka et al. Gastrointest Endosc. 86(5):904-912, 3;). The procedure was performed without peri-procedural complications, with effective weight loss during follow-up. Endoscopic bariatric interventions that target the small bowel, such as EUS-JC, offer promising tools for obesity management and should be studied further. Numerous factors including lifestyle, psychosocial, genetic, behavioral, and secondary disease processes contribute to obesity. Severe obesity (defined as a BMI > 50 kg/m2) is associated with increased morbidity and mortality with a significantly reduced response to treatment (Flegal et al. JAMA. 309(1):71–82, 4;). Weight regain can be noted in up to 50

Video 1Hydrostatic stylet technique for the performance of EUS-guided liver biopsy.

The endoscopy suite is the epicenter of hands-on training for gastroenterologists. There is a paucity of literature on the physical and intangible set up of the endoscopy laboratory to optimize education. Although no single design can optimize every aspect of training, there are general principles that may allow for the planning of an environment to prioritize training. This Editor and Trainees Perspectives article discusses key considerations of endoscopy unit design to facilitate trainee education by allowing for trainee preparation for endoscopy, learning during procedures, feedback from trainers, and reflection. We present this by using the following considerations: preparation spaces, sightlining within rooms, optimization of in-room communication, feedback rooms, in situ simulation, and education resource spaces to present a structure to allow fellowship leadership and endoscopy managers to support a safe, efficient, and cohesive learning environment for all levels of training.

Bariatric surgery is associated with complications that can be refractory to intervention in malnourished patients. We present a patient with a gastrocutaneous fistula, which occurred as a complication of Roux-en-Y gastric bypass and was initially refractory to endoscopic closure but resolved after nutritional optimization.

Background and study aims Little is known about outcomes of advanced endoscopic resection (ER) for patients with inflammatory bowel disease (IBD) with dysplasia. The aim of our meta-analysis was to estimate the safety and efficacy of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for dysplastic lesions in patients with IBD. Methods We performed a systematic review through Jan 2021 to identify studies of IBD with dysplasia that was treated by EMR or ESD. We estimated the pooled rates of complete ER, adverse events, post-ER surgery, and recurrence. Proportions were pooled by random effect models. Results Eleven studies including 506 patients and 610 lesions were included. Mean lesion size was 23 mm. The pooled rate of complete ER was 97.9 % (95% confidence interval [CI]: 95.3% to 99.7%). The pooled rate of endoscopic perforation was 0.8% (95% CI:0.1% to 2.2%) while bleeding occurred in 1.6% of patients (95 %CI:0.4 % to 3.3%). Overall, 6.6% of patients (95 %CI:3.6 % to 10.2%) underwent surgery after an ER. Among 471 patients who underwent surveillance, local recurrence occurred in 4.9% patients (95% CI:1.0% to 10.7%) and metachronous lesions occurred in 7.4% patients (95 %CI:1.5 % to 16%) over a median follow-up of 33 months. Metachronous colorectal cancer (CRC) was detected in 0.2% of patients (95 %CI:0 % to 2.2%) during the surveillance period. Conclusions Advanced ER is safe and effective in the management of large dysplastic lesions in IBD and warrants consideration as first-line therapy. Although the risk of developing CRC after ER is low, meticulous endoscopic surveillance is crucial to monitor for local or metachronous recurrence of dysplasia.

BACKGROUND AND AIMS: Endoscopic ablation can eradicate neoplastic Barrett's esophagus (BE) without visible lesions. Cryoballoon ablation (CBA) is an established but relatively newer ablative technique that can eliminate BE but data on the durability of its treatment effects are lacking. We assessed the durability of CBA treatment for neoplastic BE. METHODS: We performed a single-center cohort study of consecutive BE patients with confirmed low-grade dysplasia, high-grade dysplasia or intramucosal cancer treated with CBA to eradicate all BE. We excluded patients with prior ablative therapy. Visible lesions were removed with endoscopic mucosal resection prior to CBA. Outcomes included complete eradication of dysplasia (CE-D) and complete eradication of intestinal metaplasia (CE-IM) at 1 year, durability at 2 and 3 years after initial ablation, cumulative recurrence rate of dysplasia and IM, and rate of neoplastic progression. RESULTS: Fifty-nine patients (55.9% with high-grade dysplasia; 20.3% with prior endoscopic mucosal resection) were tracked for a median of 54.3 months. CE-D and CE-IM at 1 year were 94.6% (53/56) and 75% (42/56), respectively. Allowing for retreatment, rates of maintained CE-D and CE-IM for those who have achieved CE-D or CE-IM were 100% (53/53) and 98% (47/48) at 2 years; 100% (45/45) and 98% (40/41), at 3 years, respectively. Cumulative recurrence rate was 1.9% (1/53) for dysplasia and 14.6% (7/48) for IM (not allowing for retreatment). There was no neoplastic progression. CONCLUSION: In treatment-naive patients with dysplastic BE, CBA is a durable endoscopic eradication therapy but endoscopic surveillance after eradication is still warranted.

Outcomes of Endoscopic Ultrasound-Guided Fine Needle Biopsy Using a Novel Hydrostatic Stylet Technique Patrick T. Magahis, BA1, Donevan Westerveld, MD2, Malorie Simons, MD2, David L. Carr-Locke, MD2, Kartik Sampath, MD2, Reem Z. Sharaiha, MD, MSc2, SriHari Mahadev, MD, MS2. Joan & Sanford I. Weill Medical College of Cornell University, New York, NY; New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY.