BACKGROUND:Endoscopic sleeve gastroplasty (ESG) is an established endoscopic bariatric therapy. Two main platforms are currently used in clinical practice: the OverStitch Endoscopic Suturing System (OESS) and the triangulation Endomina System (ES). Comparative data regarding their technical performance and suture durability remain limited. This experimental study aimed to compare both systems in terms of usability, safety, and durability of full-thickness sutures. METHODS:In this prospective comparative animal study, six adult minipigs were randomized to ESG using either OESS or ES (three animals per group; five sutures per animal). Primary outcomes included ease of use, tissue apposition (TA) tightness assessed at index procedure, day 15 endoscopy, and day 30 necropsy, as well as histological evaluation of serosal fusion and bite size. RESULTS:All procedures were successfully completed without intra-procedural adverse events. Overall ease-of-use scores were higher with ES compared to OESS (median 6 vs 5; p=0.047). Immediate post-procedural TA scores were similar between groups (both tight; p=1). However, at day 15, ES demonstrated significantly higher TA scores than OESS (OR=29.1; 95% CI 4.3-200.3; p=0.026). At day 30 necropsy, TA remained significantly tighter with ES (OR=199.9; 95% CI 2.5-16245; p=0.029). No leaks or abscesses were observed. Histologically, serosal fusion was observed only in the ES group, although differences did not reach statistical significance. CONCLUSION:Both ESG platforms were safe and feasible in this animal model. While immediate suture performance was comparable, the Endomina System demonstrated superior mid-term durability and tighter tissue apposition compared with OverStitch. The clinical relevance of these findings warrants further investigation.

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.

BACKGROUND & AIMS:For the local excision of early rectal tumors (ERTs), the relative effectiveness of endoscopic submucosal dissection (ESD) vs transanal endoscopic microsurgery (TEM) is subject to debate. The comparisons are limited to retrospective, single-center studies lacking a health economic assessment. METHODS:A cost-effectiveness analysis was conducted alongside a nonrandomized, 2-arm, comparative, multicenter study. The main inclusion criterion was an ERT (adenomas, in situ and usT1N0 carcinomas) that could be resected with ESD or TEM, depending on the center. The primary effectiveness criterion was complete resection. A health care system perspective and a 1-year horizon were adopted for the cost evaluation. The results of the analysis were adjusted for baseline covariates: age, sex, body mass index, American Society of Anesthesiologists score, histology, and previous pelvic surgery. RESULTS:A total of 213 ESD and 117 TEM procedures were analyzed. At 1 year and with a willingness to pay of €2500 for complete resection, the incremental net monetary benefit of ESD was significant (€1797; 95% confidence interval, €861-€3,032; P < .001). ESD was more cost-effective for decision thresholds ranging from €0 to €6000. In terms of secondary outcomes, the en bloc excision rate favored ESD (99.0% vs 92.5%, P < .01). There were no significant between-group differences in overall and major morbidity. At 3 years, a cost-utility analysis did not reveal between-group differences in health-related quality of life, and the overall survival rates were similar. However, the disease-free survival rate was higher after ESD (94.3% vs 84.6% for TEM; adjusted hazard ratio, 3.55; 95% confidence interval, 1.64-7.75; P < .001). CONCLUSIONS:For ERT, ESD was more cost-effective and offered higher-quality excision and lower recurrence rates than TEM. (ClinicalTrials.gov, Number: NCT02885142).

BACKGROUND AND AIMS:Branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) are precancerous cystic lesions. Surgery is advised for high-risk stigmata (HRS) or multiple worrisome features (WFs), but it entails substantial morbidity, and many resections reveal only low-grade dysplasia. EUS-guided radiofrequency ablation (EUS-RFA) is a minimally invasive alternative, yet long-term data are limited. METHODS:We retrospectively analyzed a prospectively maintained cohort of consecutive patients who underwent EUS-RFA for BD-IPMNs with WFs/HRS at a tertiary referral center (2015-2024). Eligible patients were inoperable or declined surgery. Outcomes included technical success, adverse events (AEs), local control (defined as resolution of WFs/HRS with no cancer arising from the treated lesion), radiologic response, and pancreas-wide events. RESULTS:Fifty patients (62 procedures; 58 lesions) were treated. Mean follow-up was 4.1 ± 2.8 years after radiofrequency ablation. Technical success was 100%. AEs occurred in 27% of procedures, mostly mild abdominal pain; postprocedural pancreatitis occurred in 3 patients, including 1 case of necrotizing pancreatitis; there were no procedure-related deaths. Local control was achieved in 98% of lesions; 17% showed complete radiologic disappearance, and 86% decreased in size. No treated lesion progressed to cancer. Pancreas-wide disease control was maintained in 80% of patients; 4 (8%) patients developed pancreatic cancer remote from the treated cyst. Smaller cyst size and fewer WFs were associated with better outcomes. CONCLUSIONS:EUS-RFA is feasible, safe, and provides durable local control of BD-IPMNs with WFs/HRS in patients who are unsuitable for surgery or who decline resection. These results support EUS-RFA as a promising therapeutic option in carefully selected patients. Larger prospective studies are needed to refine selection criteria and confirm long-term oncologic benefits.

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.

Few studies have compared the different types of endoscopic biliary drainage, particularly endoscopic retrograde cholangiopancreatography (ERCP) versus Endoscopic ultrasound guided-Choledochoduodenostomy (EUS-CD), for jaundice caused by malignant biliary obstruction prior to pancreatoduodenectomy. Patients were divided into two groups for biliary drainage: ERCP versus EUS-CD. Groups were compared in terms of post-procedure and postoperative morbidity and mortality rates. Overall survival (OS) and disease-free survival (DFS) rates were compared according to the type of BD in patients with pancreatic ductal adenocarcinoma (PDAC). Between June 2016 and April 2023, 110 patients were included (EUS-CD, n = 32; ERCP, n = 78). There were no differences in terms of demographic characteristics, post-procedure morbidity, length of hospital stay, postoperative morbidity, and mortality after propensity score matching. Technical and clinical success rates were similar. Oncological safety did not differ between the groups. Soft pancreatic gland texture was the only factor influencing the occurrence of clinically relevant postoperative pancreatic fistula (p = 0.002). In the matched PDAC subgroup, extended resections were the only factor independently associated with overall survival (p = 0.015), whereas BD type (p = 0.020), patient sex (p = 0.032), and CA 19–9 levels (p = 0.032) were independently associated with disease-free survival. The ERCP group had numerically higher 1-, 3-, and 5-year OS rates than the EUS-CD group, without reaching statistical significance (p = 0.127). No significant difference in DFS was observed between groups (p = 0.694). Postoperative morbidity and mortality were comparable between groups, with no significant differences observed in long-term survival outcomes.

Background: Concomitant malignant gastric outlet obstruction (MGOO) and malignant biliary obstruction (MBO) represent a challenging clinical scenario in which the optimal endoscopic strategy remains unclear. Objectives: This study aimed to compare real-life combinations of endoscopic ultrasound-guided biliary drainage—hepatogastrostomy (EUS-HGS) or choledochoduodenostomy (EUS-CDS)—with gastric outlet obstruction management—EUS-guided gastroenterostomy (EUS-GE) or enteral stenting (ES). Design: This was an international multicenter retrospective cohort study involving 11 tertiary centers (2017–2023). Methods: Consecutive patients with MBO and MGOO were included. All patients underwent both biliary and gastric outlet drainage using one of four combinations: EUS-HGS/EUS-GE, EUS-HGS/ES, EUS-CDS/EUS-GE, or EUS-CDS/ES. The primary outcome was stent dysfunction (biliary or digestive). Secondary outcomes included clinical success and adverse events. Results: A total of 159 patients were included (median age 70 years; pancreatic cancer 64.8%). Stent dysfunction occurred in 12.0% of patients treated with EUS-HGS/EUS-GE versus 26.6% with EUS-CDS/ES, 36.7% with EUS-HGS/ES, and 50.0% with EUS-CDS/EUS-GE ( p = 0.059). At 12 months, stent obstruction-free survival was significantly higher with EUS-HGS/EUS-GE (84.0%) compared with EUS-CDS/ES (51.2%, p = 0.0466), EUS-CDS/EUS-GE (42.0%, p = 0.0377), and EUS-HGS/ES (52.3%, p = 0.0512). Severe adverse events were more frequent with EUS-HGS (15.0% in HGS/ES; 8.0% in HGS/EUS-GE) compared with EUS-CDS (1.6% in CDS/ES; 0% in CDS/EUS-GE; p = 0.014). Conclusion: In malignant obstruction, the choice of gastric outlet strategy appears to markedly influence biliary stent patency. When EUS-GE is performed, EUS-HGS may provide superior durability but at the cost of higher morbidity. Conversely, when ES is selected, EUS-CDS appears safer. These findings support a tailored approach integrating anatomical considerations and center expertise when selecting the optimal endoscopic double-drainage strategy.

BACKGROUND AND AIMS:Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is increasingly used; however, clinical application remains unstandardized. We assessed real-world practice among international users. METHODS:A cross-sectional 70-item survey was conducted. Results are presented descriptively (numbers, percentages). RESULTS:Overall, 91 of 175 invited physicians from Europe (74.4%), North America (13.3%), and Asia (12.2%) completed the survey. EUS-RFA was performed by 94.1% of respondents for insulinoma, with heterogeneous responses for other indications. Most physicians (96.3%) performed EUS-RFA under deep sedation or general anesthesia; marked variability was reported on antibiotic prophylaxis (57.5%), aggressive hydration (52.5%), generator power settings, ablation strategy, or probe selection. Lesions involving or located ≤ 1 mm from the main pancreatic duct were considered high risk by 97.5% and 85.0%, respectively, yet no standardized preventive strategy was identified. Post-procedural management and follow-up were heterogeneous, with a high proportion of responses for definitions of technical success (88.8%), clinical success in insulinoma (92.3%), and disease recurrence (97.5%), with high variability for definitions of partial ablation and post-RFA pancreatitis. CONCLUSIONS:Despite the global expansion of EUS-RFA, clinical practice remains highly heterogeneous and geographically skewed. The lack of standardized methodology and terminology poses significant barriers to generating high-quality evidence.

Background and study aims: Recent international guidelines (American Society for Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy) suggest endoscopic treatment plus lifestyle management for management of obesity class I and II. The aim of this prospective study was to assess results of Endosleeve gastroplasty (ESG) plus lifestyle management (LSM). Patients and methods: Twenty-nine patients (mean age 44 years) were included in a longitudinal prospective cohort study in two experienced centers. Mean weight at inclusion was 91.13 kg (± 8.4) and mean body mass index (BMI) was 34.08 (± 2.43) kg/m². ESG was performed using Endomina (Endo Tools Therapeutics S.A., Gosselies, Belgium) 6 months after LSM and patients were followed for 1 year with continuous LSM. Results: Twenty-eight patients completed 12-month follow-up. Total body weight loss (TBWL) was 11.05% (P < 0.001, 81.2% of cases with TBWL decrease > 5 %). EWL was significantly reached in 40.98% (P < 0.001). Final BMI was significantly decreased (30.52 kg/m²; P < 0.001). Glucose control and HbA1c level were significantly improved at 1 year (P = 0.01 and P = 0.003). Liver function tests (gamma-glutamyl transferase, alanine aminotransferase) were significantly decreased (P = 0.006 and P = 0.009). Diastolic arterial pressure significantly decreased at 1 year (P < 0.001). Quality of life (QoL) score (sf12) for physical activity was significantly improved (P = 0.05). Only one adverse event was noted (sustained pain; AGREE II). No nutritional deficiency assessed by biological measurements appeared during follow-up. Conclusions: ESG combined with LSM resulted in significant improvement in TBWL, EWL, BMI, and QoL. Metabolic improvements were also observed without leading to nutritional deficiency.

Background and Aims:Gastric peroral endoscopic myotomy (G-POEM) reaches an efficacy rate around 65% for gastroparesis. Endoscopic ultrasound (EUS)-guided gastroenteroanastomosis (EUS-GEA) has demonstrated efficacy in gastric outlet obstruction. We evaluated it for refractory gastroparesis. Methods:We undertook a single-center retrospective study enrolling patients with gastroparesis treated with G-POEM with failure or symptoms recurrence managed with EUS-GEA. The drain-assisted EUS-GEA technique with 20-mm lumen-apposing stent was applied. End points were clinical efficacy at 6 months, adverse events, and recurrence rate. Results:Twelve patients were included, median age 46 years (interquartile range [IQR], 16-78 y). Patients had an abnormal gastric emptying or bezoar, and 50% never improved from baseline. Median follow-up was 11.5 months (IQR, 6-26 mo). Clinical efficacy rate was 75% at 6 months. The median preoperative Gastroparesis Cardinal Symptoms Index was 4.1 (IQR, 1.6-5) versus 1.6 (IQR, 0-2.6; P < .05). No severe periprocedural adverse events occurred. Conclusions:EUS-GEA demonstrated promising results in improving patients with gastroparesis refractory to G-POEM. Prospective evaluation is required to confirm these results.

BACKGROUND AND AIMS:New techniques for endoscopic resection, including endoscopic submucosal dissection (ESD), have been developed to allow for en-bloc resection with very low recurrence rates and organ sparing in patients without inflammatory bowel disease (IBD). Data on ESD for the management of colorectal dysplasia in IBD patients are scarce. We aimed to evaluate the efficacy and safety of ESD for the treatment of IBD. METHODS:We conducted a retrospective multicenter cohort study that evaluated consecutive ESD procedures in IBD patients with visible dysplasia from 20 French centers with ESD experience. Between June 2008 and March 2022, all IBD patients included in the local ESD databases and who underwent ESD for visible dysplasia proven on biopsy were included. All patients were included from the date ESD was performed, and endoscopic follow-up and surgical data were collected. RESULTS:Among the 88 lesions resected in 82 patients (19 patients with Crohn's disease), 82% and 80% of patients had R0 and curative resection, respectively. Ten (12%) patients required surgery: 1 for complication, 3 for endoscopic failure, and 6 for noncurative resection. After a median follow-up of 20 (IQR 10.5-45) months, 4 patients experienced local recurrence, and 14 (17%) underwent surgery. Two patients died from cardiovascular issues during the follow-up. Factors associated with local recurrence were R1 resection, associated primary sclerosing cholangitis, a personal history of colorectal cancer, and active lesions at the ESD site. CONCLUSIONS:Endoscopic submucosal dissection is feasible for IBD patients with visible colorectal dysplasia and has an acceptable safety profile. These findings should be evaluated further in control trials.

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is an alternative to duodenal stenting and surgical GJ (SGGJ) in malignant gastric outlet obstruction (MGOO). European Society of Gastrointestinal Endoscopy guidelines restricted EUS-GJ for MGOO only, because of misdeployment. The aim was to evaluate its outcomes focusing on benign indications. This was a retrospective study conducted from 2016 to 2023 in a tertiary center. Patients included had malignant or benign GOO indicated for EUS-GJ. Techniques were the direct approach until August 2021, and the wire endoscopic simplified technique (WEST) afterwards. The main objective was to compare outcomes in benign vs. MGOO. Secondary end-points were technical success, adverse events rates, and describing the evolution of techniques and indications. In all, 87 patients were included, 46 men, mean age 66 ± 16.2 years. Indications were malignant in 60.1% and benign in 39.1%. The EUS-GJ technique was direct in 33 patients (37.9%) and WEST in 54 (62.1%). No difference was found in terms of technical, clinical, or adverse events rates. The initial technical success rate was 88.5%. The final technical and clinical success rates were 96.6% and 94.25%, respectively. In the last year, benign exceeded malignant indications (70.4% vs. 29.6%, P  < 0.05). Seven misdeployments occurred, six being addressed with the rescue technique. The misdeployment rate was significantly decreased using the WEST approach compared to the direct one: 3.7% vs. 18% ( P  < 0.05). The severe postoperative adverse events rate was 2.3%. This study demonstrated similar outcomes of EUS-GJ between benign and MGOO, with a decreasing misdeployment rate (<4%) applying WEST. This represents an additional step towards recommending EUS-GJ in benign indications.

Différentes thérapies bariatriques et métaboliques endoscopiques ont été développées depuis trois décennies avec pour cibles la réduction pondérale et/ou l’amélioration des maladies métaboliques. Les pertes de poids obtenues avec les techniques de réduction du volume gastrique sont d’environ 10 à 15 % du poids total dans les essais cliniques publiés, mais avec un risque de reprise de poids au décours quand il s’agit de dispositifs qui doivent être retirés secondairement. Au-delà du poids, plusieurs essais cliniques laissent entrevoir une amélioration des paramètres métaboliques. Des études en cours et à venir sont nécessaires pour documenter les effets sur l’amélioration des maladies liées à l’obésité et pour évaluer la persistance de la perte de poids sur le moyen et long terme ainsi que les risques de complications. Ces nouvelles expertises qui viennent compléter l’arsenal thérapeutique de la prise en charge de l’obésité devraient s’intégrer dans des centres accrédités par les Agences régionales de santé de prise en charge médicochirurgicale de l’obésité.

We assessed the feasibility and safety of a fully endoscopic one-anastomosis gastric bypass (OAGB) procedure in obese adult minipigs, with short bypass limb length if feasible or full length in a sham-controlled study. A natural orifice transluminal endoscopic surgery (NOTES) OAGB procedure was performed in 4 obese adult Yucatan minipigs. Weight change was compared to 2 sham-controlled animals. Endoscopic examination and necropsy were performed at 15 weeks. A 50-cm bypass limb was unfeasible in the pigs, so the 4 test animals received 150-cm bypasses. By week 15, mean weight gain compared to baseline body weight was 3.6

There are no existing data in the literature on the learning curve of French interns in colonoscopy or on the comparison between different frequencies of colonoscopy training modalities. We aimed to assess the number of procedures required for French residents in hepatogastroenterology to achieve competency in colonoscopy. The primary outcome was achieving greater than 90

New techniques for endoscopic resection, including endoscopic submucosal dissection (ESD), have been developed to allow for en-bloc resection with very low recurrence rates and organ sparing in patients without inflammatory bowel disease (IBD). Data on ESD for the management of colorectal dysplasia in IBD patients are scarce. We aimed to evaluate the efficacy and safety of ESD for the treatment of IBD. We conducted a retrospective multicenter cohort study that evaluated consecutive ESD procedures in IBD patients with visible dysplasia from 20 French centers with ESD experience. Between June 2008 and March 2022, all IBD patients included in the local ESD databases and who underwent ESD for visible dysplasia proven on biopsy were included. All patients were included from the date ESD was performed, and endoscopic follow-up and surgical data were collected. Among the 88 lesions resected in 82 patients (19 patients with Crohn's disease), 82% and 80% of patients had R0 and curative resection, respectively. Ten (12%) patients required surgery: 1 for complication, 3 for endoscopic failure, and 6 for noncurative resection. After a median follow-up of 20 (IQR 10.5-45) months, 4 patients experienced local recurrence, and 14 (17%) underwent surgery. Two patients died from cardiovascular issues during the follow-up. Factors associated with local recurrence were R1 resection, associated primary sclerosing cholangitis, a personal history of colorectal cancer, and active lesions at the ESD site. Endoscopic submucosal dissection is feasible for IBD patients with visible colorectal dysplasia and has an acceptable safety profile. These findings should be evaluated further in control trials.