Main Recommendations ESGE and ESGENA recommend that informed consent for gastrointestinal endoscopic procedures should include consent for sedation and cover best practice as outlined in the ESGE Position Statement for informed consent.Strong recommendation, very low certainty of evidence. ESGE and ESGENA recommend pre-assessment, a specific sedation regimen, and enhanced periprocedural monitoring in high-risk patients undergoing gastrointestinal procedures with sedation, to reduce the risk of sedation-related adverse events.Strong recommendation, very low certainty of evidence. ESGE and ESGENA recommend that pre-assessment, sedation regimen, and periprocedural monitoring should be determined by the complexity (duration, invasiveness) of the endoscopic procedure.Strong recommendation, very low certainty of evidence. ESGE and ESGENA suggest that the management of sedation in patients on glucagon-like peptide-1 receptor agonists should be individualized. Conditional recommendation, very low certainty of evidence. ESGE and ESGENA suggest offering the option of diagnostic colonoscopy and gastroscopy without sedation, based on the patient’s and endoscopist’s preference.Conditional recommendation, very low certainty of evidence. ESGE and ESGENA recommend that sedation should be provided by a dedicated healthcare professional trained in sedation administration and patient monitoring.Strong recommendation, very low certainty of evidence. ESGE and ESGENA recommend propofol for procedural sedation, as first line, depending on the country’s human resources, service framework, and legislation.ESGE and ESGENA recommend midazolam for procedural sedation, in combination with opiates when analgesia is required.Strong recommendation, very low certainty of evidence. ESGE and ESGENA suggest the provision of the ultrashort-acting sedative remimazolam in elderly patients and patients with cardiovascular and/or respiratory comorbidities.Conditional recommendation, low certainty of evidence. ESGE and ESGENA suggest exercising caution when combining ultrashort-acting sedatives with other sedatives or analgesics.Conditional recommendation, low certainty of evidence. ESGE and ESGENA suggest capnography monitoring for patients undergoing sedated gastrointestinal endoscopy who are at higher risk of hypoxemia.Conditional recommendation, very low certainty of evidence. ESGE and ESGENA recommend that the use of reversal agents should be restricted to managing sedation-analgesia adverse events that do not improve with nonpharmacological intervention.Strong recommendation, very low certainty of evidence. ESGE and ESGENA recommend that patients be monitored after endoscopy by trained and qualified staff until the return of the patient’s baseline observations.Strong recommendation, very low certainty of evidence. ESGE and ESGENA suggest using scoring systems and standardized discharge checklists to facilitate patient readiness for discharge. Assessments should include a detailed record of vital signs, pain levels, and psychomotor performance.Conditional recommendation, very low certainty of evidence. ESGE and ESGENA suggest that the performing endoscopist holds the overall medicolegal responsibility for the patient’s treatment, including safe recovery, but may delegate the assessment and discharge to trained and qualified personnel based on standardized discharge criteria.Conditional recommendation, very low certainty of evidence. ESGE and ESGENA recommend that patients receive oral and written information regarding the post-endoscopy period. Contact details should be provided for potential delayed complications, emergencies, or readmission.ESGE and ESGENA recommend that patients undergoing sedated endoscopy have an accompanying person at discharge.Strong recommendation, very low certainty of evidence. ESGE and ESGENA recommend performing emergency endoscopy under moderate sedation in hemodynamically stable patients. Alternatively, emergency endoscopy without sedation in cooperative patients is feasible.ESGE and ESGENA recommend sedation administration by an anesthesiology specialist in emergency endoscopy in patients at increased risk of aspiration, or with hemodynamic instability or significant comorbidities.Strong recommendation, very low certainty of evidence. ESGE and ESGENA recommend consultation with anesthetic and obstetric teams involved in the pregnant patient`s care, together with the patient’s choice for the appropriateness and choice of sedation during gastrointestinal endoscopy.Strong recommendation, very low certainty of evidence. ESGE and ESGENA recommend improving and expanding educational offerings on sedation strategies and the principles of airway management, using structured training.Strong recommendation, low certainty of evidence. ESGE and ESGENA recommend the development and implementation of a quality improvement program with performance indicators to monitor the quality of sedation practices in gastrointestinal endoscopy.Strong recommendation, very low certainty of evidence. ESGE and ESGENA recommend a rational use of sedatives to reduce the environmental impact of endoscopy.Strong recommendation, moderate certainty of evidence.

Ampullary composite gangliocytoma/neuroma and neuroendocrine tumor (CoGNET), previously called ampullary gangliocytic paragangliomas, is a rare entity, with only few reported cases in the literature. This is a multicentric retrospective cohort study of patients treated with endoscopy or surgery for ampullary CoGNET. A literature review of ampullary CoGNET was also performed. Fifteen patients were included, mostly female (n = 10) with a median age of 50 years. Patients were asymptomatic in seven cases. Four patients were treated with pancreatoduodenectomy, four with transduodenal ampullectomy, and eight with endoscopic papillectomy. Clavien-Dindo III-IV complications occurred in 2 of the 8 surgical cases, but no fatal adverse events were registered. There was only one moderate endoscopic adverse event. The median length of stay was 9 days. The median tumor size was 20 mm, the R0 resection rate was 93.8%, and two patients had nodal involvement. After a median follow-up of 29 months, there was no local or distant recurrence nor death from disease. The literature review confirmed the clinical presentation and excellent outcomes of ampullary CoGNET management, especially regarding survival, even for patients with nodal or distant metastases. Overall, ampullary CoGNET are rare tumors with excellent prognosis, even with incomplete resection or nodal involvement. Treatment should be as minimally invasive as possible, and a long-term follow-up is needed.

BACKGROUND:The management of Mirizzi syndrome has been primarily surgical, but there are no comparisons between surgical and digital single-operator cholangioscopy (dSOC)-guided treatment. The objective of this study was to compare the safety and other outcomes of the two approaches. METHODS:A large multicenter international retrospective analysis was conducted comparing dSOC and surgery in patients with type II-IV Mirizzi syndrome between January 2005 and June 2023. Patients with postsurgical anatomy, Mirizzi type I or V, or previous cholecystectomy were excluded. RESULTS:290 patients were included (dSOC, n = 176; surgery, n = 114). At baseline, patients undergoing dSOC were older P = 0.006) and exhibited more co-morbidities. While technical success was lower with dSOC (89.8 % vs. 96.5 %; P = 0.04), the need for reintervention was comparable after a median follow-up duration of 741.5 days (interquartile range [IQR] 320-1781) vs. 346 days (IQR 67-1220; P = 0.009). Overall adverse events (10.2 % vs. 41.2 %; P < 0.001) and severe adverse events (1.7 % vs. 15.8 %; P < 0.001) occurred less frequently with dSOC, findings that were confirmed with propensity score-matching. A lower need for hepaticojejunostomy (8.2 % vs. 25.4 %; P = 0.006) and lower rate of conversion to open surgery (6.0 % vs. 22.8 %; P = 0.009) were observed in patients undergoing elective cholecystectomy following dSOC compared with the primary surgery group. CONCLUSIONS:Our study demonstrates that the use of dSOC for Mirizzi syndrome is effective, showing superior safety despite being used to treat patients with more underlying co-morbidities. dSOC seems valuable in downgrading the extent of subsequent surgery, by potentially reducing the need for hepaticojejunostomy and conversion to open surgery.

Background:Endoscopic papillectomy is a standard treatment for ampullary lesions, which are typically small and confined to the papillary mound. Laterally spreading lesions (LSLs) of the papilla of Vater are a rare ampullary lesion subtype involving extensive duodenal mucosa. Data on endoscopic papillectomy outcomes for LSLs are limited. This study compared endoscopic papillectomy for ampullary LSLs and non-LSLs in matched cohorts. Methods:The ESAP study (Endoscopic papillectomy vs. Surgical Ampullectomy vs. Pancreaticoduodenectomy for ampullary neoplasm) encompassed 1422 endoscopic papillectomies. Propensity score matching used the nearest-neighbor method for age, sex, co-morbidity, and histologic subtype as cofactors. The main outcomes were complete resection (R0), technical success, complications, and recurrences. Results:Propensity score-based matching identified 232 patients with ampullary lesions (116 non-LSL, 116 LSL) with comparable baseline characteristics. After first intervention, the R0 resection rate, the primary outcome measure, was significantly lower in the LSL group (54.3% [95%CI 45.3%–63.1%]) vs. 69.0% [95%CI 60.4%–76.6%]). Following repeated endoscopic interventions, technical success was similar in both groups (82.8%). After a 22-month median follow-up, the LSL group had significantly more recurrences (41.3% vs. 15.0%) and lower 1- and 3-year disease-free survival rates (61.1% and 44.0% vs. 86.1% and 81.6%, respectively). Complication rates did not differ significantly between the two groups (LSL 32.8% vs. non-LSL 26.7%). Conclusion:LSLs can be safely resected by endoscopic papillectomy, although repeated interventions are necessary to achieve complete resection. The higher risk of recurrence in LSLs necessitates a vigilant surveillance strategy.

PRE-ADOPTION:Endoscopists performing upper gastrointestinal (UGI) endoscopy should train to recognize the appearance of early esophageal cancer and its precursor lesions, for Barrett neoplasia and for squamous neoplasia, to improve detection rates.Every endoscopist should have achieved competency in UGI endoscopy before commencing training in optical diagnosis in the UGI tract, and this requires personal experience of 300 UGI endoscopies and meeting the ESGE quality measures for UGI endoscopy. TRAINING:Endoscopists should undertake interactive training courses to improve diagnostic accuracy for esophageal preneoplastic and neoplastic lesions.Endoscopists should train with the Barrett's Oesophagus-Related Neoplasia (BORN) module to improve detection and delineation for early Barrett's esophagus-related neoplasia.Endoscopists should train in using the Prague classification to describe the circumferential and maximal extent of Barrett epithelium above the gastroesophageal junction.Endoscopists should train in using the Paris classification to describe suspected neoplastic lesions within both Barrett and squamous epithelium.Endoscopists should train in using virtual chromoendoscopy to assess both mucosal and vascular patterns in potentially neoplastic lesions in Barrett epithelium as being regular or irregular.When using acetic acid chromoendoscopy for Barrett's esophagus inspection, endoscopists should be familiar with the appearance of neoplastic lesions by assessing loss of aceto-whitening and mucosal surface patterns.Endoscopists should train in using the Japanese Esophageal Society (JES) classification to describe esophageal squamous cell lesions, to estimate the likelihood of and degree of dysplasia, and in the case of squamous cell cancer, the invasion depth.

BACKGROUND:Lumen-apposing metal stents (LAMS) are widely used to drain walled-off necrosis (WON). LAMS occlusion is a significant clinical problem and identification of risk factors for LAMS occlusion could contribute to novel preventive strategies. A previous study suggested contradictory effects of proton pump inhibitors (PPIs) on occlusion and necrosectomy rates. METHODS:We conducted a Europe-wide multicenter retrospective cohort study assessing WONs drained by LAMS. The primary aims were to assess the strength of association between PPI intake and LAMS occlusion and necrosectomy rates, respectively. The secondary aim was to assess the strength of association between PPI intake and other LAMS-associated complications. Multiple mixed-effects models were used to control for possible confounding covariates. RESULTS:893 patients with 967 LAMS from 17 centers were included. After excluding incomplete datasets and patients who took PPIs intermittently, 768 LAMS remained. The overall occlusion rate was 28.0 %. Most occlusions occurred within 10 days. Most patients received PPIs continuously (n = 577 vs. no intake n = 191). In patients who did not use PPIs continuously, lower rates of LAMS occlusion (odds ratio [OR] 0.61, P = 0.04) and necrosectomies (incidence rate ratio 0.8, P = 0.006) were observed. A post hoc analysis exhibited a dose- and compound-dependent effect of PPI intake on necrosectomy rate. No increase in other complications in the non-PPI group, such as bleeding events (OR 1.14) were observed. CONCLUSION:PPI intake was associated with higher rates of LAMS occlusion and necrosectomy.

A virtual endoscopy simulator with a 3D-printed endoscope handle (“Endonix®”) that can be used without dedicated equipment (“plug and play”) to train endoscope handling has yet not been tested. We prospectively evaluated the simulator’s validity, feasibility, and usability in novices, beginners, and experienced endoscopists. Delegates at two congresses (DGVS and ENDOCLUBNORD, both 2024 in Germany) were invited. 310 complete datasets (146 DGVS, 164 ENDOCLUBNORD) were analyzed. Each participant performed two different simulation modules and completed a survey comprising questions on endoscopy experience, simulator evaluation, as well as the System Usability Scale (SUS) and the National Aeronautics and Space Administration Task Load Index (NASA-TLX). The simulator demonstrated good face validity, but only merely sufficient content validity as 67.8

Obesity and diabetes are associated with increased mortality and morbidity. After failure of conservative therapy such as pharmacotherapy and lifestyle management, bariatric treatment is indicated for selected patients. Endoscopic techniques for weight reduction are well-established treatment for obese population who do not qualify for or are not willing to undergo bariatric surgery. This article is an overview of currently applied endoscopic techniques and summarized current published data.

BACKGROUND AND AIMS:Endoscopic papillectomy (EP) is the standard treatment for noninvasive ampullary lesions (ALs), whereas advanced cases require surgery. Managing ALs is challenging and may lead to over- or undertreatment. We developed a score to identify the best candidates for endoscopic or surgical treatment. METHODS:We analyzed 447 patients who underwent EP. The cohort was randomly split into a training set (n = 325) and validation set (n = 122). Logistic regression identified predictors for incomplete resection (R1), which were incorporated into a 4-item score. Performance was assessed using the area under the receiver-operating characteristic curve (AUROC). RESULTS:Independent predictors for R1 included size ≥30 mm (S), high-grade dysplasia and/or invasive cancer (D), laterally spreading-lesion (L), and bile or pancreatic duct dilation (D), which we named the SDLD score. ALs with 0 to 1 points had the highest complete resection rates (training, 86.0%; validation, 88.5%), whereas ≥2 points significantly increased R1 rates (training, 52.0%; validation, 57.7%; P < .001). The AUROC was 0.792 (training) and 0.708 (validation). CONCLUSIONS:The SDLD score predicts R1 in EP and aids in treatment decisions.

Cystic pancreatic lesions (CPL) pose a diagnostic challenge due to their morphological diversity and malignant potential. Given the limited study data, transabdominal ultrasound (TAUS) is currently not established for either primary diagnostics or CPL monitoring. This study compared the diagnostic accuracy of TAUS in the assessment of CPL to that of the reference method, endoscopic ultrasound (EUS), to identify patient subgroups suitable for TAUS monitoring. In a monocentric, retrospective analysis, patients with CPL who underwent EUS and TAUS within six months from 01/2016 to 06/2022 were included. Univariate and multiple logistic regression analyses were used to identify determinants for the detection of CPL via TAUS. Cross-method morphological assessments were analysed, and a patient-specific algorithm for selecting the appropriate monitoring method was developed. Among 105 patients, CPL were detected by both EUS and TAUS in 90 patients (86%). Patients with “TAUS negative” CPL ( n = 15) exhibited greater body mass indices (BMI, p = 0.002) and smaller CPL diameters ( p = 0.043). The final multivariate model (BMI, age, CPL diameter) yielded an 85% accuracy in predicting CPL detectability by TAUS. TAUS could be a cost-effective and patient-friendly imaging method for the surveillance of CPL in selected patients.

BACKGROUND AND AIMS:The incidence of acute pancreatitis is increasing in the Western world. About 10% of cases are caused by hypertriglyceridemia. Plasmapheresis was shown to reduce serum triglyceride (TG) levels, and current apheresis guidelines recommend its use in severe acute hypertriglyceridemia-induced pancreatitis (HIP). However, data on safety and efficacy are lacking. This study aimed to evaluate the clinical efficacy of plasmapheresis in hypertriglyceridemia-induced pancreatitis. METHODS:This is a retrospective multicenter cohort study of patients hospitalized for an episode of hypertriglyceridemia-induced pancreatitis from January 1, 2012 to December 31, 2022. The predefined composite primary endpoint was in-hospital mortality and organ failure. To reduce allocation bias, we performed propensity score matching. RESULTS:245 episodes of hypertriglyceridemia-induced pancreatitis from 13 German centers were included. Of those, 95 episodes were treated with plasmapheresis. After propensity score matching, the final cohort consisted of 60 well-balanced pairs. Plasmapheresis was not associated with a difference in the primary composite outcome, in-hospital mortality, and organ failure (8/60 vs. 5/60; χ2(1) = 0.776; p = 0.378), nor was there any difference in the severity of pancreatitis episodes. It showed only a moderate reduction of serum triglyceride compared to the non-plasmapheresis group, but a significantly longer hospital stay in the plasmapheresis group (12 days; IQR 14 vs. 9 days; IQR 11; U = 1356; Z = -2.46; p = 0.014). CONCLUSIONS:Plasmapheresis in patients with hypertriglyceridemia-induced pancreatitis was not associated with a better clinical outcome compared with conservative treatment in this propensity score-matched retrospective cohort study. Outside clinical studies, this costly and potentially complicative treatment should be considered with caution.

Objective Ampullary neoplastic lesions can be resected by endoscopic papillectomy (EP) or transduodenal surgical ampullectomy (TSA) while pancreaticoduodenectomy is reserved for more advanced lesions. We present the largest retrospective comparative study analysing EP and TSA. Design Of all patients in the database, lesions with prior interventions, benign histology advanced malignancy (T2 and more), patients with hereditary syndromes and those undergoing pancreatoduodenectomy were excluded. All remaining cases as well as a subgroup of them, after propensity-matching (nearest-neighbour-method) based on age, gender, anthropometrics, comorbidities, size and histological subtype, were analysed. The median follow-up was 21 months (IQR 10-47) after the primary intervention. Primary outcomes were rates of complete resection (R0) and complications. Groups were compared by Fisher's exact or chi(2) test, Mann-Whitney-U-test and log-rank test for survival. Results Of 1673 patients in the database, 1422 underwent EP and 251 TSA. Of them, 23.2% were excluded for missing or inconclusive data and 19.8% of patients for prior interventions or hereditary syndromes. Final histology showed in 24.2% of EP and 14.8% of TSA patients a histology other than adenoma or adenocarcinoma while advanced cancers were recorded in 10.9% of EP and 36.6% of TSA patients. Finally, 569 EP and 63 TSA were included in the overall analysis, with a higher rate of more advanced cases and higher R0 resection rates in the TSA groups (90.5% vs 73.1%; p<0.01), with additional ablation in the EP group in 14.4%. Severe adverse event rates were 3.2% (TSA) vs 1.9% (EP). Recurrence after histological R0 resection was 16% (EP) vs 3.2% (TSA; p=0.01), and additional therapy for R1 resection was applied in 67% of the 159 cases. Propensity-score-based matching identified 62 pairs of EP/TSA patients with comparable baseline patient and lesion characteristics. The initial R0-rate was 72.6% (EP) compared with 90.3% (TSA, p=0.02) with recurrences found in 8% (EP) vs 3.2% (TSA; p=0.07); reinterventions were more frequent in the EP group. Overall survival was comparable. Conclusions The rate of patients with poor indications due to non-neoplastic disease or advanced cancer is still high for both EP and TSA; multiple retreatments were necessary for EP. Although EP can be considered an appropriate primary therapy for certain ampullary adenomas, case selection for both therapies (especially with regard to the best step-up approach) should be studied further.

QUALITY STANDARDS:Competence in cholangioscopy should be defined as the ability to successfully perform the procedure effectively, without trainer assistance, in 80 % of procedures. Cholangioscopy should be performed in endoscopy units with a high yearly volume of endoscopic retrograde cholangiopancreatographies (ERCPs) of all grades of complexity. Cholangiopancreatoscopy practice should be considered as standard or advanced as follows: - STANDARD : Cholangioscopy for extrahepatic biliary stones; evaluation of extrahepatic biliary strictures; selective ductal guidewire cannulation and removal of migrated biliary stents/foreign body extraction - ADVANCED : Cholangioscopy for intrahepatic biliary strictures or complex hepatolithiasis; percutaneous cholangioscopy and pancreatoscopy. Endoscopy units undertaking standard cholangioscopy should have prompt access to the following (on site or within a defined rapidly responsive network): - Endoscopic ultrasound (EUS)- Interventional radiology (on-site) and hepaticopancreaticobiliary (HPB) surgery - HPB multidisciplinary meetings (MDMs). Complete extrahepatic stone clearance at the initial cholangioscopy session should be successful in 80 % of intention-to-treat cases. Cholangioscopy is recommended with visually guided biopsies in the evaluation of undefined biliary strictures, ideally at index ERCP to prevent negative visual and histological effects of prior stenting; except in cases with an associated mass lesion that may allow tissue acquisition by other means (e. g. EUS or percutaneous biopsy). In cholangioscopic evaluation of extrahepatic biliary strictures, visual assessment should be achieved in > 90 % of cases, and at least 4 visually guided biopsies should be undertaken with sufficient tissue for histological assessment being obtained in > 80 % of cases. Percutaneous transhepatic cholangioscopy is indicated in patients with transhepatic bile duct access in cases of altered anatomy or failed ERCP and an indication for cholangioscopy (stone management; biliary stricture evaluation; foreign body removal). CURRICULUM FOR TRAINING:Cholangioscopy is considered an advanced adjunct to ERCP, and prior to undertaking supervised cholangioscopic procedures trainees should be competent in the basic skills of ERCP (Schutz level 1 and 2) as defined by ESGE (duodenal intubation; biliary cannulation; distal bile duct stenting; ≤ 10-mm stone extraction). Cholangioscopy training should take place in expert referral centers with a high volume of ERCP and cholangioscopy cases. A trainee's principal trainer should be an experienced trainer ideally with at least 3 years of experience in undertaking independent cholangioscopy to the determined quality standards. Competence in cholangioscopy should be defined as the ability to successfully perform the procedure effectively without trainer assistance in 80 % of procedures.