BACKGROUND:Endoscopic closure techniques are essential for management of endoscopic defects and help prevent delayed bleeding and perforation. The SutuArt endoscopic hand-suturing system (EHS) is an innovative method for defect closure, but clinical data remain limited. METHODS:In a multicenter European registry study, all procedures using EHS from 14 centers were evaluated. The primary endpoint was technical success, defined as complete defect closure without additional closure techniques. Secondary endpoints were in-hospital clinical success (absence of post-interventional complications); overall defect closure rate (closure achieved with additional devices) and procedure time. RESULTS:Between February 2023 and January 2026, 338 procedures were included. Indications comprised 240 ESD (Endoscopic Submucosal Dissection), 32 EID (Endoscopic Intermuscular Dissection), 41 G-POEM (Gastric Peroral Endoscopic Myotomy), 10 fistulas, 6 EMR (Endoscopic Mucosa Resection), 3 STERs (Submucosal Tunneling Endoscopic Resection), 2 NEWS (Non-exposed Endoscopic Wall inversion Surgery), 1 anastomotic leak, 1 perforation, 1 EFTR (Endoscopic Full Thickness Resection) and 1 endoscopic hemostasis. The median defect size was 35 mm (range 4-155 mm), the median suturing time was 25 minutes (range: 4-120). Technical success was 96.2% (325/338). Overall defect closure rate was 96.7% (327/338). In-hospital clinical success was 97.9% (331/338). Defect size did not predict suturing time in the global size-time model, indicating that procedural complexity was not explained by size alone. Procedure-related adverse events occurred in 5/338 (1.5%), overall AEs were 10/338 (3%). CONCLUSION:EHS demonstrated high technical and in-hospital clinical success with a low observed short-term adverse event rate. Further studies are needed to assess the performance for complex defects.

Background and study aims: Patients requiring biliary interventions with endoscopically inaccessible papilla or biliodigestive anastomosis represent a challenge in clinical practice. Historically, percutaneous transhepatic biliary drainage (PTBD) has often been the only viable treatment after failed endoscopic attempts. Recently, endoscopic ultrasound (EUS)-guided techniques have emerged as promising alternatives. This study evaluated the feasibility and safety of EUS-guided transenteric ERCP (EDEE) at a tertiary referral center. Patients and methods: This retrospective, single-center study included patients who underwent EDEE between February 2020 and November 2025. Primary endpoints were safety and overall technical success, defined as successful creation of an EUS-guided anastomosis (EA) using a lumen-apposing metal stent (LAMS) followed by endoscopic retrograce cholangiopancreatography (ERCP) via LAMS. Secondary endpoints included clinical success, need for reinterventions, and procedure characteristics. Results: A total of 24 patients (70.3 ± 12.6 years; 6 female) were analyzed. Sixteen patients had surgically altered anatomy (5 Whipple, 11 Roux-en-Y), and eight presented with malignant gastric outlet obstruction. EA and ERCP via LAMS were conducted in two stages with a median interval of 29.5 days. In 15 patients, the afferent loop was accessed after filling via a previously placed PTBD, which was removed after EDEE. Technical success was 100% (24/24) for EA and 87.5% (21/24) for ERCP via LAMS; overall technical and clinical success were 87.5% (21/24). Procedure-related complications occurred in two patients (8.3%), including one aspiration pneumonia and one LAMS misplacement. Conclusions: This study suggests that EDEE is a feasible and safe method for biliary drainage in patients with inaccessible biliary anatomy, demonstrating high technical and clinical success in both malignant and benign conditions being performed at a highly specialized tertiary center.

Background and objectives: Biliary drainage(BD)in distal malignant biliary obstruction(DMBO)is often hampered by difficult biliary cannulation(DBC)during endoscopic retrograde cholangiopancreatography(ERCP). Advanced cannulation techniques(aERCP)may overcome DBC but still fail in up to 15% of cases, increasing the risk of adverse events(AEs). Early endoscopic ultrasound-guided BD(eEUS-BD)is a potential alternative. The aim of this study is to directly compare safety and efficacy of EUS-BD and aERCP. Methods: This is a retrospective, multicentric study(29 centres in United States, Canada, Europe), including patients with DMBO and common bile duct(CBD)diameter >12 mm, treated up to 2024. DBC cases managed with either eEUS-BD or aERCP were analysed. A 1:2 propensity score-matched cohort was generated to ensure comparability, with regression modeling and inverse probability of treatment weighting(IPTW)performed as sensitivity analyses. AEs rate was the primary outcome; secondary outcomes included BD failure and clinical success. Results: Standard cannulation failed in 2066/10,738(19.2%)ERCPs. aERCP and eEUS-BD were attempted in 1733 and 333 cases, respectively. After matching, 313 patients per EUS-BD group and 626 patients per aERCP group were analyzed. AEs occurred in 18.2% of aERCPs and 9.3% of eEUS-BD(p<0.01), with post-procedural pancreatitis the most frequent AE after aERCP(55 cases, 12.0%). Both regression and IPTW confirmed the robustness of these findings on the entire cohort. Technical success was significantly lower with aERCP(82.0% vs. 95.9%, p<0.01), clinical success was comparable(94.5% vs. 96.4%, p=0.89). Conclusions: In patients with DMBO and dilated CBD, eEUS-BD is associated with fewer AEs and higher technical success than aERCP, supporting its role as a safer, more effective option in DBC.

Background and study aims:Endoscopic submucosal dissection (ESD) enables curative resection of superficial gastrointestinal neoplasia but requires structured training. Although European Society of Gastrointestinal Endoscopy (ESGE)/American Society for Gastrointestinal Endoscopy (ASGE) curricula exist, real-world practices and barriers remain unclear. Methods:We conducted an anonymous web-based survey (April-July 2025) with 55 items assessing training opportunities, barriers, curriculum adherence, and quality metrics, stratified by role and annual ESD volume. Results:We received 288 responses (137 trainees, 151 trainers) from 39 countries across five geographic macro-areas. Nearly half (47.2%) had undertaken structured training, but only 46.5% fulfilled ESGE/ASGE curricula, with marked variation by center volume (69.6% in high-volume vs 26.8% in low-volume, P < 0.001). Lack of access to training models was reported by 46.5% overall, more frequently in low-volume centers. In vivo human training, animal models, and intensive courses were rated highest, whereas lack of simulators, fellowship costs, and limited time were leading barriers. Quality monitoring was reported in 62.5% of centers, prioritizing R0 and en bloc resection rates over procedure speed. Trainees valued traction and underwater techniques more than trainers. Regional differences were pronounced: North-West Europe and Asia-Pacific concentrated high-volume centers and greater curriculum adherence, whereas Africa/Middle East and South-East Europe faced resource and financial constraints. Conclusions:This international survey reveals substantial disparities in ESD training and calls for coordinated efforts to improve access to structured curricula, mentorship, and affordable training models.

BackgroundPancreatic ductal adenocarcinoma carries a poor prognosis, with the worst outcomes observed in UICC stage IV disease characterized by hepatic—and less frequently pulmonary—metastases. Considerable genetic heterogeneity, including mutations in KRAS, BRCA1/2, and ERBB2, enables the development of individualized therapeutic strategies. We report here a patient with KRAS- and BRCA1/2-wild-type but mutant TP53 and ERBB2 disease who achieved apparent remission of hepatic metastases.Case presentationA 78-year-old Caucasian male presented with newly detected dilation of the distal main pancreatic duct and prepapillary stenosis associated with a hypodiffused region. After 8 months of surveillance, rising CA19-9 levels prompted pylorus-preserving pancreaticoduodenectomy. Two small hepatic nodules were resected and confirmed as metastatic lesions. The primary tumor was identified as invasive micropapillary pancreatic ductal adenocarcinoma (PDAC). Surgery did not slow or halt the progressive rise of CA19–9 levels in serum. Adjuvant gemcitabine therapy was discontinued at the patient’s request after four infusions, and high-dose nicotinamide treatment (3 x 500 mg per day) was initiated 11 weeks later. CA19-9 levels declined from 1376 U/ml to the normal range within 5 months. Initial magnetic resonance imaging revealed multiple small hepatic metastases, which regressed in parallel with CA19-9 levels and were no longer detectable one and two years later.ConclusionRegression of CA19-9 levels and imaging-detectable hepatic metastases occurred concurrently after initiation of high-dose nicotinamide. This temporal relationship may be incidental, and the remission could represent a delayed effect of the preceding gemcitabine infusions. Nicotinamide supplementation may also have contributed anti-tumor activity. High-dose nicotinamide elevates systemic NAD+ levels, which may enhance immune function within the metastatic tumor microenvironment. In addition, partial inhibition of poly(ADP-ribose) polymerase by high-dose nicotinamide can impair DNA repair in tumor cells with underlying repair deficiencies, thereby promoting tumor cell death.

Background and Aims We report the case of a 65-year-old man who was referred to our unit with a diagnosis of a large early Barrett’s esophagus adenocarcinoma, extending for about 10 cm and involving two-thirds of the esophageal circumference. CT scan revealed a moderate esophageal variceal ectasia not visible at endoscopic evaluation; however, no sign of liver cirrhosis had been identified at abdominal ultrasound, elastography, and laboratory examinations. Therefore, after a preliminary discussion with the tumor board, we performed endoscopic submucosal dissection (ESD). Methods An ultraslim therapeutic endoscope (EG-840 TP Slim Treatment Gastroscope, Fujifilm, Tokyo, Japan) was used. This gastroscope has a 7.9-mm insertion tube endowed with a large 3.2-mm working channel and powered by an expanded angulation (210° up/160° down) that significantly improves maneuverability. Moreover, the latest-generation hybrid-knife (HYBRIDknife flex I-Type, Erbe, Tübingen, Germany) was used, further improving the cut and coagulate precision. The procedure was performed under amber-red-color imaging (Fujifilm) mode, specifically designed to enhance the visibility of deep vessels and submucosal space/muscle. Results Following significant bleeding after first mucosal incision at the distal margin, the initial therapeutic plan of tunnel creation method was changed, and a complete circumferential incision was performed followed by a submucosal dissection assisted by the saline-immersion technique and double clip-line traction method. Importantly, during ESD a dense network of marked dilated esophageal varices (up to 7 mm in diameter) were encountered in the third space, significantly prolonging the procedural time. However, varices were all preventively identified and treated. Finally, the lesion was resected en bloc, and no adverse events occurred. The patient was discharged home 3 days later asymptomatic, and histopathological evaluation revealed a curative intramucosal adenocarcinoma (pT1a, m2, L0, V0, Bd1, R0, G1) resection. At 3-month endoscopic follow-up, no significant stricture or residual/recurrence neoplastic lesion were observed. Conclusions ESD of Barrett's esophagus adenocarcinoma located at esophageal varices may be considered a viable option even without previous variceal treatment.

Background:Focal cryoballoon ablation (FCBA) is a relatively new modality for treatment of Barrett esophagus (BE)-related neoplasia. This study evaluated the efficacy and safety of FCBA for BE. Methods:Patients with BE segments (Prague classification C≤2M≤5) with dysplasia or early cancer were eligible for inclusion. Following endoscopic resection of visible lesions, FCBA was performed at 3-month intervals until complete eradication of BE (maximum five sessions). After ≥2 FCBA sessions, add-on treatment was allowed. Follow-up endoscopy was scheduled at 6 months and annually thereafter. Outcomes were complete eradication of endoscopically visible BE (CE-BE), intestinal metaplasia (CE-IM), and dysplasia (CE-D), durability of treatment response, and adverse events. Results:107 patients (mean age 65 years, 91 males, median BE C0M2) were included. Endoscopic resection was performed at entry in 65% (69/107). Patients received a median of 2 FCBA treatments. Add-on treatment was performed in 40% (43/107), mainly APC for small remaining islands (38%; 41/107). CE-BE and CE-D were achieved in 94% (101/107; 95%CI 90%–98%) and CE-IM in 91% (97/107; 95%CI 85%–95%), per intention-to-treat analysis. In per-protocol analysis, CE-BE and CE-D was achieved in 100% (101/101; 95%CI 100%–100%), and CE-IM in 96% (97/101; 95%CI 92%–99%). After a median follow-up of 18 months, 96% (97/101; 95%CI 92%–99%) remained free of endoscopically visible BE. Esophageal stricture was the most common adverse event, in 13% (13/101; 95%CI 6%–20%). Conclusion:FCBA was highly effective in selected patients with BE of limited length, although the potential risk for stricture formation warrants further research.

Non-ampullary duodenal polyps account for a group of rare tumors of the gastrointestinal tract. Although small lesions are relatively easy to remove, resection of larger lesions requires more advanced techniques such as endoscopic mucosal resection (EMR). Although this technique is considered safe, the most prevalent complication is delayed bleeding (DB) with considerable incidence rates of up to 26%. In this study, we aimed to assess whether prophylactic clipping (PC) reduces DB rates after EMR of large duodenal non-ampullary lateral spreading lesions. We retrospectively collected data from consecutive duodenal EMRs of non-ampullary lateral spreading lesions ≥ 15 mm performed between 2019 and 2022 at two medical centers in the Netherlands and Germany. A total of 186 polyps with a mean size of 25 mm were included in this study. Most were tubular adenomas (55%) and contained low-grade dysplasia (84%). PC of the resection site was performed in 84 patients (45%). The overall DB rate was 13% (24/186). DB occurred in three of 84 cases with PC versus 21 of 102 cases without PC (4% versus 21%, P < 0.01). With an odds ratio of 0.22, multivariable analysis indicated that PC significantly reduced DB (95% confidence interval 0.06–0.85; P = 0.03). PC of the resection site significantly reduced DB after EMR of large non-ampullary duodenal lateral spreading lesions.

1: ESGE recommends the combination of endoscopic ultrasound-guided tissue acquisition (EUS-TA) and endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition as the preferred diagnostic approach for tissue acquisition in patients with jaundice and distal extrahepatic biliary stricture in the absence of a pancreatic mass. 2: ESGE suggests that brushing cytology should be completed along with fluoroscopy-guided biopsies, wherever technically feasible, in patients with perihilar biliary strictures. 3: ESGE suggests EUS-TA for perihilar strictures when ERCP-based modalities yield insufficient results, provided that curative resection is not feasible and/or when cross-sectional imaging has shown accessible extraluminal disease. 4: ESGE suggests using standard ERCP diagnostic modalities at index ERCP. In the case of indeterminate biliary strictures, ESGE suggests cholangioscopy-guided biopsies, in addition to standard ERCP diagnostic modalities. Additional intraductal biliary imaging modalities can be selectively used, based on clinical context, local expertise, and resource availability.

BACKGROUND:Prophylactic application of a haemostatic gel to the resection field may be an easy way to prevent delayed bleeding, a frequent complication after endoscopic mucosal resection (EMR). OBJECTIVE:We aimed to evaluate if the prophylactic application of a haemostatic gel to the resection field directly after EMR can reduce the rate of clinically significant delayed bleeding events. DESIGN:We conducted a prospective randomised trial of patients undergoing hot-snare EMR of flat lesions in the duodenum (≥10 mm) and colorectum (≥20 mm) at 15 German centres. Prophylactic clip closure was not allowed, but selective clipping or coagulation could be used prior to randomisation to treat intraprocedural bleeding or for prophylactic closure of visible vessels. Patients were randomised to haemostatic gel application or no prophylaxis. The primary endpoint was delayed bleeding within 30 days. RESULTS:The trial was stopped early due to futility after an interim analysis. The primary endpoint was analysed in 232 patients (208 colorectal, 26 duodenal). Both groups were comparable in age, sex, comorbidities and lesion characteristics. Preventive measures, such as selective clipping or coagulation, were applied prior to randomisation in 51.9% of cases, with no difference between groups. Delayed bleeding occurred in 14 cases (11.7%; 95% CI 7.1% to 18.6%) after Purastat and in 7 cases (6.3%; 95% CI 3.1% to 12.3%) in the control group (p=0.227), with no difference between colorectal and duodenal subgroups. CONCLUSION:The application of a haemostatic gel following EMR of large flat lesions in the duodenum and colorectum does not reduce the rate of delayed bleeding.

OBJECTIVES:Achalasia is an esophageal motility disorder that impairs quality of life and is often missed (20-50%) on endoscopy. A newly developed computer-aided detection (CAD) software has shown high accuracy for achalasia diagnosis in preclinical settings. However, its benefit in a clinical setting remains unclear. METHODS:Between February and August 2023, 83 endoscopists from 27 centers assessed 50 randomized endoscopic videos (25 achalasia, 25 nonachalasia) without and with CAD. Endoscopists assessed videos without CAD, then with CAD after 2 months. The primary end-point was improvement in sensitivity for nonexperienced endoscopists (no endoscopic experience of achalasia). Sensitivity, specificity, and accuracy with and without CAD were compared using the McNemar test. RESULTS:Sensitivity for diagnosing achalasia increased significantly with CAD, rising from 74.2% (95% confidence interval [CI] 72.2-76.0%) to 91.2% (95% CI 89.9-92.4%) for all readers, showing a difference of 17.1% (95% CI 15.1-19.0%). Specifically, sensitivity improved from 66.9% (95% CI 63.6-70.0%) to 91.9% (95% CI 89.9-93.6%) among nonexperienced endoscopists, resulting in a difference of 25.0% (95% CI 21.7-28.4%), and from 79.5% (95% CI 77.1-81.8%) to 90.8% (95% CI 89.0-92.3%) among experienced endoscopists (endoscopic experience of at least one achalasia case), with a difference of 11.3% (95% CI 8.9-13.6%). Accuracy and specificity improved significantly with CAD assistance, regardless of reader's experience. CONCLUSION:CAD improves achalasia detection by 17%, confirming preclinical results. The benefit was higher for nonexperienced endoscopists. CAD assistance may lead to prompt and effective treatment, minimizing the risk of false-negative diagnosis in clinical practice. TRIAL REGISTRATION:This study was registered in the University Hospital Medical Information Network Clinical Trial Registry (https://www.umin.ac.jp/ctr/) number: UMIN000053047.

INTRODUCTION:Ductal decompression has become the main approach for treating patients with symptomatic chronic calcifying pancreatitis and signs of ductal hypertension. Digital single operator video pancreatoscopy (dSOVP) has shown high success rates when compared with more established techniques such as extracorporeal shock wave lithotripsy. However, there is still limited evidence on long-term clinical success and quality of life. METHODS:Patients with chronic calcifying pancreatitis who underwent digital single operator video pancreatoscopy guided electrohydraulic lithotripsy (EHL) of pancreatic duct stones with initial technical and clinical success were recruited for this retrospective, multicenter cohort study. Persistence of clinical success (defined as pain reduction > 50% in numerical rating scale [NRS]) as well as postinterventional quality of life (QOL) were retrospectively evaluated by database analysis and with QOL using the Mental and Physical Condition Scores (MCS, PCS). RESULTS:A total of 58 patients were included in the long-term follow-up conducted over 24 months. Significant and sustained pain relief was reported in 70.7% of patients (n = 41) at month 3; this effect persisted until month 24. MCS decreased from 50.36 ± 13.3 at baseline to 49.75 ± 11.1 at month 12 with no statistically significant difference (data available for 42 patients, p = 0.15). Similarly, the PCS showed no significant improvement, remaining constant at 44.9 ± 9.8 at baseline and 44.9 ± 10.8 at month 12 (p = 0.1). The overall adverse event rate was 26% (11 patients), primarily consisting of mild to moderate pancreatitis (n = 9, 22%). CONCLUSIONS:Digital single operator video pancreatoscopy guided lithotripsy was shown to be safe and effective in a long-term follow-up regarding pain control but had no significant influence on QOL. Complete stone removal seems to be the key point for long-term clinical success.