Per-oral endoscopic myotomy (POEM) achieves an 80–90

Barrett’s esophagus (BE) is a pre-cancerous condition with an increased risk of esophageal adenocarcinoma (EAC). Current surveillance involves white light endoscopy with random biopsies (Seattle Protocol, SP) but has limitations. This study explores high-resolution virtual chromoendoscopy (HRMC) as a potential alternative. This controlled trial will enroll 110 patients with Barrett’s esophagus (BE) across 15 gastroenterology departments in France. Each patient will undergo both HRMC and SP examinations during the same endoscopic procedure. Although the trial is non-randomized, it is important to highlight that the two endoscopists performing either the HRMC or the SP will be blinded to each other’s results. Therefore, each patient will serve as their own control. Biopsy decisions will be based on both methods, with any visible lesions resected. The primary objective is to compare the detection rate of HGD and EAC lesions using HRMC with targeted biopsies versus SP with random biopsies. Secondary objectives include comparing detection rates of LGD lesions, procedure time, missed lesions, and cost-effectiveness. If HRMC proves superior to SP for detecting HGD and EAC, it could lead to more accurate, efficient, and cost-effective BE surveillance strategies, improving patient outcomes and resource utilization. ClinicalTrials.gov NCT05229783 – First Submitted 2021-12-07.

BACKGROUND:The Limoges Bleeding Score estimates an individual's risk of clinically significant delayed bleeding (CSDB) after colorectal endoscopic submucosal dissection (ESD). We aimed to validate and update this model in a Western setting. METHODS:Procedural data and complications were prospectively recorded in French-Belgian (FECCO) and Spanish cohorts. The Limoges score was externally validated. A revised Western score was derived. Score performance was determined by discrimination and calibration. Internal validation was performed using bootstrapping and leave-one-out cross-validation. The score's performance was independently assessed in both cohorts. RESULTS:4767 ESDs were included: 33.7 % rectal and 37.7 % proximal; median lesion size 50 mm; mean patient age 68.1 years; American Society of Anesthesiologists (ASA) score I-II 72.9 %; anticoagulants 10.9 %, and antiplatelets 17.0 %. CSDB prevalence was 6.8 %. The performance of the Limoges score was modest. A new score called DEBE (Delayed Bleeding ESD) was developed: age ≥ 75 years (2 points), lesion size ≥ 50 mm (5 points), ASA classification III-IV (4 points), location in the rectum (2 points) or proximal colon (1 point), anticoagulants (7 points) and antiplatelets (3 points). The DEBE score ranged from 0 to 23 points and categorized the patients into two groups (low risk 3.9 %; medium-high risk 14.2 %). The score showed acceptable discrimination (area under the curve 0.712), adequate calibration, and consistent performance after internal validation. CONCLUSIONS:The DEBE score, based on seven preprocedural variables, allowed a personalized assessment of bleeding risk. It determined the individual CSDB risk, identified patients who would benefit from prophylactic treatment, and defined those who require monitoring after ESD.

Background Endoscopic submucosal dissection (ESD) can achieve curative resection for selected T1 colorectal cancers, but optical diagnosis poorly predicts invasion depth. Consequently, focal deep invasive pattern (FDIP) lesions are often referred to surgery. A diagnostic endoscopic dissection approach may represent a cost-effective alternative. We evaluated the clinical impact of a diagnostic endoscopic dissection strategy and modeled its environmental and economic impact versus upfront surgery. Methods This multicenter study included patients with colorectal FDIP undergoing endoscopic dissection (ESD and intermuscular dissection for rectal lesions when appropriate). Surgery was recommended for high-risk lesions (>T1 or T1 with lymphovascular invasion, high-grade budding, or poor differentiation) and discussed for intermediate-risk cases (>1000 µm invasion without additional risk factors). Carbon and cost analyses were based on life-cycle data. Results Between January 2024 and May 2025, 190 patients underwent diagnostic endoscopic dissection. Low-risk histology was observed in 86/190 patients. Intermediate-risk resections were observed in 31/190 patients, while 73/190 were classified as high-risk resections. Overall, 109 patients (57%) avoided surgery. Compared with modeled upfront surgery, diagnostic endoscopic dissection was associated with lower carbon emissions (222.2 vs 240.2 kgCO₂e per patient), shorter hospital stay, and reduced overall costs (€7,930 vs €12,960 per patient). Conclusion A diagnostic endoscopic dissection first strategy enables accurate staging while reducing surgery, environmental impact, and healthcare costs.

BACKGROUND : Endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) is emerging as an alternative to choledochoduodenostomy (EUS-CDS) for malignant distal biliary obstruction (MDBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). Comparative data on long-term patency are limited. METHODS : This retrospective international study analyzed two historical cohorts of patients who underwent EUS-GBD or EUS-CDS for MDBO after failed ERCP between March 2017 and May 2024. Eligible patients were aged ≥ 18 years with at least 6 months' follow-up or confirmed death. The primary outcome, after 1 : 1 propensity score matching, was 12-month biliary patency. Secondary outcomes included technical and clinical success, adverse events (AEs), reintervention rates, and overall survival. RESULTS : Before matching, 294 patients were included (142 EUS-GBD; 152 EUS-CDS). After matching, 200 patients were analyzed (100 per group). Technical success was 100 % for EUS-GBD and 97 % for EUS-CDS (P = 0.25). Clinical success was 80.5 % for EUS-GBD and 90.6 % for EUS-CDS (P = 0.08). At 12 months, the probability of biliary patency was significantly higher with EUS-GBD than EUS-CDS (86.2 % [95 %CI 74.2 %-92.9 %] vs. 63.8 % [95 %CI 49.5-75.0]; P = 0.01). Biliary reintervention-free survival was significantly longer with EUS-GBD (log-rank, P < 0.001). Periprocedural AEs occurred in 7.0 % vs. 10.0 % (P = 0.61), delayed AEs in 27.0 % vs. 30.0 % (P = 0.75), and reintervention rates were comparable (23.0 % vs. 26.0 %; P = 0.74). Overall survival did not differ significantly (log-rank, P = 0.59). CONCLUSION : In patients with MDBO after failed ERCP, EUS-GBD achieved higher 12-month biliary patency than EUS-CDS, with comparable rates of technical and clinical success, morbidity, reintervention, and overall survival.

BACKGROUND AND AIMS:Colorectal endoscopic submucosal dissection (ESD) is an effective curative technique for superficial colorectal lesions but remains technically demanding, with variable procedure times. This study aimed to develop and validate a preprocedure predictive model for colorectal ESD duration in the era of traction-assisted strategies. METHODS:We retrospectively analyzed prospectively collected data from patients who underwent colorectal ESD at Edouard Herriot Hospital (Lyon, France). The derivation cohort included 423 cases (January-December 2024), and an independent temporal validation cohort included 148 cases (January-May 2025). A generalized linear model with a gamma distribution and log-link function identified independent preprocedural predictors of ESD duration. Variables were selected on the basis of univariate significance and the Akaike information criterion. Model calibration and discrimination were assessed using R2, mean absolute error, and classification accuracy at predefined thresholds (60, 90, and 120 minutes). A point-based score (Lyon ESD Dissection score, [LEDS]) and nomogram were derived from model coefficients. RESULTS:Median procedure time in the derivation cohort was 50 minutes (IQR, 30-90). Independent predictors of ESD duration included dissection speed of endoscopists, lesion location (flexures, appendix, cecum, and ileocecal valve), predicted lesion size, and suspected fibrosis (all P < .05). The LEDS provides a direct estimation of the expected procedure time in minutes based on these variables, showing a strong correlation between predicted and observed durations (R2 = 0.52). Classification accuracy was 76.1%, 82.2%, and 88.1% for thresholds of 60, 90, and 120 minutes, respectively. Validation confirmed good performance (R2 = 0.48) with 91.8% accuracy for procedures ≥120 minutes. CONCLUSIONS:This validated preprocedure scoring system accurately predicts colorectal ESD duration, especially for longer procedures. It may facilitate scheduling, optimize resource use, and improve workflow in endoscopy units.

BACKGROUND : Endoscopic submucosal dissection (ESD) offers better oncological outcomes and lower recurrence rates, but is limited in colorectal use owing to concerns about adverse events, especially perforation. This study aimed to explore the clinical burden and risk factors for perforation in a Western cohort. METHODS : Analysis of intraprocedural and delayed perforations from a prospective cohort study including 3770 colorectal ESDs performed at one Belgian and 12 French centers between September 2019 and September 2022. RESULTS:  Intraprocedural perforation (n = 314; 8.3 %) or delayed perforation (n = 22; 0.6 %) occurred in 336/3770 procedures (8.9 %). Conservative management was effective for 308/336 perforations (91.7 %), especially for intraprocedural perforations (n = 304 /314; 96.8 %). Delayed perforation frequently required emergent surgery (n = 18/22; 81.8 %). Multivariable analysis identified factors associated with intraprocedural perforation, including previous resection (odds ratio [OR] 1.9, 95%CI 1.3 to 2.7), lesion size ≥ 50 mm (OR 1.5, 95%CI 1.2 to 1.9), poor maneuvrability (OR 2.0, 95%CI 1.4 to 2.5) and severe fibrosis (OR 4.4, 95%CI 3.2 to 6.1). Proximal colonic location and severe fibrosis were associated with increased risk of delayed perforation. A perforation ≥ 5 mm (OR 8.9, 95 %CI 1.0 to 76.5) and fever (OR 9.5, 95 %CI 2.4 to 38.0) or abdominal pain (OR 26.6, 95 %CI 3.3 to 213.8) were associated with surgery after intraprocedural perforation (univariable analysis). No deaths were directly linked to perforation, but one death occurred due to delayed bleeding. CONCLUSIONS:  ESD-related perforations are often manageable conservatively, with surgery being rare; however, delayed perforations remain challenging and often require surgery. Patients should be informed of both the benefits and risks.

Background Endoscopic submucosal dissection (ESD) allows for en bloc endoscopic resection of T1 esophageal adenocarcinoma arising on Barrett's esophagus (BE). Although the safety of the procedure is well established, the oncological adequacy of the procedure and the long-term follow up of the patients have not been prospectively studied. Methods We conducted a prospective, multicenter study involving 9 French and Belgian centers. We included patients treated with ESD for a visible endoscopic lesion of more than 15mm documented with dysplasia, with a 3-year follow up. The primary endpoint was the histologically complete resection rate for adenocarcinoma and high-grade dysplasia (HGD). Results A total of 141 patients were included in the study between December 2016 and January 2019. The R0 resection rate was 85% for adenocarcinoma and HGD, and 81% for invasive adenocarcinoma. The complication rate was 17%, of which 5% were early complications and 12% were late complications, mainly esophageal strictures. During a median follow-up length of 36.3 months, recurrence was observed in 15% of the patients and was endoscopically manageable in 44%. Eight patients (6%) underwent esophagectomy for a high-risk adenocarcinoma. Overall, 14 patients (12%) died during follow up, 3 of them (2.5%) from esophageal adenocarcinoma. Conclusion Endoscopic resection by ESD is a safe and effective technique to treat T1 esophageal adenocarcinoma, allowing avoidance of esophagectomy in 94% of the patients.

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: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.