Endoscopy

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is a cornerstone therapeutic procedure in pancreatobiliary disease but carries a risk of clinically significant bleeding, particularly following therapeutic interventions such as sphincterotomy. Accurate identification of bleeding predictors is essential for procedural planning, risk stratification and optimization of preventive strategies.

Problem Statement Existing studies evaluating post-ERCP bleeding risk factors have shown inconsistent findings, particularly regarding antithrombotic therapy, procedural techniques and patient-related comorbidities. A comprehensive evidence-based analysis was needed to better define independent predictors of bleeding after ERCP.

Summary This systematic review and meta-analysis evaluated nearly 150,000 ERCP procedures and identified several major independent predictors of post-ERCP bleeding. Coagulopathy emerged as the strongest risk factor, followed by hemodialysis, anticoagulation therapy and cirrhosis, highlighting the critical role of impaired hemostatic reserve and advanced systemic disease in postprocedural hemorrhage. Procedural interventions also substantially influenced bleeding risk, with endoscopic sphincterotomy and precut sphincterotomy significantly increasing the likelihood of bleeding events. Intraoperative bleeding itself was an important predictor of subsequent clinically significant hemorrhage, emphasizing the importance of meticulous intraprocedural hemostasis. Male sex was associated with a modest increase in bleeding risk, although the biologic explanation remains uncertain. Importantly, several commonly presumed risk factors—including older age, obesity, cholangitis, choledocholithiasis, pancreatic duct stones, NSAID use and antiplatelet therapy—were not independently associated with increased bleeding risk after adjusted analysis. Notably, antiplatelet therapy did not significantly elevate bleeding risk, an observation that may influence future peri-ERCP medication management strategies. Similarly, endoscopic papillary balloon dilation and covered metal stent placement were not associated with excess bleeding risk. Overall, the findings provide a refined evidence-based framework for predicting post-ERCP bleeding and support the development of individualized risk assessment models to improve informed consent, procedural planning and prophylactic management in therapeutic ERCP.

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is an essential therapeutic procedure in pancreatobiliary disease but remains associated with important adverse events, including postprocedural bleeding. Although bleeding occurs relatively infrequently, it can result in significant morbidity, need for intervention and prolonged hospitalization.

Problem Statement Previous studies evaluating predictors of post-ERCP bleeding have produced inconsistent results, particularly regarding patient comorbidities, antithrombotic therapy and procedural techniques. A comprehensive risk stratification framework is needed to better identify high-risk patients and optimize preventive strategies before ERCP.

Summary This large systematic review and meta-analysis identified several clinically important predictors independently associated with post-ERCP bleeding. The strongest risk factors included coagulopathy, hemodialysis, anticoagulation therapy and cirrhosis, emphasizing the major contribution of impaired hemostatic reserve and advanced systemic disease to bleeding risk. Procedural factors also played a significant role, with endoscopic sphincterotomy, precut sphincterotomy and intraprocedural bleeding emerging as important predictors of subsequent hemorrhage. Male sex was additionally associated with modestly increased bleeding risk. In contrast, several traditionally presumed risk factors—including older age, elevated body mass index, cholangitis, choledocholithiasis, NSAID use and antiplatelet therapy—were not significantly associated with higher bleeding risk after adjusted analysis. Notably, antiplatelet therapy did not independently increase bleeding risk, an observation that may influence future periprocedural management decisions in selected patients. The study also demonstrated that not all technically advanced interventions confer equal bleeding liability, as endoscopic papillary balloon dilation and covered metal stent placement were not associated with significantly increased bleeding rates. Overall, the findings provide a more refined evidence-based understanding of post-ERCP bleeding risk and support development of predictive models integrating patient-related and procedure-related variables to guide individualized procedural planning, informed consent and preventive strategies in therapeutic ERCP.

Introduction Endoscopic ultrasound–guided gastroenterostomy (EUS-GE) has rapidly emerged as an important minimally invasive option for the management of gastric outlet obstruction, offering an alternative to surgical bypass and enteral stenting. As adoption increases globally, EUS-GE is being applied across increasingly diverse benign and malignant indications.

Problem Statement Despite growing utilization, EUS-GE techniques remain highly variable among centers and operators, including differences in access methods, stent deployment strategies, procedural setup and adjunctive imaging techniques. This lack of standardization may contribute to heterogeneous clinical outcomes and creates challenges for training, quality assurance and procedural safety.

Summary This international modified Delphi consensus provides the first structured expert-driven technical recommendations for standardizing EUS-guided gastroenterostomy. Through a multiround consensus process involving leading interventional endosonographers, the study identified broad agreement on several core procedural principles considered essential for safe and effective EUS-GE. Strong consensus supported routine fluoroscopic guidance, free-hand deployment of electrocautery-enhanced lumen-apposing metal stents and the requirement for operator expertise in managing major complications such as perforation, bleeding, stent dysfunction and misdeployment. Consensus was also achieved regarding procedural sedation, patient positioning and the use of saline for bowel distension. More nuanced topics—including dye use, optimal bowel distension techniques and preferred catheter-assisted approaches—generated moderate agreement, reflecting evolving operator preference and ongoing technical refinement. Importantly, several unresolved areas failed to achieve consensus, particularly regarding contrast utilization and superiority of specific technical approaches, highlighting persistent procedural heterogeneity and important future research priorities. Overall, this consensus document represents a major step toward procedural standardization in therapeutic EUS and provides a practical framework for training, quality improvement and safer adoption of EUS-GE in advanced endoscopy practice.

Introduction Biliary intervention in patients with surgically altered anatomy remains one of the most technically challenging areas in therapeutic endoscopy. Conventional enteroscopy-assisted ERCP is often limited by difficult limb access, prolonged procedure time and reduced cannulation success, particularly in Roux-en-Y reconstructions and hepaticojejunostomy anatomies. Therapeutic endoscopic ultrasound (EUS) has increasingly emerged as an alternative platform for creating transluminal access pathways in these complex settings.

Problem Statement Although EUS-guided anastomosis using lumen-apposing metal stents (LAMS) has transformed access strategies in gastric bypass anatomy, evidence supporting EUS-directed transenteric ERCP (EDEE) in other surgically altered anatomies remains limited. Key concerns include procedural feasibility, adverse events, fistula persistence and the practical role of this technique compared with percutaneous or enteroscopy-assisted approaches.

Summary This multicenter study demonstrates that EDEE using EUS-guided anastomosis with LAMS is a highly effective approach for biliary intervention in patients with complex surgically altered anatomy. The technique achieved excellent rates of EUS-guided anastomosis creation and high technical and clinical success for subsequent ERCP, even in anatomies traditionally considered extremely difficult for standard endoscopic access. Most procedures were performed for benign indications, particularly hepaticojejunostomy strictures requiring repeated interventions, highlighting one of the major advantages of EDEE: the ability to establish durable and repeatable endoscopic access to the biliary limb. The study also emphasizes the technical versatility of EDEE, with multiple strategies successfully used to identify the biliary limb depending on surgical configuration. Adverse events occurred in approximately one-fifth of patients, although severe complications were relatively uncommon and most LAMS-related events were managed endoscopically or conservatively. Persistent fistula formation after LAMS removal remained a notable issue, although its long-term clinical significance outside bariatric anatomy remains uncertain. Overall, the findings position EDEE as a major advancement in interventional endoscopy for surgically altered anatomy and support its role as a minimally invasive alternative to percutaneous drainage or surgery, particularly in benign disease requiring repeated biliary access.

Introduction Gastric per oral endoscopic myotomy (G-POEM) has emerged as an effective minimally invasive therapy for refractory gastroparesis. However, post-procedural care remains variable across centers, with no clear consensus on whether patients require routine overnight observation or can be safely discharged on the same day.

Problem Statement Despite growing adoption of G-POEM, the optimal post-procedure disposition remains undefined. Routine overnight admission increases resource utilization and costs, yet concerns persist regarding delayed adverse events, unplanned readmissions and emergency visits after same-day discharge. Defining the safety of same-day discharge is essential to standardize post-G-POEM care and improve procedural efficiency.

Summary This systematic review and meta-analysis suggests that same-day discharge after G-POEM is a safe and feasible strategy in appropriately selected patients with refractory gastroparesis. Across pooled studies, same-day discharge was not associated with higher rates of readmission, emergency department visits or procedure-related adverse events compared with routine overnight observation. These findings support the clinical safety of same-day discharge when applied in carefully selected patients following uncomplicated procedures. Notably, same-day discharge was also associated with shorter procedure times, suggesting that procedural efficiency and case selection may contribute to successful early discharge pathways. Although patient selection and institutional protocols remain important, these data support a shift toward more streamlined post-G-POEM care and suggest that routine overnight admission may not be necessary for all patients. This analysis provides an important step toward standardizing post-procedural pathways and supports same-day discharge as a practical, resource-conscious approach in experienced centers.

Introduction Post-ERCP pancreatitis (PEP) remains one of the most common and serious complications of Endoscopic Retrograde Cholangiopancreatography. Rectal NSAIDs such as Indomethacin and Diclofenac are strongly recommended for PEP prevention. However, concerns about renal safety—especially in elderly patients and those with chronic kidney disease—have limited their widespread use in clinical practice. This large multicenter prospective study evaluates whether a single peri-procedural dose of NSAIDs truly increases the risk of kidney injury, addressing an important clinical hesitation. Problem Statement Despite strong evidence supporting NSAIDs in reducing PEP, many clinicians avoid their use due to fear of acute kidney injury (AKI) or acute kidney disease (AKD). Current guidelines often recommend caution or avoidance in patients perceived to be at higher renal risk. This creates a clinical dilemma: 👉 Should we compromise effective PEP prevention due to theoretical renal risks, or is this concern overstated? Summary In a large cohort of over 11,000 patients undergoing ERCP, approximately half received a single dose of rectal NSAIDs. The study found: No significant association between NSAID use and AKI or AKD Low absolute rates of kidney injury (0.5%–0.8%), even in high-risk groups Consistent findings across: Elderly patients Patients with pre-existing chronic kidney disease Propensity-matched analysis Importantly, NSAIDs were also not associated with increased bleeding or other major adverse events. These findings suggest that single-dose NSAIDs are safe from a renal standpoint in the ERCP setting, challenging the routine avoidance of these drugs.